Orthopaedic

Knowledge
Update
Sports Medicine
* erican Orthopaedic Society for Sports Me 1' .

Mark D. Miller, lVlD: Editor

.' hi“ Illifl Vll-Ii'iii"=‘ili

 Acknowledgments
Editarlal Beard, Drthnpaatlle Knawlatlga Francis H. Shen, MD
Update: Sports Medicine 5 Warren G, Stamp Endamed Prafessar
Divisien Head, Spine Surgery
Mk 13- Miller, hm Department elf Grtimpaedic Surgery
Hflfld: Difiiiiflfl flfSPWfl Mfldifiiflfi University at 1it"irginia Health Systems
3. 1Jli'ard Cassceiis Prefesser Chafiflfigsyiflgr Virgiflm 1
Department ef Drtirepaedic Surgery
Universi 9f Virginia Stephen R. Thempstnl, MD, Med, FRESH
Charigrrfipmg, Virginia Assaciate Prefesser elf Sperts Medicine
Eastern Maine Medicai Center
Stealin- F- Brockmier. MD Tire University atMaine
Asseciate Prefesser gflflgflfl Maine
Department at I[irttrepaedics
University at It'irginia Kfltifl 15- Wflks PT. DPT: EMA
Cbariettesviiie, Virginia Ciinicei Directer
. Pirysicai Therapy
Cree M- 53$t MD Champion Sperts Medicine
Asseeilrte Prefesser, 1iiiee Chair; Associate Chief Birmingham, diabanra
Medicai Inferrnatien Ufficer
Department at Radieiegp and Medical Inmging,
Drtnepaedic Surgery .
University at It'irginia Heaiti:I System ADSSM Board “f Directors, 1015
Cbariettesviiie, Virginia Annuntiate Ame-fiddle, MI}

E Wmsttm Gwathmay, hill] Prmrdent—Eiect

Assistant Prafesstrr [If Drtirtrpaedic Surgery (31131135 A“ Bush-Jnseph, hm
Department of Drtfiepaedic Surgery Vice Pfggidgflf
Universi at Virginia Heaitir System
Cirariettesviiie, 1Fiir,r_.1rinia Rifik 13- WEE-“13911: DU
Secretary
James]. Irrgang, PM}, PT, ATE, FAFI'A
Prafessar and Directer ef Clinicai Research 511d ]- {305231331 MD
Department c-f Drtircvpedic Surgerj.I Treasurer
Universi pf PittsirurgiiI .
-
Pittsburg, -
Pennsyivama Herbert A. firmer-a, MD
Past President

David R, McMIistet, MD
Prafessar and. Cbiefi Sparts Medicine Jfl A" Hannafin, MD, PhD
Department ef Urtiropaedic Surgery PM: President
David Gefien Scbaai elf Medicine at UCLA Jeseph H, Guettler, MD
Les Angeies, Caiifernia Member at Large
Matthew D. Mflewslti, MD C. Bfifliflfl'fifl Ma MD
Assistant Prefesser af Drtnepaedic Surgery and Member at Large
Sports Medicine
Eiite Sperts Medicine Rick W, Wright, MD
Cennecticut Ciriidren’s Medicai Center Member at Large
reflfl‘mflfl”,Co ””3ne
' e Christopher C. Kaeding, MD
Suntan K. Pnddat, MD Ex-ficie
Asseciate Prefesser and Dire-star; Printer}! l{Jere _
Sperts Medicine Bruce Pfe'd‘f-FMD _ _ .
Department at Famiip Medicineiflrtirapedics Eflm Ed’m’i Medias! Punhsbmg
University at Ceieradcr 7 Heard flfTTHSWES
ver Ceieradcr [w Bemberger
Executive Directtrr

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 Preface
I have always been a fan of the American Academy of Orthopaedic Surgeons
{MUS} Cirthopaedic Knowledge Update [UKU] series. As a resident when the
first OKU was published, I literally read the cover off the edition in the depart-
ment library and have referred to subsequent editions ever since.

Jail
Two years ago, Jo Ann Hannafin, then President of the American Urthopaedic
Society for Sports Medicine (AGSSM), asked me to edit UK U Sports Medicine

i
5. As is often the case with time- consuming requests from respected leaders,
I agreed, knowing that time invested would lead to value for both authors and
readers. As an academic project designed to be a useful resource for practitioners,
the DKU series ultimately benefits our patients in clinics and operating rooms.
So... 2 years and 5? chapters later, it is with great pride that I introduce the fifth
edition of Orthopaedic Knowledge Update—Sports Medicine.
The fifth edition is not a rehash of UK U Sports Medicine 4. Much of the credit
goes to the 10 section editors, Drs. Brockmeier, Gwathmey, McAllisten Irrgang,
Wilk, Shen, Thompson, Poddar, Milewski, and Gaskin. They played a key role in
deciding on chapter topics, many of which are new, and selecting authors. They
also did an outstanding job encouraging the contributors and editing their work.
In addition, new figures were found or created specifically for this edition, adding
a rich and informative contest to the written descriptions of medical processes
and terminology. Video is also included for some of the chapters.
Finally, I want to give a shout-out to Lisa Claston Moore and the other members
of the MOS publications department who worked on this project. As one of
many invested in the future of sound practice in orthopaedic sports medicine,I
am honored to be part of the team that put together this book. Thank you.
Mark D. Miiier; MD
Editor

//

//

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1

Table of Contents
Preface ........................ Iv
1Widen Abstracts .................. aJti
Section 1: Upper Extremity
Section Editor:
Stephen F. Brockmeicr, DID
Chapter 1
Shoulder Instability
Jeanne C. Patzkowski, MD
Brett D. Dweus, NED ........... . . . . 3
Chapter 2
Disorders of the Acrotnioclavicular Joint,
Sternoclavicular Joint, and Clavicle
Brian R. 1Wolf, MD, MS
Yousscf El Bitar, LID .............. 1?
Chapter 3
Rotator Cuff Disease
Evan J. Conte, MID
Stephen F. Brocloneier, MD ......... 33
Chapter 4
Superior Labrum and Biceps Pathology
Bryan G. Vopat, MD
Jeffrey E. Wong, MD
Petar Golijanin, BS
Matthew T. Provenchcr, DID ........ 43
Chapter 5
Adhesive Capsulitis, Cartilage Lesions,
Nerve Compression Disorders, and
Snapping Scapula
Maximilian Petri, MD
Joshua A. Greenspoon, BSc
Peter]. Milieu, MD,MSc . . . . . . . . . . 55
Chapter 6
Elbow Arthroscopy and the Thrower’s
Elbow
Ekaterina Y. Urch, NED
Lucas S. McDonald, MD, Isl-PHSETM
Joshua S. Diues, MD
David W. Altchelt, MD . ........... (i? EIChapter 15
Chapter 7'
AcutefTraumatic Elbow Injuries
John P. Haverstock, IvID, FBCSC
George 5. Athwal, MD, FRCSC. ..... 31
D11] 16 American Academy of Drthopaedic Surgeons
I..-
‘
Chapter 3
Chroniefflveruse Elbow Disorders
Champ L. Baker 1]], MD
Champ L. Baker Jr, MD ........... 91
Chapter 9
Hand and 1't‘ilrist Injuries
J. Taylor Jobe, MD
A. Bobby Chhabra, l'vID .......... lfll
Section 2: Hip and Pelvis
Section Editor:
F. Wmston Gwathmey, MD
Chapter Ii]
Athletic Hip Injuries
Richard Charles Mather 1]], MD, MBA
MichaelS.Ferrell,MD ...........115
Chapter 1 1
Femoroacetabular Ilnpingement
Ljiljaua Bogunovic, MD
Shane J. Nho, MD, MS ........... 127
Chapter 12
Extra-articular Hip Disorders
J.W. Thomas Byrd, MD
Guillaume D. Dumont, MD........ 141
Chapter 13
Muscle Injuries of the Proximal Thigh
James T. Beckmann, MD, MS
Marc E. Safran, MD ............. 151
Chapter 14
Athletic PubalgiafCore Muscle Injury and
Groin Pathology
Christopher M. Larson, MD
David M. Rowley, MD .......... . 163
Section 3: Knee and Leg
Section Editor:
David R. MeAllister, MID
Cruciate Ligament Injuries
Lucas 5. McDonald, HID, WHBCTM
Nathan Coleman, MD
Andrew D. Pearle, l'vID ........... HS
Drthopaedic Knowledge Update: Sports Medicine 5 w
1'
 I Chapter 16 Section 4: Rehabilitation
Collateral Ligament luries
Eduard Aleutorn-Geli, MD, MSc, PhD, Section Editors:
FEBDT James J. lrrgang, PhD, PT, ATC, FAPTA
Joseph J. Stuart, MD Kevin Willi, PT, DPT, FAPTA
J.H. James Choi, MD
Claude T. Moorman I[l, MD ....... 189 Chapter 23
Current Concepts in Rehabilitation of
Chapter I? Rotator Cuff Pathology: Nonsurgieal and
Patellofemora] Joint Disorders Postoperative Considerations
Miho J. Tanalta, MD Todd 5. Ellenbecker, DPT, MS, SCS, (JCS,
John J. Elias, PhD CSCS
Andrew J. Cosgarea, MD ......... 205 George J. Davies, DPT, MEd, PT, SCS,
ATC, LAT, CSCS, PES, FAPTA ..... 311
I Chapter 13
Articular Cartilage of the Knee Chapter 24
Andreas H. Gomoll, l'vID Nonsurgical and Postoperative Rehabilita-
Brian J. Chilelli, l'viD . ............ 121 tion for Ininries of the Dverhead Athlete’s
Elbow
Chapter 19 Kevin E. Will-t, PT, DPT, FAPTA
Nonarthroplastv Management of Todd R. Hooks, PT, ATC, (JCS, SCS,
Dsteoarthritis of the Knee NREMT-lj BEES:- CMTFT:

Ljiliana Bogunovic, MD FAADMPT .................... 319

Charles A. Bush-Joseph, lviD ....... 23?
El Chapter 25
1 Chapter 20 Hip Rehabilitation
Meniscal Injuries Keelan Enselti, MS, PT, DCS, 5C5, ATC,
Stephanie W. Mayer, MD CSCS
Johnathan A. Bernard, Md}, MPH Dave Kohhieser, DPT, PT, DCS, 5C5,
Scott A. Rodeo, lvfl) . ............ 251 CSCS
Ashley.r Young, PT, DPT, CSCS. ..... 351
Chapter 21
Leg Pain Disorders El Chapter 26
Justin Shu Yang, MD Current Rehabilitation Concepts
Thomas M. DeBerardino, MD ..... 165 Following Anterior Crueiate Ligament
Reconstruction
1 Chapter 22 Penny Goldberg, PT, DPT, ATC
Ankle and Foot Ininries and Other Giorgio Zeppieri Jr, PT, SCS, CSCS
Disorders Debi Jones, PT, DPT, SCS, {JCS
Thomas D. Clanton, MID Terese L. Chmielewski, PT,
Norman E. Waldrop III, MD PhD, SCS ...................... 359
Nicholas 5. Johnson, MD
Scott R. 1|i'ii'hilzlow, MD ............ 1?? Chapter 2?
Patellofemoral Pain Syndrome: Current
Concepts in Rehabilitation
Mark V. Paterno, PT, PhD, MBA, SCS,
ATC
Jeffery A. TaylooHaas, PT, DPT,
DCS, CSCS .................... 3?]
Chapter 23
Foot and Ankle Rehabilitation
RobRov L. Martin, PhD, PT ....... 333

lei American Aeadern].r of Drthopaedic Surgeons Drthopaedie Knowledge Update: Sports Medicine .5
 Chapter 2.9 Chapter 3?
Core Stabilization Current Applications of Drthohiologic
Rafael F. Escamilla, PhD, PT, CSCS, Agents
FACSM ....................... 393 Ryan M. Degen, MID, MSc, FRCSC
Scott A. Rodeo, MD ............. 503
Section 5: Head and Spine
Chapter 33
Section Editor: The Biology and Biomechanics of Crafts
Francis H. Shen, .MD and Implants
F. Alan Barber, MD, FACS ......... 523
Chapter 30
Concussion
Section ?: Medical Issues
Siobhan M. Statuta, M.D, CAQSM
John M. MacKnight, MLD, FACSM Section Editor:
Jeremy B Kent, MD, CAQSM Souray K. Foddar, MID
Jeremy L. Riehm, DD ......... . . . 411
Chapter 39
Chapter 3 1 Sports Nutrition
Traumatic Spine Injuries in the Athlete Jacqueline R. Berning, PhD, RD, CSSD
Sophia A. Strike, MD Kelly L. Nesdlle, MS ............. 545
Hamid Hassanaadeh, MD ......... 423
Chapter 40
El Chapter 32 Sport Psychology
The Cervical Spine Christopher M. Bader, PhD, LP;
William R. Miele, hiD CC-AASP . ................... . 553
Brain J. Neuman, MD
Asjay Khanna, M.D, hilBA......... 433 Chapter 41
Cardiac Issues in Athletes
Chapter 33 Kimberly G. Harmon, hiD
Thoracolumhar Spine Jonathan A. Dreaner, MD ......... 561
Anuj Singla, NID
Christopher A. Burks, MD ........ 451 Chapter 42
Female Athlete Triad
Section 5: Miscellaneous Topics Marissa M. Smith, MD
Marci A. Goolsby, MI} ........... 5 75
Section Editor:
Stephen R. Thompson, MD, Med, FRCSC Chapter 43
Infectious Disease in the Athlete
Chapter 34 Matthew Leiszler, MED
The Team Physician and the Ethics of Kari Sears, MLD
Sports Medicine DaridSiuith,DD ...............535
Andrew M. Watson, NED, MS
Warren R. Dunn, lyiD, MPH ....... 469 Chapter 44
Facial Injuries
Chapter 35 Jeffrey a. Housner, MD, MBA 3}/
Research Studies and Registries in Sports Laurie D. Donaldson, hvfl) ....... . fifl/
Medicine /
Robert H. Brophy, MD Chapter 45
Matthew V. Smith, hfl) ........... 4?"? Abdominal Injuries
Stephen IL Paul, BID
Chapter 36 Sagir Girish Bera, DD, MPH, MS
Current Concepts in Tendinopathy Brenden J. Balcik, MD ........... 615
Trevor Wilkes, MID
W. Benjamin Kihler, MD . ......... 493

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 Chapter 46 Chapter 52
Heat Illness and Hydration Strength Training and Conditioning in
Alexander B. Ehirlger, MD ....... . 631 Young Athletes
Tracy.r I.. Zaslow. MD. FAAP,
Section B: The Young Athlete CAQSM . ..................... 7'11
Section Editor:
Section 9: Imaging
Matthew D. Milewski, MD
Section Editor:
Chapter 4? Cree M. Gaskin, MD
‘ Gsteochondritis Dissecans
Kevin G. Shea. MD Chapter 53
Ted J. Genie}; I'dD ............. . 6-41 I'VIRI of the Glenohumeral Joint
J. Derek Stenshg, MD . ........... 7’23
Chapter 43
Anterior Cruciate Ligament Tears in Chapter 54
Skeletal]? Immature Athletes NIRI of the Elho‘nr
Benton E. Heyworth, MD Nicholas C. Naceg MD........... 731
Melissa A. Christine, MD ......... 653
Chapter 55
El Chapter 49' Imaging of the Hip
Patellofemoral Instability,r and flther Jennifer L. Pierce, MD. ........... 1739
Common Knee Issues in the Skeletall'f
Immmure Athlete Chapter 56
Aristides I. Cruz Jr. MD Imaging of the Knee
Matthew D. Milewslti, MD ........ 66? Meredith C. Northam, MID. ....... '14?

Chapter 50 Chapter 5?
Special Considerations in Head Injuries in Diagnostic Ultrasound and Ultrasound-
Adolescent Athletes Guided Procedures
Regina Kostyun, MSEd, ATC Jemtifer L. Pierce, 1'l
Carl W. Nissen, MID Nicholas C. Naceg hiD........... T55
Imran Hafeer, hfl) .............. 635
Index ........................... 5'69
Chapter 51
Shoulder and Elbow Injuries in the
Skeletally Immature Athlete
EricW.Edmonds,MD ...........?fll

16 American Academy of Drthopaedic Surgeons Orthopaedic Knowledge Update: Sports Medicine 5

@I Video Abstracts
Chapter 15 cruciate Ligament Inju rles
1ifideo 15.] Kim S], Kim SG, Kim SH, Lee DY, Jo IK: Video Excerpt. Arthroscopic Double-Bundle
ACL Reconstruction Using Quadriceps Tendon Autograft. Rosemont, IL, American Academy of
Orthopaedic Surgeons, lfllfl. {11'} min)
This video demonstrates an arthroscopic reconstruction of the ACL using a quadriceps tendon
autograft on a 30-year-old man. Examination reveals grade 2 instabilitv during the anterior drawer
test, a grade 3 Lachman test, and jumping during the pivot shift test. The graft is harvested with
a rectangular bone plug and is split sagittallv at a 3:2 ratio with regard to the anteromedial and
posterolateral bundles. The graft is whip stitched at the ends. Portals include a high anterolateral,
a low anteromedial, and an accessory anteromedial. Tunnels are reamed, and the graft is passed.
The bundles are passed alternately,r to prevent jamming. Sutures are tensioned while the knee is
cycled, and all ends are fixed with absorbable interference screws. All tests are negative and do not
indicate instability, and rehabilitation is discussed.

1"fideo 15.2 Bach Jr BR: 1|v"ideo Excerpt. Revision Single Bundle ACL Reconstruction Using BPTB
Autograft pt 1. River Forest, IL, EDIE]. (21 min)
This video demonstrates the first part of a two-part video showing a revision single bundle ACL
reconstruction using a transfibular endoscopic technique with a bone-tendon-bone autograft for a
19-year-old woman who is an athlete. An examination under anesthesia reveals a grade two pivot
shift, and the importance of checking for medial- or lateral-side instabilityr is discussed. The graft is
harvested through an incision along the medial edge of the patellar tendon. The tibial bone plug is
cut first, and the soft tissue is left attached to the infrapatellar fat pad for stabilitv while cutting the
patellar plug. Diagnostic arthroscopv is carried out through a standard infralateral portal through
the wound incision, which allows for better visualization. A medial portal is made adjacent to the
patellar tendon at the level of the patella. The remnants of the REL are removed with arthroscopic
scissors, and a posterior notchplast;-.r is performed with a spherical burr. An aecessoo.r inframedial
portal is made with a spinal needle, which aids in distaliaatiou of the insertion on the tibial
entrance site, as well as allowing for a more oblique orientation with the tibial tunnel. An aiming
device is inserted through the transpatellar portal.

Video 15.3 Each Jr BR: 1|Ii'itlean Excerpt. Revision Single Bundle ACL Reconstruction Using BPTB
Autograft pt 2. River Forest, IL, lfllfl. {13 min)
This video demonstrates the second part of a two—part video showing a revision single bundle
ACL reconstruction using a transfibular endoscopic technique with a bone-tendon-bone autograft
for a 19-year-old woman who is an athlete. The orientation of the guide pin is checked in flexion
and extension. The femoral tunnel is drilled with a cannulatcd reamer, and the removed bone is
saved for grafting, and the tibial tunnel is cleared with a shaver. The graft is delivered into the
femoral tunnel iotta-articularlv, and the knee is hyperflerted while placing the interference screw.
Improvements in Lachman and pivot shift tests are demonstrated. The tibial plug is rotated 1 Eli“
and secured with an interference screw with the knee in extension. The screw is placed on the
conical edge of the anterior aspect of the bone plug. Pivot shift and translation are tested for,
bupivacaine is used intra—articularlv and in the surgical wound, and rehabilitation and physical
therapy,r are discussed.

{7'
J" /"

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 Videe 15 .4 Jelmsen DH: ee Excerpt. Pitfalls in ACL Recenstructien. Resement, IL, American
Academy ef lI'L'Irthepaeelic Surgeens, 201B. {12 min}
This videe demenstrates varieus pitfalls that can eccur with AEL receustructien. lE'J‘ne is that a
tenden stripper may get caught en a band branching eff the tenden, which kinks the main tenden
and causes it te be cut shert. The next pitfall is patellar fracture resulting frem an “everrun”
herizental cut when harvesting a benete—bene graft. flvereealeus use ef an esteeteme en the
pat . la is alse demenstrated and discussed. Impreperly pesitiened tunnels and selutiens fer fixing
. m are discussed extensively. Insufficieutly large er brelcen bene plugs are alse discussed.

1ividee 15.5 Miller MD. Hart J. Kurkis G: Anatemic AEL Receustructiennflll Cemers.
Charlettesville, VA, 2fl13. {ll} min}
In this videe. techniques are presented fer achieving anatemic anterier cruciate ligament MEL}
recenstructiens in a variety ef clinical scenaries. The intreductien demenstrates a primary single-
bundle anatemic ACL recenstructien using a hamstring autegraft. Subsequent sectiens fecus en
adaptatiens te this technique fer primary single—bundle anatemic ACL recenstructien with a bene-
patellar tenden graft, revisien REL recenstructien, and femeral physeal recenstructien. All ef the
techniques that are shewn fecus en restering the native ACL in its anateruic feetprint.

Videe 15 .6 Shine K: 1Fv’idee Excerpt. Anatemical Rectangular Tunnel ASL Recenstructien Using
ETB Graft. Usalta, Japan, 1010. {16 min}
Three benefits ef this precedure are eutlined: that it uses the deuble bundle cencept with a single
bene-te-bene graft, that it maximises the graft-tunnel centact area, and that neteh anatemy is
preserved. Fiber arrangement is demenstrated with a diagram. and the rectangular prefile ef the
graft is everlaid. The graft is harvested and bene plugs shaped. Pertals are made: anteremedial,
auterelateral, and the far anteremedial. The ACL stump is excised, and attachment peints
are made. The tibial and femeral tunnel rectangular prefiles are demenstrated. The femeral
interference screw is intreduced with an eutside-in technique, then the graft is passed threugh the
tibial and then femeral tunnels. Beth ends are fixed, and netch er PCL impingement is net present.
Rehabilitatien is discussed.

1|viidee 15 .7" Fulkersen JP: 1videe Excerpt. ACL Recenstructien Using a Free-Tenden Quadriceps
Autegraft. Farmingten, CI". 201i]. {20 min}
This videe demenstrates ACL recensn'uctien using a free-tenden quadriceps autegraft.

Videe 15 .3 Hewell 5M: Vidflfl Excerpt. Technique fer Harvesting Hamstring Tendens fer REL
Recenstructien. Sacramente. CA, 2fl1fl. {3 min)
This videe demenstrates a technique fer harvesting hamstring tendens fer ACL recenstructien
fer a 23-year-eld man whe plays seccer. The incisien is made and a right angle clamp is placed
ever the graeilis, and its tenden and that ef the semitendinnsus are identified. Beth are retracted
with a Peurese drain. stripped with a blunt epen—ended tenden stripper. and remaining muscle is
remeved. The tendens are cembined, deubled ever, and the ends have sutures placed. The cheice
ef allegraft versus autegraft is discussed. The graft is sized and submerged in a saline bath while
still inside an B—ntm sizing sleeve te prevent drying eut ef the graft.

® _._. I 16 American Academy nf flrthepaedic Surgeens Drthepaedic Knewledge Update: Sperts Medicine 5
 Videe 15.9 Shelbeurne ED: 1F«fitlee Excerpt. Tips fer Harvesting BTE Antegraft. Indianapelis, IN,
2611'}. {13 min]
This yidee demenstrates tips fer the centralateral harvesting ef a bene-te-bene autegraft fer ACL
recenstrnctien. The patella and patellar tenden are marked, and an incisien is made aleng the
medial berder ef this tenden. An incisien is made inte the paratenen te expose the tenden, and
flaps are maintained fer clesure. A Ill-mm graft is taken frem the central third ef the tenden frem
preximal te distal. lILIentimeter-deep bene plugs are cut first medially, then laterally fer each end.
Heles are drilled in beue plug ends and sutures passed, and a sizing guide is used In ensure the
graft passes threugh an ill—mm hele. The seft tissues ef the graft are injected with bnpiyacaine and
epinephrine. Bene graft is packed late the patellar and tibial defects, and the paratenen is clesed
eyer beth. Rehabilitatien is discussed and includes high-repetitien lew-weight exercises; then
flexien and extensien are checked, a subcutaneeus drain is placed, and clesure is perfermed.

1iJ'idee 15.10 Leeney CG, Sterett WI: 1iJidee Excerpt. AC1. Recenstructien Using Achilles Allegraft
and Interference Screws. Franklin, TN, Efl'lfl'. {T min}
This 1iridee demenstrates the preparatien and placement ef an Achilles alleyaft fer ACL
recenstrnctien. The graft scales in a selutien ef kanamycin and sterile saline, and is prepared en a
graft preparatien table. The bene plug is sculpted; and the graft is cut te size, marked, and the ends
are whip stitched. Arthrescepy pertal lecatiens are demenstrated, and a netchplasty is perfermed.
The tibial and femeral tunnels are drilled, and the graft is inserted and fixed at beth ends with
bene interference screws eyer guidewires. Flexien and expensien are tested, and rehabilitatien is
discussed.

1li'idee 15.11 Hewell 5M, Andres ID: Videe Excerpt. Anatemic Single Bundle ACL Recenstructien
withent Reef and PCL impingement - Tibialis Allegraft. Sacramente, CA, lfllfl. {2111' min}
This 1sidee demenstrates a single-bundle ACL recenstrnctien with a tibialis allegraft and the
impertant steps te ayeid reef and PCL impingement. Pertals are made at the jeint line at the
medial edge ef the patellar tenden and at the appreximate midline ef the patellar tenden. A 6.5"
guide is used te gauge the space between the lateral femeral cendyle and the PCL; this space is tee
narrew, se a wallplasty is perfermed. The femeral tunnel drill peint sheuld be halfway between
the apex and the bettem ef the intercendylar netch. The sagittal trajectery is aimed te ayeid reef
impingement, and the cerenal trajectery is aimed te ayeid PEL impingement. The tunnels are
reamed and the graft passed.The knee is cycled 15 tn 1'] times, and the tibial end is fixed in full
extensien. The desirable triangular space between the I’CL and the graft is demenstrated.

Chapter 15 Cellateral na ment Injurles

1ll'idee 16.1 Gerden D, Pincaewski L: Medial Cellateml ligament - MEL - Acute Meniseetibial
Repair. Sydney, Australia, Hill. {9 min} I’
Grade 3 medial cellateral ligament {MEL} injuries inyelye tearing ef beth the superficial and deep
cempenents ef the MCL. These structures may he tern frem either the femur er the tibia. Tibial-
sided [meniscetibiall injuries require surgery te clese the knee capsule and step syneyial fluid
extrusien, which prevents adequate healing ef the MCL. In this yidee, the surgical technique fer
repair ef acute meniscetibial MCL injuries, including diagnesis, eperating theater set-up, surgical
steps, and rehabilitatien, is shewn and described.

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 Video “16.2 Miller MD. W er EC. Higgins 5: Posternlateral Corner Primary Repair and
Reconstruction. lEase Based. 'o'Zharlottesville,r VA, 2014 {13 min}
This video uses three case examples to demonstrate surgical techniques for repair and
reconstruction of the posterolateral corner of the knee. The first case presented is a primary repair
backed up by a free soft-tissue graft. The second case is a reconstruction of the posterolateral
corner. The final case is a reconstruction of an isolated lateral collateral ligament {LCL} injury
usigg a strip of biceps tendon. The posterolateral corner of the knee is often misunderstand, and
I 's video simplifies repair and reconstruction techniques.

Chapter 13 Artieular Cartllage of the Knee

Video 18.1 Chalmers P, Yanke A. Sherman S, Karas V, Cole B]: Combined Cartilage Restoration
and Distal Realignment for Patellar and Trochlear Chondral Lesions. Chicago. IL. EDDIE. {24- min}
Chondral lesions of the patellofemoral ioint are relatively common and pose a treatment challenge
to the orthopaedic surgeon because of the complex three-dimensional topography and high-
contact stresses. Anterior knee pain. either at or surrounding the patella. is the most common
symptom in patients with patellnfemoral cartilage defects; however, posterior knee pain may
also suggest a trochlear defect. Given the wide differential diagnosis for anterior knee pain. the
patient history and physical examination should focus on osseous. cartilaginous, and tendinous
structures from the hip to the ankle. MRI and CT should be considered to better visualize the state
of the underlying cartilage and to quantify the patellar alignment and tilt. Treatment options for
patellofemoral cartilage defects include realignment procedures such as anteromedialiaation of the
tibial tubercle, or cartilage restoration procedures such as autnlcgous chondrocyte implantation,
microfracture, and osteochondral allografi: transplantation. Although reasonable results have been
reported with distal realignment and cartilage restoration used in isolation, better outcomes are
seen when these types of procedures are combined.

Chapter 20 Meniseal Injuries

Video Elli Shelton WE: Video Excerpt. All-Inside Meniscus Rwair - FAST-FIE. Jackson, MS,
2&1 1. [12 min]
This video demonstrates meniscal repair using the FAST-FIE system. FAST-FIX is introduced with
its blue sheath and the first grommet is deployed automatically, and sutures are made from the
periphery to the middle. A slip knot is tied and tightened with a ringed tightener, and excess suture
is trimmed with an arthroscopic scissors. The most difficult suture to make is above the tear, and
this is demonstrated. The importance of vertically oriented sutures is emphasized. A bucket-handle
tear repair is demonstrated.

Video 10.2 Lawhorn KW: Video Excerpt. All-Inside Meniscus Repair - MaxFire Maeeu.
Fairfax, VA, 2'01 1. {3 min}
This video demonstrates meniscal repair with the MaxFire Marflmen system. Setup includes a
leg holder. and the lateral and medial portal placements are demonstrated. A tourniquet is not
used, and bupivacaine or lidncaine with epinephrine is injected into the portal sites. A. posterior
horn tear of the medial meniscus is repaired with a horizontal mattress suture. Suture tensioning is
demonstrated with the inner and outer loops. Anchors are spaced 1 cm apart to ensure a soft-tissue
bridge to enhance fixation. Vertical mattress repair of a posterior horn tear of the medial meniscus
is also demonstrated. and again suture tensioning is demonstrated. A probe is used to assess repair,
and suture ends are trimmed.

® -.!' I 16 American Academy of flrthopaedie Surgeons Orthopaedic Knowledge Update: Sports Medicine 5
 1ii'ideu 20.3 Vyas D, Harrier CD: Videu Excerpt. Pusteriur Hurn Medial Meniscus Rent Repair.
Blawnex, PA, 21311. {14 min}
This viden demunstrates a pusterinr burn medial meniscus runt repair fur a 45-year—nld man.
The tear is demunstrated an MRI, and the difficulty uf making this diagnnsis is discussed. Patient
pcsin'nning and pcrtals are demcnstrated. A diagncstic artbrnsccpy is perfarmed, alnng with a
reverse nutchplasty tn imprnve visualisatiun. The first suture, a mnnnfilament, is pierced inter the
rent with a suture shuttle; and then a braided suture is leaped thruugh the munufilament and
passed. The tear is reduced. A tibial tunnel is drilled. The braided ends are passed thruugh the
tunnel, and the ends are fixed on the tibia with a 6.5—mm cancellnus screw with a washer. Suture
ends are trimmed.

1ii'iden 20.4 Egagliune NA, Chm E: Videu Excerpt. All-Ardiruscupic Meniscus Repair With
Eiulngical Augmentatic-n. Rusemunt, IL, American Academy uf flrthupaedic Surgenns, Zfll 1. {23
min]
This viden is a cadaver demunstratiun (if an all-arthrnscupic repair uf bath a pusterinr and an
anterinr hnrn tear cf the medial meniscus. The impnrtance cf evaluating a tear fur stability and
vasculariry is discussed, as are spacing and number ef sutures. A pertal skid is used tn intruduce
needles and sutures, and is alsu used as a retractnr. The index vertical mattress suture is placed
with a curved, pruprietary device, and then platelet-rich fibrin matrix is inserted in the tear. Twc
mere sutures are made in the pusteriur hurn cf the medial meniscus, and a final suture is placed
in the anteric-r junctinn. Repair uf an anteriur burn cf the medial meniscus is demunstrated an a
different cadaver specimen. Twc sumres are placed with a clet nf platelet-rich fibrin matrix, and an
uutside—in technique is demnnstrated. The suture ends are retrieved thruugh a cut—dawn incisiun,
and the sutures are tied duwn against the capsule. Stability is checked with a prnb-e, and clusure
plurfnrmed.

Videu 20.5 Shaffer ES: Videu Excerpt. Lateral Meniscus Transplantatinn. Rusemunt, IL, American
Academy nf Drthupaedic Surgenns, 2011. [6 min]
This viden demnnstrates a lateral meniscus transplantatic-n in a 31—year-uld wuman wbu plays
snccer with a 2-year histnry uf lateral right knee pain. The patient has nurmal gait and alignment,
but the primary pusitive findings are juint line tenderness and mild valgus defermity. Graft size is
determined frum measuring an AP radingraph and MRI. A diagnustic arthrnscupy is perfurmed,
and the meniscus is resected. Then, the tcurniquet is inflated and an anterclateral incisiun is made
in line with the lateral artbrnscupic purtal. A pusterulateral incisiun is alsu made in preparatinn fur
the meniscal repair. The graft is prepared and the bane black checked in a truugh gauge. Culinear
placement is discussed, as is the need tn pussibly make an incisicn in the patellar tendcn tn achieve
this. A shall-aw guuge is used tn create a preliminary truugh, and then a deep guuge the size uf the
bane black is used. This is checked with a template. The graft is inserted thruugb the pusterinr
cnrner, and its sutures are retrieved thruugh the pusternlateral incisiun. The graft is seated and
then secured with an inside—nut technique using vertical mattress sutures.

@1015 American Academy nf flrrhnpaedic Surgeries Drtbepaedic Knnwledge Update: Sparta Medicine 5 ®

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 Viden 111.6 Cale ll]: Vida cerpt. Lateral Meniscus Transplantatinn - Bridge-in-Slnt. Rnscrnnnt,
1L, American Academyr nf IIIthnpaedic Surgenns, 2131 1. {15 min}
This viden demonstrates a lateral meniscus transplantatinn using the bridge—in—slnt technique fur a
14-vear-nld girl. The graft is prepared with nnlv twn cuts needed tn shape the bane blnclt, and snft
tissue pnstetinr tn the pnsterinr hnrn is cut awav tn imprnve visibility during placement. The graft
width is cnnfirmed in an S-mm slnt gauge, and the meniscus is marked pnsterinr tn the expected
site nf the pnpliteal hiatus. A diagnnstic flflhfflfiflflpf is perfnrmed with a standard twn-pnrtal
setup, and a standard rneniscectnrn}r is perfnrnlnd. A trans-patellar tendnn apprnach is used fur the
arthrntnmv tn establish anterinr—pnsterinr directinn. A reference slnt is made, checked with a depth
gauge, cnnverted tn a rectangular channel with a three-sided base cutter, and rasped. A lateral-side
incisinn is made while taking care tn avnicl the cnmrnnn pernneal nerve. A nitinnl pin pulls the
graft in thrnugh the arthrntnnivr frnm the lateral—side incisinn, and the graft is seated. The bone
bridge is fixed anterinrl}.r with a screw, and the meniscus is fixed with vertical mattress sutures. The
meniscus is assessed fnr balance, and the sutures tied dnwn with the knee in extensinn.

Viden 21].? Carter TR: 1|iupl'iden Excerpt. Medial Meniscus Transplantatinn - Dnuble Enne Plug.
Phennix, AZ, 21311. {1 1 min]
This viden is a demnnstratinn nf a medial meniscus transplantatinn with a dnuble bone plug graft.
The difference between medial and lateral meniscal repair is illustrated. A diagnnstic arthrnscnpv
ensures that the patient is a candidate fnr transplant befnre the allngraft packaging is npened.
Tissue is remnved at the medial nntch tn imprnve visualisatinn, and the meniscus remnant is
dehrided until bleeding tn ensure healing. The graft is shnwn and the dimensinns nf the hnne plugs
are marked, cut, and their size checked. Hnles are drilled thrnugh the plugs and sutures passed.
A F-mm siner is hrnught thrnugh the nntch tn ensure that the drill guide and guide pin will fit.
Drilling is similar tn that used in PCL repair, and the tibial tunnel is drilled nver a guide pin. A
lnnped wire is brnught up thrnugh the tunnel and will be used tn pass the pnsterinr plug sutures.
The needles fer the anterinr reductinn sutures are passed using an inside-nut technique. The graft
is pulled intn the jnint with all reductinn sutures engaged. The graft pnps intn place pnsterinrlsr
as with a bucket-handle tear repair. Bnne plug sutures are secured anterinrlv, and a pnlvethvlene
buttnn is used in this case. The meniscus is repaired as it is with a bucket-handle tear repair. The
anterinr burn and plug are secured last, as these are mere amenable tn adjustment. Tvpicallv, eight
sutures are needed. The anterinr bnne plug has a guide pin placed and then a sncket drilled fnr
press-fit fixatinn. The repair is shnwn again at 5 mnnths.

Viden 10.3 Richmnnd JC: 1|Ivi'iden Excerpt. Medial Meniscus Transplantatinn During ACL Repair.
atnn, MA, 2011.{11min}
This viden demnnstrates a medial meniscal transplant in an active vuung adult wuman print tn
ACL recnnstructinn. Piecrusting is perfnrmed tn stretch the tight medial cnllateral ligament tn
irnprnve visualizatinn nf the medial meniscal remnant. Residual rneniscal tissue is débridecl, and
a mini nntchplastv is perfnrmed cm the medial femnral cnndvle tn allnw passage cf the graft. The
allngraft is prepared and bane plugs are harvested frnm the heme black with a caring reamer.
Sutures are passed thrnugh the heme and the snft tissue. If an ACL is being recnnstructed with the
transplantatinn, the ACL tunnels wnuld be fashinned at this time. A cnunterincisinn is made at the
pnsternmedial cnmer tn retrieve the graft sutures. The tibial tunnel is reamed, and suture retrievers
are passed. The meniscus graft is passed up thrnugh the tibial tunnel, and the sutures retrieved. The
bnne blnck and meniscus are seated, and the meniscus is captured with classic insidewnut technique.
The ACL graft is passed intn place and fixed. This is cnnsidered a salvage prncedure, and the

16 American Academy nf flrthnpaedic Surgenns Drrhnpaedic Knnwledge Update: Spnrts Medicine 5

 patient is asked te cemmit te ne running or cutting sports for a vear; theugh it is encouraged to
permanentlv give up these activities for the preservation of the joint.

Chapter 22 Ankle and Foot Injuries and Other Disorders

1"fidee 22.1 Ferkel RD, Stuart KI): Video Excerpt. Autelegeus ||.'.".hrendrec3rte Implantation. 1‘vi'an
Nnvs, CA. , 2fl'11. {13 min}
The program begins with a review of published studies on ACI. Patient indications are reviewed,
and a two-stage procedure is summarised. Cultivation of biopsy tissue is discussed and one patient
case is demonstrated beginning with imaging studies {a—rav, CT, and MRI}. Preoperative planning
is discussed using :c-rav imaging. The initial incision is made at the medial malleelns and the
surgical site is dissected for complete visualization of the talar dome. The esteetemj.r is completed
using an oscillating saw and esteetome. The esteechondral lesion is identified and removed.

1if'idee 22.2 Glasehroek M: 1|Infidee Excerpt. Conventional Treatment - DEhridement Abrasion

Micrefracmre Drilling. Halifax, Neva Ecetia, 201 1. [4 min}
Anatomical structures are outlined on the patient’s skin, and the ankle joint is infused with
saline. Portals are made and tissue déhridement to improve visualisation of the ankle joint space
is completed. Loose hedies are identified using a probe and then remeved. Cartilage defects are
identified. Using a Kirschner wire, suhchendral hene penetration commences. Alternative methods
for bone penetration and gaining access to more difficult lesions are discussed. After the surgeon
makes the necessary,r holes in the bone, blood and fat can be seen extruding from the holes. This
sets the stage for fihrecartilangeens scar formation. Postoperative protocols are discussed.

1iiidec 22.3 Hangedv L: Videe Excerpt. GATE Procedure. Budapest, Hungary, 2G11. [lfl min}
Radiographic imaging demonstrates osteoarthritis dissecans in the ankle joint. Patient positioning,
application of tourniquet, and anatomic landmarks are discussed. A longitudinal incision is
made for access to the surgical site, and anatomical structures are protected. A medial malleelar
esteetem'g,r begins 121E procedure. The defect is visualized. The affected tissue at the site is
removed and graft sizing is discussed. Twe grafts, 3.5 mm and 6.5 mm, are harvested at the
knee using an arthrescepic approach. Tips and pearls regarding graft harvesting are discussed.
Optimal posifiening for graft placement is determined, and the two grafts are tapped into the
defect. Tips, including the need for congruencv, are discussed. The larger graft is placed first.
Discussion on managing larger defects with more than two grafts is discussed. 1When the grafts
are in place, screws are used to place the medial malleolus into correct posin'en and the site is
closed. Postoperative management and rehabilitation are discussed, and a follow—up radiegraph
demonstrates the repair.

Video 22.4 Cuetzee JC: 1Widen: Excerpt. Anterior Ankle Impingement. Edina, MN, 201 1. [2 min} , /
This video demenstrates arthrescepic debridement of soft tissue and bone spurs to relieve
impingement cf the ankle jeint. Surface anatomic landmarks and arthroscopic portals are
demonstrated, along with patient positioning to distract the ankle. Seft—tissue and bone spur
removal on the distal tibia causing impingement are demonsnated. Use of fluerescepv to determine
the amount of déhridement and cerrect contour of the ankle is shown. Identification of additional
pathelegjvr is discussed.

@2015 American Academy of Urthepaedie Surgeons Urthopaedic Knowledge Update: Sports Medicine 5 @

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 Viden 12.5 Wie ' A uw PA], van Dijk EN: 1riiivzlen Excerpt. Posterior Ankle
Arthrnscnpy - [m ' ent Us Trignnum FI-IL Tennsynnvitis. Amsterdam, Netherlands, lflll.
{s min}
The program begins with a demnnstratinn nf patient positioning and portal placement. The nick
and spread method is used to create pnsternlateral and pnsternmedial portals. Soft-tissue shaving is
demnnstrated to improve visualisatinn and to create nperating space in the joint capsule. Removal
of the ns trignnum is demnnstrated in the first of three cases. A lnnse bndy forceps nr rnngeur
is used to remove the ns trignnum when déhridement is completed. The second case involves
management for chronic flesnr hallucis 1nngus {FHL} tennsynnvitis. Nnnsurgical treatments failed
in this patient. The FHL is viewed and wear is seen. The FHL is decnmpressed using a basket
fnrceps. After cnmplete release there is unimpaired mutinn of the FHL. The final case invnlves
pnsternmedial ankle pain. A cyst on the talus is seen nn MR]. Edema is also present. Anatomic
landmarks are seen and then a shaver is use to improve visualisation of the joint space. A curette
is used tn unrnnf the cyst and then cnmplete débridement is accomplished. Decompression nf the
lesion is seen. Pnstnperative care is discussed.

1Widen 12.6 Wiegerinck JI, de Leeuw PA], van Diilc EN: Video Excerpt. Haglund Deformity,
Achilles Prnblems. Amsterdam, Netherlands, Hill. {3 min}
This video demonstrates an endoscopic technique for a calcanenplasty. The patient is in a prone
pnsitinn with a bnlster, and pnsternmedial and pnsternlateral portals are made adjacent tn the
Achilles tendnn and superior tn the palpable superinr border of the calcaneus. The large pnsterinr
calcaneal prnminence is demonstrated radiographically, and arthroscopy begins with the scope in
the lateral pnrtal. A burr is intrnduced thrnugh the medial portal, and bone is removed gradually
without compromising the Achilles insertion. The arthroscnpe is then changed tn the medial
portal, and the butt tn the lateral portal tn complete the prncedure. Postoperative radiographs
and arthrnscnpic views are shown. Rehabilitation prntncnl is discussed, as are the benefits of an
arthroscopic versus an open procedure.

Chapter 15 Hip Rehabilitation

Video 25 .1 Enselci K: 1'Ini'iden. Manual Perturbation, Prnne and Quadruped. Pittsburgh. PA, 2015.
[[1:23 min}
This activity emphasises dynamic hip and pelvic control in a nnn—weight-bearing position. The
patient assumes the prone position. The clinician applies randnmly directed forces tn the free end
nf the lower extremity fnrcing the patient tn utilise varinus hip muscles tn maintain stability of the
limb. This activity emphasises dynamic hip and pelvic cnntrnl in a partial weight-bearing position.
The patient assumes the quadruped position. The clinician applies randnmly directed forces tn the
pelvis, forcing the patient tn utilise varinus muscles tn maintain stability.

Chapter ss Current Rehabilitation Concepts Following Anterior Cruciate Ligament

Reconstruction
Viden 26.1 Goldberg P: Video. Perturbation Training for Neurnmuscular |IZ'Jnntrnl and Dynamic
Stability. Gainesville, FL, 21315. [0:13 min}
Rollerbnards nr wobble boards create an unstable support surface in perturbation training to
challenge knee stability and enhance prnprinceptinn and neurnmuscular cnntrnl.

It? American Academy of flrthnpacdic Surgeons Orthopaedic Knowledge Update: Sports Medicine 5
 Videu 26.2 Guldberg P: Video. Anticipatcry Strategies tn Enhance Neurumuscular Central and
Prcpriccepticn. lGaincsville, FL, 21315. {0:16 min}
Anticipatcry balance strategies can be trained by placing an c-bject, such as a cnne, c-utside cf the
patient’s base ef supp-err fer reaching tasks. The uninvnlved lcwer extremity may else be used tn
reach nutsicle ef the base ef suppnrt.

Videu 26.3 Guldb-erg P: Vidflfl. Reactive Strategies tn Enhance Neurumuscular Central and
Prcpriecepticn. Gainesville, FL, 2015. [0:]? min}
Pestural perturbaticns can alsc be applied with a ball thruwn tn the patient by annther individual
at a device such as a “Rebnundet.” The patient maintains a balanced pesitinn en a stable er
unstable surface while catching the bail.

Chapter 32 The Cervical Splne

1ii'idee 31.1 Faldini C, Gasbarrini A, IChehrassan M, lvliscinne MT, Acri F, D’nmatn M, Bnriani
L1 Enriani 5, Giannini 5: 1|li'idec. Anteriur Interbudy Fusic-n in Cervical Disc Herniatiun. Belugna,
Italy, Hill. {13 min}
Cumbined antericrr intetbcdy fusinn and cervical dishectumy is a surgical technique tu treat a
variety c-f cervical spine discrders, such as nerve tent er spinal curd cempressicn. This technique
pErmits the surgenn tn decntnpress the spinal card and nerve rec-ts and perfnrm interbn-cly fusinn
tn previtle segmental alignment in letdnsis and sulid arthrodesis with minimal surgical risk. The
aim nf this videe is tn shew the anterier cervical diskectnmy and interbndy fusinn ef a 55-year-
ulcl patient whu was suffering frnm cervical pain assc-ciatecl with intractable radiculnpathy cf
the left E6 tcet far 6 mnnths. We rank an antericr apprcach tn the cervical spine and made a
lengimdinal skin incisinn en the medial berder cf the sternncleidemastnideus {SUM} muscle. We
gently incised the platisma muscle and isnlated the medial burder cf the SCM muscle. Then we
isclated and partially retracted the hemeyeid muscle and separated the lnngus culli te expense the
C5-C6 space. The diskectemy was performed; the pnsterinr esteephyte was remeved, aleng with
the pnsterinr lengitudinal ligament tn eitpnse the dural sac. 1With the arthrcscnpe, it was pussible
te visualize and remeve the pnsterinr lengitudinal ligament and expese the dura. A E'mm anatcmic
cage was placed into the intervertebral space tn achieve the cerrect height at the intervenebral
space and cnrrect the physiclngic letdcsis. Finally, the incised fascia and muscles were reattached.
Pnsteperative care censisted nf having the patient wear a scft cellar fer 4 weeks and then undergn
physinthcrapy. Twin-year clinical and radingraphic fnllnw-up detnnnstrated scllid anterinr
intetbcdy fusinn cf the C5—C6 space.

Chapter 49 Patelletemeral Instability and Other Enmmen Itnee Issues in the Skeletelly
Immature Athlete
1il'idee 4.9.] Ellis HE, Jr, Wilsnn PL: Viden. A Surgical Technique fer Medial Patellnfemeral
Ligament Recnnstructinn in the Skeletally Immflure. Dallas, TX, 2014. {14 min}
A surgical technique tc- treat skeletally immature patients with patellar instabilityr and c-pen
physes is described. With recent evidence suppcrting anatcmic erigin cf the medial patellefetncral
ligament {MPFL} distal tn the physis, a safe surgical technique tn recnnstruct the MPFL with a
physeai-sparing technique is presented. Thirty-five censecutive patients with npen physes have
undergune MPFL recnnstructiun with feur revisicns and nu physeai injury.

@1015 American Academy cf flrthnpaedic Surgeons Drtbepaedic Knnwledge Update: Spnrts Medjcbie 5 @

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Chapter 1
Shoulder Instability
Ieanne C. Patskowski. MD Brett D. Dwens, MD
abstract
Glenohumeral instability is common in young ath-
letes. Most instability events are traumatic anterior
subluxations. Both traumatic anterior dislocation and
subluxation events result in Bankart lesions in young
athletes. Early surgical repair is recommended to optiu
mice outcome and minimize risk of bone and soft-tissue
damage. lvlany in-season athletes can return to play
[depending on their sport and position} but two—thirds
will experience recurrent events. Attention to glenoid
and humeral bone loss is increasing along with renewed
interest in bone augmentation procedures. Posterior
instability comprises approximately was of events
and usually is a subluxation. Posterior labral tears are
often seen, as well as loose posterior capsules, and
arthroscopic repair is the mainstay of treatment with
excellent results. Multidirectional instability continues
to he a common area of study, with good reported out-
comes with physical therapy and surgical stabilisation
, in select patients.
Keywords: shoulder: instability: repair
Introduction
lGlenohumeral instability is endemic in young athletes.
Instability comprises 13% of all shoulder injuries {includ-
ing contusions and strains} among National Collegiate
Dr: flwens or an immediate family member senses as a paid
consultant to Miteit and the Muscuioslreietai Transplant
Foundation, and serves as a board member; owner; officer;
or committee member of the American Drthopaedlc So-
ciety for Sports Medicine. Neither Dr. Fatzlro arslri nor any
immediate family member has received anything of value
from or has stock or stock options held in a commercial
company or institution related directly or indirectly to the
subject of this chapter:
@ lfllfi American Academy of Drthopaedic Surgeons
Athletic Association athletes.1 Given this high incidence,
instability should be actively ruled out in a young athlete
with shoulder problems. Although solely epidemiologic
studies of instability are rare, one study has confirmed E
that most instability events are anterior, and only 1i]% "fl
are posterior events:1 Posterior instability is an area of a;
1]
increased awareness and study. Approximately 35% of F”
E's
traumatic anterior events are subluxation or incomplete fill
instability events not requiring manual reduction. This is E.
a!
important because these injuries sometimes present with
a variable history and examination and can be difficult
to diagnose.
Anterior Instability
Pathophysiology
Acute anterior or anteroinferior instability is the most
common injury pattern in shoulder instability. The gle-
nohumeral joint moves through a large range of motion,
but translation of the humeral head on the glenoid is
limited by multiple static and dynamic restraints. Static
restraints include the glenoid labrum, which deepens the
otherwise shallow glenoid, joint capsule, and glenohu-
metal ligaments. The anterior band of the inferior gle-
nohumeral ligament {IGHL} is the primary restraint to
anterior translation with the arm in abduction and exter—
nal rotation jABER}. The middle glenohumeral ligament
prevents anterior translation in mid AEER, whereas the
superior glenohumeral ligament and rotator interval resist
anterior and inferior translation with the arm at the side.
The Bankart lesion, a separation of the anteroinfetior
labrum and IGHL from the glenoid, is found in up to
9D% of anterior shoulder dislocations. Humeral avulsion
of the glenohumeral ligament {Figure I} is identified in
up to 10% of shoulder instability cases.3 In the setting
of a bony Bankart lesion, variations such as glenolabral
articular disruptions and anterior labroliga mentous peri-
osteal sleeve avulsion lesions as well as acute glenoid rim
fractures can be present. Hill-Sachs lesions, or impres-
sion fractures of the posterosuperior humeral head, are
common following acute dislocations. In severe cases,
the labrum can be injured at multiple locations. Careful
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 1: Upper Extremity
1: Upper Extremity
Figure 1
Coronal Tit-weighted MRI shows humeral
avulsinn of the glenohumeral ligament.
inspection of postinjury imaging studies and recognition
of all intra—articular pathology at the time of surgery is
important to ensure that all instability components are
addressed.
The pathoanatomy of firstdtime traumatic subluxation
events is similar to acute dislocations. A prospective study
of high-risk individuals identified 1? patients who sus-
tained a primary traumatic subluxation event.“l MRI
identified Bankart lesions in 16 patients and Hill-Sachs
lesions in 15. Fourteen patients underwent surgery, 13 of
whom had Bankart lesions. Subluxation events represent
a wide spectrum of injury from microinstability to the
spontaneous reduction of a dislocation event.
Known risk factors for anterior instability include a
history of shoulder instability and participation in con—
tact or collision sports. In high-risk athletic and military
populations, those with prior instability in any direction
have a fivefold increase in the risk for the development of
subsequent instability? Identifying modifiable risk factors
can help mitigate these troublesome outcomes. A recent
prospective study of T14 young athletes without prior
instability found that only positive apprehension and re-
location signs nn physical examination, increased glenoid
index {a tall, thin glenoidj, and increased coracohumeral
distance were predictive of future shoulder instabilityf
modifiable risk factors such as strength, range of motion,
and signs of hyperlaxity were not. Increased age at the
time of dislocation and the presence of a bony Eankart
flrrhopaedie Knowledge Update: Sports Medicine 5
lesion can be associated with a positive prognosis for
future shoulder stability."r
Presentation
For the patient who presents with an acute dislocation,
the joint should be reduced as soon as possible. This can
he performed on the field or sidelines by a physician or
certified athletic trainer or in the emergency department.
With a delayed reduction, muscle spasm can prevent suc-
cessful reduction and may require the use of intravenous
sedation or intra—articular local anesthesia. Postreduction
radiographs, including axillary lateral views, should be
obtained to confirm concentric reduction and evaluate for
bony injury. Standard radiographs can be supplemented
with a 1|West Point or Stryker notch view to evaluate for
glenoid bone loss or Hill-Sachs lesions, respectively.
a thorough physical examination, to include neuro-
vascular status and rotator cuff testing, is essential. As-
sessment of seapulnthoracic kinetics can elicit weakness
patterns amenable to physical therapy. Ligamentous laxity
should also be assessed {typically with Beighton criteria]
because this can have a substantial effect on surgical
treatment outcome. Physical examination findings in
the patient with anterior shoulder instability can include
positive results for the apprehension and relocation tests
in the ABER position. The load—and—shift test helps as—
sess laxity in all directions, and the results should be
compared with the contralateral side. The Gagey sign,
or passive abduction with the arm in a neutral position,
can indicate injury to the IGHL if more than IDS“ of
abduction is noted or if substantial asymmetry to the
uninjured extremity is seen. The |l'Eragey test can also be
used to delineate the presence of inferior capsular laxity
most commonly associated with hyperlaxityr‘multidirec-
tional instability.
Advanced imaging is often obtained following shoulder
reduction or in cases of recurrent instability. Magnetic
resonance arthrography {MRA} is performed with in-
tra—articular gadolinium to delineate soft—tissue detail.
The diagnostic accuracy of MRA has recently been
questioned. In a prospective study of 13 patients with
traumatic anterior instability undergoing arthroscopic
surgery, MBA had only moderate agreement {x = (1.4?)
with arthroscopic findings for Bankart lesions and did
not identify two labral lesions that required fixation at the
time of surgery.fl MRA had poor results for identifying
superior labrum anterior to posterior tears and glenohu-
meral ligament lesions. Given the additional time and cost
associated with MRA, the authors recommended against
routine use of Milo. The ABER view has been used for
improved visualization of the inferior labrtun {Figure 2},
but this is anecdotal. Including the ABER sequence has
El 1016 American AcadMy of Urrhopaedic Surgeons

not been shown to improve accuracy; instead, the expe-
rience level of the radiologist and consensus agreement
were found to he more important. The ABER view has
a high rate of motion artifact, and 12% of patients with
instability could not tolerate the AEER position for ima g—
ing.’ MRI has known limitations regarding bony detail.
and CT is indicated in cases of suspected boneless. In a
prospective, blinded study comparing MRA and CT ar-
thrography with arthroscopic findings, CT arthrography
had superior results overall, with excellent identification
of labral and bony pathology.” MRA outperformed CT
in identifying glenohumeral ligament tears, but the studies
were equivalent in identifying humeral avulsion of the
glenohumeral ligament lesions. CT can be an acceptable
alternative to MBA for instability evaluation in the shoul—
der, but its lower cost and decreased time are balanced
by the risks of exposure to ionizing radiation.
Natural History
Multiple studies have demonstrated a high rate of recur-
rent dislocation in young, active patients, particularly in
contact and collision athletes. Recurrent instability rates
can be as high as 94%. Recurrence rates decrease sub—
stantially with each decade after age It] years, and older
patients are more likely to sustain a concomitant rotator
cuff tear or greater tuberosity fracture after shoulder
dislocation.“
Treatment
Treatment of the patient with a first—time dislocation re
mains controversial. For patients who choose nonsurgical
treatment, the shoulder is immobilized until pain resolves
and early motion is initiated. Physical therapy focuses
on regaining motion, strengthening the rotator cuff and
periscapulat muscles, and proprioceptive training. Iniu
tial immobilization in external versus internal rotation
may better reduce the torn lahrum to the anteroinferior
glenoid. Although initial clinical results were promis-
ing, follow—up studies could not reproduce the original
results and meta-analysis showed no benefit in rates of
recurrence or validated outcomes with external rotation
bracing. Compliance was reported as problematic with
the external rotation brace.”
The goal of surgical management is to restore sta-
bility by repairing the injured lahrum or glenohumeral
ligaments, and if needed, plication of the redundant
capsule. Arthroscopic Bankart repair [Figure 3} has be-
come common because it allows excellent visualisation
of the entire joint and is minimally invasive; it is now the
treatment of choice among new surgeons in the United
States.” Determining which patients need surgery after a
first-time dislocation and how soon remains in question.
El Illlti American Academy of Urtltopaedic Surgeons
Chapter 1: Shoulder Instability
E
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1]
F”
El
fill
E.
a?
MRI abduction and external rotation {ABEH}
view shows anteroinferior labral tear in a
patient experiencing recurrent su blusations
who did not demonstrate pathology in other
imaging seq uentes. This correlated with
arthroscopic findings at time of repair.
In a double-blind, randomized clinical trial evaluating
arthroscopic Bankart repair versus sham surgery, patients
with a first—time dislocation had decreased recurrence of
instability and improved outcome scores after repair.H
Surgery resulted in lower costs and higher patient sat-
isfaction, but overall outcomes were related to shoulder
stability, not necessarily the surgery itself. Patients in the
repair group also had a higher rate of return to contact
sports. Similarly, a systematic review of only level I and II
studies demonstrated decreased recurrence of instability
following arthroscopic Bankart repair when compared
with physical therapy and sham surgery, both together
and in isolation.” The patients in the repair group were
noted to have one-fifth the rate of recurrent instability
and improved 1Et'lli’estern flute tio Shoulder Instability Index
(WUSI) scores. The patients were 22 to 25 years old and
primarily male, representing the highest risk cohort of
shoulder instability patients.
Technologic advances have increased the orthopae-
dic surgeon’s ability to manage shoulder instability ar-
throscopically. High rates of patient satisfaction and
improved outcome scores have been reported in the short
term and mid term, with low rates of recurrent instability
and disability.'5 Radiographic evidence of dislocation
arthropathy can present with longer term follow-up and
was reported in 41% of patients ll years after arthroscopic
Eirthopaedic Knowledge Update: Sports Medicine 5
 Sectinn 1: Upper Extremity
1: Upper Eatrem tty
Figure 3 Arthrnsrnpir image at the right shnulder at a
19-year-nld wnman vvhn plays rugby shnws a
Bankart repair.
Bankart repair.” The presence nf radingraphic arthritis
did nnt cnrrelate with nutcnme scnres.
lIflpen Bankart repair has histnrically prnvided gnnd
results fnr shnulder stability. The prncedure requires tran~
seetinn, nr splitting, nf the subscapularis tendnn, and
mild lnsses in fnrward elevatinn and external rntatinn
can nccur, typically between 3“ and 1D“. In a series nf
49 patients, including 31 elite rugby players, 16% had
recurrence nf instability during the 16 —year fnllnw—up pe—
rind after npen Bankart repair.” Of these patients, 65%
had radingraphic evidence nf arthritis at final fellow-up,
mnst nf which was cnnsidered mild, and 311% repnrted
being pain free. Ninetyvfnur percent nf patients resumed
athletic activity, 15% nf thnse at their nriginal level nf
cnmpetitinn.
The treatment nf cnntact nr cnIIisinn athletes remains
cnntrnversial, and snme repnrts suggested higher rates
nf recurrent instability in these patients fnllnwing ar-
thrnscnpic management. In a recent randnmiaed clini—
cal trial cnrnparing npen versus arthrnscnpic Bankart
repair, an increased rate nf recurrence was nnted after
arthrnscnpic repair {23% versus 11% in npen repair].”
The highest rate nf recurrence was nnted in males ynunger
than 25 years with Hill-Sachs lesinns. The arthrnscnpic
grnup cnmprised mnre cnntact athletes and hnne Inss
was nnt evaluated; hnth facrnrs have been shnwn tn in-
fluence recurrence. In a trial nf isnlated Bankart lesinns
randnmised tn arthrnscnpic versus npen repair, imprnved
Disability nf the Ann, Shnulder and Hand {DASH} scnres
were nnted in the arthrnscnpic grnup, with an substan-
tial difference itt recurrence nnted?“ A differential lnss
tn fnllnw-up between grnups was nnted, and mnre than
flrrItnpae-die Knnwledge Update: Spnrts Medicine 5
50% nf patients had nn nrnre than twn suture anthers
placed during the repair in bnth grnups. A systematic
review nf mnre recent meta-analyses demnnstrated nn
difference in recurrence between the twn techniques, but
nnted that the analyses perfnrtned befnre EDD? favnred
npen surgery in recurrence rates, whereas thnse published
after 10!}? shnwed nn difference.“ Similarly, the latest
Cnchrane database review stated that evidence was insuf-
ficient tn claim superinrity nf nne technique nver annther
in recurrence, need fnr subsequent surgery, and shnulder
fu nctinn.21
Many athletes want tn return tn spnrt fnllnwing a trau-
rnaric anterinr shnulder instability event during his nr her
athletic seasnn. In a prnspective study bf 45 intercnllegiate
cnntact athletes, 73% returned tn spnrt after accelerated
rehabilitatinn.” Sixty-seven percent finished the seasnn,
but 54% had recurrent instability during the seasnn. Ne
difference in recurrence was repnrted between thnse whn
sustained an initial dislncatinn versus sublurratinn event,
but these with sublurratinns had a higher nverall rate nf
return tn spnrt and did sn mnre quickly. WDSI and Sim-
ple Shnulder Test {SST} scnres at the time nf injury were
predictive nf ability tn return tn play, and WflSI, EST, and
American Shnnlder and Elhnw Surgenns {ASESJ scnres
cnuld predict the time needed tn return tn play. Nnne at
the nutcnme scnres were predictive nf recurrence.
Recurrent shnulder instability increases the risk that
existing intra-articular pathnlngy will wnrsen, including
bnny attritinn nf the anternin ferinr glennid, enlargement
nr engagement nf a Hill—Sachs lesinn, and snft—tissue
cnruprnntise. {liver the lnng terrn, nstenarthritis nf the
glennhumera] jnint can develnp in these patients. With
excellent nutcnmes repnrted after surgical management
nf instability, it must be questinned whether cnntinuing
spnrts pa rticipatinn er rehabilitatinn nnly in the setting nf
recurrent instability is wise fnr future shnulder functinn.
A systematic review cnntpared arthrnscnpic management
nf instability perfnrmed after the initial instability event
er in a delayed fashinn after multiple recurrences and
repnrted nn substantial differences in pnstnperative re-
currence, range nf mntinn, nr cnmplicatinns.“ |Ei'l'utcnme
measures varied acrnss studies, precluding in-depth analy-
sis. The lnvvest rates nf recurrence were nnted with suture
anchnr fixatinn nver elder implants. In the shnrt term,
delaying surgical management did nnt appear tn have
adverse effects.
Recurrence
Recurrent instability after surgical repair is a challeng-
ing prnblem. Snme studies demnnstrated recurrence
rates ranging between 4% and 19% fnr arthrnscnpic
repair, mnst nf which nccurred during the first year after
El 1016 American Aesdenty nf Drrhnpaedie Surge-ens

surgery.” Independent risk factors included age at time of
surgery, glenoid bone loss greater than 25%, an engaging
Hill-Sachs lesion, male sex, competitive sports partic—
ipation, fewer than three suture anchors, ligamentous
laxity, and the presence of an anterior labroligamentous
periosteal sleeve avulsion lesion.”-15
Revision open Bankart repair has demonstrated re-
liable results after failed arthroscopic repair. Improved
outcome scores, pain, and return to almost prcinjury
activity levels have been shown with low rates of recur-
rence. Patients with substantial bone loss are still at risk
for recurrent instability following open Bankart repair.”
In appropriately selected patients, revision arthroscopic
stabilization can be a reasonable option. Recurrence rates
ranging from 6% to 10% have been demonstrated with
revision arthroscopic Bankart repair in patients without
substantial glenoid or humeral head bone loss, without
hyperlaxity, and in those willing to comply with postop-
erative restrictions and therapy.ma Revision arthroscopic
surgery including bony augmentation can be considered
after an open index procedure, but patient selection is
critical. Low recurrence rates and high patient satisfaction
can be achieved with meticulous attention to detail and
surgical technique. Patients should be cautioned that pain
may persist and osteoarthritis can still progress.” Studies
of revision arthroscopic Bankart repair demonstrated
the importance of good surgical technique. In a study
of 56 patients with recurrent postoperative instability,
more than one—half had suture anchors placed above the
equator during the index procedure.”
Instability With Bone Loss
Bone loss should be suspected in patients with unsuccessr
ful instability repair, multiple subluxations andlor dislo-
cations, or instability with minimal provocation {such as
activities of daily living or during sleep}. Attritional bone
loss can be noted on the anteroinferior glenoid, result-
ing in an inverted pear glenoid or as a large Hill-Sachs
lesion. Glenoid and humeral head bone loss typically do
not occur in isolation, and the interaction of the two is
important in determining the risk of continued instability.
The humeral head defect can fall into, or engage with, the
area of the glenoid bone defect. In the glenoid track con-
cept, glenoid bone loss narrows the track available for the
humeral head to articulate. If a concomitant Hill—Sachs
lesion is wide or occurs in a medial enough location, the
humeral head can slip off track, resulting in an anterior
dislocation“ [Figure 4].
Suspicion of bone loss warrants advanced imaging to
quantify the defect for preoperative planning. Glenoid
bone loss of greater than 2fl% to 25% is the general—
ly accepted threshold for choosing a bony restoration
4D Illlii American Academy of Urthopaedic Surgeons
Chapter 1: Shoulder Instability
E
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e
1]
F”
E's
fill
E.
a!
Figured lviFil abduction and external rotation {ABEH}
view shows the glenoid traclc concept in a
patient with a large Hill-Sachs lesion but no
glenoid bone loss. The lesion remains on track
in this arm position.
procedure because this is an independent risk factor for
postoperative recurrence.”-15 Multiple techniques have
been described to measure glenoid bone loss, but no gold
standard currently exists. CT, particularly three—dimena
sional {3D} CT, appears to be the most reliable means of
calculating glenoid bone loss when compared with plain
radiography and MRI. All imaging modalities underesti-
mated the degrec of bone loss to some extent, but 3D CT
demonstrated the least inconsistency.31 3D CT has also
demonstrated high specificity and positive predictive val-
ues for the detection of Hill—Sachs lesions, with an overall
accuracy of Sfl‘i’h. Shallower lesions and lesions without
subchondral bone damage are not as easily appreciated.“
Glenoicl augmentation procedures include open or
arthroscopic coracoid transfer, iliac crest autograft, distal
clavicle autograft, and various allograft techniques. The
open coracoid transfer, or Latarjet procedure {Figure 5},
has demonstrated excellent long-term results with low
rates of recurrence and high patient satisfaction.” The
procedure is technically challenging, and a recent sys-
tematic review of level IV case series found a 3ll‘i’is com-
plication rate with an average follow-up of 6.3 years.“
Recurrent instability was found in 3.?% of patients, most
within the first year after surgery, and was associated with
suboptimal graft placement. Most complications were
related to coracoid fracture, nonunion, or lysis. Low rates
of neurovascular injury were reported. External rotation
Drrhopaedic Knowledge Update: Sports Medicine 5
 Sectien 1: Upper Extremity
1: Upper Extremity
?1'-"2"‘*-”r‘=
1'" -I I I.
- - "_*
r - ., '
Figure 5 AP radiegraph at a Lataerjet ceraceid transfer
in a patient with unsuccessful arthreseepic
Bankart repair and sex gleneid bene less.
was reduced by an average ef 13“. An all—arthreseepic
technique has been described with rates ef recurrence
appreaching these ef the epen precedure, but is asseci—
ated with a steep learning curve.” Iliac crest and allegraft
gleneid augmentatien have alse demenstrated reliable
leng—tcrm results,“ and the must recent systematic review
available feund an evidence te suppert ene technique
ever anetherfi?
Management ef a large Hill-Sachs lesien may else
be necessary te restere sheulder stability. In cases ef
substantial gleneid bene less and a large Hill-Sachs le-
sien, treatment ef the gleneid bene less may be all that is
needed te stabilize a jeint. In cases with minimal gleneid
bene less, the Hill-Sachs lesien can be addressed using
multiple techniques. Remplissage invelves suturing the
infraspinatus tenden inte the hmneral head defect using
either an arthreseepie er epen appreach. In a study ef
recurrent anterier sheulder in stability with gleneid bene
less less than 25% and an engaging Hill-Sachs lesien,
patients whe underwent cembined primary arthreseep-
ic remplissage and Eankart repair were cempared with
centre] patients undergeing Bankart repair duly.” All
patients demenstrated healing ef the tenden te bene at
the remplissage site at 2 years en MRI; ne recurrent in-
stability was reperted in patients undergeing the cem—
bined precedure. In these undergeing Bankart repair
enly, instability recurrence was 20%. Eighty percent ef
patients treated using remplissage returned te spert at
their previens level and shewed substantial imprevements
flrrhepaedic Knewledge Update: Sperm Medicine 5
in University ef Califernia Les Angeles {UCLA}, Rewe,
and Censtant sceres. Similar results were reperted in a
series ef 4? patients whe underwent remplissage with
Bankart repair.3L9 flnly ene patient experienced recurrence
ef instability, and 63% returned te sperts participatien at
their previens level. External retatien was reduced by an
average ef 3" and abductien by an average ef 9".
Either precedures can be used te treat a Hill—Sachs
lesien, including esteechendral allegraft, retatienal
{Weber} esteetemy, and arthreplasty. Allegraft recen-
structien may be indicated in yeung patients with very
large defects, whereas arthreplasty is reserved fer large
defects in elderly patients. Currently, ne abselute guide-
lines exist te indicate these precedures. A recent systemat‘
ic review demenstrated high rates ef serieus cemplicatiens
with Weber esteetemy, allegraft recenstructien, and ar-
threplasty.” The lewest rate ef recurrent instability was
feund with allegraft recenstructien, but cemplicatiens
. '-
.,-| _
such as esteenecresis and cellapse were seen in up re
74% ef patients. Arthrescepic remplissage remains a vi-
able eptien, with lew rates ef recurrence and the highest
safety prefile.
Pesterier Instability
Epidemielegy
Pesterier sheulder dislecatien is much less cem men than
anterier dislecatien, cemprising appreximately 5 “if: ef all
sheulder dislecatiens, with a prevalence ef LUIUGflDfl
per year.“1 A slight male predeminance exists, and frank
pesterier dislecatiens are mere cemmenly asseciated
with seizure activity and electrecutien than are anterier
dislecatiens. Almest twe-thirds ef pesterier dislecatiens
are the result ef trauma such as meter vehicle cellisiens
er falls, and 31% are related te seizure activity.“1 Up tn
5{1% ef pesterier dislecatiens can be missed in the emer-
gency department setting; ehtaining an axillary lateral
radiegraph is critical fer cerrect diagnesis. In athletes,
pesterier instability can be mere subtle, with primari~
ly subluxatien events in the at-risk pesitien ef ferward
flexien, adductien, and internal retatien.l Feetball
linebackers are at particularly increased risk. Pesterier
instability in athletes can primarily manifest as pain,
particularly during the bench press, push-ups, er ether
upper extremity weight—bearing activities. Recent reperts
suggest that cembined instability pathelegy may be mere
cemmen than previeusly theught in certain pepulatiens.
0f 231 censecutive military patients undergeing surgery
fer sheulder instability, enly 5?% had iselated anterier
pathelegic changes.”ll Twenty-fen: percent had iselated
pesterier pathelegy, and 19% ef patients had cembined
anterier and pesterier findings. MRI was enly 58%
El 1016 American Academ~y ef Unhepaedic Surge-ens

accurate for predicting intra-articular lesions.
Pathophysiology
Multiple lesions are associated with posterior instability.
Kim et al‘” described multiple lesions on the posterior
labrum in the setting of posterior instability, most com-
monly, an incomplete stripping of the posteroinferior
labrum without displacement. A prospective cohort of
EDD shoulders with isolated posterior instability found a
patulous posterior capsule in 69% and posterior labral
tears in 54%.“ Of note, patients with labral tears had
lower preoperative ASES scores, with no differences noted
postoperatively. Other lesions include damage to the re-
tator interval, reverse Hill—Sachs lesions, bony deficiency
of the posterior glenoid, injury to the posterior capsule
or posterior band of the IGHL, and glenoid retrover-
sion. In a prospective series of military cadets, increased
glenoid retroversion at baseline was predictive for the
development of posterior shoulder instability, with every
1“ increase in retroversion increasing the risk of posterior
instability by 1T%.“5
Presentation
Patients presenting with an acute posterior dislocation
typically hold the arm in an adducted, internally rotat-
ed position. Full radiographic work—up that includes an
axillary lateral view is critical to determine the presence
of an acute dislocation. A high index of suspicion should
be maintained in patients presenting to the emergency
department after sustaining a seizure or electrocution
event. These patients are also at higher risk for bilateral
dislocations. Patients presenting with chronic posterior
dislocations can have profound lack of external rotation
with a mechanical block. Radiographic evaluation can
demonstrate large reverse HillHSachs lesions or humeral
head erosion. Chronic dislocations typically require an
open reduction. Arthroplasty may be required in chronic
cases with excessive bone loss.
Patients with posterior shoulder subluxation may pres—
ent primarily with pain. Symptoms are typically noted in
the position of forward flexion, adduction, and internal
rotation, and may be exacerbated by push—ups, bench
press, and other activities that place a posteriorly directed
load on the shoulder. Physical examination should include
a posterior load—and—shift test, ierk test, and posterior
apprehension sign, along with testing for anterior and
inferior instability because these conditions frequently
coexist. A sulcus sign that persists in external rotation
can indicate rotator interval incompetence. MRI with or
without intra-articular contrast can be used to evaluate
the status of the posterior labrum, capsule, and other
intra-articular structures, whereas CT scanning can help
Eb Ifllli American Academy of Urthopaedie Surgeons
Chapter 1: Shoulder Instability
determine humeral head bone loss, glenoid bone loss, and
glenoid retroversion.
Treatment
Nonsurgical management is the first—line treatment of
posterior shoulder instability. Physical therapy focuses
on periscapular and rotator cuff strengthening, particu-
larly of the infraspinatus. In a prospective series of 112
patients with posterior dislocations, recurrent instability
did not develop after a formalized physical therapy reg-
imen in 32% of shoulders. Persistent deficits in shoulder
motion and function were seen in all patients at 2-year
follow-up, irrespective of recurrence. Recurrent insta-
bility was independently predicted by age younger than E
4i} years, dislocation resulting from seizure, and a large "fl
reverse Hill-Sachs lesion. Hyperlaxity was not predictive s;
1]
of dislocation recurrence.“ F”
E's
Surgery is indicated for patients with recurrent instabil- re
ity, pain, or functional limitations following appropriate 3.
a!
therapy. Although both arthroscopic and open techniques
are described to treat the various lesions that can contrib-
ute to posterior instability, most surgeons currently prefer
arthroscopic management {Figure Er}. In a prospective
cohort of if“) patients undergoing surgical stabilization
for isolated posterior instability, Bradley et al‘”I reported
good results with arthroscopic capsular plication andfor
labral repair; 94% of patients were satisfied with the result
and would undergo surgery again, and 90% returned to
sports {64% at their previous level of competition}. Sim-
ilar results were noted in contactr'collision athletes. Six
percent of patients had failing ASE-S scores in pain and
function, and Til: were noted to have continued instabil-
ity. All failures were identified within the first 7" months
after surgery. (if those patients in whom treatment failed,
62.5%- had signs of multidirectional instability {MEI} at
the time of revision. In the remaining patients in whom
treatment failed, poor tissue quality was noted, typically a
result of prior thermal capsulorrhaphy or ea rly aggressive
rehabilitation outside the established protocol.
Gpen procedures to address posterior instability in-
clude open capsular shift and bone block augmentation.
A retrospective series of 44 patients with posterior in-
stability undergoing open capsulorrhaphy reported 34%
overall satisfaction with a T4% rate of return to sport.“'5
Recurrent instability developed in 19% of patients, but in
patients without signs of MD] at the time of surgery, the
recurrence rate was only 13%. Anterior instability devel-
oped subsequently in an additional 13% of patients, high-
lighting the risk of overaggressive posterior constraint.
lChondral injury and age older than 33 years at the time
of surgery were associated with worse outcomes.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 1: Upper Extremity
1: Upper Extremity
a.‘=_‘
Figure 5 Arthroscopic image of the right shoulder of a
20—year-old man who is a football player shows
a complete posterior labral repair.
Instability 1lili‘ith Bone Loss
Bone loss is a rare but challenging problem in the set-
ting of posterior shoulder instability. Although posterior
glenoid bone loss has been studied less than its anterior
counterpart, both arthroscopic and open posterior bone
block augmentation techniques have been described for
this rare condition {Figure 7’]. A biomechanical cadaver
study demonstrated that the bone block can overconstrain
posterior translation while not treating inferior transla*
tion in the setting of an incompetent posterior band of the
IGHL.“ Precise positioning of the bone block is critical
to achieve the preferred mechanical effect.
An all-arthroscopic technique using autograft iliac
crest for recurrent posttraumatic posterior shoulder insta-
bility has been described in 13 patients.“3 Graft union was
reported in all cases, however, complete lysis of the graft
requiring revision proceeded to develop in one patient.
Sixteen patients reported satisfaction with the procedure,
but a complication rate of 36%, steep learning curve,
and worse outcomes in patients with glenoid dysplasia
were noted.
Long—term follow—up after open bone block procedures
may not be as promising. [if 11 patients followed for 13
years, 3 had residual instability, 2 of whom eventually
required arthrc.tdesis.‘l'ir All patients had evidence of radio—
graphic osteoarthritis at long-term follow-up, and clinical
outcomes diminished over time. The worst outcomes were
found in patients with hyperlaxity or MDI, and this pro—
cedure should be avoided in these populations.
flrrhopaedic Knowledge Update: Sports Medicine 5
-——_F-.—-'—_—-'I—-.—-—
Figure I Postoperative CT scan axial image from a
patient with glenoid dysplasia shows healing
of posterior gle noicl augmentation with
osteoarticular autograft from the ipsilateral
clistal clavicle.
Multidirectional Instability
Pathophysiology
MDI is poorly defined, but most authors agree that it
encompasses a shoulder joint with excessive translation
in two or more directions. Patients may or may not have
a structural lesion such as a labral tear. Although many
cases are atraumatic, traumatic onset does not rule out the
diagnosis. Patients with multidirectional laxity {asymp-
tomaticj can sustain a traumatic injury, and the treatment
needs to incorporate an understanding of the physiologic
laxity for a particular patient, with the need for capsular
tightening to augment a labral repair or capsulorrhapby.
Multiple underlying etiologies exist with the common
theme of a patulous infBrior capsule, increased glenohu-
meral joint volume, and IGHL laxity.
Treatment
The natural history of MD] is poorly documented, and
various definitions of the disease have made interpre-
tation of the literature difficult. Classically, MD] was
considered a self—limited condition that partially resolves
with increasing age, resulting in its universal treatment
with physical therapy alone. Multiple protocols exist but
share a common theme of rotator cuff and periscapular
muscle strengthening as well as proprioceptive training.
El ll] 16 American AcadMy of Cirrhopaedic Surgeons

Hewever, athletic patients may net be willing te medify
their activities and symptems may centinue even with
aggressive rehabilitatien.
In the largest lengitudinal study te date, 64 patients
with MDI were fellewed fer a minimum cf 3 years.jfl All
patients underwent fermal physical therapy with a heme
exercise pregram. At 2 years, 20 patients had undergene
surgery, and ef these whe had net, enly ene-half repert—
ed geed er excellent eutcemes fer pain and stability. Df
these whe impreved with therapy, substantial gains were
neted by 3 menths. At 3-year fellew—up, ene additienal
patient had undergene surgery, seven had given up sperts
cempletely, and an additienal nine admitted te substan-
tial lifestyle and eccupatienal changes te accemmedate
their sheulders. The need fer surgery was asseciated with
unilateral invelvement, mere severe laxity, and difficulty
perferming activities ef daily living. All patients whe
underwent surgery had persisted with fermal physical
therapy fer at least 6 menths. At lung-term fellew-up,
enly 3U% ef all patients reperted geed er excellent Rewe
sceres. This pepnlatien was yennger and mere active than
these ef previeus reperts, but the diminishing subjective
eutcemes and need te medify lifestyles evident at lengcr
term fellew~up were cencerning.
A recent prespective cehert cempared patients with
MDI whe underwent physical therapy en ly, physical ther—
apy after epen capsular shift, and nermal centrel subjects
witheut histery er physical findings ef instability.“ Sub-
jects underwent kinematic and electremyegraphic testing
during humeral elevatien. In the physical therapy—enly
greup, the strengthening pregram did net restere the
muscular activity er duratien parameters ef the nermal
shenlder, and at the 2- and 4-year peints, the values tested
were similar te these ebtained befere therapy began. In
centrast, the subjects whe underwent capsular shift and
pesteperative therapy had values similar te these ef the
centrel greup that persisted threugheut fellew-up. Sur-
gery cembined with therapy ceuld restere the stability
and muscular centrel ef the shenlder, whereas therapy
alene was less reliable.
Beth epen capsular shift and arthrescepic capsular
plicatien have been described fer the treatment ef MDI,
with the main geals ef decreasing capsular velnme and
tightening the IGHLs.fl In a systematic review ef avail-
able level IV studies, similar eutcemes were reperted
fer recurrent instability, return te spert, less ef external
retatien, and cemplicatiens between the ewe techniques.
The arthrescepic technique demenstrated a small increase
in rate ef recurrence and impreved rate ef return te spert,
but these results did net reach significance. The system-
atic review was limited by variability in the definitien
ef MDI used in the literature and incensistent reperting
Eb Ifllti American Academy ef Urthepaedic Surgeens
Chapter 1: Sbeulder Instability
ef athletic activity. In the studies that stratified results
by spert played, everhead athletes, elite athletes, and
swimmers had the lewest rates ef returning te spert at
their previeus level. Dverall, both epen and arthrescepic
techniques can be censidered safe, effective eptiens fer
the management ef MDI unrespensive te nensurgical
measures.
5 u m m a ry
Sheulder instability is a cemmen preblem in a yeung,
athletic pepnlatien. Traumatic anterier instability cem-
prises mest instability events and can be treated using
arthrescepic er epen techniques. Preeperative evaluatien E
fer bene less is impertant because unrecegnixed bene "fl
less is a substantial risk facter fer recurrence and peer e,
1]
eutcemes. Further research is needed te determine the F”
E's
mest accurate, reliable way te quantify bene less, deter- m
mine which patients are at highest risk ef recurrence, and E.
a!
identify the best precedure te restere stability. Pesterier
shenlder instability may be mere cemmen in athletes and
excellent eutcemes can be achieved with arthrescepic
repair. MDI is treated with fermal physical therapy, but
seme patients have persistent muscular deficits and un-
satisfactery eutcemes. Selected patients will benefit frem
arthrescepic er epen repair ef the capsule and injured
structures.
Key Study Peints
*- Traumatic anterier instability cemprises the majer—
ity ef shenlder instability cases, with sublnxatien
events mere cemmen than dislecatiens.
I Must traumatic anterier subluxatiens and disleca-
tiens in yeung athletes result in a Bankart lesien,
but physicians sheuld be cautieus ef the HAGL,
which eccurs in up te lfl‘l‘r'i. ef patients.
1‘ Preeperative risk stratificatien — including advanced
imaging fer bene less assessment—is critical tn a
successful eutceme when selecting a surgical stabili-
xatien appreach in patients with anterier instability.
I Pesterier instability may present with pain alene,
and must cases have gee-d eutcemes with arthre-
scepic repairfplicatien.
Annetatetl References
1. Dwens ED, Age] ], Meuntcastle 5E, |Cameren KL, Nel-
sen B]: Incidence ef glenehumeral instability in cellegiate
Drrhepaedic Knewledge Update: Sperts Medicine .5
 Sectien 1:1}pperExtremity
athletics. Am I Spell-1‘s Med lflflfififlfiirl'fifl-I'fid.
Medline DUI
This retrespective analysis ef the Natienal Cellegiate
Athletic Asseciatien injury database ever a 15—year pe—
ried reperted the incidence ef sheulder instability events
was ELIE per 1,001] athlete expesures. Males and feetball
players sustained the mest injuries, with mere instability
events neted during cempetitiens than practices.
Uwens ED, Duffey ML, Nelsen B], DeEerardine TM,
I Tayler DC, Meuntcastle SE: The incidence and charac-
teristics ef sheulder instability at the United States Mili-
tary Academy. Am I Sperts Med lflfl?;35{?}:1163-11T3.
Medline DUI
Hui-Mansfield LT, Banks KP, Tayler DC: Humeral avul-
sien ef the gleeehumeral ligaments: The HAUL lesien.
1: Upper Extrem fty
Am I Sperts Med 200?;35f11]:196fl-1966. Medline DUI
Uwens ED, Nelsen E], Duffey ML, et al: Patheanatemy
ef first-time, traumatic, anterier glenehumeral sublux-
atien events. I Bette jefnt Strrg Arr-r Elli fl;91{?}:16fl5 4611.
Medline DUI
This prespective cehert reperted ee 27" patients whe sus-
tained a primary, traumatic anterier subluxatien event.
MRI and surgical findings demenstrated high rates ef
Bankart and Hill-Sachs lesiens. Feur ef thirteen had recur-
rence ef instability with uensurgical management. Level
ef evidence: II.
IZlameren KL, Meuntcastle SE, Nelsen E], et al: Histery
ef sheulder instability and subsequent injury during feur
years ef fellew-up: A survival analysis. _,I BDHE jeirrt Surg
Am 2fl13;95{5}:439~445. Medline DUI
This prespective cehert studied 'FI-‘I- high-risk subjects.
Subsequent instability was 5.6 times mere likely te devel-
ep in patients with print instability in any directien than
these witheut a histery ef instability. Level ef evidence: I.
|Uwens ED, Campbell 5E, Cameren KL: Risk facters
fer anterier glenehumeral instability. Am I Sperts Med
lfl]4:42{11j:1591-1596.Medline DUI
This prespective cehert studied "F14 high—risk yeung ath-
letes. The risk ef sheulder instability was asseciated with
pesitive apprehensiee and relecatien signs en physical ex-
aminatien, increased gleneid index, and increased cerace-
humeral distance. Medifiable risk facters and hyperlaxity
were net predictive ef instability. Level ef evidence: II.
Salemenssen E, ven Heine A, Dahlbern M, et al: Eeny
Bankart is a pesitive predictive facter after primary sheul-
der dislecatien. Knee 3mg Sperts Trenmrrfef Artfaresc
lfl]fl;13[lfl}:1425-1431.Medline eel
In 39 patients treated nensurgically after a first-time an-
terier dislecatien, the enly pregnestic facters fer a sta-
ble sheulder at 3 years after injury were age elder than
312} years at time ef injury and the presence ef a bony
Bankart lesien en MRI.
Urrhepaedic Knewledge Update: Sperts Medicine 5
3. van der 1Eileen HE, |Cellies jP, Rijk PC: Value ef magnetic
resenauce arthregraphy in pest—traumatic auterier sheul-
der instability prier te arthrescepy: A prespective evalu—
atien ef MRA versus arthrescepy. Arc}: Gil-thee Trname
3mg 2U12:132{3]:3T1-3?5. Medline DUI
This prespective, blinded evaluatieu ef 13 patients with
pesttraumatic anterier instability cempared MRA find-
ings with arthrescepy. Mederate agreement was seen fer
Bankart lesiens: etherwise, peer agreement was seen fer
ether intra-articular pathelegy.
van lIGrinsven 5, Hagenmaier F, van Leen C], van Gerp
M], van Hints M], van Kampee A: De-es the experience
level ef the radielegist, assessment in censensus, er the
additien ef the abductien and external retatien view
impreve the diageestic repreducibilityr and accuracy ef
MRA ef the sheulder? Effie Recife! 2fl14;69{11,1:115?-
1164. Medline DUI
In this blinded prespective evaluatien ef 53 patients with
sheulder instability undergeing arthrescepy, radielegists
evaluated MEAs and ABER views. The ABER view did
net impreve accuracy er repreducibility, but the experi-
ence level ef the radielegist and censen sus agreements did.
Many patients were unable te telerate the AEER pesitien.
If}. Acid 5, Le Cerrellet T, Aswad R, Pauly V, Champsaur
P: Preeperative imaging ef anterier sheulder instability:
Diagnestic effectiveness ef MDC'I' arthregraphy and cem-
parisen with MR arthregraphy and arthrescepy. AJR Am
I Reenrgeeef lfl12:193{3}:eEI—EEI Medline DUI
This prespective evaluatien ef 4!} patients cempared multi-
detecter rew CT and MBA with arthrescepy. Multide-
teeter rew CT identified labral and beny pathelegy and
was recemmended as the preeperative imaging study ef
cheice. MRA had superier results fer identifying lesiens
ef the glenehumeral ligaments.
11. Rebinsen CM, Sher N, Sharpe T, Ray A, Murray IR:
Injuries asseciated with traumatic anterier gleeehumeral
dislecatiens. ,7 Bette jeint Surg Aer 2fl12:94{1}:13-16.
Medline DUI
This prespective analysis reperted en 3,633.- censecutive
patients with a traumatic anterier sheulder dislecatien
at an average age ef 415 years. Neurelegic deficits were
feued in 13.5% fellewing reductien, and 33.4% had ei—
ther a retater cuff tear er greater tuberesity fracture. The
likeliheed ef neurelegic deficit was increased in patients
with a retater cuff tear er greater tuberesity fracture.
Level ef evidence: II.
12. Liu A, Rue X, Chen T, Bi F, Tan 5: The external reta-
tien immebilisatien dees net reduce recurrence rates er
impreve quality ef life after primary anterier sheulder
dislecatien: A systematic review and meta-analysis. Injury
2014:45i111flfi42-1341Medline eel
This meta—analysis ef seven retater cuff tears cempared
external and internal bracing after acute glenehumetal
dislecatien. Ne difference was funnd in rates ef recurrence
er eutceme sceres. Werse cempliance was reperted iu the
external retatien greup.
El 1016 American AcadMy ef Urrhepaedic Surgeens

13. Dwens ED, Harrast J], Hurwit: 5R, Thnmpsnn TL, Wnlf
JM: Surgical trends in Hankart repair: An analysis nf data
frnm the American Enard nf Urthnpaedic Surgery certifi-
catinn esaminatinn. Am ,F Spa-rte Med 1011;39i9}:1365-
1355'. Medline DUI
This retrnspective analysis cf the American Beard nf flr—
thnpaedic Surgenns database frnm Zflflfi tn lflflfl repnrted
that prinr tn lflilS, ?1% nf Bankart repairs were perfnrmnd
arthrnscnpically, versus 33% after EDDIE.
14. Rnbinsnn CM, Jenkins P], White TD, Ker A, Will E:
Primary arthrnscnpic stabilisatinn fer a first-time an-
terinr dislncatinn cf the shnulder. A randnmised, dnu—
ble-blind trial. ] Bnrrefnint Surg Am Elli] 3.390(41903-1'21.
Medline DUI
15. Chahal J, Marks PH, Macdnnald PB, et al: Anatnmic Ban-
kart repair cnmpared with nunuperative treatment andfnr
arthrnscnpic lavage fnr firstwtime traumatic shnulder disln-
catinn. Arifrrnscnpy 2012;23l4lfii55 -.5 F5. Medline DUI
This systematic review nf level I and II studies cnmpared
arthrnscnpic Eankart repair with physical therapy nr
sham surgery. Patients whu underwent Bankart repair had
substantially decreased recurrence and imprnved WDSI
scnres. Level nf evidence: II.
16. Ahmed I, Ashtnn F, Rnbinsnn CM: Arthrnscnpic Bankart
repair and capsular shift fnr recurrent anterinr shnul-
der instability: Functinnal nutcnmes and identificatinn
nf risk factnrs fnr recurrence. ,l' finite lei-1st Surg Am
Zfl12:94(14}:1303-1315.Medline DUI
In this study, 3fl2 patients were treated with arthrnscnpic
Bankart repair. Recurrent instability was nnted in 13.1%.
Imprnved 1|i‘vii'lliiill and DASH scnres were nnted at 1 years,
but senres were decreased in patients with recurrence.
Three independent risk factnrs fnr recurrence were age,
gleunid bnne lnss greater than 15%, and an engaging
Hill-Sachs lesinn. Level nf evidence: I.
1?. Elmlund AD, Ejerhed L, Sernert N, Rnstgdrd LC, Kartus
J: Dislncatinn arthrnpathy and drill hnlc appearance in
a mid- tn lnng-term fnllnw-np study after arthrnscnpic
Bankart repair. Knee Sung Spurrs Traumdtni Artbrnsc
lflllglflllllfiljfi—llfil.Medline DUI
In this study, 41% nf patients demnnstrated radingraphic
signs cf nstcnarth ritis 3 years after arth rnscnpic Bankart
repair fnr shnulder dislncatinn. |Eli'ntcnme scnres did nnt
cnrrelate with radingraphic findings. Level nf evidence: III.
13. Fabre T, Abi- Chahla l'vIL, Billaud A, llilieueste M, Duran-
deau A: Lnng-term results with Eankart prncedure: A
16-year fnllnw—up study nf 5D cases. } Sbnaider Elbow
Surg lfllfl;19(2l:313-323. Medline DUI
This Edeyear fnllnw-up reviewed 50 shnulders that under-
went np-en Eaukart repair after shnulder dislncatinn. Mnst
patients were elite rugby players. At final fnllnw—up, 15%
had recurrent instability, 65% shnwed signed nf arthritis,
94% returned tn spnrts, and Edit. were pain free. Level
nf evidence: IV.
Eb Ifllii American Academy bf Urtlmpaedic Surgenns
Chapter 1: Shnulder Instability
19. Mnhtadi NG, Chan D5, Hnllinshead RM, et al: A ran-
dnmised clinical trial cnmparing npen and arthrnscnpic
stabiliaatinn fnr recurrent traumatic anterinr shnulder
instability: Twp-year fnllnw—up with disease—specific quali-
ty-nf-life nutcnmes. I Hesse faint Sui-g Am 2fl14;95{51:353-
36:}. Medline DUI
Higher recurrence nf instability was nnted in patients in
the arthrnscnpic Eankart grnup, particularly in ynung
males with Hill—Sachs lesinns. The arthrnscnpic grnup
had more cnntact athletes, and nn qua ntificatinn nf bnne
lnss was performed. Level nf evidence: I.
20. Archerti Hetm H, Tamanlti M], Lensa M, et al: Treat-
ment nf Bankart lesinns in traumatic anterinr insta-
bility cf the shnulder: A randnmised cuntrnlled trial
cnmparing arthrnscnpyr and npen techniques. Arthrnscnpy
2fl12:23{?}:9flfl-9fl3.Medline DUI E
Imprnved DASH scnres were nnted in tbe arthrnscnpy "fl
s;
1]
grnup, but nn substantial differences were nntnd in Rnse
nr UCLA scares, range nf mntinn, nr recurrent instability. F”
Lewl cf evidence: II. El
:1:
E.
2.1. Chalmers PH, Mascarenhas lit, Leruus: T, et al: Du arthrn— a!
scnpic and npen stabilisatinn techniques restnre equiv-
alent stability tn the shnulder in the setting nf anterinr
glennhumeral instability? A systematic review nf nver-
lapping meta-analyses. Arthrnscnpy 2015:31{2]:335-363.
Medline DflI
Dverall, no difference was nnted in recurrence rates nnt-
ed. Studies published befnre It'll]? favnred npen surgery
in recurrence rates, whereas thnse published after 101]?
demnnstrated nn difference. Level nf evidence: IV.
21. Pulavarti R5, Symes TH, Rangan A: Surgical interven-
tinns fnr anterinr shnulder instability in adults. Enchrarte
Database Syst REF Eflflflfiflflflififl TIT. Medliue
Insufficient evidence exists frnm available randnmiaed
clinical trials tn favnr nne technique nver annther.
23. Dickens JF, |['iwens ED, Camernn KL, et al: Return tn play
and recurrent instability after in—seasnn anterinr shnulder
instability: A prnspective multiceutcr study. Am 1 Sports
Med 2014:42I121:2 342-2350. Medline DUI
Ferty-five inrercnllegiate athletes with in-sea snn shnulder
instability were fnllnwed after accelerated rehabilitatinn
and return tn play, ?3% returned tn cnntact spnr'ts, but
64% had recurrent instability during the seasnn. Level
nf evidence: I].
24. Grumet RC, Each BR Jr, Prevencher MT: Arthrnscnpic
stabilisatinn fnr first-time versus recurrent shnulder insta-
bility. Arthrnscnpy 2G1fl;26{2}:239-243. Medline DUI
This systematic review cnmpared arthrnscnpic Eankart
repair immediately after first dislncatinn versus after mul—
tiple recurrences. Hun difference was nnted in pnstnperative
recurrence nf instability, range nf mntinn, nr cnmplica-
tinns. Level nf evidence: II.
15. Randelli P, Ragnne V, Carminati 5, Cabitsa P: Risk factnrs
fnr recurrence after Bankart repair a systematic review.
Drrhnpaedic Knnwledge Update: Spnrrs Medicine 5
 Sectien1:UpperExtremity
Knee Strrg Sperts Traumatel Arthresc lfl11;20{11l:1129-
2133. Medline DUI
Facters associated with recurrent instability after artl1re-
scepic Bankart repair included age yeunger than ED years,
male sex, cempetitive spurts pa rticipatien, fewer than
three suture anchers, gleneid bene less, large Hill-Sachs
lesiens, ligamenteus laxity, and anterier labreligamenteus
periesteal sleeve avulsien lesiens. Level ef evidence: 11.
26'. Che NS, YiJW, Lee BG, Rhee 't'G: Revisien epen Bankart
surgery after arthrescepic repair fer traumatic anterier
sbeulder instability. Am I Sperts Med 20 09:3T{11}:2153-
2164. Medline DUI
Uf 26 sheulders that underwent revisien upen Bankart
repair after failed arthrescepic precedures, 33% had
geed er excellent results, with impreved pain and stability
1: Upper Extremity
sceres. Three additienal dislecatiens eccurred in patients
with engaging Hill—Sachs lesiens and hyperlaxity. Level
ef evidence: IV.
2?. Eartl C, Schumann K, Paul J, Vegt S, Imheff AB: Ar-
threscepic capsulelabral revisien repair fer recur-
rent anterier sheulder instability. Am I Sperts Med
2fl11;39{3l:511-513.Medline DUI
Fifty-six patients underwent revisien arthrescnpic surgery
fellewing unsuccessful epen er arthrescepic anterier sta—
bilisatien. Rese, Censtant, and SST sceres substantially
impreved with 36% geed er excellent results, with 11%
recurrence. Level ef evidence: IV.
23. Arce G, Arcuri F, Ferre D, Pereira E: Is selective arthro-
scepic revisien beneficial fer treating recurrent an-
terier sheulder instability? {filer Urthep Refer Res
2fl12:4?fl{4l:965-9?1.Medline DUI
In this retrespective analysis, 16 patients underwent revi-
sien arthrescepic Eanltart repair. Strict exclusion criteria
included substantial gleneid er humeral head bane less,
hyperlaxity, and participatien in centact spurts. UELA,
|Censtant, and Rewe sceres impreved substantially, and
three recurrences were reperted at mean 31-menth fel-
lew—up. Level ef evidence: I‘v’.
29. Eeileau P, Richeu J, Lisai A, Chuinard C, Eiclcnell RT: The
rele ef arthrescepy in revisien ef failed epen anterier sta-
bilisatien ef the sheulder. Artbrescepy lflfl9;25[1 Dial}???-
103 4. Medline DUI
Twenty-twp patients with unsuccessful epen anterier sta-
bilitatien precedures underwent arthrescepic revisien.
Geed er excellent results ebtained in 35%, and ene case
ef recu rrent dislecatien was reperted. Usteearthritis pre-
gressed by ene stage in three patients. Level ef evidence: IV.
3-3. Trivedi 5, Pemerants ML, Gress D, Gelijanan P,
Prevencher l'vIT: Sheulder instability in the setting ef bi-
pelar {glennid and humeral head} bane less: The glean-id
track cencept. Cfffi- Urrhep Relat Res Eli 14:4?213}:2 352-
2362.. Medline DUI
This systematic review reperts en the biemechanical
and cadaver data related In the glennid traclt cencept.
Urthepaedic Knewledge Update: Sperts Medicine 5
Resteratien ef the gleneid track sheuld be a primary geal
ef instability surgery.
31. Rerlte MA, Pan I, Denaldsen C, Jenes GL, Eishep IT:
Cemparisen ef varieus imaging techniques te quantify
gleneid bene less in sheulder instability. _l Shealder Elbert:
Sttrg ED13:22{4]:523-S34. Medline DUI
This cadaver study reviewed three sizes ef gleneid bene
defects created and then imaged using 3D CT, CT, MRI,
and plain radiegraphy. Altheugh 3D CT was the must ac—
curate and reliable, all imaging medalities underestimated
bene less te same extent. Level ef evidence: III.
32. Usalti R, Nakagawa S, lvlitune H, Mae T, Yeneda lvl:
Hill-sachs lesiens in sheulders with traumatic anteri-
er instability: Evaluatien using cemputed temegraphy
with 3-dimensienal recenstructien. Am J Sperts Med
2fl14t42111}:259?-EEDS.Medline DUI
3D CT perfermed in 135 patients with traumatic anterier
sheulder instability undergeing arthrescepic Bani-tart re-
pair identified Sil‘lb ef Hill— Sachs lesiens with a sensitivity
ef 35%, a specificity ef IRE-'36, a pesitive predictive value
ef mess, and a negative predictive value cf 46%. 3D CT
was less accurate in shallevvr lesiens and these witheut
sub-chendral bene damage. Level ef evidence: II.
33. Hevelius L, Sandstrtim l3, Ulefssen A, Svenssen U, Rahme
H: The effect ef capsular repair, bene bleclt healing, and
pesitien en the results ef the Bristew-Latariet precedure
{study III}: Lung-term fellew-up in 319 sheulders. ] Sher-ti-
der Elbert: 3mg 2111 2;11{.S 1:64.?- 650. Medline DUI
In three series ef patients undergeing epen Latarjet pre-
ccdure with between .5 and 23 years ef fellew—up, 1% ef
patients required revisien surgery fer recurrence and 96%
reperted satisfactien with the precedure. Recurrence was
asseciated with graft placement that was tee medial.
34. |[Siriesser M], Harris JD, l'vIcCey BW, et al: Cemplica-
tieus and re-eperatiens after Bristew—Latarjet sheulder
stabilisatien: A systematic review. I Shealder Elbert: Sarg
2fl13;22{l}:236-292.Medline DUI
This systematic review ef epen and arthrescepic Latar-
jet precedures reperted an everall cnmplicatinn rate c-f
311%, must ef which related te healing er fracture ef the
ceraceid. Recurrent instability was neted in 3.??6, rsss
ef these within the first year fellewing surgery. The mean
less ef external retatien was 13". Level of evidence: IV.
3S. Dument GD, Fegerty S, Hesse C, Lafesse L: The arthre-
scepic latarjet precedure fer anterier sheulder insta-
bility: 5—year minimum fellew—up. Am j Sperts Med
2014:42i11}:256fl-2566.Medline DUI
This retmspective case series reperted en 62 patients whe
underwent an arthrescepic Latarjet precedure with a min-
imurn 5-year fellew—up. Recurrent instability was seen in
1.6%, and high WUSI sceres were reperted in all demains.
Level ef evidence: IV.
. Sayegh ET, Mascarenhas R, Chalmers PN, Cele B], Venus
NH, Remee AA: Allegraft recenstructien fer glennid
El 1016 American AcadMy ef Urthepaedic Surge-ens

bane lnss in glennhumeral instability: A systematic review.
Artlrrnscnpjr 2014:30i12}:1642-1649. Medline DUI
This systematic review evaluated multiple allngraft tech-
niques fnr anterinr glennid recnnstructinn. At an aver-
age 44—mnnth inllnw—up, 93% nf patients were satisfied
with the nutcnme, despite lfl‘iis with residual pain. High
Rnwe scnres and recurrent instability in 11% were re-
pnrted; lflfl‘fl: graft incnrpnratiqn was nnted. Level [if
evidence: IV.
3?. Beran l'vlC, Dnnaldsnn CT, Bishnpj'f: Treatment pf chron-
ic glennid defects in the setting ni recurrent anterinr shnul-
der instability: A systematic review. I Sbnuider Elbnw Burg
lfllflflSiSh'FSB-‘F'Sii.Medline DUI
A systematic review cf the current evidence demunstrated
nn data tn suppnrt nne glennid bnne restnratinn technique
nver annther. Level nf evidence: IV.
33. Franceschi F, Papalia R, Riaaelln G, et al: Remplissage
repair—new frnntiers in the preventinn nf recurrent shnul-
der instability: A 2-year fnllnw-up cnmparative study. Am
I Spurts Mad 2fl12;4fl{11}:1461«2459. Medline DUI
This retrnspective cnhnrt nf patients with Bankart and
engaging Hill— Sachs lesinns was treated with remplissage
and Bankart repair nr Bankart repair alnne. Patients in the
remplissage grnup had substantially decreased recurrence.
All had imprnved nutcnrne sen-res, returned tn spurts, and
had minimal mntinn lnss. All remplissage tendnns were
fully healed at 2 years an MRI. Lewl nf evidence: III.
39. Enileau P, {J‘Shea K, Vargas P, Pinedn l'vI, Ifllld J, Zum-
stein ivi: Anatnmical and functinnal results after arthrn-
scnpic Hill-Sachs remplissage. I Brine Inint Surg Am
2012;94{?}I:SIS-Sld.Medline DUI
A retrnspective analysis evaluated 4? patients undergoing
arthrnscnpic remplissage with Bankart repair fnr recurrent
instability. Recurrence was repnrted in DIIE patient; 63%
returned tn previnus level pf spnrt. The average mntinn
less in REEF. was 3" tn 9". Level nf evidence: IV.
4G. Lnngn UG, apini l'vl, Riaselln G, et al: Remplissage,
humeral nstenchnndral grafts, weber nstentnmy, and
shnulder arthrnplasty fur the management nf humeral
bnne defects in shnulder instability: Systematic review
and quantitative synthesis nf the literature. Arihrnsenpy
su14,suus}:1ssn-isss. Medline DUI
This systematic review evaluated all fnur techniques tn
treat humeral head defects. |Eilverall, remplissage was an
effective, safe technique. High rates {if substantial enm-
plicatinns were repnrted with nther techniques. Level nf
evidence: IV.
41. Rubinsnn CM, Seah M, Akhtar MA: The epideminlngy,
risk nf recurrence, and functinnal nutcnme after an acute
traumatic pnsterinr dislncatinn cf the shnulder. I Buns
faint Surg Am 2fl11;93{1?}:15i}5 4613. Medline DDI
This prnspective cnhnrt nf 110 patients with isnlated
pnsterinr dislncatinns reviewed epideminlngy, assnciated
injuries, and functinnal nutcnmes. The risk nf recurrence
was independently predicted by ynung age, large reverse
Eb Ifllii American Academy nf Urthnpaedic Surgenns
Chapter 1: Shnulder Instability
Hill-Sachs lesinns, and seizure as an etinlngy nf dislnca-
tic-n. Level nf evidence: II.
42. Snug DJ, Cnnk JE, Krul KP, et al: High frequency nf
pnsterinr and cnmbined shnulder instability in ynung ac-
tive patients. I Sbnuider Elbnw 3mg 1015;24{2}:13i5519fl.
Medline DUI
In this retrnspective analysis, 231 patients underwent sur—
gical stabilizatinn fnr shnulder instability. Isnlated anterinr
labral tears were fnund in 57"?4: {if patients, with isnlated
pnsterinr tears in 24% and cnmbined labral injuries in
19%. Level cit evidence: III.
43. Kim SH, Ha KI, Park JH, et al: Arthrnscnpic pnsterinr
labral repair and capsular shift fnr traumatic unidirectinn-
al recurrent pnsterinr subluxatinn nf the shnulder. I Hnue
juint SHTE am anus,ss-ais}:14vs-14sv. Medline E
"fl
44. Bradley JP, McClincy MP, flruer JW, Tejwani 5G: Ar- g
1]
thrnscnpic capsulnlabral recnnstructinn fur pnsterinr F”
instability nf the shnulder: A prnspective study nf lflfl ii
shnulders. Am: J Sprints Med 2G13:41{9}:2flfl$-2fl14. fit
Medliue DUI
3.
c!
This prnspective case series evaluated 2nu shnulders with
unidirectinnal pnsterinr shnulder instability treated with
arthrnscnpic capsulnlabral recnnstructinn. At 36-mnnth
fnllnw-up, patients demnnstrated imprnved nutcnmes re-
lated tn stability, pain, and functinn. Level nf evidence: II.
45. flwens ED, Campbell SE, Camernn KL: Risk factnrs
fur pnsterinr shnulder instability in ynung athletes. Am
I Spain‘s Med1013;41:11}:1645-1549. Medline DUI
This prnspective cnhnrt study nf high—risk, ynung athletes
in whnm pnsterinr shnulder instability develnps repnrted
that the must substantial risk factnr fur subsequent pns-
terinr instability was increased glennid retrnversinn. A
was increase in risk at acute pnsterinr instability with
every 1" increase in retrnversinn was demnnstrated. Level
pf evidence: I].
46. Wait ER, Strickland S, 1Williams R], Allen AA, Altehek
DW, 1|ilil'arren RF: |Iii-“rpen pnsterinr stabilizatinn fur recurrent
pnsterinr glennhumeral instability. ] Sbnuider Eihnw Surg
lflfl5;14{2]:15T—IE4.Mcdline DUI
4?. Wellmann lid, prnwitsch E, Khan N, et al: Binmnchan-
ical effectiveness nf an arth rnscnpic pnsterinr bankart
repair versus an npen bane blnck prncedure fur pnsterinr
shnulder instability. Ann I Spurts Med 2D11:39{4]:T96-Sll3.
Medline 130]
This cadaver binmechanical study evaluated eight matched
pairs nf shnulders with a simulated pnsterinr Bankart
lesiun and laceratinn of the pnsterinr band cf the IGHL.
Pathnlngic translatinn in all directicrns was returned tn
the intact state using an arthrnscnpic pnsterinr Eankart
repair, whereas the jnint was nvercnnstrained tn pnsterinr
translatinn and inferipr instability was nnt addressed with
the brine blnck prncedure.
43. Schwartz DIG, |IGnebel 5, Piper K, Knrdasiewicz E,
Bnyle S, Lafnsse L: Arthrnscnpic pnsterinr hnne blnck
Drrhnpaedic Knnwledge Update: Spurts Medicine 5
 Sectien 1:1}ppcrExtrcmity
augmentatinn in pestericrr shnulder instability. I Sbnflider
Eibnw 3mg 2013;22i3}:1i}91—11{H. Medline DUI
This retrnspective case series reviewed 19 arthrnscnpic
pesterinr bane black precedures fur patients with recurrent
pnsteric-r instability and heme less. Level nf evidence: W.
45. Meuffels DE, Schuit H, van Eieacn FC, Reijman M, 1Infer-
haar JA: The pesrerier bnne blnck precedure in pnsterinr
shcrulder instability: A lung-term fnllnw-up study. I Brine
Joint Surg Br 1010;3l}:551— 655. Medline D01
In this pruspective case series of 11 patients when under-
went pesterier bcme bleclr. precedure with 13-year felr
lbw-up, patients with traumatic etinlngy nf instability had
the best results versus hyperlaitity nr MDI. Mare than
cue—half nf patients had residual instability, and diminish—
ing nutcentes were mated ever time. Level nf evidence: W.
1: Upper Entrem ity
5f}. Misan-mre GW, Sallay PI, Didelnt W: a luugitudinal study
nf patients with multidirectinna] instability ef the she-alder
with seven- tn ten-year fellow-up. I Sbnufder Efbpm 5mg
EDDS ,14-{5 }:4EE-4?fl. Medline DUI
flrfltnpaedic Knnwledge Update: Sparta Medicine 5
51. Nyiri P, Illyés A, Kiss Iii, Kiss J: Intermediate biume-
chanical analysis flf the effect nf physiotherapy nnly
campared with capsular shift and phys-intherapy in mul-
tidirecticmal shcmlder instability. I Sheafder Elbe-w Snrg
2010;19l5}:3{}1-313.Mcdlinc DUI
A ccrhnrt of patients with MDI when underwent physi-
cal therapy alnne was compared with these whc: under-
went physintherapy after an epen capsular shift. At 1
and 4 years after therapy, the cembined surgicalftherapy
grnnp had kinematic and electrcniyngraphic values similar
tn these cf centre] patients. Therapy alcme was unable tc:
restere nc-rmal jeint kinematics and prevent instability.
Level nf evidence: II.
52. Jacebsen ME, Riggenbach M, 1iiii'b:::luilridge AN, Bishep JY:
Dpen capsular shift and arthrnscnpic capsular plicatinn
fur treatment nf multidirectinnal instability. Artfarnscnpy
ac:s,2srv:;:s1s—1mv. Medline no:
This systematic review campared npcn and arthrnscnpic
surgical management of MDI. bin substantial differences
were repc-rted; bnth app-ear tn be safe, effective techniques.
Overhead athletes and swimmers were least likely tn re-
turn tn price level nf spurt. Level cf evidence: IV.
El 1016 American Acadenw crf Drrhnpaedic Surge-ans
Chapter 2

Disorders of the Acromioclavicular

Joint, Sternoclavicular
Joint, and Clavicle
Brian R. Wolf, MD, MS Youssef El Bitar, MD

Abstract
Acromioclavicular {AC} joint separations and clavicle
fractures are common injuries involving the shoulder
girdle; injuries to the sternoclavicular {SC} joint are less
common. Ma nagement of AC joint separations depends
on the injury type; management of type III is the most
controversial. Clavicle fracture management depends
on the fracture location along the clavicle shaft. Near
type II lateral third fractures and complex unstable
middle shaft fractures require surgical intervention. SC
joint injuries are mostly treated nonsurgically, except
in cases of instability and pain. An understanding oi?
the mechanism of 1njury for these shoulder Injuries
is important, along with knowledge about the
commonly used classification systems for each'111]
management options based on classification,
arive rehabilitation, outcomes reported in th *'
and possible complications.
Keywords: acrornioclavicular joint separation:
clavicle fracture; sternociavicular joint dislocation
Introduction
Shoulder injuries can result in various pathologies in—
cluding suhlusations, dislocations, and fractures.
him-aura Action :1
Acromioclavicular (AC) joint injuries are common in
young athletes, ranging from a simple sprain to frank
dislocation. Managing the AC joint separation is usually
nonsurgical in type I and ”I injuries, and type IV to VI
injuries are treated surg@Thc management of type
III AC joint scparan ,' ,rovcrsial, with proponents
for both non “- “.1 surgical treatment Clavicle
fractures are ,. , r juries in adults, affecting patients
who are ho, u '
'
noclav1cular (SC) joint is injured less often than the
"i; *1: AC joint or the clavicle because the surrounding ligaments
are strong. The most common type of management of 5C
joint injury is nonsurgical. Closed reduction is required in
type 3 SC joint dislocation whether anterior or posterior.
Occasionally, open reduction and internal stabilization is
required for unstable, symptomatic dislocations.
AC Joint Injuries
Injuries to the AC joint comprise 9% of shoulder injuries
and are often caused by direct trauma to the shoulder or
a fall on an outstretched hand.1 Younger, physically ac=
rive athletes are at particularly increased risk} especially

Dr. Woif or an immediate famiiy member serves as a paid consultant to CONMED Linvatec; has received research or
institutionai support from the Orthopaedic Research and Education Foundation; has received nonincome support
{such as equipment or services), commerciaiiy derived honoraria, or other non-research-reiated funding (such as paid
trove!) from Arthres; and serves as a board member, owner; offices or committee member of the American Academy
of Orthopaedic Surgeons, the American Orthopaedic Society for Sports Medicine, and the Mid-America Orthopaedic
Association. Neither Dr. E! Eitar nor any immediate famiiy member has received anything of vaiue from or has stock or
stock options heid in a commerciai company or institution reiated directiy or indirectiy to the subject of this chapter.

Q 2016 American Academy of Orthopaedic Surgeons Orthopaedic Knowledge Update: Sports Medicine 5 l,i
i' l‘.
.

j
l a
i ,
l
 Sectinn 1:1}pperExtremity
thnse invnlved in cnntact and extreme spnrts, as well as
high-risk activities such as skiing and cycling. The extent
nf injury tn the AC and cnracnclavicular {CC} ligaments
as well as the amnunt and directinn nf clavicle displace-
ment nften determine the severity nf AC jnint separatinn.
Debate cnutinues regarding the best management nf such
injuries, especially type III AC jnint separatinn. Several
factnrs play a rnle in decisinn making nn the management
nf these cnmmnu injuries including age nf patient, type
nf injury, time frnm injury, activity level, and re snme
extent, aesthetic appearance. Treatment invnlves nnnsur—
gical and surgical measures, including acute repairs with
nr withnut augmentatinn nr late recnnstructinn. Overall,
the nutcnmes are favnrable with mnst treatrnent nptinns.
1: Upper Extremity
Mechanism of Injury
Injuries tn the AC jnint are usually the result nf a direct
blnw tn the superinr and lateral aspects nf the shnulder
with the arm in an adducted pnsitinn, resulting in the
displacement nf the acrnrninn inferinrly and medially
relative tn the clavicle. The first ligament injured is the
AC ligament. 1|With increasing severity nf injury, the CC
ligaments are injured next, fnllnwed by the deltntrapeeial
fascia.5| Annther less cnmmnn mechanism nf injury is a
fall nn an nutstretched hand, resulting in the prnximal
humerus being pushed intn the acrnminn with a superinrly
directed fnrcex”
Classification
In 1963, AC jnint injuries were initially classified in 1953
intn types I, II, and III.“i The classificatinn was later ex-
panded by Rnckwnnd in 1934 tn include types W, V,
and VI,5 relying nn cnmparative films nf the cnntralat-
eral shnulder rn determine each type {Figure 1}. A type I
injury invnlves AC ligament sprain withnut injury tn the
CC ligaments, and nn AC jnint widening nr clavicular
displacement. Type II injuries cnnsist nf cnmplete rupture
nf the AC ligament, CC ligament sprain, widening nf
the AC jnint, and increase nf the CC distance by mnre
than stern tn less than 25% cnmpared tn the cnntralateral
shnulder. In type III injuries, the AC and CC ligaments are
disrupted, the AC jnint is widened, and the CC distance
is increased 15% tn 1i] [1% cnmpared tn the cnntralateral
shnulder. A type IV AC jnint separatinn is diagnnsed when
the distal clavicle is displaced pnsterinrly intn the trape—
zius muscle. Type V injury is similar tn type III, except the
CC distance is increased by mere than lflfl% cnmpared
tn the cnntralateral shnulder because nf disruptinn nf
the deltntrapeaial fascia and renting nf the nverlying skin
can result. Type VI injury is rare and invnlves inferinr
displacement nf the clavicle intn the subcnracnid space
[Table 1}.
flrrhnpaedic Knnwledge Update: Spurts Medicine 5
Management
Type I and Type II N: Jnint Injuries
Nnnsurgical management has been the first-line treatment
nf type I and type II AC. jnint separatinns, using an arm
sling fnr immnbilieatinn and pain cnntrnl. Additinnally,
several nther therapeutic modalities are used including
rest, nral analgesics, NSAIDs, icing, and activity mndi-
ficatinn. Snme studies advncate the use nf intra-articular
lnng-acriug anesthetic injectinns intn the AC jnint in high-
ly cnmpetitiye athletes tn allnw faster return tn play in the
acute setting. The arm sling is usually used fnr apprnxi‘
mately 1 week in type I injuries, and fnr 2 tn 3 weeks in
type II AC jnint separatinns. When the pain subsides, the
arm sling is discnntinued and physical therapy is initiated
with active and passive shnulder range-nf-mntinn {REM}
exercises. Strengthening exercises are started after full
ROM is nbtained. Patients shnuld refrain frnm returning
tn cnntact spnrts nr heavy lifting for apprnximately Z tn 3
mnnths, until restnratinn nf full, painless shnulder ROM.
Currently, nn evidence suppnrts early surgical manage‘
ment fnr type I nr type II AC jnint separatinns. Hnwever,
patients are at risk fnr recurrent nr persistent shnulder
symptnms after type I and type II injuries. Injury can
nccur tn the AC jnint articular cartilage nr articular disk
that can result in shnulder cnmplaints subsequent tn the
injury. Retrnspective studies have repnrted persistent
symptnms in up tn “1% tn 5fl% nf patients at 1, E, and
1|} years after injuryf'"it Despite the relatively high per-
centage nf persistent symptnmatic patients, nnnsurgical
treatment is still the standard nf care in type I and type
II AC jnint injuries. In nne study, 3% nf patients under-
went surgical interventinn at a mean nf 26 mnnths after
injury."r Distal clavicle resectinn, either arthrnscnpic nr
npen, cnuld prnvide a pntential snlutinn in patients whnse
nnnsurgical treatment failed secnndary tn the develnp-
menr nf nstenarthritis in the AC jnint.El
Type III AC Jnint Injuries
The initial management nf type III AC jnint separatinns is
still cnntrnversial in the literature and in clinical practice.
Several studies have advncated nnnsurgical treatment
with gnnd tn excellent nutcnmes at final fnllnw—upg‘jI nther
studies have repnrted persistent pain and symptnms}1
A 2011 study recnmmended surgical management for
type III AC jnint separatinn in ynung, active patients
in the acute setting.11 Therefnre, nn cnnsensus has been
reached regarding the best treatment nptinn fur type III
AC jnint injuries. These injuries shnuld be treated nn a
case-by-case basis, depending cm the age and activity
level nf the patient. A 200? study repnrted the results nf
a survey nf 664 members and residency directnrs from
the American Drthnpaedic Snciery fnr Spnrts Medicine:
El ll] 16 American AcadMy nf Cirrhnpaedie Surgenns
 IShapter 2: Disprclers at the Accumicclavicular Jeint, Seemedavicular Joint, and Claeicle

E
"fl

11:
1]

H1

E's
I'D
E.
a!

WW TI'PEV Til-“3W
Illustratien demenstrates the six types at acremieclauicular jeint separatien. {flepreduced frern Huber GW. flewen
Hit: Acrerninclavimlarjnint injuries and distal clavicle fractures. JAm Acad' Drflmp Surg 1997;5[1]:I1-IE.1

Classification of AC Joint Separation

Increase in
A: EC Deltatrapezial Radiegra phic Ci: At: Hadieg ra phic A: Joint
We Ligaments Ugaments Fascla Distance Appearance Heducihle
I Sprained Intact Intact Narmal {1.1 'lD Normal NA
1.3 cm]
H Disrupted Sprained Intact c25% Widened ‘r'es
III Disrupted Disrupted Disrupted 25% 111 100%” Widened ‘r'es
W Disrupted Disrupted Disrupted Increased Pesterinr clavicle ND
displacement
V Disrupted Disrupted Disrupted mate to 3012119 HA He
VI Disrupted Intact Disrupted Decreased HA He
AI: = acremlnclaulcular. CE = curacecla'lrlcular. NA = net applicable.

'. Displacement is tempered with that at the centralateral sheulder [described by Hechweed} and net determined accerding tc- clauicular
diameter.

4D Ifllii American Academy nf flrdinpaedjc Surgeries Dnhnpaedie Knnwledge Update: Spur-ts Medicine .5 e
 Section 1:1}pperExtremity
36.3% preferred nonsurgical treatment of uncomplicated
type III AC joint injuries.”
Several studies have compared results of nonsurgical
and surgical management to treat type III AC joint sep-
arations using randomised trials, cohort studies, and
retrospective designs. Support for both initial nonsurgi-
cal treatment”!15 and early surgery15 was found. A 1011
meta-analysis of six nonrandomiaed studies compared
nonsurgical and surgical management of type III AC
joint injuries in 330 patients.” No difference was found
between the groups in pain, strength, throwing ability,
or incidence of AC joint osteoarthritis. Patients in the
surgical group had substantially greater duration of sick
leave with better cosmetic appearance.”
1: Upper Extremity
If surgery is preferred or deemed necessary, early sur-
gical repair of type III AC joint injuries with or without
augmentation seems to result in better patient satisfac—
tion and clinical outcomes compared with delayed re-
constructionJ“ A 1014 systematic review compared early
and delayed surgical intervention in complete AC joint
dislocation involving mostly type III injuries.” Dverall,
superior functional outcomes were found in the early
surgical group (P c 0.115} compared with delayed sur-
gery. Partial dislocations or redislocations were found in
26% of cases in the early treatment group compared with
33.1% of cases in the delayed group {P e DJJS].
Type IV, V, and VI AC Joint Injuries and Surgical
Management
Surgical management is usually indicated for type IV and
V AC joint separations given the high likelihood of shoul-
der pain and dysfunction and substantial deformity of
the shoulder. Type VI injuries are extremely rare and are
treated surgically. Surgery for type IV and type V injuries
is usually recommended in the acute or subacute setting,
but can be performed on a delayed basis if nonsurgical
treatment fails or if the patient presents for treatment late.
A recent retrospective study looked at conservative treat-
ment of type V AC joint separations in active—duty service
members.lEI After exclusions, 21 underwent conservative
treatment initially, whereas 3 underwent acute repair. In
the conservative group, 11 patients (61%) returned to full
duty without surgery at an average of 9'13 days, whereas
in the acute surgical group, I5 patients 95%] returned
to full duty at an average of 169.3 days. Type IV and
type V injuries are relatively less common, with most
published data involving small case series, case reports,
or as part of larger series involving type III injuries. Sev—
eral key elements of surgical intervention are critical for
successful outcomes in treating those high-grade injuries.
Anatomic reduction of the dislocated clavicle to correct
posterior, superior, or anterior translation is important
flrtltopaedie Knowledge Update: Sports Medicine 5
for successful outcomes. Repairing andfor reconstructing
the CC ligaments are important for maintaining anatomic
reduction. Supplementing the CC ligament repair andfor
reconstruction with synthetic material or plate fixation
can provide adequate stability for CC ligament healing.
Repairing or imbricating the damaged deltotrapeaial fas-
cia are integral parts of surgical management to optimize
outcomes.
Numerous surgical techniques are described in the
literature for the surgical management of AC joint in-
juries. No consensus exists on technique or timing of
surgery. For type III injuries, options for primary fixation
without reconstruction are available. The objective is to
reduce the AC joint and directly repair the CC ligaments
or allow them to scar or heal together. Reduction of the
AC joint promotes healing of the damaged CC ligament
tissue. AC joint reduction can be maintained using var—
ious techniques. A book plate is a clavicular plate that
includes a lateral extension that goes under the acromion,
reducing the AC joint. Other methods focus on direct fixi
ation between the clavicle and the coracoid and include a
screw through the clavicle into the coracoid, heavy sutures
around or through the coracoid and clavicle, or button
suture constructs aroundfthrough the coracoid and clav—
icle (Figure 2). A 2fl14 study compared arthroscopically
assisted reduction of acute AC joint separation using the
double~button suture technique compared with the hook
plate technique.“ Both techniques had good to excel-
lent results, with comparable outcome scores and com-
plication rates. A 2013 study followed 23 patients who
underwent arthroscopically assisted acute CC ligament
reduction using two doubleubutton sutures {one for each
CC ligament).22 There were 3 type III, 3 type IV, and
1‘? type V AC joint injuries, and patients were followed
for an average of 53 months; 96% of patients were very
satisfied or satisfied at final follow-up, with a significant
improvement in the visual analog scale and Constant
scores, even with eight radiographic failures.
Ligament reconstruction is another method for surgical
management and is commonly used for acute surgical
management of grade IV and V injuries, as well as for
delayed treatment {longer than 5 weeks] after type III
injury. Reconstruction is performed to reconstruct or
replace soft-tissue stabilizers of the AC joint using ham-
string autograft or allograft, tibialis anterior allograft, or
coracoacromial ligament transfer {the 1‘il'llieaver-lll nnn pro-
cedure}. The ligament reconstruction techniques provide
options for managing both acute and chronic AC joint
injuries. In lfllfl, free tendon anatomic reconstruction
of the CC ligaments became widely accepted for surgical
management of AC joint.” Anatomic reconstruction uses
a free tendon graft and nonahsorbable sutures that wrap
El ll] 16 American AcadMy of Urthopaedic Surgeons
 IEhapter 1: Disorders of the Acromiociavieular Joint, Sternociavicular Joint, and Ciavicle

L1“ E
"fl

s;
1]
Figure 2 A, Preoperative AP radiog ra ph of the left shoulder of a 25-year-old woman who is an athlete demonstrates a
type V acromiotlavicular {AC} joint separation. B, AP radiograph obtained 2 weeks following acute repair using a F”

double-endobutton suture ted'lnique, demonstrates adequate reduction of the AC joint separation. El

fill
a.
a!

"Ill.

II‘II._ r'_
l' *3.-

Figure 3 A, Illustration demonstrates the den hie-loop coracoclavicular ligament reconstruction technique for chronic
unsta b-le acrornioclavicular [AC] joint separation. I. Postoperative AP radiogra ph of the left shoulder of a 49-year-
old man wlth type III A: joint separation whose nonsurgical treatment was unsuccessful shows adequate reduction
of the AI: joint.

around the base of the coracoid and are passed through
the clavicle using small bone tunnels. Several variations
of this technique have been reported.“45 A small distal
clavicle resection is occasionally.r performed with AC joint
reconstruction if the distal clavicle has become deformed
and cannot be reduced. The decision to routinely,F perform
a distal clavicle resection with reconstruction is contro-
versial. A Zfllfl stud}.r reported on 1? cases managed using
anatomic ligament reconstruction, 14 of which were suc-
cessful with excellent improvement in American Shoulder
and Elbow Surgeon and Constant scores.13 A 21314 study
rcported on seven patients who underwent reconstruction
using a doubled loop of tendon graft with zero failures at
shortrterm foliowwup24 [Figure 3}.
Postoperative Rehabilitation
Following snrgerv, the shoulder is usually,F immobilized
in a sling or supportive brace for 6 to 3 weeks. Elbow,
wrist, and hand exercises are encouraged as long as the
shoulder is kept stable. Passive supine shoulder flexion
and abduction up to 90” in the plane of the scapula
can be considered safe early in the rehabilitation phase.
However, motion can also be delayed until 6 to 3 weeks
with minimal risk of stiffness. Gradual progression of

El Ifllli American Academy of flrdiopaedic Surgeons Drrbopaedie Knowledge Update: Sports Medicine .5
 Section 1:11pperExtrecnity
shoulder RUM exercises are usually started 6 to 3 weeks
after surgery and slowly progressed until 12 to 14 weeks.
Strengthening exercises for the shoulder muscles can be
started when the patient achieves painless shoulder ROM
at approximately 12 weeks postoperatively, taking care to
avoid downward force on the arm and shoulder. Return
to work without restrictions usually occurs at 16 to 14
weeks following surgery, with full—contact athletic activ—
ities resumed at approximately 6 months postoperatively,
after the patient has achieved similar shoulder strength
and RUM compared with the unaffected shoulder. Full
recovery can take 9 to 11 months.~"'n~15
Complications
1: Upper Extrem fty
Both nonsurgical and surgical management of AC joint
separations can result in complications. Complications as-
sociated with nonsurgical management include persistent
pain, crepitus, and swelling at the AC joint; late arthrosis;
and persistent instability. Usteolysis of the distal clavi-
cle also has been reported. Postoperative complications
depend on the type of surgical technique used. Implant
failure and migration, resulting in vascular injuries, have
been reported. Hence, Kirschner wires and pins are not
advised. Aseptic foreign body reaction and erosion of
the coracoid or clavicle have been reported with the use
of synthetic suture loops. Early or late fractures of the
clavicle or coracoid process have been reported as well,
especially with surgical techniques that involve tunnels
through the coracoid andl'or clavicle. Painful hardware
related to the hook plate or CE screw usually requires a
second procedure for implant removal. Loss of AC joint
reduction, persistent pain, and instability can potentially
complicate surgical outcomes. Neurologic injuries are
rare, but can involve nerve root injuries secondary to
traction during surgery, direct injury to the suprascapu
ular nerve resulting from aggressive dissection during
reconstruction, or injury to the brachial plexus with tech-
niques that pass grafts or suture loops under the coracoid
processf‘
{lavicle Fractures
Fractures of the clavicle comprise 2% to 5 “xi. of all fractures
in adults and 35% to 44% of all fractures in the shoul-
der, with an incidence of 50 to 64 per 10!],iIDiI persons
annuallyFfi'lf The risk for clavicle fracture is increased in
men age 30 years or younger and all patients older than
Tl} years. Middle third fractures are the most common
types of injuries, comprising approximately 69% to 31%
of all clavicle fractures. Lateral third fractures account
for approximately IT'if: to 23% of all clavicle fractures,
and medial third fractures comprise the remaining 2% to
flrrhopaedie Knowledge Update: Sports Medicine 5
3%.“‘13 Nousurgical management has been the preferred
initial mode of treatment for most clavicle fractures. How-
ever, according to more recent literature, nonunion can be
a substantial cause of morbidity, with some publications
reporting unfavorable patient—based outcomes. Therefore,
treatment of clavicle fractures should be tailored to each
patient and the type of fracture, amount of displacement
and comminution, age and level of activity of the patient,
and to some extent, the esthetic appearance of the shoul-
der, should be considered.
Mechanism of Injury and Classification
The most common mechanism of injury in clavicle frac-
tures is a direct blow to the shoulder, whether following a
fall or because of direct trauma. Less commonly, a fall on
an outstretched hand can result in clavicle fracture; this
mechanism was initially thought to be the most common
cause of these fractures. These injuries are rarely open,
despite being caused by high-energy trauma?”
Clavicle fractures were initially described in 196?
based on their anatomic location and in descending order
of incidence."Mil Type I fractures involve the middle third
of the clavicle; type II and type III fractures involve the
lateral and medial thirds, respectively. In 1953 [Neer
classification)” and 1996 {Craig classification},m type II
{lateral third} clavicle fractures were subclassified into
three types, depending on the integrity of the CC liga-
ments and the relationship of the fracture line with the
CC ligaments and AC joint. Type I lateral third fractures
occur lateral to the CC ligaments and are usually stable.
Type II lateral third fractures are medial to the CC lig-
aments, are usually unstable, and require surgical man-
agement. Type II was further subclassil'ied into type 11.91,
in which the fracture is medial to the intact conoid and
trapezoid ligaments, and type IIB, in which the fracture
is lateral to the torn conoid ligament but medial to the
intact trapezoid ligament. Type III lateral third fractures
are intra-articular fractures through the AC joint with
intact CC ligaments. These fractures are usually stable,
but can result in the development of AC joint arthritis.
Type IV fractures are rare and involve disruption of the
clavicular periosteal sleeve in pediatric patients, in whom
the epiphysis and physis remain with the AC joint and the
displacement occurs at the junction of the metaphysis and
physis. In type V fractures, a small, inferior cortical bone
fragment remains attached to the CC ligaments, with the
proximal and distal fragments of the clavicle fracture not
connected to the coracoid process {Figure 4). These frac-
tures are rare and generally require surgical intervention
for reduction and stabilization.
The Edinburgh classification was proposed in 19193,
with clavicular fractures divided by anatomic location
El 1016 American AcadMy of Cirrhopaedic Surgeons
 IIShapter 2: Disorders of the Acromioclavicular Joint, Seernoclavicnlar Joint, and Clavicle

E
"fl

a,
1]

F”

E's
m
E.
a!

Fig u re 4 Illustration demonstrates the Heer classification for distal clavicle fractures. AC = acromioclavicular. [Reproduced
from Banerjee H, Watennan B, Padalecki J, Robertson W: Management of dlstal davlde fractures. J' Am Acad
firthop 5mg 2H11:15Ii‘l:392-dfl1.l

into type I {medial third}, type II {middle third}, and
type III {lateral third}?1 Further subclassification of each
type was based on fracture magnitude and displacement.
Subgroup A indicates displacement less than 100% and
subgroup B indicates displacement more than Iflfl%. Ar-
ticular involvement determined further subdivision of
types I and III. Subgroup 1 indicates no articular involve-
ment and subgroup 2. indicates intra-articular extension
of the fracture. Type II fractures are also subdivided:
subgroup 1 indicates simple or wedge-type fractures and
subgroup 2 indicates comminuted or segmented fractures
{Figure 5]. A 2011 study compared the previous classifi—
cation systems and reported that the Craig classification
best predicted nonunion or delayed union of lateral third
clavicle fractures, and the Robinson classification had
the best prognostic potential for middle third clavicle
fractures.31
Management and Complications
Medial Third Clavicle Fractures
The treatment of media] third clavicle fractures is usu-
ally nonsurgical, with satisfactory outcomes and low
nonunion rates of 4% to 8%.“ These fractures are un-
common and are usually nondisplaced. The SC joint is
rarely involved in such injuries. Treatment consists of an
arm sling for comfort, with shoulder immobilization for

Eb Ifllii American Academy of Urthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Sectien 1:1}pperExtremity

|i'.‘.crtical alignment fractures {type 3A}

Extra-articular {type 3A1} Inna-articular {type 3A2}

Displaced fractures [type 3A)

1: Upper Extremity

Extra-articular (type 331) Intra-articular (type 332}

Figure 5 Illustratien demenstrates the Hebinsen classificatien fer distal clavicle fractures. {Repreduced frcIm Ba nerjee
It. Waterman B. Padaledti l, Hebertsen W: Management cf distal clavlcle fractures. Lem Arad Orthep Sury
act 1;1s[?]:392-4s1.l

2 ta 5 weeks. Sheulder RUM is started as seen as the
pain subsides er becemes telerable. Ice can help decrease
the swelling, with eral medicatiens fer pain centre]. Use
cf NSAIDs is centreversial, with some studies net rec—
cmmending them because ef the pessibility ef delayed
fracture healing. Centact sperts sheuld be aveided fer
at least 2 re 3 menths te allcw cemplete fracture healing
and sheulder rehabilitatien.”
Surgical management ef medial third clavicle fractures
is usually reserved fer fractures asseciated with injury te
the mediastinal structures secendar},r te fracture displace-
ment. These fractures sheuld be reduced fairly emergent-
ly, with an attempt at clesed reductien. Open reductien
and internal fiaatien {GRIP} is semetimes necessary te
maintain reducticn cf an unstable fracture. Several tech-
niques have been used fer DRIP cf displaced medial third
clavicle fractures including wire fiaaticn, plate-and-screw
ccnstructs, cr intercssecus sutures. Because this type cf
clavicle fracture is rare, few case reperts er small series
exist en this subject, with faverable eutcemes.”
Middle Third IElavirle Fractures
Middle third clavicle fractures cemprise mast clavicle
fractures and have been treated nensurgically with re-
perred successful eutcemes. A nenunien rate less than
1% has been reperted fer nensurgical management, less
than rates reperted fer surgical management.” High pa-
tient satisfactien has alse been reperted fellewing nen—
surgical treatment. Hewever, the mere recent literature
has previded mere infcrmatien abeut clavicle fracture
management, with many studies reperting less faverable
eutcemes fellewing nensurgical management with high
nenunien t*ates.3""'3T A 2i] [)5 meta-analysis cempared sur-
gical and nensurgical treatment ef middle third clavicle
fractures in 1,144 cases with a mean fellew-up ef £1
menths.“ Hensurgical management was perfcrmed in
1,145 {53.4%} cases, with a nenunien rate ef 5.9%, as
eppesed te a nenunien rate c-f 1.2% in 999 surgically
treated cases. 1|iii'hen examining displaced fractures sep-
arately, 159 cases were treated nensurgically, resulting in
a nenunien rate cf 15.1%, as eppesed te 2.1% fer 612

flrrhcpaedic Knewledge Update: Sparta Medicine 5 El 1016 American Acadenw cf Cirrhepaedic Surgeries
 IIShapter 2: Disorders of the Acromioclavicular Joint, Sternoclavicular Joint, and Clavicle
surgically treated cases. A lflil meta-analysis compared
surgical and nonsurgical management of middle third
clavicle fractures.345 The nonunion rate was substantially
higher in the nonsurgical group, with both groups achiev-
ing comparable Constant shoulder and Disabilities of the
Arm, Shoulder and Hand scores at final follow-up.
Two multicenter randomized clinical trials compared
the clinical outcomes of surgical and nonsurgical man—
agement of displaced middle third clavicle fractures-“*3?
The |Constant and Disability of the Arm, Shoulder and
Hand scores as well as patient satisfaction were substan-
tially superior in patients in the surgical group.35~~"i The
risk of nonunion and malunion was significantly higher
in patients in the nonsurgical group, and patients in the
surgical group had higher risk of wound infection and
implant irritation requiring removalfif-JT The mean time
to union in a 2430? study was substantially shorter in the
surgical group [16.4 weeks} compared with the nonsur-
gical group (23.4 weeks, P = Oflflllfii Surgical treatment
of middle third clavicle fractures is usually reserved for
patients between age 16 and El} years, with no infection
or skin compromise at the surgical site, and who are med-
ically fit and have an active lifestyle. In general, the indi-
cations for surgical management of middle third clavicle
fractures include fracture displacement with shortening of
more than 2 cm, skin tenting with an impending or open
fracture, neurovascular compromise, floating shoulder,
and obvious clinical deformity.~""I
GRIP of middle third clavicle fractures is usually
performed with a plate—and—scrcw construct or with ins
tramedullary pinning. The plate-aud-screw fixation tech-
nique provides rigid fixation, allowing early mobilisation.
However, implant prominence and irritation usually rev
suits in a second surgical procedure for implant removal.
|Either complications such as infection, implant failure
with nonunion, subsequent fracture following implant
removal, hypertrophic scarring, and adhesive capsulitis
of the shoulder have been reported. Intramedullary pin
fixation has become more common because of better
cosmetic appearance following surgery. However, some
intramedullary pins lack a locking mechanism, resulting
in no rotational control at the fracture site. Those pins re-
quire routine removal, with complications such as implant
migration or breakage, skin breakdown and infection,
and temporary brachial plexus palsy reported.”
Lateral Third Clavicle Fractures
Most lateral third clavicle fractures are nondisplaced or
minimally displaced extra-articular fractures; therefore,
treatment has been typically nonsurgical. The nonsurgi-
cal management modalities are similar to those used for
middle third and medial third clavicle fractures.31
Eb Ifllii American Academy of Urthopaedic Surgeons
Surgical management of distal clavicle fractures de-
pends on several factors including fracture stability [which
relies on the status of the CC ligaments}, fracture displace-
ment, and patient age. Displacement of the clavicle occurs
in bleer type II or Edinburgh type 313: fractures, with
nonunion rates up to 23% for nonsurgical treatmentdifig
fllder age has also been associated with an increased risk
of nonunion.39 Intra—articular extension of the fracture
can increase the risk of AC joint arthrosis, requiring distal
clavicle resection when symptomatic.
Several surgical techniques have been described in the
treatment of lateral third clavicle fractures, which are
more technically challenging than middle third fractures.
1'i'lliire fixation has been abandoned because of reported E
cases of pin migration. CC screw fixation has resulted in "E
mostly favorable outcomes, with only small cohorts re- s,
"U
ported.” Hook plate, standard plating, and locking plate F”
ii
fixation have also been successful despite the reported rare fill
incidence of complications such as nonunion, stiffness, E.
a!
fracture around the plate, and progression of AC joint
arthritis.“ Last, some unstable lateral third clavicle frac-
tures can be repaired using reconstruction techniques also
used for high-grade AC joint separations and include CC
ligament reconstruction and suture augmentation. Hybrid
plating of the clavicle and CC ligament reconstruction is
also an option for unstable lateral fractures. Hook plates
and CE screws require removal at a later stage secondary
to decreased RUM and discomfort and are associated
with a risk of screw breakage and hook plate damage to
the AC joint. In addition, use of CC screws or traditional
plate-aud-screw constructs is occasionally not possible
when the distal fragment is small, although the number
of plates designed for the lateral clavicle has increased.
CC ligament suture or ligament reconstruction techniques
have resulted in generally acceptable functional results
with high union rates.“I
Postoperative Rehabilitation
Postoperative rehabilitation for lateral third clavicle frac-
tures generally follows that used following surgical man-
agement of grade III through VI AC joint dislocations,
with shoulder immobilization for 6 weeks. Generally,
rehabilitation is slower and more conservative for lateral
third fractures compared with medial or middle third
fractures. Following surgical management of medial or
middle third clavicle fractures, an arm sling is used for
pain control and comfort, with shoulder RUM started
as soon as postoperative day 1. lEllverhead lifting is with-
held until approximately ti weeks after surgery. Resolu-
tion of pain is successful enough following DRIP using
plate—and-screw constructs that patients sometimes need
to be prevented from overdoing shoulder exercises and
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectien 1:1}pperExtremity
activities te prutect the cunstruct. When intramedullary
pinning is perfermed in middle third clavicle fractures
and sums cencern exists regarding retatienal stability
ef the fixatiun, furward flexiun and abductiun exercises
fer the sheuldcr sheuld be restricted te 90" fer the first
4 weeks. Shuulder muscle strengthening can be started
as seen as 1 weeks pesteperatively as lung as fracture
reductien is maintained and cenfirmed en sheuldcr ra—
diegraphs. Seme athletes return te nuncuntact athletic
activities as seen as 1 tu 3 weeks and tu centact spurts
in 6 te 3 weeks fellewing surgical management ef middle
third clavicle fractures.
‘I: Upper Eatrem ity
5C Jeint Injuries
SC jeiut injuries cumprise 3% uf all injuries invelving the
sheuldcr girdle and are uncemmen because ef the high
energy required te disrupt the SC ligaments. Altheugh
rare, these injuries semetimes result in damage te adjacent
structures such as the trachea, esephagus, lungs, and great
vessels. The management ef such injuries depends en the
directien uf sublustatien er dislucatiun. Acute anteriur
5C jeiut strain er sublunatien in any directien is usually
treated nensnrgically as lung as the jeiut is reduced. Acute
anteriur ur pusteriur dislucatiens are treated in the acute
setting with clesed reductien, especially when mediastinal
structures are at risk, with DRIF reserved fur certain
unstable cases. Chrunic pain and instability uf the SC
jeint can be managed by ligament recenstructien as well
as medial clavicle resectien, either upen er arthrescepic.
The risk uf majur cumplicatiuns is asseeiated with upen
surgical interventien because ef the preximity ef majer
vital structures re the SE jeint."3'1‘H
Mechanism uf Injury and Classificatiun
SC jeint dislucatien usually requires a large ferce be—
cause ef the strung suppurt previded by the surruunding
ligaments. Athletic injuries and meter vehicle accidents
cemprise mere than 30% cf injuries re the SC jeint. An—
terier dislucatien, the must cummen furm uf SC juint
dislucatien, usually results frem an indirect ferce te the
sheuldcr, with ferces transmitted threugh the clavicle
re the SC jeint. Pesteriur SC juint dislucatien can result
frem beth indirect and direct ferces, with direct antere-
medial ferce usually resulting in the clavicle being pushed
pesteriurly intu the mediastinum. The media] clavicle
epiphysis dues nut fuse with the shaft until age 23 re
25 years.” Therefere, the injury re the 5C jeiut can, in
seme instances, result in a fracture thruugh the medial
physis, with the clavicle shaft subluaating er dislucating
anterierly er pesterierly, leaving the epiphysis attached
re the sternum.“
flrrhupaedie Knuwledge Update: Spurrs Medicine 5
Classifieatiun uf SC juint instability can be based en
the directien ef clavicle sublunatienfdislecatien {anteriur
er pusteriur}, cause ef injury {traumatic er atraumatic}, in-
jury severity (sprain, subluaatiun, ur dislucatiun), and the
unset ef injury {acute er chrenic]. 5C jeint injuries have
been classified intu three types based en the extent ef 5C
jeint ligament injuries.If Type 1 invelves SC ligament and
capsule sprain, with ac sublunatien er dislucatiun. Type 2
invelves disruptien ef the 5C ligaments and capsule, with
subluaatiun ef the medial clavicle anteriurly ur pusteriurly.
Type 3 invelves rupture ef all supperting ligaments tn the
SC jeint, with cemplete anteriur er pusteriur dislucatien
ef the medial clavicle.M
Management and Cemplicafiens
Type 1 and Type 2 5E Jeint Injuries
The management ef type 1 5C jeint injury is typically
nensnrgical. The sheuldcr is immebiliscd in an arm sling
fur apprunimately 1 week fur pain centrel. Ice applicatiun
and eral HSAIDs can help decrease pain and centrel
inflammatien. After the pain subsides, generally a few
days fulluwing the injury, the arm sling can be discard-
ed and the patient can resume nermal daily activities,
with gradual integratien intu cempetitive sperts."'3'-“ 1EIiith
type 2 injuries, the medial clavicle is typically sublurrated
anterierly. The sublunatien can be reduced in a clesed
manner by pushing the sheuldcr pesterierly and medially.
Generally, a lunger peried is spent in an arm sling with
er witheut a figure-ef—B clavicle brace, typically 4 te 6
weeks, until the EC ligaments are healed. At 4 re 6 weeks,
the sheuldcr is mubilized, with RUM and strengthening
exercises started fer rehabilitatienfi‘“
Type 3 5C Jeint Injuries
The management ef type 3 SC jeiut dislecatiens depends
en the directien ef clavicle dislucatiun. Anterier dislu-
catiens are mere cummen than pusteriur dislucatiuns.
Acute anteriur dislucatiens are usually treated with clesed
reductien under anesthesia er sedatien. The patient is
placed supine en the table, with a pad between buth scap-
ulae. Direct pusteriur pressure is applied te the medial
clavicle until reductien is ebtained. 1|When reductien is
successful and stable, figure-uf—B sling immehilizatien is
applied fer ti weeks te allew seft tissues te heal. Hew-
ever, unlike pusteriur dislucatiens, anteriur dislucatiens
are usually unstable because uf the less ef the stabilizing
effect uf the turn SC ligaments, and cuuld require acute
er delayed upen surgical reductien with stabilisatien.‘3*‘“
Acute pusteriur dislucatiun can be asseeiated with
cencemitant injuries te vital surreunding structures
that cuuld require urgent management by a cardiethe-
racic surgeun. In stable patients, clesed reductien under
El 1016 American AcadMy uf Drrhupaerlie Surge-ens
 IIShapter 2: Disnrders cf the Acrnminclavicular Jnint, Sternnclavicular Jnint, and Clavide
A "fl
A. lllustratinn demnnstrates the 'l'tnman numeral I" recnnstructinn technique fnr 5C jnint separatinn. B.
Intranperative phntngraph demnnstrates the finished recnnstru ctinn.
anesthesia is the first-line treatment, preferably with a
cardinthnracic surgenn available in case nf mediastinal
injury. The patient is placed supine nn the table, with a
pad between bnth scapulae and the affected shnulder
pnsitinned at the edge nf the table. In a slender patient,
the clavicle can be manually grasp-ed and pulled anterinrly
intn pnsitinn. Shnulder and arm extensinn can assist in the
reductinn. Alternatively, tractinn is applied tn the affected
extremity, with cnuntertractinn applied tn the chest using
a large sheet. Tractinn is then increased with the upper
extremity mnved intn extensinn. This can help lever a
pnsterinrly dislncated clavicle intn a reduced pnsitinn.
Last, tractinn can be applied tn a fully adducted arm, in
additinn tn pnsterinrly directed pressure tn the shnnlder
tn lever the clavicle anterinrly. If thnse twn techniques fail,
a clamp can be used under sterile cnnditinns tn hnld the
medial aspect nf the clavicle and pull it anterinrly while
extending the abducted upper extremity. When reductinn
is nbtained, it is usually stable, and the patient requires
shnulder immnbiliaatinn in a figure-nf—B brace fnr 4 tn 6
weeks tn allnw snft-tissue healingJ‘J-‘H Reductinn can be
cnnfirmecl using an U-atm in the nperating rnnm nt CT
pnstnperatively.
ID'pen reductinn and internal stabilizatinn is indicated
fnr acute anterinr nt pnsterinr dislncatinns that have failed
clnsed reductinn nr are unstable, pnsterinr dislncatinns
in patients with an npen physis,“ and in cases nf chrnnic
anterinr nr pnsterinr subluxatinnsfdislncatinns that have
becnme symptnmatic. Internal stabilizatinn can be per—
fnrmed by varinus means, including suture fixatinn and
ligament recnnstructinn. Wire-a nd-pin fixatinn has been
abandnned because nf fatal cnmplicatinns, and suture
fixatinn has yielded subnptimal binmechanical results.
Eb Ifllii American Academy nf Urthnpaedic Surgenns
E
g
1]
F”
ii
m
E.
a!
Currently, ligament recnnstructinn is the rnnst widely
used technique fnr 5C jnint stabilizatinn.‘“-‘H
In ann4, a binmechanical study cnmpared three dif-
ferent types nf ligament recnnstructinn techniques nf the
SC jnint ligaments.“ The figure~nf~3 technique had sub-
stantially higher mechanical strength in bnth the anterinr
and pnsterinr directinns cnmpated with the subclavian
tendnn technique and the intramedullary tendnn tech-
nique. Hnwever, all three techniques were fnund tn be
binmechanically inferint tn the native SC jnint ligaments.
Mnst clinical studies published nn ligament recnnstruc—
tinn nf the SC jnint are case repnrts nr case series with
generally favnrable nutcnmes. A 2fl14 study repnrted cm
the recnnstructinn nf chrnnic anterinr SC jnint instability
using autngraft {palmaris lnngus tendnn nr gracilis ten-
dnni." Twentyuseven patients were fnllnwed fnr a median
nf 54 mnnths (minimum, 2 years}, with significant im-
prnvement in Western Gntarin Shnulder Instability scnres.
Twn patients underwent successful revisinn surgery for
recurrent instability. A lfl13 case series repnrted nn six
patients undergning SC jnint recnnstructinn using a mnd-
ified extra-articular “aan numeral 1".“ recnnstructinn
using hamstring tendnn autngraft fnr anterinr instability“El
(Figure 6}. All patients had substantial imprnvement in
their functinnal scnres and visual analng scale scnres at
a mean fnllnw—up nf 4D mnnths. All patients returned
tn preinjury activity level including spnrts, with nne pa-
tient requiring revisinn surgery 4 years later fnr SC jnint
arthrnsis.
Pnsttraumatic arthritis nf the SC jnint can becnme
symptnmatic in patients treated nnnsurgically nr sur-
gically fnllnwing an EC jnint injury. When nnnsurgical
treatment fails, medial clavicle resectinn, either npen nr
Drthnpaedic Knnwledge Update: Spnrts Medicine .5
 Section 1:1}pperExtremity
arthroscopic, can be performed to alleviate pain and im-
prove outcomesfig-‘SD To avoid recurrent instability, it is
recommended to avoid resecting more than 1.5 cm of the
medial clavicle. The arthroscopic technique is advanta-
geous because it is minimally invasive, with faster rehabil—
itation possible. However, this procedure is still associated
with the risk for damage to vital nearby structures such
as carotid arteries, subclavian veins, and the trachea.“
Postoperative Rehabilitation
The postoperative care of patients undergoing open reduc—
tion and internal stabilization of unstable 5C joints is the
same for anterior or posterior dislocations. The surgical
upper extremity is immobilized in an arm sling for 6 to
1: Upper Extremity
3 weeks to allow soft-tissue healing, and only pendulum
exercises are allowed during this period. Active shoulder
RUM is started at 5 to 3 weeks postoperatively, with the
arm maintained at 90“ or less. The patient can be weaned
from the arm sling over a period of 1 to 2 weeks. Full,
active ROM and strengthening exercises are initiated at
12 weeks, with return to manual labor or athletic activ-
ities allowed at 5 to 6 months.‘i‘l-‘”~i’d
Summary
Managing AC joint separations, clavicle fractures, and
SC joint dislocations depends on several factors, including
patient age, level of activity, level of pain, presence of in-
stability or deformity, and potential complications in per—
forming surgical intervention. Applying these guidelines
provides the orthopaedic surgeon with an appropriate
plan to treat any of the injuries discussed in this chapteL
flrrhopaodic Knowledge Update: Sports Medicine 5
Key Study Points
1* Type I and II AC joint injuries are treated nonsur-
gically, type IV, V, and VI AC joint separations are
treated surgically.
I Nonsurgical management of type III AC joint sep-
aration is the most common first-line treatment,
followed by surgical intervention if nonsurgical
treatment fails.
1* Management of medial third and lateral third clav-
icle fractures is usually nonsurgical, except in the
case of Neer type II lateral third fractures {Edin-
burgh type SE fractures}, which are unstable and
require open reduction and internal stabilisation.
1* Surgical management of middle third clavicle frac-
tures yields improved results, with fewer cases of
nonunion and malunion and improved patient sat-
isfaction compared with nonsurgical management.
| Anterior SC joint dislocations are usually unstable,
even after closed reduction, often requiring surgical
intervention.
i Posterior 5C3 joint dislocations can result in in-
jury to vital surrounding structures, with surgi-
cal interventinn being associated with substantial
complications.
Annotated References
1. Maasocca AD, hrciero RA, Eicos J: Evaluation and treat—
ment of acromioclavicular joint injuries. Am 1 Sports Med.
2Ufi?;35{2}:316-329.Medline D01
2. Kaplan LD, Flanigan DC, Norwig J,]ost P, Bradley]: Prev-
alence and variance of shoulder injuries in elite collegiate
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Medline D01
3. Johansen 1s, Grutter PW, McFarland EG, Petersen SA:
Acromioclavicular joint injuries: Indications for treatment
and treatment options. ] Shoulder Elbow Surg 2011;201’2,
Suppl}STfl-532.Medline DID]
The study reviews the pathoanatomy, biomechanics, clas-
sification, presentation, and evaluation of AC joint inju—
ries, with analysis of the literature involving both surgical
and nonsurgical management.
4. Tossy JD, Mead NC, Sigmund HM: Acromioclavicu-
lar separations: Useful and practical classification for
tL'eatment. CIr'rr Grtbop Rafa: Res 1963;1fljlfljflll-119.
Medline
.5. Rockwood CA: Injuries to the acrornioclavicular joint, in
Rockwood (in, Green DP, eds: Fractures in Adults ,ed 2.
El 1016 American AcadMy of Unhopaedic Surgeons
 Chapter 2: Disorders of the Acromioclavicular Joint, Sternoclavicular Joint, and Clavicle
Philadelphia,1s Lippincott, 1934, pp sac-sis, ass-ass,
vol 1.
Mikel: M: lazing-term shoulder function after type I and
II acromioclavicular joint disruption. Arr: J Sports Med
2Uflfl;36l11}:114‘?—2150.Medline DUI
Mouhsine E, ICaroi'alo R, Crevoisier K, Farron A: Grade
I and II acromioclavicular dislocations: Results of conser-
vative treatment. ] Shoulder Elbow Sarg 2!] [13:1 2151:599-
6(1'2. Medliue I311
Shaw ME, ivIcIuerney J], Dias J]. Evans PA: Acromiocla-
vicular joint sprains: The post-injury recovery interval.
Injury Eflfl3:34lfij:433-442. Medliue DUI
Huber CW, Bowen MK: Arthroscopic treatment of acm-
mioclavicular joint injuries and results. Clir: Sports Med
lflfldtlljllflfll—dllflcdliuc DUI
Ill. Calvo E, Lopes-Franco M, Arrihas Ii'vl: Clinical and radio-
logic outcomes of surgical and conservative treatment of
type III acromioclavicular joint injury. } Shoulder Elbow
Surg lflfldflifllfiflfl-SDS. Medline DUI
11. Schlegel TF, Burks RT, Marcus RL, Dunn HE: A
prospective evaluation of untreated acute grade III
acromioclavicular separations. Arr: } Sports Med
lflfll;29lfij:699-Tfl3. Motllinfl
12. Liaaur A, Sana-Reig J, Unnaalea-Parrefio 3: Long-term re—
sults of the surgical treatment of type III acromioclavicular
dislocations: An update of a previous report. J Bone Joint
Surg Br Zfllljfidlfljflflfifl-IDSE. Medliue DUI
This study followed 33 patients for a mean of 24.1 years
following surgical management of type III AC joint sep—
aration, with satisfactory results and complete resolution
of pain in 35 patients, and comparable outcome scores
in both the surgical and contralateral shoulders. Level of
evidence: IV.
13. Nissen CW, Chatterjee A: Type III acromioclavicular sep-
aration: Results of a recent survey on its management. As:
I Urtbop (Belle Mead NJ} 200?:36i2}:39-93. Medliue
14. Bannister CC, Wallace WA, Stableforth PG, Hutson MA:
The management of acute acromioclavicular dislocation.
A randomised prospective controlled trial. I Bone Joint
Surg Br 1939;?1l5}:343-35i}. Medline
15. Taft TH, Wilson FC, Ugleshy PW: Dislocation of the aero-
mioclavicular joint. An end-result study. _,I Bouejoint Surg
Ans 193T;59[?}:1fl45-1fl51. Medliue
IE. Gstettner C, Tauber I'vI, Hitsl W, Resch H: Rockwood type
III acromioclavicular dislocation: Surgical versus conser-
vative treatment. ] Shoulder Elbow Surg 2i] flSfllhllfl-
125. Medline DUI
1?. Smith TU, Chester R, Pearse EU, Hing CB: Uperative ver-
sus non-operative management following Rockwood grade
III acromioclavicular separation: A metavanalysis of the
U Iflld American Academy of Urthopaedic Surgeons
current evidence base. ] Urtbop Traumatoi lflllglljllfl 9-
IR. Medline DUI
This meta-analysis reported on surgical versus nonsurgical
management of type III AC joint separation, with surgi-
cal mauagement resulting in better cosmetic appearance
but increased sick leave. No difference was reported in
strength, pain, throwing ability, or incidence of AC joint
osteoarthritis.
13. Rolf U, Hann von Weyhern A, Ewers A, Eoehm TD,
Gohlke F: Acromioclavicular dislocation Rockwood
III—V: Results of early versus delayed surgical treatment.
Arch Urtbop Trauma Surg EUflSflESiIGmISS-llfil
Medline DUI
19. Song T, “fan K, Ye T: Comparison of the outcome of
early and delayed surgical treatment of complete acro- E
mioclavicular joint dislocation. Knee Surg Sports Trau-
matoi Ambrose 2fl14; Aug 14 [Epub ahead of print].
"fl
o,
1]
Medline DUI F”
ii
This review compared outcomes of early and delayed I'D
surgical management of AC joint separations, with early E.
surgery resulting in better functional outcomes and fewer a!
resublurationstredislocations. Uverall complication rates
were comparable. Level of evidence: IV.
2.0. Krul RF, Cook 13, Hu J, Cage JIvI, Bottoni CR, Tol-tish
JM: Successful conservative therapy in Rockwood type
V acromioclavicular dislocations. Urtbop } Sports Med
EDISflIS, suppl 1}.
In a retrospective study, the authors assessed conservative
treatment of type V AC joint separations in active-duty
service members. In the conservative group, 11 patients
{61%} returned to full duty without surgery at an average
of 5‘13 days, whereas in the acute surgical group, 6 pa-
tients [TESS] returned to full duty at an average of 169.3
days. Level of evidence: IV.
11. Jensen G, Katthagen JC, Alvarado LE, Lill H, Voigt C:
Has the arthroscopically assisted reduction of acute AC
joint separations with the double tight-rope technique
advantages over the clavicular hook plate fixation? Knee
Surg Sports Traumutol Arthrosr: 2fl14;2 21:21:412-43 i].
This study compared 26 arthroscopically assisted AC
joint repairs with 30 book plate fixation procedures for
acute AC joint separation. Both techniques resulted in
comparable clinical and radiographic outcomes as well
as comparable complication rates. Level of evidence: IV.
Medline DUI
12. Venjakoh A], fialzmann UM, Gabe] F, et al: Arthroscopi-
cally assisted l—bundle anatomic reduction of acute acro-
mioclavicular joint separations: 53-month findings. Arr:
j Sports Med 2013;41j3}:515-EEI. Medline DUI
This study reported outcomes following arthroscopically
assisted AC joint reduction in 23 patients at a mean fol-
low-up of 53 months. Clutcome scores showed substantial
improvement: 96% of patients were very satisfied or sat-
isfied at final follow-up. Level of evidence: IV.
Urrhopaedic Knowledge Update: Sports Medicine 5
 Sectien 1:1}pperExtremity
23. Carefine EC, Maxxecca AD: The anatemic ceracecla-
vicular ligament recenstructien: Surgical technique and
ind icatieus. } Sbeufder Elects: Surg 1010;19i5uppl Ilka?-
46. Medline DUI.
The anthers reperted their technique fer CC ligament
recnnstructinn in the treatment ef AC jnint separation in
1? patients. C'utceme sceres were substantially impreved.
Three Failures were reported, twe ef which required revi—
sien surgery. Level ef evidence: I‘v".
E4. Westermann RW, Martin W, Welf BR: Deuble-Ieep
Anatemic Acremieclavicular Recenstructien: Surgical
Technique and Early Results. Tecil:I Sheufder Elbert: 3mg
seisassiss. net
The anthers reperted their technique fer AC ieint recen—
structien using semitendinesis tenden fer AC jeint sepa-
1: Upper Extrem tty
ratiens. Seven patients were included with gee-d results at
final fellew—up, ne cemplicatiens, and ne less ef reductien.
Level ef evidence: IV.
Tee JC, Ahn JH, 1it'een JR, Tang JH: Clinical results ef
single—tunnel ceraceclavicular ligament recenstructien
using autegeneus semitendinesus tenden. Am } Sperts
Med lfllflfiflifihflSfl-EST. Medline DUI
The study reperted clinical results fellewing CC ligament
recenstructien fer AC jeint scparatieu. All 21 patients had
geed te excellent results at final fellewrup; 1? patients
maintained reductien. Level ef evidence: IV.
26. Pestacchini F, Gumina S, De Santis P, Albe F: Epide-
mielegy ef clavicle fractures. I Shenfder Elbow Surg
2i]fl1;11{5}:451—456.Medline net
2?. van der Meijden DA, Gaskill TR, Millett P]: Treatment
ef clavicle fractures: Current cencepts review. ] Sheulder
tess' Sssrg 2fl12:21{3}:423-429. Medline DUI
This review article describes the classificatien, surgical
indicatiens, and techniques fer treatment ef clavicle
fractures.
23. AIlman FL Jr: Fractures and ligamenteus injuries ef
the clavicle and its articulatien. ] Bette feint Surg Am
:ssvastessssss. Medline
29. Nee: CS II: Fractures ef the distal third ef the clavicle.
Gin: Grtbep Relat- Res 1963;53i53}:43-Efl. Medline
3‘3. Craig EV: Fractures ef the clavicle, in Reckweed CA,
Green DP, Eucheh: RW, I-Iecltman 1D, eds: Fractures in
Adults ,ed 4. Philadelphia, PA, Lippincett-Raven, 1996,
pp nuanss.
31. Rebinsen CM: Fractures ef the clavicle in the adult.
Epidemielegy and classificatinn. I Hesse Innis-st Surg Br
1993;Efl{3}:4TE-434.Medline DCII
32. ICIV‘I'tleill E], Hirpara KM, C‘Eriain D, McCarr C, Kaar
TK: lEllavicle fractures: A cemparisen ef five classificatien
systems and their relatienship te treatment eutcemes. In:
Drrhep 2011:35ifi}:909-914. Medline DUI
flrthepaedic Knewledge Update: Sperts Medicine 5
This article cempa red five classificatien systems fer clavi-
cle fractures. The Craig classificatien shewed the greatest
pregnestic value fer lateral third fractures and the Hub—
insen classificatien shewed the greatest pregnestic value
fer middle third fractures. Nnnuninn was mere cemmen
in lateral third fractures.
33. Hanhy CK, Pasque CB, Sullivan IA: Medial clavicle
physis fracture with pesterinr displacement and vascu-
lar cempremise: The value ef three—dimensienal cem-
puted temegraphy and duplex ultraseund. Drrhepsdr‘cs
lflfl3;26|{ll:31-fi4. Medline
34. Zlewedxlti M, Zelle EA, Cele PA, Jeray K, McKee MD:
Evidence-Based Drthepaedic Trauma Werlting Grnup:
Treatment ef acute midshaft clavicle fractures: systematic
review ef 2144 fractures: en behalf ef the Evidence-Based
Drthepaedic Trauma Werlting |Crnup. I Drthep Trauma
lflfl5;19[?}:5fl4-5fl?. Medlirte DIG]
3.5. Canadian Drthepaedic Trauma Seciety: Heneperarive
treatment cempared with plate fixatic-n ef displaced
midshaft clavicular fractures. A multicenter, randem-
ised clinical trial. I Ben-e Jet's: Snrg Ans 200?:3 9(1}:1-1i}.
Medline DUI
36. McKee EC, Iiii'helan DE, Schemitsch EH, McKee MD:
Dperative versus neneperative care ef displaced midshaft
clavicular fractures: A meta-analysis ef randemiaed clin-
ical trials. J Hesse Jeint Su-rg An: 2012:94I3}:6?5rfifi4.
Medline [101
This meta-analysis examined surgical and nensurgical
management ef middle third clavicle fracnlres in 411 pa-
tients. Neuunien rates and symptematic malunien rates
were higher in nensu rgical cases.
3?. Rebinseu CM, Geudie EB, Murray IR, et a1: Dpen re—
ductieu and plate fixatien versus neneperative treatment
fnr displaced midshaft clavicular fractures: A. multi-
center, randemixed, centrelled trial. }' Bette jeint Surg
Am 2fl13;95{17}:157ti-1534. Mcdline DUI
This randemired, centrelled trial cempared DRIP" and
nensurgical treatment ef displaced middle third clavi-
cle fractures: IDS patients were treated nensurgically, 95
were treated with lCIRIF. Better functienal eutcemcs and
reduced nenunien rates were feund in the surgical greup.
Level ef evidence: I.
33. Altamimi 5A, McKee MD: Canadian Grthepaedic Trau-
ma Seciety: Neneperative treatment cempared with plate
fixatien ef displaced midshaft clavicular fractures. Surgi-
cal technique. I Benejefnt Surg Am 2003;9{ii5uppl 1 Pt
lid-E. Medline
3?. Rebinsen CM, Ceurt—Erewn CM, McQueen MM, Walte—
field AE: Estimating the risk ef nenunien fellewing nen-
eperative treatment ef a clavicular fracture. I Herrefeint
Surg Am see4,ss_a(v}:1sss_1sss. Medline
4D. Yamaguchi H, Arakawa H, Kehayashi M: Results cf the
Beswerth methed fer unstable fractures ef the distal clav—
icle. In: Grtbep 1993;22{fil:366-363. Medline DUI
El ll] 16 American Academ~y ef Drthepaedie Surge-ens
 IEhapter 2: Disnrders nf the Acrnminclavicular Jnint, Sternnclavicular Jnint, and Clavicle
41. Band DW, Lui DF, Lennard M, Mnrris S, McElwain JP:
Clavicle hnnl-t plate fixatinn fnr displaced lateral-third
clavicle fractures [Neer type II}: A functinnal nutcnme
study. I Sbnnlder Elbnw Saar-g 2fl12;21{3}flfl45-1fl43.
Medline [ll-DI
The study examined functinnal nutcnmes fnllnwing GRIP
fnr displaced lateral third clavicle fractures: 35 patients
were included with a mean time tn uninn nf 3 mnnths and
95% uninn rates. Hnwever, 92% nf plates required later
remnval. Level nf evidence: IV.
42.. Levy 0: Simple, minimally invasive surgical technique
fnr treatment nf type 2 fractures nf the distal clavicle.
I Sbnnlder Elbntn Surg1003;12[1}:24-13. Medline DUI
43. Grnh GI, 1illi'irth MA: Management nf traumatic sternn-
clavicular jnint injuries. I Am Acnd Grtbnp 3mg
smmstna—x Mndlinfl
This review discusses injuries tn the 5C jnint, describing
anatnmy, mechanisms nf injury, classificatinn nn 5E jnint
injuries, itnaging, and management nptinns including nnn-
surgical, clnsed reductinn, nr np-en reductinn and internal
stabilisatinn.
44. Martetscbliiger F, 1lili’arth R], Millett P]: Instability and de-
generative arthritis nf the sternnclavicular jnint: A current
cnncepts review. Am I Spnrts Med 2fl14:42{4}:999-lflfl1
Medline DUI
This review examines instability and degenerative arthritis
nf the SC inint. Diagnnstic modalities and classificatinn
as well as management nptinns and cnmplicatinns are
described.
45. 1r'an awegen C, 1Flil'nlf E: Suture repair nf pnsterinr
sternnclavicular physeal fractures: A repnct nf twn cases.
Inwa Drtbnp J lflflfl;13:49-51. Medline
Eb Iflld American Academy nf Urthnpaedie Surgenns
46. Spencer EE Jr, Kuhn JE: Einmechanical analysis nf re-
cnnstructinns fnr sternnclavicular jnint instability. I Butte
jnint Surg Am 10134;.36 -A{1}:93-1i}5. Medline
4?. Bal-t K, ah K: Recnnstructinn nf the chrnnic anterinr
unstable sternnclavicular jnint using a tendnn autngraft:
Medium-term tn lung-term fnllnw—up results. ,I Sbnnlder
Elli-nit! Sflrg 2014:23i3}:245-250. Medline DUI
The study repnrted mid-term tn lung-term results nf SC
jnint recnnstructinn in 2'? patients fnllnwed for a mini-
mum nf 2 years, with substantial itnprnvement in nutcnme
scnres. Twn failures were treated successfully with revisinn
surgery. Level nf evidence: IV.
43. Guan I]. 1FJilblf BR: Recnnstructinn fnr anterinr sternn-
clavicular jnint dislncatinn and instability. }' Sbnulder
Elbnw Snrg 2013;11{E}:T?5-?31. Medline DUI E
This article repnrted the results nf surgical management "fl
s;
1]
nf anterinr SC inint dislncatinn and instability. Six pa-
tients were fnllnwed fnr a mean nf 4i) mnnths; all patients F”
shnwed irnprnved functinnal scnres and all had up at min- E's
m
itnal pain. Level nf evidence: IV. E.
a!
45‘. Tytherleigb-Strnng G, Griffith D: Arthrnscnpic excisinn
nf the sternnclavicular jnint fur the treatment nf sternn-
clavicular nstenarthritis. Artbrnscnpy 2D13;29{9]:143?—
1491. Medline DUI
This article repnrted the results nf arthrnsenpic excisinn nf
the 5C jnint fnr treatment nf nstenarthritis. Uf If] patients,
all had nn nr minimal pain at final fnllnw—up, and 9 had
gnnd tn excellent results. Level nf evidence: IV.
50. Enckwnnd CA Jr, Grub GI, 1It'lil'irth MA, Grassi FA: Re-
sectinn arthrnplasty nf the sternnclavicular jnint. j Hens
jnint Snrg Am 199?;T’9i3}:33?—393. Medline
Drthnpaedie Knnwledge Update: Spnrts Medicine 5
Chapter 3
Rotator Cuff Disease
Evan I. Conte. MD Stephen F. Brockmeier, MD
Abstract
Disease of the rotator cuff is common and increases in
prevalence with age in the general population. Rotator
cuff disease can present as an acute injury or insidiously
with shoulder pain and weakness. Physical examination
and imaging studies can help guide treatment. Surgical
and nonsurgical treatment can be effective in correct-
ly chosen patient groups. The sequelae of untreated
long-standing larger tears of the rotator cuff can cause
joint destruction and profound disability.
Keywords: rotator cuff; impingement syndrome;
rotator cuff tear; rotator cuff repair; reverse total
shoulder arthroplasty
Introduction
Rotator cuff disease is one of the most commonly treated
upper extremity ailments, and management strategies
continue to evolve. Modern understanding of this entity
can be traced to 1934 when rotator cuff function, pathol-
ogy, and proposed treatment were first described. During
the next SCI years, abundant basic science and clinical
investigations have expanded knowledge of the natural
history of rotator cuff disease and helped refine treatment
options. Although rotator cuff pathology can present in
younger patients after trauma or in overhead athletes, it
Dr. Brockmeier or an immediate famiiy member serves as
a paid consultant to Biomet and MicroAire Surgical instru-
ments; has received research or institutionai support from
Arthrex, Biomet, Tornier; and serves as a board member;
owner; officer; or committee member of the American fir-
thopaedic Society for Sports Medicine and the MidAtiantic
Shoulder and Elbow Society. Neither Dr. Conte nor any
immediate famiiy member has received anything of value
from or has stock or stocic options held in a commercialI
company or institution related directly or indirectiy to the
subject of this chapter:
@ lflld American Academy of Drthopaedic Surgeons
is predominantly prevalent in middle—aged and elderly
patients.‘ Treatment ranges from nonsurgical modalities
focusing on rest and phased rehabilitation to arthroscopic
or open tendon repair to salvage options including reverse E
total shoulder arthroplasty. "fl
a,
1]
F”
Natural History and Societal Effect E's
fit
Numerous studies have reported an age-associated in- 3.
a!
crease in the prevalence of rotator cuff tea rs beginning in
patients approximately 51'} years old and increasing with
each decade of life {Figure 1}. Rotator cuff abnormalities
are prevalent in both symptomatic and asymptomatic
patients, and bilateral rotator cuff tears are common in
patients with unilateral symptoms. The prevalence of
tears has been reported to range from 13% for patients
in their 50s to SUSS for patients 3f] years or olden;3
The factors that cause an asymptomatic tear to become
symptomatic have not been completely elucidated, but
natural history data collected in recent studies have linked
symptom emergence to progression from a partial- to a
fullnthickness tear, an increase in size of a fulluthickness
tear, development of muscle atrophy, fatty infiltration of
the muscle, or new biceps pathology.” The societal bur-
den of rotator cuff disease can be substantial when lost
days of work are factored in, and a 2fl13 study reported
that a rotator cuff repair procedure could result in a cost
savings of up to -$?3,flflfl when compared with nonsur-
gical management, depending on the age of the patient.‘
Eiomechanics. Anatomy. and Genetics
The rotator cuff has a dual function for the shoulder: it
helps initiate and assist with active shoulder motion and
it provides dynamic stability to the glenohumeral joint
during this motion. Given the short arc length of the
glenoid, the humeral head requires not only substantial
stabilisation from soft—tissue structures including the
glenohumeral ligaments, but also the force-couple mo-
ment provided by contraction of the four rotator cuff mus-
cles during motion. The supraspinatus and infraspinatus
tendons, which comprise the posterosuperior rotator cuff,
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 1:1}pperExtremity
IHGT El Homear
all
Ellis
Ens
ass
or
s
Efls
title
The
1: Upper Extremity
Bills
13% sees 40% case sex moss
Figure 1 Graph demonstrates the prevalence of rotator
cuff tears {EU} in the native population lay age.
are confluent centrally and insert on the greater tuberosity
of the humeral head. Studies have shown that most tears
occur in the anterior portion of the supraspinatus tendon
and are more likely to be larger and associated with fatty
muscle degeneration.” Additionally, the common types of
tear geometry have resulted in the “cablexrescent” con~
cept: a thickened, horseshoe-shaped region that comprises
the anteriormost 3 to 12 mm of the supraspinatus, termed
the rotator “cable,” which is critical for the structural and
functional integrity of the superior cuff. The relatively
stress-shielded center section is called the “crescent." Bio“
mechanical test results have shown that tears involving
the cable result in increased tear gap distance and strain
when compared with these in the crescent area“
The etiology of rotator cuff disease involves both in—
trinsic and extrinsic factors. Most early studies focused on
mechanical phenomena secondary to external impinge-
ment against the undersurface of a prominent anterior
or lateral acromion, eventually resulting in the develop-
ment of a tear. New studies investigating genetic influence
have suggested that rotator cuff disease is not a purely
mechanical problem, but is most attributable to intrinsic
degenerative tendinopathic changes. These are thought to
involve changes in both the molecular composition of the
tendon substance as well as its vascularity, which allows
for the gradual development of tendinosis and eventual
structural failure and tearing. As with other degenerative
tendinopathies, certain individuals may be more at risk.
One study has shown a familial hereditary pattern of ro-
tator cuff diseasef another has identified five genes found
more commonly in patients with substantial disease.m
flrdmpaedic Knowledge Update: Sports Medicine 5
-_
Classification of Rotator Cuff
Muscle Degeneration
Grade Doscription
{i No fatty strea its
Some fatty streaks
hWhJ—I
More muscle than fat
As much muscle as fat
Less muscle than fat
IElsie-situation
Rotator cuff tears can be described and classified based on
several factors, including size, location, number of tendon
units involved, tear geometry, level of tendon retraction,
and muscle atrophy and fatty infiltration. Tears were first
classified based on size in 1934;“ a subsequent classifica—
tion combined coronal and sagittal variables as well as
tear thickness.” The quality of the injured myotendinous
unit is also important. Atrophy of the muscle belly diam—
eter as well as the degree of fatty infiltration, as classified
in 1994 (Table 1], can help indicate tendon quality during
repair.” Most recently, a new classification was presented
to assist with surgeon-to-surgeon communication as well
as provide prognostic and treatment considerations. This
new geometric classification describes rotator cuff tears
as viewed directly via the lateral arthroscopic portal.“
The patterns include crescent-shaped, L-shaped, reverse
Lushaped, Iii-shaped, or massive contracted-type tears
that require more advanced techniques such as interval
slides and marginal convergence to repair successfully
{Figure 2}.
Physical Examination
Initial evaluation of a patient with symptoms of rota—
tor cuff disease starts with a comprehensive history and
physical examination. The examination should be broad,
including the cervical spine, scapula, shoulder girdle,
and neurologic testing of the extremity, followed by a
systematic shoulder exa minatioo with specific tests for the
rotator cuff and common concomitant pathology. Visual
inspection of the shoulder can reveal rotator cuff muscu-
latu re atrophy as well as signs of rotator cuff dysfunction
and anterosuperior escape. Assessment of passive range of
motion is important to rule out adhesive caps ulitis, which
would ideally be treated before attempting surgical repair.
It is important to assess for other pathology that could
be the cause of concurrent symptoms and potentially
El 1016 American deadeniy of Cirrhopaedic Surgeons

[1 Measure tear
Figure 2 Illustratinn demnnstrates cuff tear classificatien
using genmetry. lI'IHL = cnracnhurneral
ligament. I5 - infrasplnatus. L - length,
Ftl = rntatnr interval. Eula = subscapularis,
55 = supraspinatus, W = width.
treated during rntatnr cuff repair such as biceps tendnn
disease, acrnminclavicular jnint arth rnsis, nr impingement
syndrnme.
The muscles cf the rntatnr cuff shculd be tested in-
dividually. The ae test, nr empty can test, isnlates the
supraspinatus and is perfnrmed with the arm at 91')“ nf
abductinn, 30° nf flexinn in the scapular plane, and with
the fnrearm prnn ated. The infraspinatus can be tested by
assessing external rntatinn strength with the arm in ad—
ductinn and the elb-nw at 9i)“ nf flexinn. The subscapularis
can be assessed by using the lift-nff and belly-press tests.
Either tests cnmmnnly used are the external rntatinn lag
sign and the hnrnblnwer sign, bnth nf which assess fnr
failure nf the infraspinatus and teres miner, and the drnp
arm test fnr the superinr rntatnr cuff. Hn single test fnr
rntatnr cuff disease has prnved tn he nf greater diagnnstic
value. Rather, a 2014 study validated a cnmbinatinn nf
pnsitive tests that greatly increases the specificity nf a
rntatnr cuff disease diagnnsis.”
Diagnnstic Imaging
A series nf plain radingraphs nf the shnulder, including
a Grashey AP view, lateral nutlet viewi'scapular T view,
and an axillary lateral view shnuld he the first diagnnstic
Eb Ifllti American Academy nf Urthnpaedic Surgenns
Chapter 3: Entatnr Cuff Disease
studies nbtained. The presence nf superinr migratinn cf
the humeral head with a diminished acrnminhumeral
interval, glennhumeral inint space narrnwing that sug-
gests nstenarthritis, acrnminclavicular jnint arthrnsis,
and features nf rntatnr cuff arthrnpathy with mnrphnlngic
changes nf the humeral head, glennid, and acrnmial arch
are all detectable findings nn plain film radingraphs.
MRI has prnved incredibly useful in diagnnsing rnta-
tnr cuff disease. Nnt nnly dnes MRI prnvide the surgenn
with a qualitative diagnnsis, it alsn can help determine
the cnnditinn nf the muscle, the size and lncatinn nf the
tear, the amnunt nf tendnn retractinn, and perhaps mnst
impnrtantly, the presence nf nther pathnlngy that shnuld
be managed during surgery tn prnvide the best pnssible E
nutcnme. A new methnd tn assess the quality nf the mus- "fl
culature nn MRI is the tangent sign {Figure 3}, which a,
1]
is the failure nf the supraspinatus tn intersect the line F”
E's
frnm the superinr bnrder nf the cnracnid prncess tn the m
superinr bnrder cf the scapular spine. This methc-d is E.
a!
quick and has been shnwn tn predict the reparability nf
rntatnr cuff tears.”
The use cf ultrasnnngrapby has steadily increased in
recent years, and it can be as accurate as MRI in di-
agnnsing rntatnr cuff tears. Ultrasnnngraphy has alsn
been recently shnwn tn accurately assess the degree nf
degeneratinn nf muscle in chrnnic rntatnr cuff tears.” It
is less expensive than MRI, and may best be used nnt as
an initial diagnnstic agent but tn assess repair integrity
in pnstnperative patients.
Nnnsurgical Treatment
Nnnsu rgical management nf rntatnr cuff pathnlngy typi-
cally cnnsists nf E tn 12 weeks nf rest, symptnm manage-
ment, and physical therapy with a hnme exercise regimen
that fncuses nn passive and active range nf mntinn and
strengthening the scapular stabilizing muscles and rnta-
tnr cuff musculature. NSAIDs and the nccasinnal sub-
acrnmial injectinn can alsn be cnnsidered in the painful
shnulder but cnuld affect the pntential fnr pnstnperative
healing. Bursal injectinn can be perfnrmed using an an-
terinr, lateral, nr pnsterinr apprnach, the anterinr and
lateral apprnaches demnnstrated increased accuracy in
nne recent study.”
Effnrts have increasingly fncused nn determining which
patients can be mnst predictably treated nnnsurgically,
and thnse whn are more likely tn be recalcitrant tn nnn-
surgical effnrts and require interventinn. The Multicenter
Drthnpaedic IE'tutcnmes Netwnrlc shnulder grnup studied
a grnup nf 452 patients with asymptnmatic full-thickness
rntatnr cuff tears initially treated nnnsurgically with a
physical therapy prntncnl. At 2-year fnllnw-up, 3% nf
Drthnpaedic Knnwledge Update: Spnrts Medicine 5
 Section 1: Upper Extremity
1: Upper Extremity
Figure 3 Magnetic resonance image demonstrate the
tangent sign- A, Medial sagittal T1 -weighted
image depicts su praspinatus muscle atrophy
and fatty infiltration just below the tangent
line of the scapula (red line}. B, |Eoronal T2—
weighted image depicts a corresponding large,
retracted posterosuperior rotator cuff tear.
C, Medial sagittal T1—weighted image depicts
a healthy su praspinatus muscle occupying the
entire su prasca pular fossa and without fatty
infiltration {red line}. D, Eoronal Til—weighted
image depicts a corresponding normal
so praspinatus myotendinous unit.
patients did not go on to surgery, and most therapeutic
failures occurred in the first 12 weeks.”1
Large, welludesigned studies comparing surgical and
nonsurgical treatment of rotator cuff tears have only re—
cently been published. A Norwegian group compared
physical therapy with immediate repair in a single-center
randomized controlled study.m Small and medium {:3
cm} tears were confirmed on MRI. Overall, patients in
the surgical group had slightly better Constant and Amer-
ican Shoulder and Elbow Surgeons scores, but the data,
although significant, were likely not clinically important.
flf note, one-third of the nonsurgically treated patients
had poor outcomes with an associated increase in rear
size greater than 5 mm.
Surgical Considerations
The rate of arthroscopic rotator cuff repair has increased
dramatically since its development, with a concurrent
decrease in open rotator cuff repairs. A shift toward
flrdiopaedic Knowledge Update: Sports Medicine 5
outpatient treatment of rotator cuff tears has also oc-
curred.21 Numerous studies have demonstrated equiva-
lent outcomes when comparing open and arthroscopic
techniques. The arthroscopic technique has become more
mechanically similar to the open technique, with the ties
velopment of a medial- and lateral-row suture bridge
construct commonly,r referred to as a tra nsosseous-equiv-
alent repair. This type of arthroscopic repair has shown
excellent outcomes with maintenance of functional out-
comes scores and strength at 5 years.ll A typical approach
to arthroscopic rotator cuff repair has been illustrated
[Figures 4 and 5}.
Despite these advances, primary repair can still fail,
especially in the setting of large and massive, retracted
tears. Thus, the ability to augment or biologically en-
ha nce a repair has received substantial attention. Biologic
augmentation with products in the family of platelet—rich
plasma {PEP}, platelet-rich fibrin matrix {PRFM}, or
platelet-leukocyte membrane has been studied extensively.
The preparation, method of delivery, and incorporation
into repairs has not been standardized and continues
to make evaluation of these new products challenging.
Several recent randomized controlled studies have pro—
vided new data that could help to discern the potential
benefit of biologic augmentation of rotator cuff repairs.
Longer follow—up and an assessment of patient subgroups
[such as age, sex, and tear sine and location] could help
find specific indications for use of PRPIPRFM in repairs.
Several large, blinded, randomized studies have shown
no substantial difference in outcomesFl“ Additionally,
a systematic review of all level I or II studies on PEP for
rotator cuff repair augmentation did not identify any
benefit greater than the minimum clinically important
difference?
The incorporation of either synthetic or natural graft
material can also be used to augment repairs. Kenografts,
dermal or collagen grafts, and synthetic mesh-type grafts
have been studied. A few short-term outcomes studies
have shown promise, but further longer term review is
lackingfif'lf
Although most studies show that rotator cuff repairs
have successful, enduring clinical outcomes that can result
in the assumption of tendon-to-bone healing, evidence
increasingly shows that the integrity of many repairs may
not be what is expected. Actual tendon—to—bone healing
may not always be necessary to achieve a successful clin-
ical outcome, especially in the short term. Both MRI and
ultrasonography have been used to quantify the structural
success after rotator cuff repair. A systemic review iden-
tified an overall re-tear rate of 20.4%.“ Another study
reported a re—tear rate for medium to massive tears of
12% to 22%, with no difference in patient outcome versus
El 1016 American AcadMy of Cirrhopaedic Surgeons

illustratlen demenstrates a typical appreads te
arthrescepic transesseeus—equivalent retater
cuff re pair. A. The cuff tissue is viewed frern
the lateral pertal fer debridement ef bursal
adheslens. The tear pattern is determined
and the tissue ntebility is assessed using a
nentraumatic grasp-er. B, The greater tube resity
{G T} is deb rided ef seft tissue te allew punctate
bleeding. Medial-rew anch ers are placed just
lateral tn the articular margin percuta neeusly
te allew a mere fave ra ble insertien angle.
C. The sutures are passed th reugh the retater
cuff tenden lateral to the myetendineus
junctien and tied te reduce the tenden te the
medial rew anchers. D. The suture limbs are
bre ug ht te lateral revv ltnetless anchers te
cemplete the repair. ALF = anterelateral pertal,
AP = anterier pertal. I5 = lnfraspinatus.
PLP = peste relateral pe rial, PP = pesterier
pertal. 55 = supraspinatus.
the intact repairs.” Altheugh tenden-te—bene healing may
net result frem all repairs, eutcemes remain faverable. A
meta-analysis ef seven level I er II studies suggests that the
integrity ef the repair dees net cerrespend with entceme
but it dees cerrespend with strength.”
El Ifllii American Academy ef flrfltepaedie Surgeens
Chapter 3:1letater Cuff Disease
E
"fl
e,
1]
F”
E?
l'lll
a
Figure 5 Arthrescepic view dem enstrates a cempleted a!
tra nsesseeus-e-qulvalent arthresceplc retater
cuff re pair.
Pesteperative Cencerns
Traditienal pesteperative rehabilitatien regimens have
emphasized an immebiliaatien peried ef 6 weeks, with
gradual passive range ef metien fellewed by active-
assisted range ef metien starting in the early pesteperative
peried. The ratienale fer early metien has been te limit
the develepment ef tissue adhesiens; extended itnmehili-
aatien enceurages tissue healing in a lewnstress enviren-
ment fellewed by subsequent return ef range ef metien.
The eptimum time te start passive range ef metien has
been debated censiderably. Pl. prespective randemiaed
study shewed ne difference in eutceme and final range
ef metien with early versus late initiatien ef metien fer
small- er medium-size tears (53 cm].“ This finding was
supperted by a recent meta-analysis, which cencluded
that small- er medium-size tears have a lewer risk ef re-
test when metien is started within 1 week. Hewever, it
alse reperted that massive tears {3+5 cm} have a greater risk
ef re-tear when metien is started early, suggesting that
patient-specific pesteperative pretecels can be beneficial.32
Tenden Transfers
Yeunger patients with massive, irreparable tea rs represent
a particularly difficult subset te treat. Altheugh elderly,
lew-demand patients can eften be treated effectively with
reverse tetal sheulder arthreplasty, this is net yet an ac-
cepted eptien in the middle-aged patient with a massive
Drthepaedie Knewledge Update: Sparta Medicine .5
 Section 1:1}pperExtremity
tear that has become irreparable. Direct transfers of the
latissitnus dorsi musculotendinous unit for irreparable
posterosuperior tears has been used by many authors as
a salvage option for irreparable tears in patients younger
than Efl years. The transferred tendon has been postu—
lated to function as a tissue augment, an external rotator
of the shoulder joint, a humeral head depressor, and to
act in concert with the intact subscapularis {which is a
prerequisite for consideration of a latissimus dorsi trans-
fer} to restore the rotator cuff force couple and assist the
dcltoid in elevation and abduction. fl. successful latissimus
dorsi transfer can improve patient subjective outcomes,
decrease pain, and improve strength and range of motion,
but not as well as that of a reparable tear.’J Poorer results
1: Upper Extremity
can be expected in patients with concomitant deficiencies
of the subscapularis and teres minor.“ In the setting of
a tendon transfer, it is important to counsel patients not
to expect an undeliverable outcome.
Reverse Total Shoulder Arthroplasty
In patients with irreparable massive tears with a low
shoulder functional demand and in the setting of rotator
cuff tear arthropathy, reverse total shoulder arthroplasty
is a proven, effective treatment. The function of the pro-
cedure is to alter the joint mechanics, thus providing a
mechanical advantage to the dcltoid muscle by medialie—
ing the center of rotation and translating the humeral side
inferiorly, allowing the dcltoid to function without the
assistance of the rotator cuff musculature while replacing
the wnm articular surfaces. Concerns related to longevity
should be considered in patients younger than 51'] years
because long-term implant survivorsbip is not yet clear.
The outcomes for reverse total shoulder arthroplasty in
patients with rotator cuff disease have been favorable.”
Patient selection is paramount because studies including
patients younger than 65 years can have less favorable
long-term outcomes?5
5 u or ma ry
Rotator cuff disease increases in prevalence with age,
with many patients having both symptomatic and asy mp-
tomatic tears. Tears typically occur in reliable patterns,
and for chronic tears in older patients, most can ini—
tially be treated nonsurgically with a high success rate.
Repair is now commonly performed arthroscopically,
with equivalent outcomes to open surgery despite a
less-than-ideal rate of definitive healing, especially in
larger tears. Physical therapy tailored to patient- and tear-
specific factors should be started in the postoperative pe-
riod. Salvage operations including tendon transfers and
flrdtopaedic Knowledge Update: Sports Medicine 5
reverse total shoulder arthrnplasty have favorable out-
comes and should be considered on a case—by—case basis.
Hey Study Points
in Rotator cuff disease is common and the incidence
increases with age in patients older than 50 years.
It History and physical examination followed by MRI
confirmation help guide treatment.
It lviany chronic small rotator cuff tears can be treated
successfully uonsurgically.
it Both arthroscopic and open repair techniques can
yield good results.
1* Postoperative therapy protocols are best when
individualized based on tear size.
Annotated References
1. Mather RC III, Koenig L, Acevedo D, et al: The societal
and economic value of rotator cuff repair. ] Hone joint
Surg Am .2013;95{22}:1993—1flflfl. Medline DUI
This study examined the effect of rotator cuff disease
on earnings, missed workdays, and disability payments
using a Markov decision mode] to determine the economic
effect of the disease on society. Societal cost savings were
estimated at approximately $3.44 billion per year due to
rotator cuff repairs.
2. “'r'amamntn A, Takagishi Ii, lElsawa T, et al: Prevalence
and risk factors of a rotator cuff tear in the general pop-
ulation. I Sboufder Efbottr Snrg lfllfl;19{1}:116-12fl.
Medline DUI
This study used ultrasonography to determine the preva-
lencc of rotator cuff tears in a mountain village in Japan
for patients of all ages. Rotator cuff tears are rare in young
patients but increase steadily for each decade in life after
age 5D years.
3. Ternagucbi K, Ditsios K, Middleton WI], Hildebolt CF,
Galata Ll'vi, Teefey SA: The demographic and morpho—
logical features of rotator cuff disease. A comparison of
asymptomatic and symptomatic shoulders. I Bone joint
Surg Am Zflfl6;33{31:1699-1?fl4. Medline DUI
This article investigated the correlation between symp-
toms and cuff tear siec progression. Larger tears were
more likely to be symptomatic and be accompanied by a
contralateral cuff tear.
4. Moosmayer S, Tariq R, Stiris M, Smith H-]: The natu-
ral history of asymptomatic rotator cuff tears: A three-
year follow—up of fifty cases. I Bone joint Surg Am
2013;95f14}:1249-1255.Modline not
This study followed patients with asymptomatic cuff tears
using ultrasonography to determine the natural history
El ll] 16 American AcadMy of Drtbnpaedic Surgeons

of the disease and which factors were associated with
symptom generation. Increase in tear size and decrease
of muscle quality were associated with development of
symptoms. Level of evidence: II.
Mall NA, Kim HM, Keener JD, et al: Symptomatic pro-
gression of asymptomatic rotator cuff tears: A prospective
study of clinical and sonographic variables. 1 Bone Joint
Surg Am lfllflfllflfihlfilfi-EEES. Medline DUI
This research study followed asymptomatic patients us-
ing ultrasonography to determine that symptoms begin
with increases in tear size or progression from partialv to
full-thickness tears. Leml of evidence: III.
Kim HM, Dahiya bi, Teefey 5A, Keener JD, IIlialatz LM,
Yamaguchi K: Relationship of tear size and location to
fatty degeneration of the rotator cuff. I Bone joint Ens-g
Ans 2010;91H}:329-339. Medline D-UI
This article determined that fatty degeneration of the
rotator cuff musculature is associated with both loca-
tion and tear size. The loss of the fibers of the anterior
supraspinatus tendon can result in development of fatty
degeneration of the muscle.
Namdari S, Donegan RP, Dahiya bl, Galatz LM, Yama-
guchi K, Keener JD: Characteristics of small to medi-
um-sized rotator cuff tears with and without disruption
of the anterior supraspinatus tendon. j Sbonfder Efbow
Snrg companies—1v. Medline nor
This article examined the results of rotator cuff tear re—
pairs that involved the anterior supra spinatus tendon and
those that did not. Anterior tears involving the rotator
cuff cable were larger and more likely to have associated
muscle degeneration but had no influence on structural
results after surgery. Level of evidence: III.
Mesiha MM, Derwin EA, Sibole SC, Erdemir A, McCa—
rron JA: The biomechanical relevance of anterior rotator
cuff cable tears in a cadaveric shoulder model. J Bone joint
Snrg Ant lfl13;95{1fl}:131?-1324. Medline DUI
This biomechanical cadaver study showed that tears
involving the anterior 3 to 12 mm of the supraspinatus
tendon, in which the rotator cuff cable is present, devel-
op larger gaps when subject to loading that tears in the
posterior supraspinatus, the crescent area. This supports
the importance of the rotator cuff cable in load bearing
versus the more stress-shielded crescent area.
Motta CdaR, Amara] Mini, Rezende E, et al: Evidence
of genetic variations associated with rotator cuff dis-
ease. ] Shonfrier Elbow Snrg' 2fl14;13{2}:22?-235.
Modline DUI
The authors investigated the link between 23 single-nu-
cleotide polymorphisms within six genes and their asso-
ciation with degenerative processes in the development
of rotator cuff disease. These genes correlated with the
presence of rotator cuff disease as well as female sex and
Caucasian race. Leml of evidence: III.
ID. Tashiian RE, Farnham JM, Albright F5, Teetlink CC, Can-
non-Albright LA: Evidence for an inherited predisposition
U Ifllii American Academy of Urthopaedic Surgeons
Chapter 3: Entamr Cufl' Disease
contributing to the risk for rotator cuff disease. J Bone
joint Surg Am 2009:91i5]:113ti-1142. Medline DUI
This study used genealogic data from a population in Utah
to determine the presence of excess familial clustering for
rotator cuff disease. The findings strongly supported a
heritable predisposition to rotator cuff disease. Level of
evidence: III.
11. DeUrio JK, Coiield RH: Results of a second attempt at
surgical repair of a failed initial rotator-cuff repair._,I Hone
joint Snrg Ant 1934,55l4]:563-561 Medline
12. Patte D: Classification of rotator cuff lesions. Cffn Urtbop
Refer Res 1990;254:31—36. Medline
13. Goutallier D, Postel JM, Eernageau J, Lavau L, Voisin
MC: Fatty muscle degeneration in cuff ruptures. Pre- and E
postoperative evaluation by CT scan. Cfin Urtfiop Reins "fl
Res 1994:3fl4:?3-33. Medline s,
1]
F”
14. Davidson J, Eurkhart 55: The geometric classification of E?
n:
rotator cuff tears: A system linking tear pattern to treat- E.
ment and prognosis. Arthroscopy lfilfl;16{3}:41?-424. c!
Modline DUI
The authors proposed a new classification for rotator cuff
tears based on geometry of the cuff tear that was linked
to prognosis and treatment technique.
15. Somerville LE, Willits K, Johnson AM, et al: Clinical
assessment of physical examination maneuvers for rota-
tor cuff lesions. An: I Sports Med lfll4:41{33:1 911—1919.
Medline DUI
This study investigated the sensitivity and specificity of
various physical examination tests for rotator cuff disease
when correlated with surgical evidence of rear. No test in
isolation provides enough data for diagnosis but rather
that a combination of tests improves the ability to diagnose
rotator cuff disease. Level of evidence: I.
16. Kissenberth M], Rulewicz C], Hamilton SC, Bruch
HE, Hawkins Ii]: A positive tangent sign predicts the
repairability of rotator cuff tears. }' Shoulder Elbow Sang
lDl4;23{?}:Ifl23-Ifl21Medline DUI
The authors proposed the tangent sign, a novel, quick
method to determine muscle quality in the setting of re-
tator cuff tears. This method was shown to be predictive
of reparability of cuff tears. Level of evidence: II.
1?. Wall LB, Teefey 5A, Middleton WD, et al: Diagnostic
performance and reliability of ultrasonography for fatty
degeneration of the rotator cuff muscles. I Hone joint Sang
An: ED12;94{12]:e33. Medline DUI
This study compared the diagnostic performance and
observer reliability of ultrasonography in grading fatty
degeneration of the rotator cuff musculature when com-
pared with MRI. The group found that ultrasonography
and MRI were comparable. Level of evidence: II.
13. Maman E, Harris C, 1'ilii'hite L, Tomlinson C, Shashank
M, Eoynton E; EranMaman: Outcome of nonoperative
Urthopaedic Knowledge Update: Sports Medicine 5
 Seetien 1:1}pperExtremity
treatment ef symptematic retater cuff tears meuitered
by magnetic resenance imaging. ,I Ilene fefrrt 3mg Am
2UD9;91{3}:1393-19fl6. Medline DUI
This retrespective study investigated the natural histety
ef patients with retater cuff disease using nensurgical
metheds with MRI at d menths er lenger. After age
ED years, fatty infiltratien er the presence ef a full-thick-
ness tear were asseciated with tear pregressien. Level ef
evidence: IV.
15. Kuhn JE, Dunn WE, Sanders R, et al: MUUN Sheul—
der Greup: Effectiveness ef physical therapy in treating
atraumatic full-thickness retater cuff tears: A multi-
ccnter prespective cehert study. I Sbeufdet Elbert! Surg
2fl13;32{lfl):13?1-13?9.Medline DUI
This prespective multicenter study examined the effec-
1: Upper Ertrem ity
tiveness ef physical therapy as a treatment medality fer
atraumatic full—thickness retater cuff tears in a cehert
ef 451 patients. All patients began physical therapy and
were subsequently allewed te cheese surgery er further
physical therapy. Fewer than 25% ef patients elected te
underge surgery, and mest cemmenly did an between 6'
and 12 weelrs.
If}. Meesmayer S, Lund G, Seljem U5, et al: Tenden repair
cemparcd with physietherapy in the treatment ef re-
tater cuff tears: A randemised centrelled study in 1&3
cases with a five-year fellew-up. I BDHE fefrrt Serg Am
lfl]4:96{13l:1504—1514. Medline DUI
This randemised centrelled study cernpared surgical
and nensurgical treatment ef retater cuff tears less than
3 cm in size: 24% ef patients in the nensurgical greup
underwent secendary tenden repair with inferier results
cernpared with these treated with primary repair. Over-
all, the differences in eutcemes berween the greups were
small, and the clinical significance may be miner. Level
ef evidence: I.
21. Iyengar J], Samagh SP, Schairer W, Singb G, Valerie FH III,
Feeley ET: Current trends in retater cuff repair: Surgical
technique, setting, and cest. Arthrescepy 2014;3fli3}:234-
233. Medline DUI
This study reperted en current trends in retater cuff repair
using a Flerida database. fl. rapid increase in arthrnscepic
repair, decrease in epen repair, and increase in the number
ef cases perfenned in eutpan'ent centers were reperted.
Guletta LU, Nhe SJ, Dedsen CC, Adler RS, Altcbei:
DW, MacGillivray JD; H55 Arthrescepic Retater Cuff
Registry: Prnspective evaluatien ef arthrnscepic reta-
ter cuff repairs at .5 years: Part I—functienal eutcemes
and radiegraphic healing rates. } Sheulder Elbert: Surg
2D11:20{6J:934-940.Medli11e DUI
This prespective cehert study ef 193 patients whe un-
derwent all-arthrnscepic retater cuff repair was fellewed
fer 5 years. The midrange results were geed, with lasting
functienal imprevements. The healing rate, determined
using ultrasenegraphy, eentinued te increase ever n'rne.
Level ef evidence: II.
Urrhepaedie Knewledge Update: Sperrs Medicine 5
23. Weber 5C, Kauffman _]I, Parise C, Weber 5], Kat: 5D: Plate-
letaricb fibrin matrix in the management ef artbrescepic
repair ef the retater cuff: A. prespective, randemised,
deuble-blinded study. Am ] Sperts Med 2013:41i2i:263-
2T0. Medline m
This investigatinn ef the use ef PRFl'vI in retater cuff repair
shewed ne substantial difference in eutceme er structural
integrity. Level ef evidence: I.
24. Castricini R, Lenge UG, De Benedette M, et al: Plate—
let-rich plasma augmentatieu fer arthrescepic retater cuff
repair: A randemiaed centrelled trial. Am I Sperts Med
1011;39i2}:253-265. Medliue DUI
The anthers perfermed a randemized centrelled trial In
determine if PRP augmentatieu impreved retater cuff
repair ef small- er medium-sire tears. Ne imprevement
was detected. Level ef evidence: I.
2.5. Wartb R], Deman G], James EW, Heran MP, Millett
P]: Clinical and structural eutcemes after arthrnscepic
repair ef full-thickness retater cuff tears with and witheut
platelet—rich preduct supplementatien: a meta-analysis
and meta-regressien. Arthrescepy 2015:31i2]:3ilE-32il.
Medline DUI
This meta-analysis ef level I and II studies ef PEP aug-
mentatien ef retater cuff repairs feund ne substantial
difference in everall gain in eutceme scere er re-tear rates.
Hewever, evidence supperted decreased re-tear rates fer
tears greater than 3 cm, which received PEP augmentatieu
during repair. Level ef evidence: 11.
26. Ciampi I", Scetti C, Nenis A, et al: The benefit ef syn-
thetic versus bielegical patch augmentatieu in the repair
ef pesteresuperier massive retater cuff tears: A 3-year
fellew-up study. Am I Sperts Med 2014;41{5l:1169-11T5.
Medliue DUI
The anthers investigated mechanical augmentatieu ef
retater cuff repair with twe patch types versus a centrel
greup. Pelyprepylene patches were feund te impreve eut-
cemes at 36 menths. Level nf evidence: III.
2?. IGupta AK, Hug K, Beggess B, lGavigan M, Teth AP:
Ivlassive er E-tenden retater cuff tears in active patients
with minimal glenehumeral arthritis: Clinical and radie-
graphic eutcemes ef recenstructien using dermal tissue
matrix :tenegraft. Am I Sperts Med 2U13;41[4}:3T2 -3T9.
Medline DUI
This study determined that recenstructien ef irreparable
twe-tenden retater cuff tears with dermal senegraft ceuld
impreve euteemes at 3 years. Level ef evidence: IV.
23. Slabaugh MA, Nhe 5], Grumet RB, et al: Dees the liter—
ature cenfirm superier clinical results in radiegraphically
healed retater cuffs after retater cuff repair? Artbrescepy
IDID;IE{3}:393-4DlMedIine DUI
This systematic review assessed the literature te deter—
mine a cerrelatien between cuff healing and eutceme. The
everall re-tear rate was 31.4% and the study suggested
that intact cuff repairs can impreve seme eutceme sceres.
Level ef evidence: I‘v'
El 1016 American AcadMy ef Urrbepaedic Surge-ens

29. Kim KC, Shin HD, Lee WT: Repair integrity and func-
tinnal nutcnmes after arthrnscnpic suture-bridge rnta-
tnr cuff repair. I Hurts Inner Surg Am 2fl12;94{3}:e43.
Medline [II-DI
This study used ultrasnnngraphy nr MRI tn assess heal-
ing rates nf rntatnr cuff repairs. The authnrs fnund an
increased rate nf re-tear fnr larger tears but fnund nn
cnrrelatinn between integrity nf the repair and clinical
nutcnme. Level nf evidence: I‘v".
30. Russell RD, Knight JR, Mulligan E, Khazzam MS: Struc-
tural integrity after rntatnr cuff repair dnes nnt cnrrelate
with patient funetinn and pain: A meta-analysis. I Bursa
Infra-t 3mg Am 2014;95i4}:265-2?1. Medliue DUI
This meta-analysis nf level I nr II studies fnund a 213%
nverall rate nf re—tear, nu difference in rear size between
intact and failed repairs, and nn cnrrelatinn between intact
repairs and re-tnru repairs nn clinical nutcnmes. Level nf
evidence: II.
31. Keener jD, Galatz Ll'vI, Stnbbs-Cucchi G, Pattnn R, Ta-
maguchi K: Rehabilitatinn fnllnwing arthrnscnpic rntatnr
cuff repair: a prnspective randumised trial uf immubiliaa-
tinn enmpared with early mntinn. I Bursa jurist Sarg Am
2014;95i1}:11-19.Med1ine DUI
This level I study nf patients undergning arthrnscnpic
repair nf small nr medium—sized tears randnmited tn early
nr delayed pustnperative range nf mntinn grnups fnund
as clinical advantage tn early passive mntinn versus im-
mnbilizatinn. Level nf evidence: I.
32. Klucsynski MA, Nayyar S, Maren JM, Eissnn L]: Early
versus delayed passive range nf mntinn after rntatnr cuff
repair: A systematic review and meta-analysis. Am I Sparta
Med 2015;43{3}:3fl57~2053. Medlil‘le DUI
This study analysed the literature tn determine re-tear
rates when pnstnperative passive rnntinn is started within
1 week nr delayed 3 tn 5 weeks. Gl'flllpfid level I studies
found an difference in re—tear rates. Hnwever, re-tear rates
were higher fur massive tears when early mntinn was ini-
tiated and higher fnr smaller tears when early mntinn was
Eb Ifllfi American Academy nf flrflinpaedje Surgenns
lIEhapter 3: Rntatnr Cuff Disease
delayed, suggesting that rehabilitatiun prngrams shnuld
be patient-specific based nn tear size.
33. Namdari 5, Unleti P, Baldwin K, Glaser D, Huffman GR:
Latissimus dnrsi tendnn transfer fnr irreparable rntatnr
cuff tears: A systematic review. I Enne Inner Surg Am
1012;94[101:391-393.Medline DUI
This systematic review nf available literature cnnfirmed
that latissimus dnrsi tendnn transfers fnr irreparable rnta-
tnr cuff tears imprnve shnulder functinn, strength, mntinn,
and pain relief. Level nf evidence: I‘v'.
34. Gerber C, Rahm 5A, |L'L‘atansarn S, Farshad l'v'I, Mnnr BK:
Latissimus dnrsi tendnu transfer fnr treatment nf irrepara-
ble pnsternsuperinr rntatnr cuff tears: Lung-term results
at a minimum fnllnw-up nf ten years. I Bees faint Sarg
am sulssspnasau-iass. Medline but E
A lung-term study sf 5? shnulders fullnwed fnr at least "fl
a,
1]
lfl years cnnfirmed that latissimus dursi transfers are suc-
cessful and prnvide lasting imprnvement tn patients with F”
irreparable rntatnr cuff tears. Level nf evidence: IV. E?
m
E.
35. Wall E, Nevé-Jnsserand L, D’Cnnnnr DP, Edwards TE, a!
Walsh G: Reverse tntal sbnulder arthrnplasty: A review
nf results accnrding tn etinlngy. } Burrs jnfrtt Surg Am
lDU?;39{?]:14T6—1435.Medline DUI
This study stratified the nutcnmes nf reverse tntal shnulder
arthrnplasty hy indicatinn, finding that patients with rats-
tnr cuff arthrnpathy had better clinical results that patients
undergning the prncedure fnr pnsrtraumatic arthritis nr
in revisinn cases. Level nf evidence: II.
36. El: ET, Heultnm L, Catanaarn 5, lGerber C: Reverse
tntal shuulder arthrnplasty fur massive irreparable rn-
tatnr cuff tears in patients ynunger than 65 years nld:
Results after five tn fifteen years. I Sbnnfder Ebb-nu: Sing
1013:22{9]:1199-12fl3. Medline DUI
The anthers studied the nutcnme nf reverse tutal shnulder
arthrnplasty fnr patients ynunger than 65 years. Substan-
tial, lastiug imprnvement was fnund in nverall functinn up
tn ID years frnm surgery. Level nf evidence: IV.
Drrhnpaedis Knnwledge Update: Spnrrs Medicine .5
Chapter 4

Superior Labrum and

Biceps Pathology
Bryan G. Vopat. l'vID Jeffrey E. Wong, l'vID Petar Golijanin, BS MatthewT. Provencher. MD

Abstract Introduction

Superior labrum anterior to posterior [SLAP] tears E

Superior labrum tears were first described in 1935‘; they
and pathology involving the long head of the biceps "fl
were subsequently classified in 15‘5”).i These detachment s;
1]

[LHB} tendon are both common issues that can result

injuries, or superior labrum anterior to posterior {SLAP} F”

in shoulder pain, dysfunction, and activity limitation. ii

However, it can be difficult to identify SLAP and LHB
pathologies as the sole culprit because they are com-
monly seen with other injuries. The treatment of both
issues remains controversial and a subject of continued
research. SLAP repairs have had more beneficial results
in patients younger than 4!} years and when not associ-
ated with a rotator cuff repair. Ideal treatment of LHB
tendon pathology is still evolving; patient desire and
s tgeoflpSela-ET: 3“” i131? dfllifliftmp31%;:Tlfflmy,
or fighdflffzdjo 53’ hiE:flTl'lisgl?t:ra:n1:Ffiafls not cle fl’
fionstrated agar Priors icalo tion 1-] e er its:
. upe . org? Pi ' . v 'w
tenodcsis or tenotomy1smd1cated,tenodes1s should be
performed in those with higher levels of physical ac-
tivity patients concemed with cosmesis and workers’
co
! j
tears, also can possibly involve the long head of the biceps to
E.
{LH E} tendon. The LI-IB tendon has been identified as a!
an important pain generator in the shoulder; however, it
can be difficult to isolate the LHB involvement because it
commonly occurs with other disorders. Currently, this pa-
thology can be treated with either a tenodcsis or ten otomy.
The glenoid labrum is composed of fibrocartilaginous
tissue. The suprascapular artery, the circumflex scapu-
lat branch of the subscapular artery, and the posterior
humeral circumflex artery provide the labrum‘s vascular
I The l . . hi tb . h I
supp in se “355E E arbortae Wt 11 E petlp era aspect
of the labrum. The inner portion of the labrum is avas-
cular1! and the superior labrum is less vascular compared
. .

mpensatlon cases. Several types of tenodcsis proce- with the inferior and posterior labrum 3
. -

r can be performed but the literature has not . . . '

23:11:;fiecl fl t'mal “'3‘“;a F t re research is neededt
p1 u u
1:“ hElP ldmtlfl" fl“: best treatment optlons for patients.
Keywords: biceps tendinopathy; SLAP; biceps
tenodesis; biceps tenotomy; biceps tendinitis
The supenor labrum is usually triangular but can have
a meniscoid shape. It commonly attaches medial to the
articular margin of the glenoid rim. This medial attach-
ment at the supraglenoid tubercle creates a subsynovial
recess; 40% to 60% of the LHB tendon originates from
the supraglenoid tubercle, and the remaining fibers insert
directly into the superior labrum. The LHB can have
an entirely posterior, posterior—dominant, or equally

Dr. Vopat or an immediate family member serves as a paid consultant to DePuy. Dr. Frovencher or an immediate family
member has received royalties from Arthrex; serves as a paid consultant to Arthrex and the Joint Restoration Founda—
tion; and serves as a board member; ownei: officer. or committee member of the American Academy of flrthopaedic
Surgeons. the American Grthopaedic Society for Sports Medicine. American Shoulder and Elbow Surgeons. the Arthros-
copy Association of North America. the international Society of Arthroscopy. itnee Surgery. and Orthopaedic Sports
Medicine. the San Diego Shoulder institute. and the Society ofMilitary Orthopaedic Surgeons. Neither of the following
authors nor any immediate family member has received anything of value from or has stocic or stock options held in a
commercial company or institution related directly or indirectly to the subject of this chapter: Dr. vvbng and Mn Goliianin.

@ lfllfi American Academy of Drthopaedic Surgeons Orthopaedic Knowledge Update: Sports Medicine S e
 Section 1: Upper Extremity
1: Upper Extremity
Figure 1 A. Arthroscopic view via the posterior portal demonstrates normal attachment of the long head of the biceps
tendon with the patient in the decubitus position. B. Arthroscopic vievv demonstrates a cordlilte middle
glenohumeral ligament. a normal variant. which can be identified with the probe inserted via the anterior portal.
This structure should not be repaired.
anterior-posterior attachment at the superior labrum. In
most cases, the LHB has a posterior-dominant or entirely
posterior labral insertion.‘l The LHB anchor has some
inherent physiologic motion, and overconstraint from
repair can contribute to stiffness.
Anatomic variants in the superior labrum must also
be recognised. Variants include a sublabral foramen or
absence of the superior labrum, often seen together with
a cordlike middle glenohumeral ligament {MEI-IL}. The
following labral anatomic variants were identified: 3.3%
had a sublabral foramen, 3.6% had a sublabral foramen
with cordlike MGHL, also called a Buford complex [Fig-
ure 1}, and 1.5% had an absent anterosuperior labrum.5
Surgical repair of these anatomic variants can result in
loss of external rotation.
The LHB passes intrararticularly over the humeral
head before exiting the glenohumeral joint in the bicipital
groove? The LHE pulley, especially the coracohumeral
ligament and superior fibers of the subscapularis, stabilize
the extra-articular LHB as it enters the bicipital groove.
A subscapularis tear should be highly suspected in the
setting of LHB instability, and vice versa. The subscapu—
laris tendon, supraspinatus tendon, coracohumeral liga-
ment, and superior glenohumeral ligament comprise the
soft—tissue sling.“ The LHB tendon is innervated by thinly
myelinated sensory neurons. Most of this innervation
occurs at the LHB origin: therefore, pathology in this
region can generate pain.‘I Blood is supplied to the LHB
tendon from the thoracoacromial and brachial arteries
via the osteotendinous and musculotendinous junctions,
respectively.|Ii A hypovascular zone found near the tendon
origin at the superior glenoid attachment corresponds
flrdiopaedic Knowledge Update: Sports Medicine 5
to where it commonly tears at the LHB pulley near the
proximal groove.”
Fiathophymiologirr
SLAP tea rs can be caused by forceful traction to the arm,
direct compression loads, and repetitive overhead throw~
ing. Certain anatomic and biomechanical factors can
predispose the overhead athlete to SLAP tears. Increased
external rotation of the shoulder in the late cocking phase
increases torsional force at the LHB root, resulting in
a peeluback injury to the posterosuperior labrum {Fig-
ure 2]. Iniurics can also result from repetitive contact
of the posterosuperior labrum with the nndersurface of
the rotator cuff in the late cocking phase? Studies have
shown that SLAP tears are seen more frequently in the late
cocking position. It has been proposed that the essential
lesion is posterior capsular contracture.” Because of this,
throwing athletes have increased shoulder external rota~
tion and decreased internal rotation in abduction, which
causes posterosuperior migration of the humeral head in
the late cocking phase, which can result in a peel-back
SLAP tear. Increased external rotation results in greater
torsional loads across the superior labrum from the more
posteriorly oriented LHB tendon. The labrum and LHB
tendon displace medially over the glenoid rim, creating
a SLAP tear {Figure 3}. The proximal LHB tendon has
been recognized as a source of substantial paing“ this
can be difficult to diagnose because it is known to occur
with other pathologies including SLAP lesions, rotator
cuff disorders, impingement, bursitis, and other acro-
mioclavicular joint disorders.
El 1016 American Academ~y of Urrhopaedic Surgeons

A E
Figure 2 Arthroscopic views obtained via the posterior portal with the patient in the lateral decubitus position. A. View
shows the biceps attachment to the Iabrum. E, 1ii'iew shows the peel—back sign of the la brunt with abduction and
external rotation.
Figure 3 Arthroscopic view obtained via the posterior
portal with the patient in the lateral decubitus
position demonstrates a type III superior
Iabrum Ell'l'EEll' ti} FDStEl‘lDI" t-Efll". NEI'L‘E the
biceps displaced medially over the glenoicl rim
as a bucket-handle tear of the long head of the
biceps tendon {arrows}.
Pathology of the LHB tendon can include tendinitis,
tears, sublustation, entrapment, delamination, and dislo-
cations out of the bicipital groove.11 Because of the rela-
tively anterior position of the bicipital groove along the
humeral head along with humeral retroversion, the ten-
don is exposed to media] instability, which can increase
degeneration.” The different variations of the bicipital
groove can also increase the risk of LHB tendon pathol-
ogy. However, isolated LHE tendon pathology can still
occur in isolation but is frequently associated with other
shoulder pathologies, especially rotator cuff pathology.
fit Ifllli American Academy of flrfltopaedie Surgeons
Chapter 4: Superior Labrum and Biceps Pathology
"fl
g
1]
F”
ii
fill
When seen in isolation, primary LHE tendinitis usually a.
a!
occurs in younger patients who participate in overhead
activities such as volleyball and baseball.H With LHB ten-
don instability, the patient describes a clicking or snapping
with overhead motions. In addition, a subscapulatis tear
is associated with LHB medial instability and a supraspi—
natus tear is associated with posterolateral instability.”
Classification
Snyder's original classification system of SLAP tears is
the most widely used and recognised? [Figure 4}. Type
I lesions consist of fraying of the superior labrum with
localized degeneration [Figure 5,. A}. The superior labrum
and LHE anchor remain intact. Type II lesions are the
most common and are characterised by detachment of
the superior labrum andfor LHE anchor from the gle-
noid (Figure 5, B}. These lesions demonstrate abnormal
mobility of the labrum and Ll-IB anchor. Type III lesions
are characterized by a bucket-handle tear of the superior
labrum with an intact LHB anchor {Figure 5, E]. Type
IV lesions have a bucket-handle tear of the superior la-
brum that extends into the LHB anchor {Figure 5, D}.
The original classification system has been expanded to
include type V, a SLAP tear combined with a Bankart
lesion; type VI, a SLAP teat combined with an unstable
flap tear of the labrum; and type VII, a SLAP tear that
continues to the MGHL origin.”
Physical Examination
The clinical diagnosis and physical examination of a
SLAP tear or symptomatic LHB tendinopathy is often
challenging because the findings are similar to other
Drrhopaedie Knowledge Update: Sports Medicine 5
 Sectien 1:1}pperExtrernity
1: Upper Extremity
Figure 4 A drawing demenstrating a type I superier
Iahrum anterier te pesterier {SLAP} tear [A]
with fraying ef the superier labru n1, type II
SLAP tear (Bl that includes detachment ef the
su perier la bru n1. type III SLAP tear [E] tensist‘ing
ef a bucket handle-tear ef the su perier la brurn,
and a type IV SLAP tear {DJ demonstrating a
bucket-handle tear that extends inte the bicep.
pathelegies within the glenehumeral jeint.” Ne single
physical examinatien finding is cempletely accurate fer
diagnesing a SLAP tear. It is impertant te inspect fer
shenldcr asymmetry and atrephy ef the retater cuff
muscles. Iselated atrephy ef the infraspinatus can indi-
cate the presence ef a spinegleneid cyst, which is eften
asseciated with a superier labral tear. Range ef metien
and retater cuff strength must be assessed and both are
usually preserved. LHE-specific tests {such as the Speed
and Yergasen tests} can re-create sheulder pain in patients
with SLAP tears. Apprehensien, relecatien, and lead-
and-sbift tests can be perfetmed te assess fer sheulder
stability. Hewever, evert instability in the setting ef an
iselated SLAP tear is rare. Glenehumera] internal retatien
deficit sheuld be assessed in everhead athletes; extreme
deficits greater than 25" re 30“ can predispose patients te
internal impingement and SLAP tears.9 The D’Brien active
cempressien test is the mast cemrnenly used maneuver
te evaluate fer a pessible SLAP tear.” Clinical examina—
tien alene is unreliable in diagnesing SLAP tears when
flrdtepaedic Knewledge Update: Sperrs Medicine 5
multiple physical examinatieu tests have been tempered
with intraeperative findingsdfl"
A defermity ef the LHE tenden such as a Pepeye sign
indicates tenden rupture. The mest cemmen physical
examinatien fer LHB diserder is tenderness caused by
palpating the tenden within the hicipital greeve.” An
examiner can test fer synevitis that is lecalieed in the
hicipital greeve by palpating the tenden medial te the
pecteralis majer insertien during internal retatien with
resistance}1 Fer a mere accurate diagnesis. the examiner
sheuld test the centralateral side and cempare it with
the affected side. Multiple tests have been established te
identifyr LHE tendinitis and asseciated pathelegies but
nene have a reperted pesitive predictable value. Beth the
Yergasen and Speed tests are specific but net sensitive in
detecting LHB tendinitis, rupture, and SLAP lesiens.” A
painful click er tenderness te palpatien at full abductien
and external retatien indicates medial LHB instability.
If the tenden is dislecated, it can be relied under the
examiner’s fingers.21 Different types ef injectiens can
be used fer further treatment and diagnesis. Mest cem-
menly, a subacremial certisene injectien is given first
te differentiate pain caused by impingement frem LHE
tendinitis. If the pain persists, a certisene injectien inte
the hicipital greeve can be given te diagnese and treat
LHB tendinitis.
Imaging
Fer all cases, typical plain radiegraphic views {scapular
‘1’, AP, and axillary lateral} sheuld be ebtained te assess
the jeint fer abnerrnalities. MRI is used te assess the bi—
cipital greeve, LHB tenden, fluid, and beny esteephytes
and can help identify cencemitant pathelegies. Hewev—
er, studies have demenstrated peer cerrelatien between
MRI and arthrescepic findings regarding LHB pathelegy
and peer te mederate sensitivity fer inflammatien, par-
tial-thickness tears, and ruptures.23 Magnetic resenance
arthregraphy {MBA} is mere specific and sensitive for
LHE pathelegy and SLAP tears {Figure 6} than MRI.“
MRA in patients with ne pathelegy shews the tenden
surreunded by centrast fluid and it resembles a kidney
bean. Beth MRI and MBA are needed in the sagittal
eblique and axial planes because LHB snbluxatien and
dislecatien are asse-ciated with pa rtial— and full—thickness
subscapularis tenden tears15 {Figure 7'}.
Ultrasenegraphy is accurate and cest-effective in the
diagnesis ef LHE dislecatien, subluxatien, and rupture.
Hewever, it is net as accurate in diagnesing partial-thick-
ness tenden tears.“ The exact rele ef ultrasenegraphy
fer the diagnesis ef tenden inflammatien has net been
fully defined.
El ll] 16 American Academ1r ef Unhepaedic Surge-ens
 Chapter 4: Superior Lahrum and Biceps Pathology

fiajwasnra .ieddn :j
C
Figure 5 Arthroscopic images obtained Ivia the posterior portal with the patients in the lateral decubitus position {A
through E} and the beach chair position {D}. A, View shows a type i superior labrum anterior to posterior {SLAP}
lesion, with fraying of the superior labrum and localized degeneration {arrows}. B. View shows a type II SLAP
lesion with the superior labrum and biceps anchor detached from the glenoid (arrows). C. View shows a type Iil
SLAP lesion with a bucket—handle tear of die superior labrum and an intact biceps anchor. D. View shows a type
IV SLAP tear of more than Ellie diameter of the long head of the biceps tendon; the tear extends up the biceps
tendon.

Nonsurgical Treatment same level. The nonsurgical protocol consisted of NSMDs

Honsurgical treatment of SLAP tears consists of rehabili-
tation focused on improving posterior capsular flexibility
and strengthening of the rotator cuff muscles and scapular
stabilizers. Intra—articular steroid injections can help in the
diagnosis and treatment of patients with a possible SLAP
tear. In the only study reporting on the nonsurgical treat-
ment of SLAP tests,” the authors found that functional
scores, quality-of-life scores, and pain scores all improved
substantially in 19 patients at an average follow-up of 3.1
years; ?1% of athletes returned to preparticipation levels,
but only 66% of overhead athletes returned to sport at the
and a physical therapy protocol focused on scapular sta-
bilisation and posterior capsular stretching.
The initial step for the treatment of LHB tendon pathol-
ogy is nonsurgical and should encompass physical therapy
to correct scapulothoracic dyskinesia. Because the LHB is
continuous with the synovium of the glenohumeral joint,
cortisone injections can also be used for initial treatment
in the subacromial space or the glenohumeral joint. Some
authors have recommended a diagnostic and potentially
therapeutic corticosteroid injection in the tendon sheath
at the groove; however, this can increase the risk of LHE
rupture if injected within the tendon itself. The authors of

El Ifllti American Academy of Urthopaedje Surgeons Drthopaedic Knowledge Update: Sports Medicine .5
 Section 1:1}pperExtremity
a 1011 study reported an 36.?% accuracy of injection in
the sheath using ultrasonography versus 26.?% without,
and another 40.0% was injected into the tendon itself;
therefore, ultrasonographic guide ncc was recommended.”
Surgical Treatment
Surgical treatment for SLAP tears should be considered
in patients with persistent symptoms whose nonsurgical
1: Upper Extremity
Figure 6 Coronal T1—weightecl magnetic resonance
arthrogram of the shoulder shows a labral tear
[a rrows} on the superior aspect consistent with
a superior labrum anterior to posterior tea r.
Figure I" Axial TEE-weighted magnetic resonance arth rog rams demonstrate an empty bicipital groove. The biceps tendon
can be seen medial to the groove {arrows}. indicating a subscapularis tear [asterisk in A).
flrfltopaedic Knowledge Update: Sports Medicine 5
treatment was unsuccessful for approximately 3 months.
High-level athletes with a SLAP tear are usually allowed
to compete and finish the season. Earlier intervention can
be offered to those patients with evidence of suprascapular
nerve compression from a spinoglenoid cyst.
Arthroscopic surgery can he performed in the lateral
decubitus or beach chair position. Type I tears are usually
debrided. Type II lesions should be repaired when the
history and examination suggest a SLAP tear and the
arthroscopic examination confirms findings of a type II
tear {Figure 3}. The gold standard for the diagnosis of
SLAP tears on arthroscopic examination uses the Snyder
criteria. This includes separation of the chondrolabral
junction, erythema at the LI-IB anchor junction, and a
minimum 5 mm of labral excursion.1 Degenerative type II
tears associated with other lesions in older patients do not
require repair but can he better addressed with debride—
ment, tenodesis, or tenotomy. Type III tears are treated
with either repair of the bucket handle or, depending on
size and tissue quality, a resection of the unstable labral
fragment and repair of the MGHL if it is attached to the
torn fragment. Treatment of type IV tears depends on the
patient age and the extent of LHE tendon involvement. If
less than 30% of the tendon is involved, these tears are
usually treated with debridement. Tears of more than
3fl% of the LI-IB tendon are usually treated with LHE
tenodesis. Although some studies have suggested superior
Iabral ring repair, what to do with the remaining poten-
tially unstable superior labrum after tenodesis remains
controversial.29
Eioabsorbable tacks are no longer used because of con-
cerns about synovitis and cartilage damage caused by the
degradation and release of loose bodies.” SLAP repair
El ll] 16 American AcadMy of Drthopaedic Surgeons
 Chapter 4: Superior Lahcum and Biceps Pathology

Segment; saddn :1
Figure B Arthroscopic views demonstrate a type Ii superior labrum anterior to posterior (SLAP) tear with posterior
extension via the posterior portal, with the patient in the lateral decuhitus position. A. Probe inserted via the
anterior portal. B. The sutures are passed via the anterosu perior portal around the tea r. E. The repaired SLAP tear.

failure is not limited to the use of hioahsorahle tacks. A
reoperation rate of 6.3%, with a 4.3% rate of revision
SLAP repair, has been reported.“ Revision surgery and
failure after index SLAP repair correlated with the use of
absorbable poly-L-D-lactic acid suture anchors. Paralabral
ganglion cysts associated with SLAP tears can success
fully be treated arthroscopically:u The authors of a 1014
study examined patients who underwent open subpectoral
tenodesis for a failed repair of type II SLAP tears in a mili—
tary population.M An 31% return to spurt and active duty
was reported. LHB tenodesis is a predictable, safe. and
effective treatment of failed arthroscopic SLAP repairs.
Concomitant repair of rotator cuff tears and SLAP
tears have shown good clinical outcomes with high pa-
tient satisfaction. In patients 5i} years and older with a
degenerative SLAP tear, a combined LHB tenotom}.r or
tenodesis and rotator cuff repair have shown superior
outcomes compared with rotator cuff and SLAP repair
combined.5M
Data suggest that the rate of SLAP repairs is increas-
ing. A statewide database study in New York reported a
464% increase in the number of SLAP repairs from Zflfll
to Zflifl.” The authors of a EDIE study found that the
percentage of SLAP repairs reported by American Board
of li'Ciirthopaedic Surgery candidates was three times the in—
cidence reported in the current literaturefifi A substantial
increase in the number of SLAP repairs was also noted
in a database study.“ The authors noted that this trend
is slightly worrisome given the relatively high number of
SLAP repairs performed.
Most studies have reported on the outcomes of patients
treated for type II SLAP tears. Pain relief and return of

Eb Ifllti American Academy of Urthopaedic Surgeons Drrhopaedic Knowledge Update: Sports Medicine .5
 Section 1:1}pperExtremity
function can he expected after SLAP repair. However,
retuni to sports is often less predictable. The authors of
one study reported 9?% good to excellent clinical results
and an 34% rate of return to sport in 132 patients treated
with suture anchors for SLAP repair.“ flther studies have
reported 90% to 94% good to excellent results, with
return to preinjury athletic levels ranging from ?5% to
91%. Long—term outcomes after isolated SLAP repair
were found to be independent of patient age, with 33%
reporting good or excellent results at 5-year follow-up.~“"l'41
The authors of a 2010 study also reported favorable results
independent of patient vocation or sport.“1 The authors
of a 2014 study reported prospective clinical outcomes of
arthroscopic treatment of type II SLAP tears in young, ac—
1: Upper Extremity
tive patients.” The study showed substantial improvement
in shoulder outcomes. A reliable return to preinjury level
of activity was less predictable: a 3?% failure rate and a
23% revision rate were reported. In addition, an increased
relative rislc of failure was reported for patients older than
36 years. It has been reported that S?% of patients had
an unsatisfactory result and 9% to 55% were unable to
return to prior activity levels.“ Given these findings, the
reported outcomes after primary SLAP repair have some
inconsistencies.
The optimal surgical treatment of LHB tendon pa-
thology remains controversial. No definitive consensus
exists regarding LHB tenodesis compared with an LHB
tenotomy.“ An increased incidence of cosmetic deformity
{Popeye deformity} in LHE tenotomies was found when
compared with LHB tenodesis (43% versus 3343.}:*6 For
postoperative bicipital pain, similar results were found in
the tenodesis group compared with the tenotomy group
{24% versus 9%}.
Current indications proposed for LHB tenodesis in-
clude degenerative SLAP tears, high-grade SLAP tears,
failed SLAP repairs, those patients who are reasonably
active, patients concerned with cosmesis, and workers’
compensation cases.‘H Relative indications for tenodesis
include a tear of 25% or more of the tendon, longitudinal
tears that decrease gliding in the bicipital groove, sub-
luxation of the LHE tendon, an hourglass {hypertrophy}
LHB,“ disruption of the sling, or if a concomitant sub—
scapularis tear is present.11 However, the surgeon must
also consider the characteristics of the patient, such as
age and activity level. as well when deciding to perform
tenodesis. IEither proposed relative indications include a
symptomatic type II tear in a patient older than 50 years,
failed SLAP repair, a type I'lvF SLAP tear, and LHB tendi—
nitis pain for which conservative management has failed.”
Among LHB tenodesis procedures, no technique is
clearly superior. Tcuodcsis techniques include arthro—
scopic, mini-open, and open procedures; proximal versus
flrtltopaedic Knowledge Update: Sports Medicine 5
distal fixation; and multiple types of fixation constructs.
The authors of a 2015 study fou ud degenerative changes
in the proximal intra-articular and middle intragroove
portions in all 36 cases and up to the distal extra-articular
portion in 29 {3 0.6%}.‘? Therefore, su bpectoral tenodesis
was optimal for these patients. However, no clinical out-
come studies have demonstrated any tenodesis technique
as superior to other techniques. It was demonstrated in
a 2313 study that the open subpectoral approach placed
the tenodesis tunnel 2.1 cm distal to the arthroscopic su-
prapectoral approach.‘13 However, both of these techniques
placed the tenodesis tunnel distal to the bicipital groove,
which may allay concerns about the bicipital groove as a
source of pain after this procedure. According to a 2.314
study, there were no significant differences in clinical
outcomes when comparing arthroscopic suprapectoral
and open subpectoral LHE tenodesis with a minimum
2-year follow-up.” No difference was found regarding
failure of fixation type when comparing unicortical and
interference screw fixation for subpectoral tenodesisfgd"
Substantially less displacement was found during cyclic
loading for the interference screw compared with the
unicortical button.“ However, arthroscopic suprapece
toral and open subpectoral LHB tenodesis techniques
using an interference screw implant in a cadaver model
were compared; arthroscopic tenodesis overteusioued the
LHB and has a substantially decreased ultimate load to
failure compared with the open technique“1 {Figure 9}.
In the future, studies should define when a tenodesis is
indicated, along with the position and type of fixation
used when performing an LHB tenodesis.
Summary
The treatment of SLAP tears and Ll-IB pathologies re
mains controversial. The clinical diagnosis and physical
examination of a SLAP tear or symptomatic LHB ten-
dinopathy is often challenging because the findings are
similar to the other pathologies within the glenohtuneral
joint. No single physical examination finding is complete-
ly accurate for the diagnosis of a SLAP tear. MRA helps
diagnose LHB pathology and SLAP tears because it is
more specific and more sensitive than MRI. SLAP repairs
have had more beneficial results in patients younger than
41:] years and if they are not associated with a rotator cuff
repair. The ideal treatment of LHB pathology is also still
evolving. Both tenotomy and LHB tenodesis are accept-
able treatment options, but the literature has not clearly
demonstrated which surgery is superior. Several types of
tenodesis surgeries can he performed and the literature
has not identified which is optimal. Future research is
needed to help identify the best treatment options.
El 1316 American AcadMy of Unhopaedic Surgeons
 Chapter 4: Superior Lahnim and Biceps Pathology

AllL-UEUHE Jeddn :1
‘ F I L I

I y {‘5' Tfe'
II
l *- . »_ I
' I
-.-
I“
s.
l_:i-:: i. I

.. j
--r, 'I_'
‘_ . .- . .l H
-
. II.

Figure 9 Photographs of the open su bpectorel biceps tenodesis. A, The tendon pulled out of the shin. B, The tendon is
stitched 2 cm proximal to the musculotendinous junction with Mo. 2 suture. C. Conipleted tenodesis.

Key Study Points Annotated References

1‘ SLAP repairs have proved more beneficial than
tenodesis in patients younger than 40 years and
may be even more successful if not associated with
rotator cuff repair.
No clear advantage has been reported when com-
paring LHE tenodesis and tenotomy. An increase of
Popeye deformities is seen with tenotomies. Howev—
er, current indications proposed for LHB tenodesis
include patients with high levels of physical activi-
ty, patients concerned with cosmesis, and workers”
compensation cases.
Different tenodesis techniques include proximal
arthroscopic fixation, in which the tendon remains
in the bicipital groove, or the tendon can be fixed
distally so it is removed from the groove. The loca-
tion of tenodesis has shown substantial differences
in clinical outcomes when comparing arthroscopic
suprapectoral and open subpectoral LHB tenodesis.
. Andrews JR, Ea rson WC; Jr, McLeod W1): Glenoid labrnm
tears related to the long head of the biceps. Am I Sports
Med 1935;13[5}:33T-341. Medline DUI
. Snyder S], Kari-tel RP, Del Pizzo W, Feritel RD, Friedman M]:
SLAP lesions of the shoulder. Arthroscopy 199D;E{4}:2?4-
1?"). Medline DUI
. Cooper DE, Arnoczlty 5P, G'Bfififl 5], Warren RF, DiCarlo
E, Allen AA: Anatomy, histology, and vasculari of the
glenoid lahrurn. An anatomical study. I Bone Joint Snrg
am 1991;?4{1]:4E-52. Medline
. Tuoheti Y, Itoi E, Minagawa H, et a]: Attachment types of
the long head of the biceps tendon to the glenoid labrum
and their relationships with the glenohunieral ligaments.
Arthroscopy 1fl05;21{1fl]:1142-1149. Medline DUI
. Rao AG, Kim TK, lChronopoulos E, McFarland EG: Ana-
tomical variants in the anterosuperior aspect of the glenoicl
labruni: A statistical analysis of seventy—three cases. J Bone
joint Surg Am lflfl3;35-A{4}:553 659. Medline

Eb Ifllti American Academy of flrfliopaedic Surgeons Drrhopaedic Knowledge Update: Sports Medicine .5
 Sectien 1:1}pperExtremity
Werner A, Mueller T, Beehm D, GehIl-te F: The stabilizing
sling fer the lung head ef the biceps tenden in the retater
cuff interval: A histeanatemic study. Am ] Sperts Meal
2flflfl;28[1}:23-3L Medline
Alpantalci K, McLaughlin D, Karagegees D, Hadjipavleu
A, Kentakis G: Sympathetic and sensery neural elements
in the tendeu ef the leng head ef the biceps. j Bette jeint
Surg Am 2Dfl5;32{2l:153l}-1533. Medline DUI
Cheng NM, Pan WE, 1ll’ally F, Le Rena: CM, Richardsen
MD: The arterial supply ef the lung head ef biceps tendeu:
Anatemical study with implicatiens fer tendeu rupture.
Gifts Aunt 201 U;23I{E):633-592. Medline DUI
This cadaver study feund that the regien ef hypevascularity
eene fer the LI-IB tendeu {via injectien with either a radi-
epaque lead esidei'milk mixture er India ink} was 1.2 te 3.0
1: Upper Eatrem ity
cm frem the tenden erigin, extending frem midway threugh
the glenehumeral jeint te the presimal intertubercular
greeve. Altheugh this was feund te be a vital reasen fer
tendeu rupture, mechanical facters alse play an imp-ertant
rele. Level ef evidence: IV.
Keener JD, Brephy RH: Superier labral tears ef the sheul-
der: Pathegenesis, evaluatien, and treatment. I Am Aced
Urtbep Snrg 2009;12flflhfi22- 53?. Medline
This review discussed the advances in surgical techniques
fer secure SLAP injuries repair. This is supperted by re-
cent eutcemes demenstrating geed functieual results and
an acceptable rate ef return te athletic activities. Level ef
evidence: V.
Ii}. Burkhart SS, Mergan CD, Kibler WE: The disabled threw-
ing sheulder: Spectrum ef thelegy. Part I: Patbeanate-
my and biemechanics. Art rescepy 2flfl3;19{4}:4i}4-42D.
Medliue DUI
11. Hitchceck HH, Bechtel CU: Painful sheulder: |Dbservarieus
en the rele ef the tendeu ef the leng head ef the biceps
brachii in its causatien. ] BDHE jeini Surg Am 1943;30-
AiE}:263—223. Medline
I2. Seabe I, Beileau P, Walch G: The presimal biceps as a pain
generater and results ef tenetemy. Sperts Med Artbresc
2flflfifldfilflflfl-Iflfi.Medline DUI
13. Ahrens PM, Beileau P: The leng head ef biceps and asseci-
ated tendinepathy. ] Beac jeiat Sarg Br 2flfl2:39[3}:10i}1-
Ii] [19. Medline DUI
14. Patten WC, McCluskey GM III: Biceps tendinitis and
sublustatien. Cfin Sperts Med 2flfl1;2fl(3}:5fl5-529.
Medliue DUI
15. Lafesse L, Reila nd Y, Baier GP, Teussaint B, Jest B: Aute-
rier and pesterier instability ef the lung head ef the biceps
tena in retater cuff tears: A new classificatien based en
arthrescepic ebservatiens. Artivrescepy 2flfl2;23{1}:23-3fl.
Medline DUI
1-6. Maffet MW, ISartsman GM, Meseley B: Superier la-
brum-biceps tenden cemplesc lesiens ef the sheulder. Am
I Sperts Med 1995;23il}:93-93. Medliue DUI
Urdtepaedic Knewledge Update: Sperts Medicine 5
1?. Nhe S], Strauss E], Leuart EA, et al: Leng bead ef the
biceps tendinepathy: Diagnesis and management. I Am
Acud Urtbep Surg 2B1ii;13i11}:645— 656. Medline
This review article described arth rescepic and epen biceps
tenedesis techniques; beth shew premising results. Level
ef evidence: V.
IS. U’Brien S], Pagnanwi M], Fealy S, McGlynn SR, 1li'lll'ilseu
JB: The active cempressien test: A new and effective test
fer diagnesing labral tears and acremieclavicular jeint ab—
nermality. Am I Sperts Med 1993;26l5hi‘ilfl-SI 3. Medline
15". Parentis MA, Gleusman RE, Mehr KS, Yecutu LA: Au eval-
uatien ef the prevecative tests fer snperier labral anterier
pesterier lesiens. Am I Sperts Med 2Dfld;34{2]:255-263.
Medliue DUI
2B. Ceelt C, Beaty S, Kissenberth M], Siffri P, Pill SG, Haw-
kins R]: Diagnestic accuracy ef five erthepcdic clinical
tests fer diagnesis ef snperier labrum anterier pesterier
[SLA P} lesiens. J Sheafdsr Elbmv Sarg 2012:21{1]:13-22.
Medline DUI
This study analysed five clinical tests fer SLAP lesien di-
agnesis. The Biceps Lead II test demenstrated efficacy fer
diagnesing SLAP-enly lesiens. The results had a pesitive
predictive value ef 26 {95% ceniidence interval [CI]: 13—31],
negative predictive value ef .93 {95% CI: 34-92}, pesitive
likeliheed ratie ef 1.? {95% |IEI: 1.1-2.6}, and negative lilce-
liheed ratie ef 0.39 [95% ISI: 0.14-0.91}. Ne ether tests
demenstrated diagnestic utility fer SLAP lesien diagne-
sis, including these with cencemitant diagneses. Lewl ef
evidence: III.
21. Sethi N, Wright 11, Tamagucbi K: Diserders ef the lung head
ef the biceps tenden. I Sbeufder Eibete Strrg I 999$ [51:644 -
654. Medline DUI
22. Heltby IL, Rasmjeu H: Accuracy ef the Speed’s and ‘fer-
gasen‘s tests in detecting biceps pathelegy and SLAP le-
sieus: Cemparisen with arthrescepic findings. Arifvrescepy
2flfl4;2fl[3]:231-23ti.Medline DUI
23. Mehtadi HG, Vellet AD, lClark ML, et al: A prespective,
deuble-blind cemparisen ef magnetic resenance imaging
and arthrescepy in the evaluatien ef patients presenting
with sbeulcler pain. }' Sbealder Eibew Sarg 2flfl4:13[3]:253-
265. Medline D-UI
24. Pfirrrnann CW, Zanetti M, 1|iii-"'eishaupt D, Gerber C,
Hedler J: Subscapularis tendeu tears: Detectien and grad-
ing at MR arthregraphy. Rediefegy 1999;213l3}:2fl9v214.
Medline DUI
25. Gambill ML, Melegne TS, Prevencher MT: Dislecatien ef
the leng head ef the biceps tendeu with intact subscapu-
laris and supraspinatus tendens. __I Sbeuider Eibew Sarg
2Dfld;15{£]:e2D-e22.Medline DUI
2d. Wall LB, Teefey SA, Middleten 1WD, et al: Diagnestic
perfermance and reliability ef ultrasenegraphy fer fatty
degeneratien ef the retater cuff muscles. 1' Benejeiat Ssrrg
Am 2012;94{12}:e33. Medline DUI
El 2016 American Academy ef Urthepaedic Surge-ens

This study analyzed diagnostic performance and reliabilit
of nltrasonography for fatty degeneration of the rotator f
muscles by comparing it with MRI. Ultrasonography can
be used as the primary diagnostic modality. The agreement
between MRI and ultrasonography was substantial for
the supraspinatus and infraspinatus {It = [US and 0.?1,
respectively} and moderate for the teres minor {11: = 0.437}.
Lew] of evidence: 11.
2?. Edwards SL, LeejA, Bell, et al: Nonoperative treatment
of superior lahrum anterior posterior tears: Improvements
in pain, function and quality of life. Am I Sports Med
201B;SS{?}: 14515-1451. Medliue DUI
The outcomes of nonsurgical treatment of SLAP tears in
39 patients were analysed. Honsurgical treatment can he
trialed in patients with an isolated superior lahral tear.
Uverall, mean American Shoulder and Elbow Surgeon
scores increased from 53.5 to 345', Simple Shoulder Test
scores increased from 3.3 to 11.1}, and visual analog scale
pain scores decreased from 4.5 to 2.1. In overhead athletes
end in those patients where pain relief and functional im-
provement is not achieved, surgical treatment should be
considered. Level of evidence: IV.
ES. Hashiuchi T, Sa lturai G, Morimoto M, Komei T, Taltaltura
Y, Tanalta Y: Accuracy of the biceps tendon sheath injection:
Ultrasound-guided or unguided injection? A randomized
controlled trial. I Shoulder Elbow Surg 2011;2[liflflildfl—
1013. Medline DUI
This study analyzed the accuracy of ultrasonographically
guided or unguided biceps tendon sheath injection in 30
patients. Injection into the LHB tendon sheath is more accu-
rate under ultrasonographic guidance. Level of evidence: 11.
29. Chalmers PH, Tromhley It, Cip J, et al: Postoperative res—
toration of upper extremity motion and neuromuscnlar
control during the overhand pitch: Evaluation of tenodesis
and repair for superior labral anterior-posterior tears. Am
I Sports Med 2014:42i12}:ESES-ESSS. Medline DUI
This study evaluated shoulder motion in overhand pitch—
ers after biceps tenodesis and SLAP repair in 13 patients.
SLAP repair and biceps tenodesis can restore physiologic
neuromuscnlar control, but pitchers who undergo SLAP
repair may have altered thoracic motion when compared
with control patients. Level of evidence: IV.
SD. Sassmannshausen G, Sultay Ivi, Mair SD: Broken or dis-
lodged poly—L4actic acid bioabsorbable tacks in patients
after SLAP lesion surgery. Arthroscopy Zfifldtllldltdlfi-
619. Medline DUI
311. Pa rlt l'vi], Hsu JE, Harper U, Sennett B], Huffman GR: Po-
ly-LfD-lactic acid anchors are associated with reoperation
and failure of SLAP repairs. Arthroscopy Efll1:2?{1fl}:1335-
1341}. Medline DUI
33. Abboud JA, Silverherg D, Glaser DL, Ramsey IvIL, 1|i'l'i'illiams
UR: Arthroscopy effectively treats ganglion cysts of the
shoulder. Clio Urtfaop Relat Res lflflfit444f44411129-133.
Medline DUI
33. McCormick F, Nwaclmltwu BU, Solomon D, et al: The
efficacy of biceps tenodesis in the treatment of failed
4D Ifllti American Academy of Urthopaedie Surgeons
Chapter 4: Superior Labrum and Biceps Pathology
superior lahral anterior posterior repairs. A111] Sports Med
2014;41j4}:320-325.Medline DUI
This study prospectively evaluated revision biceps tenod-
esis after failed arthroscopic repair for type II SLAP tear.
Most patients obtained good to excellent outcomes using
validated measures with a substantial improvement in range
of motion. Level of evidence: IV.
34. Franceschi F, Longo LTU, Rustini L, Ritcello G, la ffulli N,
Denaro 1'1": Ho advantages in repairing a type II superior la-
brum anterior and posterior {SLAPJ lesion when associated
with rotator cuff repair in patients over age 5D: A random-
ized controlled trial. A111] Sports Med lflflS;SE{1}:14?-ESS.
Medliue DUI
35. Unyeltwelu I, Khatih U, clterman JD, Roltito AS, Kwon
YW: The rising incidence of arthroscopic superior Iabrum
anterior and posterior {SLAP} repairs. J Shoulder Elbow E
Surg 2D12;21{S}:?23-?31. Medline DUI "fl
g
1]
The study analysed the increase of arthroscopic SLAP re- F”
pairs in New York state from 20111 to 201D. Substantial in- ii
creases in the number of arthroscopic SLAP repairs {464%} fit
and in the age of patients treated with ard'troscopic SLAP 3.
repairs were noted. Level of evidence: V. a!
SS. Weber SC, Martin DF, Seiler JG III, Harrast J]: Superior
lahrum anterior and posterior lesions of the shoulder: In-
cidence rates, complications, and outcomes as reported by
American Board of Urthopedic Surgery. Part II: candidates.
Am J Sports Med lfl]1;4D{7j:1533-1543. Medline DUI
A database of cases was examined for board certification
on the demographics of SLAP lesion repair. A concerning
number of repairs was noted in middle-aged {9.4% of all
shoulder cases, increased to 111.1% in EMS} and elderly
patients and emphasized the importance of educating or-
thopaedic surgeons to appropriately recognise and treat
symptomatic SLAP lesions to reduce the rate of SLAP re-
pairs. Level of evidence: III.
3?. Zhang AL Kreulenf:,Ngo SS, Hame SL ,Wang JC, Gam-
radt SC: Demographic trends In arthroscbpic SLAP rcpair
in the United States. A111 ,1 Sports Med 2fl12-,4fl[5}: 1144-
1141 Medline DUI
Demographic trends in arthroscopic SLAP repairs were
examined. From 2004 to 2009, the findings show substan-
tially more arthroscopic SLAP repairs were performed each
year, with the highest incidence rates in the 211- to 29-year—
olds {2 9.1 per 111,013 El} and Afl- to 49-year-olds {27.3 per
ID,fl{lfl}I and in men. Level of evidence: ‘1’.
SS. Morgan {3D, Eurkhart SS, Palmeri M, Gillespie M: Type
II SLAP lesions: Three subtypes and their relationships to
superior instability and rotator cuff tears. A1I'tfsrosr.".op}r
1393;14f5}:553-555.Mcdlinc DUI
35'. Sch render GP, Sitare U, lISrjengedal E, Uppheim G, Reikeras
U, Bron JI: Long-term results after SLAP repair: A
5-year follow-up study of If}? patients with comparison
of patients aged over and under 40 years. Arthroscopy
1fl12;23{11}:16fl1-Ifii}1Medline DUI
4D. Ide ], Maeda S, Taltagi IL: Sports activity af-
ter arthroscopic superior labral repair using suture
Urrhopaedie Knowledge Update: Sports Medicine 5
 Section 1:1}pperExtremity
anchors in overhead-throwing athletes. Am J Sports Med
2005;33l4l:5fl?r514.Medline DUI
41. Kim SH, Ha KI, Kim SH, |IEhoi H]: Results of arthroscopic
treatment of superior labral lesions. j Bone JIor'nt Sntg Ant
2flfl2;S4-A{6}:SSl-SSS. Medline
42. Friel NA, Karas V, Slabaugh MA, Cole E]: Gutcomes of
type II superior labrum, anterior to posterior {SLAP} repair:
Prospective evaluation at a minimum two—year follow-up.
J Shoulder Elbow Sarg 2010;19l6}:SSS-36?. Medline DUI
The outcomes of SLAP II lesion repairs via bioabsorbable
sutures were examined. At an average 3.4-year follow-up,
this type of suture anchor provided a significant improve-
ment in functional capacity and pain relief {mean Amer-
ican Shoulder and Elbow Surgeon scores improved from
59.49 to 33.32; mean Simple Shoulder Test scores improved
1: Upper Extremity
from 2.23 to 19.20; visual analog scale 3.93-1.52}. Level
of evidence: IV.
43. Provencher MT, McCormick F, Dewing C, McIntire 5,
Solomon D: A prospective analysis of 129 type 2 superior
labrum anterior and posterior repairs: Clurcomes and fac-
tors associated with success and failure. An: I Sports Med
2fl13;41[4]:SSD-SS6.Medline [ID]
This prospective analysis of SLAP I] repairs in 1?? patients
examined factors associated with success and failure and
found a 37% rate of returning to previous athletic activity
and a 23% rate of failure. Patients aged 36 years and older
have higher risk of failure. Level of evidence: III.
44. Kate LM, Hsu S, Miller SL, et al: Poor outcomes after SLAP
repair: Descriptive analysis and prognosis. Arthroscopy
lflfl9515{3}:349-355. Medline not
This study examined failed SLAP repairs in 39' patients
{41“.} shoulders}. After revision, 32% of patients still had
suboptimal results. Conservative treatment resulted in poor
outcomes {21% of patients: mean patient age, 43 years} after
failed repair. Level of evidence: V.
45. Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Each
ER: Biceps tenotomy versus tenodesis: A review of clinical
outcomes and biomechanical results. J Shoulder Elbow
Stu-g 2611;20l2}:326-332. Medline DUI
This review compared biceps tenotomy and tenodesis for
biceps tendon rupture from 1966 to 2010. Higher cos-
metic deformity and lower load to tendon failure were
found in patients who underwent tenotomy {40%}. Level
of evidence: V.
46. Slenlter NR, Lawson K, Ciccotri MG, Dodson CC, Cohen
SE: Biceps tenotomy versus tenodesis: Clinical outcomes.
Arthroscopy sorenempsrs-sss. Medline not
This systematic review analyzed clinical outcomes of biceps
tenodesis versus tenotomy and found that tenotomies result
in cosmetic deformities {43%} more often than tenodesis.
No consensus was reported regarding the use of tenotomy
versus tenodesis for the treatment of LHE lesions. Level
of evidence: V.
4'2. Moon SC, Cbo NS, Rhee TC: Analysis of “hidden le-
sions“ of the extra-articular biceps after subpectoral biceps
Drthopaedie Knowledge Update: Sports Medicine 5
tenodesis: The subpectoral portion as the optimal tenodesis
site. Am I Sports Med 2flIS;43[I}:63r63. Medline DUI
This study examined the optimal tenodesis site by analyzing
the extension and delamination of extra-articular lesions in
the retrieved biceps after subpectoral biceps tenodesis in 36
patients. Lesions were observed beyond the bicipital groove,
extending to the distal extra—articular portion {313%}. The
subpectoral portion may be the optimal tenodesis site. Level
of evidence: IV.
4E. Johannsen AM, Macalena JA, Carson ESV, Tompkins M:
Anatomic and radiographic comparison of arthroscopic
suprapectoral and open subpectoral biceps tenodesis sites.
Art: I Sports Med 2H13;41[I2]:2919-2924. Medline DDI
The authors conducted anatomic and radiographic evalua-
tion of arthroscopic and open subpectoral biceps tenodesis.
In 20 specimens, the open subpectoral approach placed
the tunnel 2.2 cm distal to the arthroscopic suprapectoral
approach. Thus, patients undergoing the arthroscopic su-
prapectoral approach may still have postoperative bicipital
groove pain. Level of evidence: V.
49. Buchhols A, Marretschléiger F, Siebenlist S, et al: Biome-
chanical comparison of intramedullary cortical button
fixation and interference screw technique for subpec-
toral biceps tenodesis. Arthroscopy 2GlS;29I{S}:S4S-SSS.
Medline DUI
This study analysed intramedulla ry cortical button fixation
and interference screw technique for subpectoral biceps
tenodesis. Intramedullary cortical button fixation showed
no failures during cyclic tcsting; however, a 30% failure rate
was reported for screw fixation. Cortical button fixation
provides an alternative technique for subpectoral biceps
tenodesis with comparable and, during cyclic loading, even
superior biomechanical properties to interference screw
fixation. Level of evidence: V.
Si]. DeAngelis JP, Chen A, Wexler M, et al: P-iomechanical
characterization of unicortical button fixation: A novel
technique for proximal subpectoral biceps tenodesis. Knee
Sarg Sports Tranmatol Arthrosc EMS. [Epub ahead of
print] Medline
This study analyzed mechanical properties of unicortical
metal buttons and interference screws in proximal biceps
tenodesis in six pairs of fresh-frozen shoulders. The ultimate
load to failure and stiffness for both methods were the same.
A unicortical button provides a reliable alternative method
of fixation with a potentially lower risk of postoperative
humeral fracture and a construct that permits early mobi-
lieation following biceps tenodesis. Level of evidence: IV.
51. Werner BC, Evans CL, Holegrefe RE, et al: Arthroscopic
suprapectoral and open subpectoral biceps tenodesis: A
comparison of minimum 2—year clinical outcomes. Am
1' Sports Med 2fl14t42[11}:2533-259fl. Medline DC]
This cohort study compared open subpectoral {32 patients}
and arthroscopic suprapectoral {fill patients} biceps tenod-
esis at a minimum 2-year follow-up. Both groups had
excellent clinical and standardized outcomes: no clinical
differences were seen in clinical or standa rdized outcomes.
Level of evidence: III.
El 2016 American AcadMy of Urthopaedie Surgeons
Chapter 5
Adhesive Capsulitis, Cartilage
Lesions, Nerve Compression
Disorders, and Snapping Scapula
Maximilian Petri. MD Joshua A. Greenspoon, BSc Peter I. Millett, MD. MSc
Abstract
The most common shoulder pathologies in sports medi-
cine are rotator cuff tears, instability of the glenohnmeral
and acromioclavicular joints, and tears of the long head
of the biceps tendon. However, other disorders such as
stiffness, focal chondral lesions, neural compression,
and pathologies of the scapulothoracic joint can cause
pain and loss of function for patients. It is important
to be cognizant of the current concepts for treatment of
adhesive capsulitis, cartilage lesions, nerve compression
disorders, and snapping scapula syndrome for optimal
outcomes.
Keywords: adhesive capsulitis: cartilage lesions;
nerve compresslon disorders: suprascapular nerve
entrapment: snapping scapula
Dr. Petri or an immediate family member has received
nonincome support (such as equipment or services), com-
mercially derived honoraria. or other non-research-reiated
funding {such as paid travel} from Arthreir. Dr. Miliett or
an immediate family member has received royalties from
Arthrerr; serves as a paid consuitant to Arthrerr and MYtJS;
has stock or stock options held in Game Ready and Vuivtedi:
and has received research or institutional support from
Arthrerr, (Tissue Siemens. and Smith a Nephew. Neither Mr:
Greenspoon nor any immediate family memhm has received
anything of value from or has stock or stock options held
in a commercial company or institution related directly or
indirectly to the subject of this chapter.
@ lfllfi American Academy of Drthopaedic Surgeons
humans; .raclcln :j
Introduction
llfi‘rlenohutneral instability, rotator cuff tears, pathologies
of the long head of the biceps tendon, and instability of the
acromioclavicular joint represent most shoulder disorders.
Although disorders such as adhesive capsulitis, chondral
defects, suprascapular nerve entrapment, and snapping
scapula syndrome are less common, they can cause sub-
stantial disability in patients. Comprehensive knowledge
of these pathologies is necessary to establish the proper
diagnosis. flpen and arthroscopic surgical treatments
can be used to manage these disorders. Clinical outcomes
studies have primarily been conducted as case series {level
IV evidence}; comparative studies are challenging because
each entity is relatively rare. However, good to excellent
results can be achieved with appropriate patient selection
and surgical technique.
Adhesive Capsulitis
Adhesive capsulitis, commonly lrnown as frozen shoulu
der, is characterised by spontaneous onset of pain and
progressive restriction of shoulder movement. A cascade
of inflammation involving abnormal tissue repair and
fibrosis modulated by abnormal production of growth
factors and cytoltines is pathogenetic.1~l
Adhesive capsulitis can be idiopathic in origin {pri-
mary} or occur secondary to systemic diseases such as cli-
abetes mellitnsi or hypothyroidism. Additional secondary
causes include previous trauma or an rgery.‘ Breast cancer
treatment with surgery and radiotherapy has also been
linked to the development of adhesive capsulitis.5 The
condition is generally self-limiting; however, it often has
a prolonged course, ta king more than 2 years to resolve.‘
The diagnosis for primary adhesive capsulitis is usu-
ally established by sudden onset of pain without history
of major trauma, infection, or surgery of the affected
shoulder, combined with a global limitation of both active
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 1:1}pperExtreenity
and passive range of motion. Similar findings apply for
secondary adhesive capsulitis, but with a history of pre—
vious trauma or surgery or medical disease. Differential
diagnoses include calcific tendinitis, glenohumeral and
acromioclavicular osteoarthritis, rotator cuff tendinopa—
thy or tear, and lesions of the long head of the biceps ten-
don. Imaging modalities such as radiography, MRI, and
ultrasonography should support the clinical diagnosis."5
Nonsurgical Treatment
Nonsurgical management should be recommended to
patients initially; reported success rates range from ?D%
to 90%.? Adhesive capsulitis is commonly treated with
physical therapy and exercise in primary cases. A recent
1: Upper Extremity
randomised controlled trial found that group exercise
classes for physical therapy achieved substantially higher
Constant and Oxford Shoulder scores than both individ—
ual physical therapy sessions with a therapist and home
exercises completed by the patient alone.til
NSAIDs and corticosteroid injections have proved to
be useful adjuncts to therapy? Calcitonin has also been
suggested as an adjunct therapy. Patients should attempt
nonsurgical management for at least I5 months before
considering surgical intervention.""”
Electrotherapy, Extracorporeal Shock Wave Therapy,
and Suprascapular Nerve Stimulation
Electrotherapy aims to reduce pain and improve func-
tion by means of an increase of electrical, sound, light,
and thermal energy into the body. Two recent Cochrane
reviews-“1 found no evidence regarding the addition of
pulsed electromagnetic field therapy and other electrothers
apeutic modalities to the standard regimens of manual
therapy and exercise, corticosteroid injection, or NSAIDs.
However, low~level laser therapy combined with exercise
appeared to be more effective than exercise alone for pain
and function.” In a recent randomised clinical trial of 36
patients, extracorporeal shock wave therapy was shown
to substantially improve pain and range of motion.‘1
Given that the suprascapnlar nerve accounts for 713%
of shoulder capsule sensitivityfir'“ pulsed radiofreqnency
stimulation of the suprascapnlar nerve guided by ultra—
sonography represents a new therapeutic approach. This
suprascapnlar nerve stimulation combined with physical
therapy provided better and faster pain relief and im—
proved passive range nf motion compared with physical
therapy alone.”
Distension Arthro-graphy
Arthrographic joint distension with corticosteroids and
saline improves patients’ pain, satisfaction, and active
range of motion?!” Improvements in range of motion and
flrfltnpaedic Knowledge Update: Sports Medicine 5
pain relief were reported in 1?! patients who underwent
treatment with distension arthrography using radiopaque
contrast material and lidocaine.” This approach pro-
vides both a therapeutic and diagnostic intervention in
depicting rotator cuff tears by extrusion of the contrast
agent. A recent randomised controlled clinical trial found
no difference in outcomes between ultrasonographically
guided posterolateral capsular distension and fluoroscop-
ically guided anterior capsular distension.”
Differences between corticosteroid ancl hyaluronate
injections in patients with adhesive capsulitis were in-
vestigated in a randomised clinical trial.“' Both groups
demonstrated improvements in clinical outcomes scores
and range of motion, however no significant differences
were found between the two groups.
Nonsurgical treatment of adhesive capsulitis conuuonly
consists of manual therapy and exercise, often with the
addition of NSAID s. Corticosteroid injections and disten-
sion arthrography can effectively improve patient pain,
satisfaction, and range of motion, but is associated with
the inherent risks of invasive procedures such as bleeding,
infection, and nerve damage. Laser therapy, extracor-
poreal shockwave therapy, and pulsed radiofrequency
stimulation of the suprascapnlar nerve can be considered
if standard nonsurgical treatments fail.
Surgical Treatment
If nonsurgical management fails to relieve symptoms,
surgical treatment can improve range of motion and
alleviate pain. For surgical intervention, regional anes-
thesia with an interscalene nerve catheter is particu-
larly important postoperatively. This allows aggressive
physical therapy with aggressive rangerofrmotion and
stretching exercises.‘
Manipulation under anesthesia {MUM is often com-
bined with local anesthetic and corticosteroid injections,
and good results have been reported? However, because
MUA does not allow a controlled release of adherent tis-
sues, this procedure is associated with the risk of humeral
fractures and labral and rotator cuff tears.‘
Various surgical techniques have been suggested for
the treatment of adhesive capsulitis, particularly the ex-
tent of capsular release.“HF Ho benefit has been proved
with combined anterior, inferior, and posterior capsular
releases compared with anterior capsular release sinned-"d“
The contractnres of the coracohnmeral ligament and ro-
tator interval must be treated. Most shoulder specialists
advocate for selective capsular release, starting anteriorly
and with the rotator interval. If the shoulder is still right,
posterior and inferior releases are performed. Extra-ar-
ticular releases also can be performed, particularly in
secondary adhesive capsulitis.
El ll] 16 American AcadMy of Drthnpaedic Surgeons
 Chapter 5: Adhesive l'Iiapsulitis,I Cartilage Lesions, Nerve Compression Disorders, and Snapping Scapula
The authors of a 2014 study compared arthroscopic
capsular release and subacromial decompression with
subacromial decompression combined with MUA and se-
lective arthroscopic capsular release and reported that all
surgical treatments substantially improved glenohumeral
range of motion.” No substantial difference was found
between the techniques.
Arthroscopic capsular releases between patients with
and without diabetes at 2-year follow-up were prospec-
tively comparedfi Both groups had substantial improve-
ments in modified Constant scores; however, the clinical
results in diabetic patients were substantially inferior.
Similarly, nonsurgical treatment and MUA yielded fewer
good results in diabetic patients.
Currently, the literature lacks studies detailing long-
term outcomes on the treatment of adhesive capsulitis. In
a cohort of 1D patients with refractory adhesive capsulitis,
arthroscopic treatment substantially improved range of
motion at a minimum 6-year follow-up?
Cartilage Lesions
|Chondral lesions of the shoulder can result from trauma,
instability, osteonecrosis, osteochondritis dissecans, os—
teoarthritis, or iatrogenicalljrfilt21 Fecal cartilage lesions
should be suspected in patients with previous shoulder
trauma or surgery, dislocations, mechanical symptoms
such as clicking or catching, pain, interrupted sleep, wealt-
ness, or loss of range of motion.”-
Cartilage lesions are graded according to the In
teruational Cartilage Repair Society, or Guterbridge
classification, with grade IV a full-thickness lesion?"12
Fullrthickness chondral lesions are encountered in 5%
to 29% of patients undergoing arthroscopy.“~11 Differ-
entiating between focal chondral lesions and generalized
glenohtuneral osteoarthritis is important because treatr
ment varies between the two.
Honsurgical Treatment
Nonsurgical treatment options include activity modifica-
tion, physical therapy, NSAIDs, steroid joint injections,
and viscosupplementation {such as hyaluronic acid}. These
options can mitigate symptoms; however, nonsurgical
treatment cannot fill cartilage defects or alter the progres-
sion of osteoarthritis.“ Also, if loose bodies are associated
with the defect, surgical treatment is recommended to
mitigate the effects of third-body wear.
Surgical Treatment
Palliative Treatment
For older patients with lower physical demands, palliative
treatment consisting of débridement and chondroplasty
El Ifllri American Academy of Urthopaedic Surgeons
can provide symptomatic pain relief. However, these pro-
cedures do not restore cartilageEl-il"MET
Repa rative Treatment
Microfracture has been performed in the shoulder with
good success. The hyaline cartilage of the humerus is 1.2
to 1.3 mm thick at the center, thinning to 1.0 mm in the
periphery.12 Thin cartilage can limit the use of micro-
fracture in the shoulder. Interest has recently increased
in the outcomes of microfracture for treating focal gleno-
humeral cartilage defects:11 Improvements in pain and
mean American Shoulder and Elbow Surgeons scores
have been noteiflla along with substantial improvement
in mean Constant scores” (Figure 1]. The best results E
were seen in humeral lesions, and even bipolar lesions "fl
improved.” g
1]
F”
E?
Restorative Treatment m
Restorative treatment attempts to re-create the damaged E.
a!
or absent cartilage. The two treatment options for restor-
ative treatment are osteochondral grafting and autologous
chondrocyte implantation. Both procedures require open
surgery and can potentially result in donor site morbidity.
Patient selection is important for success: the ideal patient
is young, active, and has isolated cartilage defects.“ As
with microfracture, these procedures have been investi-
gated in the knee with good results, but the shoulder is
much less studied. flsteochondral grafts obtained from
the knee can help treat both bone and cartilage defects.
Good clinical results with osteochondral grafts in the
shoulder have been demonstrated; however, a significant
incidence of donor site morbidity was reported. 31 Auto-
]ogous chondrocyte implantation eliminates the risk of
donor site morbidity. Due case report of this technique
performed in the shoulder of a young baseball player was
published.Ell Recently, use of a ICTrmatched medial tibial
plateau surface has been suggested for osteoarticular al-
lograft reconstruction of the glenoid.“
Nerve Compression Disordersl'Suprascapular
Nerve Entrapment
Suprascapular Nerve Entrapment
Patients with supra scapular nerve entrapment usually
present with vague posterolateral shoulder pain and may
report rapid onset of muscle fatigue with overhead activ-
ities. Atrophy of the infraspinatus andfor supraspinatus
muscles with weakness in external rotation andfor abduc—
tion may be noted, depending on the location of the lesion.
However, patients can also be asymptomatic. Differential
diagnoses of peripheral nerve injury of the shoulder in-
clude central neurologic disorders such as cervical spinal
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 1: Upper Extremity
1: Upper Eittrem ity
Arthroscopic views of a 2 v: E-cm glenoid lesion in a 55-year-old man before {A} and after {B} microfracture.
{Reprod uced with permission from van tier Meijden IDA, Gaskill TH, Millett PJ: Gle nohumeral joint preservation: A
review of management options for young, active patients with osteoarthritis. Adv Grthop 2012:1012:150923. doi:
“ll 155f2fl12i16fl923. Epub Mar 2?, 2012.}
disk protrusion, cervical spine instability, and spinal cord
contusion, as well as transient brachial plexopathy.
Suprascapular nerve entrapment can occur at several
locations. If the nerve is compressed pronimally at the
transverse scapular ligament, both the supraspinatus and
infraspinatus are involved. If the nerve is compressed dis—
tally by the spinoglenoid ligament or a structural lesion
at the spinoglenoid notch such as a paralabral cyst, only
the infraspinatus is involvedEH {Figure 2}.
Most diagnoses can be made using physical examina-
tion alone. For appropriate diagnosis and localization
of the lesion, electromyography and nerve conduction
velocity can be helpful. However, sensitivity and specific-
ity of these tests are not lflfl‘l’b and their results must be
correlated with clinical findingsfi‘hi'f Three—dimensional
soft-tissue imaging using MRI can help measure the de-
gree of atrophy of the infraspinatus andfor supraspinatus
muscles, and more importantly, help determine whether
a compressive lesion such as a ganglion cyst exists. MRI
also provides information about other concomitant shoul-
dcr pathologies, such as superior labrum anterior to pos—
terior tears, which are often associated with spinoglenoid
notch cysts.“
Suprascapular nerve entrapment can also have idio—
pathic causes. Four cases of complete fatty infiltration of
intact supraspinatus and infraspinatus muscles caused by
suprascapular neuropathy without any traction or com—
pression mechanisms have been reported.” Immediate
flrdtopaedic Knowledge Update: Sports Medicine 5
improvement in pain and subjective shoulder values were
reported following arthroscopic suprascapular nerve
decompression.
The shape and size of the suprascapular notch are
among the most important risk factors for suprascapular
nerve entrapment. A fiverpart classification of entrapment
according to morphologic features and anatomic varia-
tions has been suggested.“ A narrow, deep suprascapular
notch (type I} with sharp bony margins could be predis-
pose a patient to suprascapular nerve injury by repeated
microtrauma resulting from "kinking” the nerve.
Nonsurgical Treatment
Acute injuries to the suprascapular nerve can be treated
with rest and pain control, followed by physical therapy
with progressive range-of-motion and strengthening est-
ercises as tolerated. Iiii'verhead athletes should be followed
for IE to 12 months with recommended activity restriction
and periscapular therapy. Periodic electromyographiclf
nerve conduction velocity studies should be performed
to monitor clectrophysiologic nerve recoveryfi“1
Surgical Treatment
Nerve decompression is usually performed arthroscop-
ically. The surgical technique was described in detail in
21305.“ After standard diagnostic arthroscopy, the ar-
throscope is briefly placed in an antcrolatcral portal, and
accessory anterior and posterior portals are established.
El 1016 American deadeniy of Cirrhopaedic Surgeons
 Chapter 5: Adhesive l'IIapsulitisjl Cartilage Lesions, Nerve Compression Disorders. and Snapping Scapula

“mm at Wm Iorn The coracoid process is visualized with dissection car-

Wren my atenoie nnmh oroaelierl ned medlall}? along the posterior aspect of the coracold
lbemsfl 1W process. The supraspinatns muscle hell}? is posteriorly
retracted to visualize the coracohnmeral and coracocla-
vicular ligaments. The suprascapular notch is identified at
the medial base of the coracoid. The suprascapular artery
is cauterized with the radiofregnenctr ablation device,
and the ligament is released using handheld arthroscopic
tissue punches. The nerve is probed to ensure full decom-
pression {Figure 3]. Good to excellent outcomes can he
expected following arthroscopic decompression, with
decreased pain and improved function for releases at both
the spinoglenoid notch and the snprascapnlar notchci‘m‘El
E
"fl
Snapping Scapula
e
1]

Snapping scapula syndrome is uncommon and likelyr F”

ii
underdiag nosed. It can produce substantial pain and dis- fill

ability; however, the precise origin remains unknown. E.

Figure 2 Illustration of the anatomy of the su prascapular
“ENE 35 i1 passes through the suprascapular
and spinoglenoirl notches. Common
compression mechanisms are depicted at
each site. {Reproduced with permission from
M'IIE“ Fir Harm" “5- Pachem ”*1 EDIE-"IF fl:
Suprascapular nerve entrapment: Technlque for
arthroscopic “gleam Tech Shoulder ElbowSurg
measures-94.}
a?
Potential factors causing snapping scapula syndrome in-
clude hon}: changes at the superomedial scapular angle,
dFSbfllflm-ifl ”E the F'EriSCQPUI-flr 1111153135: and Napalm-110'
racic hursitisfil‘” Patients often present with decreased
- - . .
athletic performance and Increased pain svtth overhead
act1v1tles. Crepitus also can he reported.“ Plaln radio-
graphs and CT scans provide detailed information about
. . .
osseons ahnormahttes; MRI characterizes hnrsal and
other soft-tissue pathologies.“

A
Figure 3 Arthroscopic views of the suhacrornial space via the posterolateral portal. A. Suprascapular nerve {red arrowi is
under the transverse scapular ligament {arrow}. B, Elevator is in the anterolateral portal. exposing the nerve {short
arrow} after releasing the transverse scapular ligament (long arrow} at the notch [red arrow]. {Heprod need with
permission from Millett Fl, Barton H5. Pacheco IH, teaie It: 5n prasca pular nerve entrapment: Technique for
arthroscopic release. Tech Shoulder Elbow Surg 2m;1[2]:flE-Ea.}

El Ifllii American Academy of Urthopaedie Surgeons Drthopaedic Knowledge Update: Sports Medicine 5 e
 Section 1:1}pperExtreenity

Nonsurgical Treatment
Nonsurgical management remains the first treatment
option;‘“"l1 surgery is recommended after 6 months of
nonsurgical treatment with no improvement. Strength-
ening weal: periscapular muscle groups combined with
simultaneous stretching of contracted muscles and train-
ing of antagonistic muscle groups can yield good clinical
results.3“5"‘11 In addition. physical therapy. injections with
local anesthetics andJ'or steroids, and NSAIDs can be
useful. Nonsurgical treatment will “ii-Ely fail if scapu-
lothoracic masses such as osteochondromas of the rib or
scapula are present."1

Surgical Treatment
1: Upper Eatrem ity

Scapulothoracic bursectomy with or without partial scap-

Figure 4 Illustration of the right posterior shoulder
demonstrates the gross location of
neurovascular structures important in
scapulothoracic articulation. Black dots indicate
typical portal locations, noting the distance
from the medial scapular border. {Heprod uced
with permission from Millett PJ. Gaskill TR,
Horan MP, van der Meijden DA: Technique
and outcomes of arthroscopic sca pulothoraclc
hursectomy and partial scapulectomy.
Arthroscopy 2m 2;:EI1 21:1116-1 133.]
ulectomg.r is currently the most effective primary method
of treatment in patients whose nonsurgical therapy is
unsuccessful. This procedure can be performed open...”I1
artl‘uoscopica11y.it’d‘f'di'i‘E or using a combined approach.“
Detailed knowledge of neurovascular anatomy of the
periscapular region is crucial. The main branches of the
spinal accessory nerve are at risk if portals are placed
above the scapular spine. The dorsal scapular nerve and
accompanying dorsal scapular artery run 1 to 2 cm medial
to the medial border of the scapula, deep to the major and
minor rhomboid muscles. Therefore, portals or incisions
should be placed 2 to 3 cm from the medial scapular
borderih‘” {Figure 4}. The amount of resection of the
superomeclial angle is still debated, ranging from 1 to T
cm‘fl-‘i’i {Figure 5}.

-
‘ We»
e .‘ Lit?" . i i' I

1..

' ‘ 4a.
I

Supe ', '"__L-‘i' at'angie '

A
Figure 5 Arthroscopic views of a left scapula viewed from the inferomedial portal demonstrate the superomedial scapular
border- A, Before resection. B. Completed resection of the superomedial border. Note the absence of the hooked
su pe ro medial border of the scapula; the supraspinatus musculature {*l also can be visualized. {Reproduced with
permission from Millett PJ. IL-‘iaslcill Tl-'t. Horan MP, van der Meijden DA: Technique and outcomes of arthroscopic
scapulothoracic bursectomy and partial scapulectomy. Artitroscopy 2012:23lllldTT6-1Tflll

flrdtopaedic Knowledge Update: Sports Medicine 5 El 1016 American Academ~y of Unhopaedic Surgeons
 Chapter 5: Adhesive Capsulitis, Cartilage Lesions, Nerve Compression Disorders, and Snapping Scapula

Table‘i

Results of Surgical Treatment of Snapping Scapula Syndrome

Authors and Year Treatment No. of Patients Results
Nicholson and Open 1? (all with bursectomy, 4 ASES score, VHS, and
Duckworth“ 2002 also with bony scapular simple shoulder test all
resection} substantially improved
after 2.5 years
Lien et al" 20113 Combined 12 ASES score. VAS. and
simple shoulder test all
substantially improved
after 3.1 years
Harper et al” 1999 Arthroscopy Successful outcome in 6
patients {asst}
E
Favliit et al“ 20:13 Arth roscopy 10 Mean HAS
postope ratively 2.5 "fl

s,
1]
of 10; UCLA score: 4
excellent. 5 good, 1 fair F”

E's
Fearse et al‘” sans Arth roscopy 13 Nine improved with mean m

Constant score of B? of 2.
e2
10D; four unchanged
or worse, with mean
|IEonstant score of 55 of
we
Millett et al“ 2m: Arthroscopy 23 {2 with bursectomy ASES, SAME and
only, 21 with QuickDASH scores all
bu rsectomy + substantially improved
scapuloplasty} at mean 2.5 years
follow—up
Merolla et al“ 21114 Arthroscopy 1O Substantial improvement
for WGRC and Constant
score after 2 years
{P -c [1.01]
ASES - American Shoulder and Elbow Surgeons score, qu icicDASi-I - quid: Disabilities of the Arm. Shoulder and Ha nd. SAME - single assessment
numeric evaluation, UCLA = University of California - Los Angeles score. VAS = visual analog scale. WEIR: = Western Dntario iiotator Cuff indent.

A recent review identified 31 articles dealing with Summary

snapping scapula syndrome, including 9 level IV out-
comes studies.” The results of the relevant studies after
surgical therapy are sunnnarised in Table 1. The largest
series reported on 23 shoulders and found substantial
pain and functional improvement following arthroscopic
bursectomy and scapuloplasty.”
Although most patients improve after surgical treat-
ment, some patients continue to experience shoulder
disability. Further studies are needed to investigate the
modifiable factors associated with poor outcomes after
surgical and nonsurgical management for snapping scap-
ula syndrome.
Glenohumeral stiffness, focal chondral lesions, neural
compression, and pathologies of the sea pulothoracic joint
are relatively uncommon. However, these disorders can be
debilitating for the patient and require specific treatment.
A sound awareness and working knowledge of these pa-
thologies is necessary to arrive at the appropriate diagno-
sis. If nonsurgical treatment fails, open and arthroscopic
surgical techniques can be used to treat these disorders. A
thorough understanding of the local anatomy including
neurovascular structures is crucial for success with surgi-
cal treatment. Good to excellent results can be achieved
with appropriate patient selection and surgical technique.

Eb 2fl1ii American Academy of flrfliopaedic Surgeons Drrhopaedic Knowledge Update: Sports Medicine 5
 Section 1: Upper Extremity
Hey Study Points
' It is important to include adhesive capsulitis, focal
chondral defects, suprasca pular nerve compression,
and snapping scapula syndrome in the differential
diagnosis of shoulder pathologies.
' Nonsurgical treatment has a success rate of I'll'i‘ir to
was in patients with adhesive capsulitis.
' Micrnfract ure yields good clinical results for glerin-
hum‘i’fl] filial “hflfldml lis‘flfli' _ z Levine was, Kashyap cs, ask ss, Ahmad cs, Elaine Ta,
' AHhTDEEUPIC 5"q35:311‘1131' 1131'“? dECflmPT'ESElflfl
yields good results when nonsu rgical treatment fails.
I Arthroscopic scapulothnracic bursectomy with par-
tial scapulectorny is currently the most effective
1: Upper Extremity
treatment in patients ““1105: nonsurgical till-"HP? for
snapping scapula syndrome is unsuccessful.
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El 1016 American AcadMy of Cirrhopaedic Surgeons
 Chapter 5: Adhesive Capsulitis. Cartilage Lesions. Nerve Compression Disorders. and Snapping Scapula
Ultrasonographically guided pulsed radiofrequency stimv
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compression seems promising when humeral osteophytes
are present.
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1]
lar transplantation. autologous chondrocyte implantation.
bull: allograft reconstruction. and biologic resurfacing. F”
ii
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matof Arthrosc 2U1I];13{12]:1?6?—1T?3. Medline DUI
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termediate term. Level of evidence: IV.
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25. Richards DP. Eurkhart 55: Arthroscopic debridement and
capsular release for glenohumeral osteoarthritis. Arthros-
copy 2fl0?;23[9}:1i}19-1fl22. Medline DUI
26. Van Thiel GS. Sheehan 5. Frank RM. et al: Retrospective
analysis of arthroscopic management of glenohumeral
degenerative disease. Arthroscopy 2i] 1i];16{11}:1451-1455.
Medline DUI
Arthroscopic dEbridemcnt for glenoh umeral osteoarthri-
tis can potentially help avoid arthroplasty and increase
function with decreased pain. Grade 4 bipolar disease.
joint space less than 2 mm. and large osteophytes are
substantial risk factors for failure. Level of evidence: IV.
1?. Millett P]. Huffard EH. Horan MP. Hawkins It]. Stead-
man JR: Outcomes of full'thiclrness articular cartilage
injuries of the shoulder treated with microfractnre. Ar-
tbroscopy Zflflflglflfllflfifiuflfil Medline DUI
Microfracture for full-thickness cartilage lesions of the
shoulder showed the greatest improvement for smaller
lesions of the humerus: the worst results were in patients
with bipolar lesions. with a total failure rate of 19%. Level
of evidence: IV.
Urrhopaedic Knowledge Updare: Sports Medicine 5
 Section 1:UpperExtremity
23. Frank HM, Van Thiel GS, Slabaugh MA, Romeo AA, lBole
E], Verma NH: Clinical outcomes after micrefracture of
the glennhumeral joint. An: 1 Sports Merl 2fl10;33{4j:??l-
731. Medline DUI
Micrnfracture of the glenohumeral joint resulted in sub-
stantial improvements in pain relief and shoulder function
in patients with isolated, full-thickness chondral injuries
at a mean follow—up of 23 months. Level of evidence: W.
29. Snow M, Fuel: L: Micrefracture ef chendral lesions of the
glenohumeral joint. Int I Shoulder Snrg lflfl3;2{4}:?2-?6.
Medline DUI
3d}. Cole B], “faults A, Prevencher MT: Nonarthroplasty al-
ternatives for the treatment of glenohumeral arthritis.
J Shoulder Elbow Surg lflfl?;16[5uppl 51:5231-524fl.
Medline DUI
1: Upper Ettrem lty
31. Scheibel M.I Eartl C, Magosch P, Lichtenberg S, Haber-
meyer P: Usteochondral autelegous transplantation for
the treatment of full-thickness articular cartilage defects
of the shoulder. ] BorteJolnt Surg Br Eflfl4;36{?]:991-991
Medline DUI
32. Romeo AA, Cole H], Maaaecca AD, Fest JA, Freeman
KB. Joy E: Antelogeus choudrocyte repair of an articular
defect in the humeral head. Arthroscopy lflfllflfllflhfllj-
9'29. Medline DUI
33. Rios D. Jansson KS, Martetschliiger F, Beyltin RE. Millett
P], Wijdiclts CA: Normal curvature of glenoid surface can
be restored when performing an inlay esteochondral al-
legraft: An anatomic computed tomographic comparison.
Knee Sang Sports Tranmarol' Arrbrnsc lfll4:22{2]:442-
44?. Medline DUI
The radius of curvature of the glenoid and the medial tibial
plateau surface have a statistically similar relationship as
measured using three—dimensional CT. This can allow the
medial tibial plateau tn be used as a donor for names rtic-
ular allograft reconstruction of the gleneid.
34. Millett P]. Barton R5. Pacheco ICH. Unbeaie FL: Supras-
capular nerve entrapment: Technique for arthroscopic
release. Tech Shoulder Elbow San-g 1006;?{2}. DUI
3.5. Post M: Diagnosis and treatment of suprascapular nerve
entrapment. Elia Urtlrep Rslet Res 1999;363:92-100.
Medline
36. LeClere LE, Shi LL, Lin A, 1t‘annepoules P, Higgins LD.
1Warner J]: |Eemplete Fatty infiltration of intact rotater
cuffs caused by suprascapular ueuropathy. Arthroseopy
1fl14;3fl{5}:539-E44.Medline DUI
Suprascapular neuropathy with complete neurogenic fatty
infiltration can also occur in the absence of traction or
compression mechanisms. Arthroscopic supra scapular
nerve decompression resulted in immediate improvement
in pain and subjective shoulder values in all four patients.
Level of evidence: IV.
Urrhnpaedic Knowledge Update: Sports Medicine 5
3?. Polguj M, Sibil'lslti M, Graegertewski A, I2'3reelalt P, Mains
A, Topel M: 1llariation in morphology of suprascapular
notch as a factor of suprascapular nerve entrapment. Int
Uri-“bop 2fl13t3?l{11}:2135-2192. Medline DUI
Knowledge of the anatomic variations of the suprascapular
notch is important for both endoscopic and open proce-
dures of the suprascapular region.
33. Uiaumi N, Suenaga N, Minami A: Snapping scapula
caused by abnormal angulatien of the superior angle of
the scapula. J Shoulder Elbow Surg 2i] fl4:13{1]:1 15-113.
Medline DUI
39. Harper GD, McIlrny 5. Bayley JI, Calvert PT: Arthroscopic
partial resection of the scapula for snapping scapula: A
new technique. I Shoulder Elbow Surg 1999;3{1}:53-5?.
Medline DUI
41!}. Millett P], Pacheco IH, Gob-eaie Ft, 1Warner J]: Manage-
ment of recalcitrant scapulothnracic bursitis: Endoscop—
ic scapulothnracic bursectnmy and scapulnplasty. Tech
Shoulder Elbow Surg lllfliififlflfl-ZDS. DUI
41. Gaskill T. Millett P]: Snapping scapula syndrome: Di-
agnosis and management. I Arr: deed Urtlrop Surg
2fl13;11{4}:214—124.Medliue DUI
Neesurgieal therapy is the initial treatment of choice for
snapping scapula syndrome. If nonsurgical treatment fails.
open and endoscopic techniques have been used with
satisfactory results. Familiarity with the neuroanatomic
structures surrounding the scapula is critical to avoid
iatrogenic complications.
41. Nicholson UP. Duckwerth MA: Scapulethoraclc bursec-
tomy fer snapping scapula syndrome. I Shoulder Elbow
Sui-g lflfllflilllflfl-BS. Medline DUI
43. Merolla G. Cercielln 5. Paladini P. Porcellini U: Scapu-
lothoracic arthroscopy for symptomatic snapping scapula:
A prospective cohort study with two—year mean follew‘up.
Mascalesltelet Surg 2014 March 2013. Epub ahead of
print. Medline DUI
Arthroscopic decompression showed substantial clinical
improvements in 1H patients with snapping scapula syn-
drome at 1-year follow-up. Level of evidence: I‘v’.
44. Pearse EU, Eruguera J, Massoud SN, Sferaa U, Cope-
land SA, Levy U: Arthroscopic management of the pain—
ful snapping scapula. Arthroscepy lflfln:22{7]:?55-?61.
Medline DUI
4.5. Millett P]. Gaskill TR, Heran MP, van der Meijden UA:
Technique and outcomes of arthroscopic scapulotberac-
ic bursectnmy and partial scapulectomy. Arthroscepy
2D]2;23{11}:1??fi—1?33.Modline DUI
Although substantial pain and functional improvement
can be expected following arthroscopic bursectnmy and
scapuloplasty in patients with snapping scapula syndrome,
the mean postoperative American Shoulder and Elbow
U 1016 American AcadMy of Urrhnpaedic Surgeons
 Chapter 5: Adhesive Eapsulitisjl Cartilage Lesiuns, Nerve Cumpressic-n Diserders. and Snapping Scapula
Surgeeus and Single Assessment Numeric Evaluaticn
scnres remain luwer than expected. Level nf evidence: IV.
46. Pavlil: A, Aug K. Cughlau J. Bell 5: Arthruscupic treatment
c-f painful snapping {if the scapula by using a new superinr
pnrtal. Arthrnscnpv 2003;19i6}:5i]fl-612. Medline DUI
4?. Lien SB, Sheri PH, Lee CH, Lin LC: The effect {if endnscnp-
ic hursectnlnv with mini-npen partial scapulectnrnv nn
snapping scapula svudrume. 1 Surg Res 200 3:1 Sflillfldfi—
242. Medline DUI
43. Lehtiuen JT, Tetreault P, Wflrfltr J]: Arthruscupic man-
agement pf painful and stiff scapulutheracic articulatiun.
Aflisrnscnpy 2fl03;19{4):E13. Medline DUI
45'. Uiaumi N. Suenaga N. Funaltushi T. Tamaguchi H, Min-
ami A: Recnverv pf scnsnrj.r disturbance after arthrnscnpic
Eb Ifllii American Academy pf Urthapaedic Surgeans
decpmpressiun nf the suprascapular nerve. ] Sbeuider
Eihuu: Surg 2D12;21{6}:?59-?E4. Medline DUI
The sensnrj.r disturbance at the pnsternlateral aspect [If the
shnulder can he a diagnpstic critericrn fcrr snprascapnlar
nerve palsy. Arthroscupic release cf the suprascapular
nerve is useful tn treat nerve entrapment at the supra-
scapular nntch. Level pf evidence: IV.
50. Wart}: R]. Spiegl U]. Millet: P]: Scapulethcracic hursi-
tis and snapping scapula svndrnrne: A critical review Inf
current evidence. Am } Spurts Med 2915;43[1}I:236-145.
Medline DUI
Snapping scapula svudrume is a liltel}r underdiaguused
cunditirm and can prc-duce substantial sheulder dysfunc-
tipn. Scapulnthnracic hursectclrn‘g.‘r with nr withput partial
scapulectemv is currently.r the must effective prin'larj,r meth—
od uf treatment in patients whuse unnsurgical therap}r is E
unsuccessful. "fl
a:
1]
F”
E's
m
E.
a!
Unhppaedic Knuwledge Update: Sparta Medicine 5
Chapter 6
Elbow Arthroscopy and
the Thrower’s Elbow
Ekaterina Y. Urch, MD Lucas S. McDonald. MD. MPHStTM
The throwing athlete is at increased risk for various
elbow injuries clue to the substantial repetitive forces
exerted on the joint during the throwing motion. The
management of these injuries requires a resolute un-
derstanding of the underlying biomechanics involved
in this complex motion. Surgical intervention is often
required to attain acceptable clinical outcomes and to
allow the athlete to return to his or her sport. Along
with the various open surgical techniques available,
elbow arthroscopy.r has quickly come to the forefront
of surgical treatment in these athletes.
Keywords: elbow arthroscopy; thrower's elbow;
valgus extension overload; lateral epicondylitis;
posteromedial impingement ulnar collateral
ligament
Introduction
Elbow arthroscopyr is a modern surgical technique pop-
ularized in 1935; the first study on the topic described
visualisation of the elbow joint through anterolateral,
anteromedial, and posterolateral portals with the patient
supine.I Historically, elbow arthroscopy was associated
Dr. Dines or an immediate family member has received
royalties from Biomet; is a member of a speakers' bureau
or has made paid presentations on behalf of Arthreie
and serves as a paid consultant to Arthrex and CDNMED
Linvatec. None of the following authors or any immediate
family member has received anything of value from or
has stoclr: or stocir options held in a commercial company
or institution related directly or indirectly to the subject
of this chapter: Dr. Aitchelc Dr. McDonald, and Dr. Urch.
@ lfllfi American Academy of Drthopaedic Surgeons
Ioshua S. Dines, MD David W. Mtchek, MD
E
with inconsistent outcomes and an unacceptably high "fl
complication rate. Since the initial outcome studies, im- e
1]
proved instrumentation, advanced surgical technique, F”
El
and better understanding of arthroscopic elbow anatomy fit
have made arthroscopy a safe, effective treatment for 3.
a?
elbow pathology.
Indications and Contraindications
The advantages of elbow arthroscopy include decreased
surgical morbidity and improved joint visualization, mak-
ing the technique an excellent option for numerous elbow
conditions. However, the small size and compartmental-
iaation of the joint, along with the proximity of portals
to neurovascular structures, makes the procedure techs
nically challenging. The treating surgeon must not only
be familiar with the anatomy and surgical technique, but
also must be proficient in identifying patients most likely
to benefit from the procedure. Classically, the indications
for elbow arthroscopy include the removal of loose bod-
ies, olecranon osteophyte excision, synovectomy, capsular
release, and the evaluation and treatment of osteochondrir
tis dissecans {0CD} lesions} More recently, indications
have expanded to include treatment of septic arthritis,
lateral epicondylitis, intra—articular fracture management,
and plica excision.“
Arthroscopy is contraindicated in patients with dis-
torted soft tissue or osseous anatomy, precluding safe
portal placement. Such situations include anlcylosed
joints, history of prior elbow trauma or surgical inter-
vention, soft—tissue pedicle flaps, skin grafts, burns, and
the presence of heterotopic ossification!” Additionally,
soft-tissue infection at the portal sites is an absolute con-
traindication. Because of the increased risk of ulnar nerve
injury, elbow arthroscopy is relatively contraindicated in
patients with prior ulnar nerve transposition. If arth ros-
copy is performed in these patients, it is critical to visual-
ice the ulnar nerve before establishing the medial portal.5
Orthopaedic Knowledge Update: Sports Medicine 5
 Sectinn 1: Upper Extremity
Patient F'nsitinning
Patient pnsitinning is based primarily nn surgenn prefer—
ence. Advantages and disadvantages at the varinns meth-
nds have been described. Classically, elbnw arthrnscnpy
was perfnrmed supine with the surgical arm draped acrnss
the chest ever a bnlster.5
The modern cnnccpt nf arm suspensinn frnm the supine
pnsitinn, keeping the arm in 9i)“ nf shnulder abductinn
and 911]“ cf elbnvv flexinn, was intrnduced in 1935.1 The
advantages nf the supine pnsitinn include simplified air-
way access, familiar nrientatinn, and ease nf cnnversinn
tn an npen prncedure. Disadvantages include elbcnv in-
stability during the prncedure and difficult access tn the
1: Upper Eittrem ity
pnsterinr cnmpartment.5
Tn address these cnncerns, the mndified supine pnsitinn
was develnped, suspending the arm nver the chest with
the elbnw in 90“ nf flexinn while the fnrearm, wrist, and
hand are secured in a cnmtnercially available mechani-
cal hnlder [Figure 1}. This pnsitinn facilitates easy arm
adjustment, prnviding access tn bnth the anterinr and
pnsterinr cnmpartments nf the elbnw. Furthermnre, this
arm pnsitinn decreases the risk nf injury tn the anterinr
neurnva scular structures by allnwing them tn drnp away
frnni the anterinr capsule.1
|Either nptinns include the lateral decubitus and the
prnne pnsitinns. In the lateral decubitus pnsitinn, the pa~
tient is pnsitinned laterally an a beanbag with the surgical
arm flexed tn PH“ and suspended nver a well-padded pnst.
Jnint distractinn is prnvided by a weight attached tn the
hand. The advantages cf the lateral pnsitinn include im-
prnved arm stability, pnsterinr elbnw access, and relatively
easy airway management. The disadvantages include nri-
entatinn challenges frnm reversed anatnmic landmarks
and difficult access tn the anterinr cnmpartment. In the
prnne pnsitinn, the arm is suspended nff the table in an
arm hnlder with the arm in 9G“ nf shnulder abductinn
and the elbnw in 90" nf fleainn in a similar pnsitinn tn the
lateral decubitus pnsitinn. The advantages nf the prnne
pnsitinn include natural tractinn, easy access tn the pns-
terinr cnmpartment, and a thenretically increased space
between vascular structures and the anterinr capsule. The
disadvantages include the necessity fnr general anesthesia,
difficult airway access, reversed anatnmy, and pnnr access
tn the anterinr cnmpartment.
Irrespective nf the pnsitinn used, it is crucial tn assess
the elbnw fnr access tn each cnmpartment and tn pnrtal
sites befnre starting the prncedure. Pressure cm the an—
tecubital fnssa shnuld be avnided tn decrease the risk nf
injury tn anterinr neurnvascular structures. A tnurniquet
is placed as prnrtimal cm the arm as pnssible and can be
insufflated as needed.
flrfltnpaedic Knnwledge Update: Sparta Medicine 5
r "i
“r
a II . -- ,
--
.3
.5
Ph etngraph demnnstrates the modified supine
pnsitinnI which suspends the arm nver the
chest with the elbnvv in IBITl nf fleainn, and
the fnrearm. wrist. and hand secured in a
cnmmercially available mechanical hnlder. The
medial elbnvv pnrtal is marked relative tn the
underlying essenus anatnmy. The prnsimal
medial pnrtal is 2 cm prmtimal tn and 1 tn 2
cm anterinr tn the medial epicnndyle. The
transtriceps pnrtal is visible pnsterinrly.
Pnrtal Placement
Print tn pnrtal cre atinn, the elbnw jnint is insu filated with
3d mL nf saline th rnugh the lateral snft spnt lncated in the
center nf a triangle created by the radial head, the lateral
epicnndyle, and the tip cf the nlecrannn. This distends
the capsule, mnving the neurnvascular structures further
away frnm the jnint and facilitating easier access tn the
space. Anatnmic landmarks are marked, including the
medial and lateral epicnndyles, ulnar nerve, radial head,
and nlecrannn.
Althnugh many different methnds and lncatinns are
used fnr pnrtal placement, the authnrs nf this chapter
prefer tn first create the prnrcimal lateral pnrtal, lncated
1 tn 2 cm prnrtimal tn the lateral epicnndyle and 1 cm
anterinr tn the humerus {Figure 2}. The radial and pns-
terinr antebrachial cutanenus nerves are at greatest risk
during creatinn nf this pnrtal; therefnre, nnly the skin is
incised sharply, and a trncar is used tn enter the ulnnhu-
meral jnint.5 This pnrtal is primarily used as a viewing
pnrtal. Tn access the anterinr cnmpartment, a prmtimal
medial pnrtal can be established 2 cm presima] and 1
tn 2 cm anterinr tn the medial epicnndyle {Figure I}, it is
impnrtant tn stay anterinr tn the medial intermuscular
septum, minimizing the risk nf ulnar nerve injury. An ad-
ditinnal wnrking anternmedial pnrtal can be established
2 cm anterinr and 2 cm distal tn the medial humeral
El 1016 American AcadMy nf Cirthnpaedic Surge-ans
 Chapter 6: Elbow Arthroscopy and the Thrower’s Elbow

epicondyle. This portal is near the medial antebrachial Complications

cutaneous nerve and should be localized first under direct
visualisation with a spinal needle. Elbow arthroscopy has historically been associated with
Diagnostic arthroscopy of the anterior elbow is per- complication rates as high as 20%.”
formed while viewing through the proximal lateral portal. The most common complication is neurovascular in-
Trochlear and coronoid fossa articular cartilage lesions, jury resulting from surgeon inexperience, poor technique,
coronoid process osseous spurs, synovitis. and loose hod- and lack of knowledge of elbow anatomy. Compression
ies can be identified. The anterior radiocapitellar joint is
evaluated for osteochondral lesions and any concomitant
pathology.r of the radial head. If débridement is performed
in this area, extreme caution must be used because of the
proximity of the radial nerve to the anterolateral joint
capsule. If ulnar collateral ligament {UCL} insufficiency is
suspected, an arthroscopic valgus stress test is performed.

fljwansa .ladtln :j
A standard 3.4-m111 hook probe is inserted through the
proximal medial portal to help measure gapping, and
based on a 1996 cadaver study. a gap of only 1 or 2 turn
suggests a complete anterior bundle UCL injury. Large
increases in gspping suggest injury to the posterior bundle
as well‘ {Figure 3].
For visualisation of the posterior compartment, the
posterolateral portal is created 1 cm posterior to the
lateral epicondyle at the level of the olccranon tip {Fig-
ure 2}. To access the posterior compartment, a midlateral Figure 2 Photograph demonstrates the lateral elbow
portals marked relative to the underlying
portal can be created through the lateral soft spot or a osseous anatomy. The proximal lateral portal
transtriceps portal {the portal preferred by the authors of is l to 2 on proximal to the lateral epieondyle
this chapter) can be created in the midline of the triceps and 1 cm anterior to the humerus. The
posterolateral portal is 1 cm posterior to the
just proximal to the tip of the olecranon {Figure 2}. The lateral epicon dyle at the level of the olerra non
posterior compartment is evaluated for olecra non osteo- tip. The tra nstn'ceps portal is marked posteriorly
in the midline of the triceps tendon just
phytes. posterior recess loose bodies, capitellar GED, proximal to the tip of the plane non.
and chondral injuries.

no my!"
7.‘1u.M '1 ‘
..

Figure 3 A. Arthroscopic view depicts the valgus stress test of an elbow without an ulnar collateral ligament iUCL} injury,
demonstrating no medial-side ulnohumeral joint opening. B. Arthroscopic view depicts the valg us stress test on an
elbow with a UEL injury. demonstrating 3 mm of ulnohumeral joint opening {arrow}.

El Ifllli American Academy of flrfltnpaedie Surgeons Drthnpaedie Knowledge Update: Sports Medicine 5
 Sectien1:Upperlintreruit'f,r
frem cannulas, fluid extravasatien inte surreunding seft
tissues, le-cal anesthesia, and laceratien with the scalpel
er cannula are the mest cemmenl}.r cited insults.‘ Mest
ef these injuries are transient, reselving witheut residual
deficit. Impreved surgeen training, better understanding
ef elbew anatemv, and surgical technique standardisa-
tien have all increased the safety.r ef clhevv arthrescepv.
A recent stud}:r demenstrated that mest cemplicatiens,
including weund healing and infectien, are new these
ubiquiteus te flfil‘lfflSCflPT ef ether jeints.lfl Specifically,
an increased risk ef pesteperative infectien was neted in
patients receiving an intra-articular stereid injectien at
the end ef the precedure, and the anthers ef this chapter
de net recemmend this treatment.
1: Upper Estrem ftv
|Currently, nerve injuries are exceedingly rare, with
reperted transient nerve injury,r rates ranging frem 1.73%
te 23% .“L” Despite the advent ef mere temples; arthre—
scepic precedures including cemplete svnevectemv,
radial head resectien, esteecapsular arthreplastv, and
medial epicendvlectemv, ne substantial asseciatien
has been feund between cemplicatien rate and surgical
cempleaitv.”l I{Hither knewn cemplicatiens include artic-
ular cartilage injury, svnevial fistula fermatien, instru-
ment breakage, and tissue injury secendar},r te use ef a
teurniquet.
Specific Precedures
Leese Bedies
Leese bedies are esteechendral er chendral fragments
caused by either traumatic insult re the elbew er underly-
ing patheleg}.r such as flCD. Leese bed}r remeval frem the
elbew jeint is the must cemmenl},r perfermed arthrescepic
therapeutic interventienfi The su rgeen sheuld perferm a
thereugh diagnestic arthrescepv, assessing all cempartu
ments fer leese bedies, chendral injurv, and an}? ether
pathelegv. Leese bedies are mest cemmenlv lecated in
the pestetier recess. Prier te cempletien ef the precedure,
an intraeperative arthrescepic valgus stress test te assess
UCL insufficiencyF is recemmended.
{JED Lesiens
0CD is mest eften seen in feung athletes ranging be-
tween 11 and 21 vears ef age.j It classically,F affects the
capitellum and is caused bv repetitive micretrauma tn the
vulnerable epiphvsis, which has a tenue us bleed sulrilalv.1
Repetitive leading ef the lateral cempartment ef the el-
bew results in sub-chendral bene degeneratien causing
cartilage fragmentatien. Management ef 0CD depends
en the integrity.F and stabilitv ef the everlving cartilage, as
well as the size and lecatien ef the lesien. Indicatiens fer
arthrescepic débridement include failure ef nensurgical
flrrhepaedic Knewledge Update: Sparta Medicine 5
treatment, the presence ef leese bedies, and mechanical
svmptems. 0CD lesiens are mest cemmenl‘f.r seen at the
pestereinferier aspect ef the capitellum, an area best visu-
alized via the pestcrelateral pertal with the elbew flexed
mere than 9H”. Use ef a TB“ arthrescepe can assist with
visualiaatien. The midlateral pertal is used fer cartilage
flap déhridement, leese bedv remeval, and percutaneeus
drilling.
Lateral Epicendylitis
Lateral epicendvlitis affects between 1% te 3% ef the pup-
ulatien and is an angiefibreblastic hyperplasia ef the ex-
teuser carpi radialis tenden {ECRB}, a neninflammaterv,
dvsvascular degenerative precess caused by repetitive
micretrauma.”'13 Up te 90% ef cases are self-limiting,
reselving within 1 re 2 years.” Patients whese nensurgical
therapv fails are candidates fer surgical treatment. l['Jlas—
sicallv, the precedure is perfermed threugh a small inci-
sien, fecusing en debridement ef the degenerative tenden;
repair ef the tenden te the lateral epicendvle sheuld be
censidered. After the advent ef elbew arthrescepv, seme
surgeens advecated arthrescepic treatment te include
debridement ef beth the tenden and the anterelateral
capsule. The advantages include the abilityr te visualize the
entire jeint and re treat cencemitant pathelegv, including
svnevial plicae, which can mimic lateral epicendvlitis.”*”‘
Arthrescepic release is perfermed using a medial visuali~
aatien pertal and a lateral werlcing pertal. The medial
pertal is placed preitimallv eneugh te ensure visualizatien
ef the entire ECRB insertien. The lateral pertal is placed
directly.r threugh the site ef the damaged ECRB tenden
{the Hirschl lesien}, 2 cm anterier tn the intermuscular
septum. The jeint is entered just preJcimal te the artic—
ular margin ef the capitellum.12 The capsule is débrided
first, fellewed by débridement ef the ECRB tenden until
healthy,r tissue is visualized. The lateral epicendvle is de—
certicated with a shaver, werlcing anterier te the equater
ef the radial head te aveid injurv re the lateral cellateral
ligament cemples. The ECRB tenden can be plicated te
the everlving eatenser carpi radialis lengus tenden er
secured te the anterier aspect ef the lateral epicendvle
using a suture ancher.“1
Arthrescepic débridement ef lateral epicendvlitis
demenstrates substantial imprevement in svmptems with
geed everall eutcemes.‘1=”~”' Furthermere, it has been
suggested that arthrescepic treatment prevides substan-
rial imprevement in functienal entcemes when cempared
with the epen methed.” The same stud};r feund ne differ~
ence in cemplicatien er failure rates between epen and ar-
threscepic treatment.” Ca reful patient selectien remains
parameunt: manual laberers and patients with werkers’
cempensatien claims are asseciated with a EUh-Stflfltlflll?
El 1016 American Academv ef Drrhnpaedic Surgenns
 Chapter 6: Elbow Arthroscopy and the Thrower's Elbow

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Windup Early Late Aooeleration U | Follow- E
cooking oooltinq § I mmugh ; "fl

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Start Hands Foot Mammal Ball 3 Finish fill
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apart down ma("3' release a!
nnaaon

Fiq u re 4 Illustration depicts the throwing motion divided into six distinct stages: windup, early arm cocking, late coclrlng,
acceleration. deoeleratlen. and follow-through. {Reproduced from lplsvastl fl. ElAttrache H5. lobe rw:
Understanding shoulder and elbow injuries in baseball. IAm Atari Drthop SuryaI 2Dfl?;15[3]:139-14?.]

increased risk of poor functional outcomes following a valgus force as high as 64 him is generated in the elbow
arthroscopic treatment.” by the forward rotation of the upper trunk and pelvis
with associated external rotation of the shoulder.'.1‘-'1 Con-
comitantly, up to Sill] Hm of compression can be placed
Th rovver's Elbow
on the lateral radiocapitellar joint?“I As the arm is driven
Biomechanics of Throwing forward into acceleration, the elbow is rapidly extended
The overhead throw involves coordination of the upper as the humerus adducts and internally rotates. The trunk
extremity, trunk, and lower extremity in one fluid motion. and upper extremity shift forward. During this time,
Elbow static and dynamic stabilizers play a critical role the elbow accelerates at up to fiflflfiflfl“ per second.“
throughout this motion. Static stabilizers of the elbow A countering varus torque generated through the elbow
include the anterior joint capsule, the UCL complex, and opposes the valgus torque created by shoulder external
the radial collateral ligament complex. Dynamic stabilis- rotation and rapid acceleration. The UCL has been found
ers include the flexor pronator mass made of the pronator to supply almost 50% of the force required to oppose the
teres, the flexor carpi radialis, the palmaris, the flexor dig— valgus force when the elbow is in 9H“ of flexion."1r
itorum superficialis, and the flexor carpi ulnaris. To better Such high loads exceed the ultimate tensile strength of
understand the biomechanics of overhead throwing, the the UCL and over time result in attritional changes. The
motion is divided into six distinct stages: windup, early deceleration phase is initiated at ball release. Deceleration
arm cocking, late cocking, acceleration, deceleration, and occurs at a rate of Sflflfiflfl“ per second over a span of
follow-through‘fl” {Figure 4}. approximately 51'} ms.” During this stage, maximum el-
During wind—up, the elbow is flexed with the forearm bow extension velocity can reach 2,?flfl“ per second.” The
in pronation. The arm is moved overhead and into adduc- shoulder reaches maximum internal rotation, the elbow is
tion. In early cocking, elbow flexion and pronation are extended to roughly 2|)“, and the flexor-pronator muscles
maintained while the shoulder is abducted and externally contract to prevent posteromedial impingement of the
rotated. The leading lower extremity is advanced forward. olecranonflflfl The arm moves into the follow-through
In late cocking, elbow flexion is increased to between stage, marking the end of the throwing motion.
90" and 120°. The forearm is pronated with maximum
shoulder abduction and external rotation. At this stage,

4D Ifllti American Academy of flrfltopaedic Surgeons Drrhopaedic Knowledge Update: Sports Medicine .5
 Sectiun 1: UpperExtremity
Va’lgus Extensiun Dverluacl
Must thruwing injuries uf the elbuw uccur during the
acceleratiun stage in which high valgus furces are cuun-
tered by rapid elbuw extensiun. This mutiun results in
three distinct pathulugic furces: a tensile furce un the
medial stabilising structures, a cumpressiun force at the
radiucapitellar juint, and a medially directed shear force
in the pusteriur cumpartment.”
These furces cause a spectrum uf injuries cumprising
the valgus extensiun uverluad WED} syndrume. This
injury pattern is the must cummun diagnusis requiring
surgical treatment in baseball players and uther uverhead
thruwing athletes.2 Because must uf these injuries uccur
during the late cucking and early acceleratiun stages, it is
1: Upper Extremity
nut surprising that 35% uf uverhead athletes with VED
experience symptums during the acceleratiun phase uf
thruwing}I Athletes usually present with ch runic medial
elbuw pain and cuncumitant changes in perfurmance,
including decreased pitch speed and stamina. Sume re-
purt elbuw clicking ur lucking. Key physical examinatiun
maneuvers include the muving valgus stress test and the
milking maneuver. Evaluatiun fur ulnar neuritis ur sub-
luxatiun is critical fur future surgical planning.
Pathupuhysiulugyr u'f UED
The large valgus force exerted un the elbuw in uverhead
thruwing, created by humeral turque and trunk rura—
tiun, is cuuntered by rapid elbuw extensiun. As repetitive,
near—failure tensile stresses are exerted un the UCL, the
ligament is subjected tu micrutrauma and subsequent
attenuatiun cf the anteriur bundle. The anteriur bundle
uf the UCL is the must impurtant static stabilizer uf the
medial elbuw and damage tu this structure results in val-
gus instability. Even subtle UCL laxity results in stretch
uf uther medial structures, including the ulnar nerve and
the flexurrprunatur mass causing ulnar neuritis and flexur
mass tendinitis ur tears. In skeletally immature athletes,
medial epicundyle apuphysitis can uccur. Similarly, as
a result uf UCL incumpetency, usseuus cunstraints uf
the pusterumedial elbuw becume key stabilizers during
thruwing. The repetitive shear stresses frum cuntinued
thruwing cause pusteriur cumpartment impingement.
Valgus laxity secundary tu UCL stretching further ex-
acerbates the cunditiun by altering the cuntact area be-
tween the medial humeral crista and the ulecranun?-I The
abnurmal nlnuhumeral cungruency results in increased
cuntact pressures causing pusterumeclisl impingement.
With chruuic impingement, athletes bccume susceptible tu
synuvitis, ulecranun tip usteuphyte furmatiun, ulecranun
stress fractures, luuse budies, and chundral lesiuns cf the
pusterumedial truchlea. Finally, because uf the high cum—
pressiun fumes exerted un the lateral radiucapitellar juint,
flrrhupaedic Knuwledge Update: Spurrs Medicine 5
athletes are at risk fur chundrumalacia, luuse budies, and
lateral usteuphyte furrnatiun.
Management
The management uf elbuw injuries in thruwing athletes
begins with preventiun. Yuuth pitchers are must suscepti-
ble tu this injury. Athletes lugging mure than IUD games
per year are 3.5 times mure likely tu sustain an elbuw
injury.l3 Dther facturs knuwn tu increase the risk uf elbuw
injury are playing baseball mure than 3 munths per year,
pitching mure than Bi] pitches per game, and thruwing
faster than 35 miles per huurF‘l
UEL Injuries
Nunsurgical management is indicated in yuung athletes
with acute injuries and athletes with partial UCL injuries
{grade I ur II sprains)?” These patients are placed un ac-
tive rest fur 5 tu 12 weeks. Nunsurgical mudalities include
physical therapy emphasizing elbuw and shuulder range
uf mutiun and strengthening, NSAIDs, bracing, and cryu—
therapy. The gual uf nunsurgical treatment is tu address
any issues with pitching mechanics. shuulder kinematics,
shuulder mutiun deficits, as well as cure strengthening.“
After painless range uf mutiun is established, the pa»
tient is prugressed tu an isumetric prugram fulluwed by
an isutunic upper arm and furearm—based strengthening
prugram with cluse attentiun given tu flexur—prunatur
mass training.” An integrated gradual thruwing pru-
gram is initiated after pain has resulved and all kinetic
chain deficits have been treated. Appruximately 40% uf
patients return tu spurts participatiun at ur abuve their
preinju ry level uf play after an apprupriate rehabilitatiun
prutuculfi“r A 2D 1D study repurted successful nunsurgical
treatment uf prufessiunal fuutball quarterbacks with UCL
injuries.“ Must cases were cuntact injuries, suggesting an
acute, traumatic UCL rupture. The study cuncluded that
these types uf injuries cunld be amenable tu nunsurgical
management. Huwever, this dues nut apply tu chruuic
UCL injury seen mure uften in baseball pitchers. The
use uf platelet-rich plasma (PEP) can be cunsidered as
an augment tu healing, with une study repurting an 33%
rate uf return tu preinjury play in athletes treated with
PEP.“ Althuugh scattered repurts appear prumising, data
un the efficacy uf PEP remain limitedfimfl Steruids are
nut recummended because uf the risk uf tendun rupture.
Athletes whuse nunsurgical treatment was unsuccess-
ful ur thuse preferring tu quickly return tu their prein-
jury level uf play are candidates fur surgical treatment.
Sume studies have suggested the value uf diagnustic elbuw
arthruscupy tu evaluate fur articular cartilage lesiuns
and luuse budies, as well as fur usteuphyte ddbridement
and capsular release?!” Additiunally, an intrauperative
El 1016 American AcadMy uf Drrhupaedic Surge-nus

arthroscopic valgus stress test can confirm UCL insuffi-
ciency. However, with a thorough clinical history, accu—
rate physical examination, and corresponding imaging,
diagnostic arthroscopy is rarely needed and is recom-
mended only if presentation suggests intra-articular
pathology.
Direct repair of the UCL is indicated in the flaw patients
with acute avulsion injuries, with good outcomes reported
in young, nonprofessional athletes.“ The surgical man-
agement of choice for a chronically injured, attenuated
UCL is reconstruction using an ipsilateral palmaris ten-
don autograft. Alternative graft options include the grac-
ilis tendon or contralateral palmaris tendon.
In 19?”, UCL reconstruction of the elbow, commonly
referred to as Tommy john surgery, was popularised. This
“Li-ply technique” used two convergent bone tunnels in
the ulna and two divergent bone tunnels in the humerus.
Autograft tendon was passed through the tunnels and su-
tured to itself for tensioning. Concerns over graft fixation
and appropriate tensioning prompted several modifica-
tions, including the Jobe modification {a muscle-splitting
approach without ulnar nerve transposition}, the Amer-
ican Sports Medicine Institute modification {a posterior
approach between the two heads of the flexor carpi
ulnaris, flexor-pronator elevation without takedown,
and ulnar nerve transposition}, the docking technique
{a muscle~splitting approach, reconstruction performed
via converging tunnels distally and a Y—shaped humeral
tunnel with graft clocking in a single proximal tu nnell, the
hybrid technique {humeral fixation with suture anchors),
and the Tommy john DANE T] modification.”
The DANE T] method uses a muscle-splitting ap
proach through the posterior one third of the common
flexor mass, within the anterior fibers of the flexor carpi
ulnaris. The procedure reconstructs the deep central fi-
hers of the UCL. After the remnant of the ligament is
taken down, the ulnar side of the graft is fixed by placing
an interference screw into a single drill hole at the UCL
insertion. 0n the humeral side, the docking technique is
used, with the limbs of the graft secured within a single
15-mm bone tunnel made using a 4-mm burr. The graft
is secured with two suture limbs that are passed through
two divergent drill holes and tied over the top of the
epicondyle.
The illliuthors'r Preferred Technique
Preoperatively, the patient is evaluated for the presence of
an ipsilateral palmaris tendon; if absent, gracilis tendon
autograft is used. If present, the palmaris tendon graft
is harvested first through a 1-cm transverse incision just
proximal to the volar wrist crease, where the tendon is
easily identified and isolated. Using blunt dissection, the
Eb Illlti American Academy of Urthopaedic Surgeons
Chapter 6: Elbow Arthroscopy and the Thrower’s Elbow
E
.I'
"fl
lntrao berative photograph demonstrates the
o,
1]
medial approach performed through a 1lJ-cn'l
incision from the distal intramuscular septum to
F”
the sublime tubercle. flare is taken to identify
E's
fill
and protect the medial antebrachial cutaneous E.
nerve. a!
mndon is delivered out of the incision using two mosquito
clamps. A locked Krakow stitch is run along the tendon
using No. 1 nonabsorbable, braided suture and the tendon
is cut distal to the suture before harvesting with a closed
tendon stripper. The wound is irrigated and closed with
interrupted nylon sutures.
Under tourniquet for visualization, the medial elbow
is approached through a llJ—cm incision from the dis-
tal third of the intramuscular septum to 2 cm distal to
the sublime tubercle, protecting the medial autebrachial
cutaneous nerve {Figure 5 l. The flexor pronator mass
is split through the posterior third of the muscle belly,
taking care to identify the ulnar nerve by palpation and
remaining anterior to it. The native UCL is identified and
the anterior bundle is split, longitudinally exposing the
joint. Two bone tunnels are made in the ulna 4 to 5 mm
distal to the sublime tubercle. A 3-mm bu tr is used create
the tunnels, one anterior and one posterior to the tuber-
cle. The tunnels are connected with small curved curet,
maintaining a 2-cm osseous bridge. For humeral fixation,
a 4-mm burr is used to create a longitudinal tunnel along
the axis of the medial epicondyle. Care is taken to avoid
violating the posterior cortex. On the upper border of the
epicondyle, at the proximal end of the tunnel, two small
anterior exit points are made using a 1.5-mm drill or a
small burr. These points are positioned anterior to the
intramuscular septum {LE to Ll} cm apart. The native
UC L is repaired using a 2-H absorbable, synthetic suture.
For graft passing and fixation, the forearm is main-
tained in supination with a mild varus stress applied to
the elbow. The graft is passed from anterior to posterior
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 1:1}pperExtremity
through the ulnar tunnel. The previous placed trac-
tion sutures are passed into the humeral tunnel and out
through one of the two exit holes. This litub is held taught
while the elbow is moved from flexion to extension to
confirm isometry. Optimal graft length is determined
using the exit hole as a reference point. This point is
marked on the graft, and a second locked Krakow stitch
is placed into the free end of the graft just proximal to
the mark before trimming excess graft. The second limb
of the graft is passed up into the humeral tunnel and
through the empty exit hole, completely docking the graft
{Figure 6}. The sutures are tied over the osseous bridge on
the humerus, securing the graft in place. Subcutaneous
ulnar nerve transposition is performed only if clinical
1: Upper Extremity
symptoms are present preoperatively or it is found to be
unstable at the time of surgery.
|lifiutcemes following UCL reconstruction are favorable.
In 2010, a large case series evaluated clinical outcomes
in 7’43 athletes using the American Sports Medicine In-
stitute modification“ and found that 33% of athletes
returned to the same level of competition after surgery
or higher, with an average time of 11.6 months from sur-
gery to competition. lEither studies have found excellent
functional outcomes in 90% of patients following the
decking technique with a trend to greater rates of return
to play when compared with the Jobe modificatieufilrfl
The DANE TJ modification has also been shown to have
excellent outcomes, with 36% of athletes returning tn
preinjury level of play.“
The most common complication following UCL re—
construction is ulnar nerve neurapraxia, which usually
resolves over the course of several months.” Rates of
ulnar nerve neurapraxia can be as high as 16%, although
these results are associated with older surgical techniques
in which transposition of the ulnar nerve was regularly
performed.31 |D‘utcemes studies involving the decking and
DANE T] methods have shown a substantial decline in
postoperative neurapraxia secondary tn limited handling
of the nerve. |Either reported complications are rare and
include iatrogenic fractures, wound complications, and
stiffness.25
Flexer-Prenator Mass Injuries
The flexor-pronater muscles are key dynamic stabiliz-
ers in the elbow, countering the high valgus load during
the throwing motion. During the acceleration phase of
the throwing motion, these muscles cnntract repetitively
tn stabilise the elbow. Similarly, the muscles contract
eccentrically to protect the elbow from pesteromedial
impingement in the deceleration phase as the elbow moves
into extension. Acute rupture, although rare in overhead
athletes, can occur during such forceful movements. In
flrdtopaedie Knowledge Update: Sports Medicine 5
Figure 6 Intraoperative photograph demonstrates
final graft placement after shuttling through
the ulnar tunnel and decking into the
humeral tunnel. The native ulnar collateral
ligament remnant is incorporated into the
reconstruction.
most cases, acute rupture is preceded by prodromal symp-
toms manifesting as the final stage of a chronic pathelegic
process. More commonly, flexer-pronater injuries occur
on a spectrum ranging from mild overuse and chronic
tendinitis to partial tears. These injuries are often as-
sociated with UCL attenuation, exposing the muscles
to increased stress.” Similarly, age is a substantial risk
factor for combined UCL and flexor~pronator injuries.”
Nonsurgical treatment of these injuries is the mainstay
of management. Treatment with active rest, ice, NSAIDs,
and physical therapy with gradual return to throwing is
almost always curative.
Surgical management, consisting of débridement and
repair, is indicated in patients whose nonsurgical treat-
ment has failed. This commonly presents as recurrence
of weakness andi'er pain with throwing. In such cases, a
missed underlying pathology such as a UCL injury may
be the cause.” A high level of suspicion and careful re-
evaluation of the athlete and imaging are critical.
Radiocapitellar Joint IE'iverl ead
Radincapitellar joint overload is a phenomenon caused
by the tremendous compression forces exerted on the
joint during the overhead throw. Although the underlying
pathophysiolngy is thought to be the combination of re-
petitive compressive trauma, ischemia, and genetic predis—
position, the distinct cause remains unclear.” The injury
most commonly presents with less of elbow extension,
swelling, joint effusion, and lateral elbow pain with both
palpation and valgus stress. Radiocapitellar joint over-
load can manifest in various injury patterns, including
marginal osteophytes, chondremalacia, or GED of the
capitellum. A trial of nonsurgical treatment is indicated
El 1016 American Academy of Cirrhopaedic Surgeons

Figure i" Arthrescepic views depict an esteech en dritis disseca ns {GED} Iesien ef the elbevur befere {A} and after {B}
mirrefracture.
fer patients in whem early {stage I] DIED lesiens have been
diagnesed. Yenng patients with epen capitellar grevvth
plates, lecaliaed flattening er radielucency witheut sub-
chend ral bene invelvement, and geed elbew functien are
prime candidates fer nensurgical care.”
Patients whese nensurgical treatment has failed and
these with advanced [stage II and III} 0CD lesiens are
indicated fer surgery. Stage II lesien are unstable, parr
daily detached fragments ef cartilage with lateral buttress
invelvement.3 Treatment censists ef arthrescepic débride-
ment using the lateral and pesterelateral pertals. Altheugh
fracture fixatien ef acute grade II lesiens has been de-
scribed, healing rates are unpredictable.” Alternatively,
fragment eacisien and arthrescepic er mini—epen micrev
fracture can be perfermed fer lesiens smaller than 7’ mm in
diameter”5 {Figure 7"}. Mesaicplasty can be perfermed fer
defects greater than T' mm, with geed early eutcemesF‘E'E-a?
In these cases, graft can be harvested frem the far lateral
er medial edges ef the lateral femeral cendyle.
Stage III lesiens are unstable, fully detached cartilage
fragments that present as intra-articular leese bedies.
These injuries are treated in a manner similar te stage
II lesiens; micrefracture is indicated fer smaller lesiens
and grafting can be censidered fer larger lesiens. Reperts
demenstrate geed early eutcemes with impreved range
ef metien and a high rate ef return te spurt in preperly
selected adelescent athletes. I.'.Zlverall, appreitimately 35%
ef patients return te their preiniury level ef play?!” Clut-
cemes in yeunger patients with epen radial physes and
these with large lesiens are less censistent.“l In skeletally
Eb Ifllti American Academy ef flrdiepaedie Surgeees
Chapter 6: Elbew Arthrescepy and the Threwer's Elbew
E
"fl
e,
1]
F”
ii
m
E.
a!
immature athletes, radial head enlargement can develep
and may predispese these patients te early esteearthritis.
Similarly, patients with large lesiens can alse be at in-
creased risk fer early arthritis and are thus less likely te
report geed leng—term eutcemes.” It is imperative fer
treating physicians te educate patients abeut these risks
te manage leng—tertn geals and expectations.
Pesteremedial lrnpingernent
Cemmenly, symptematic pesteremedial impingement
in everhead athletes is treated surgically. Hensurgical
management is reserved fer everhead athletes with radie-
graphic signs ef impingement and wbe remain asymptem-
atic. Similarly, symptematic individuals whe medify their
sperts activity, either by changing pesitiens er reducing
the intensity er frequency ef play, can defer te nensurgical
management, including rest and physical therapy with
dynamic stabilizing and strengthening exercises.
Rehabilitatien fer cempetitive athletes with symptem-
atic pesterier medial esteephytes er intra-articular leese
hedies is usually unsuccessful and surgery is indicated. As
described previeusly, pesteremedial impingement is fre-
quently secendary te underlying UCL insufficiency. Treat-
ment ef impingement witheut apprepriately treating the
UCL injury results in peer functienal eutcemes. There-
fere, arthrescepic management ef pesteremedial impinge-
ment is preferred because it allews surgeens te evaluate
the integrity ef the UCL using the arthrescepic valgus
stress test and perferming recenstructien if necessary. The
pesterelateral and pesterier pertals previde visualizatien
Drthepaedic Knewledge Update: Sperts Medicine 5
 Sectinn 1: Upper Extremity
1: Upper Extremity
A
Figure 3 Arthrnscnpic views of pnsternrneclial nlec rannn nstenphytes nbtainecl frnrn the pnsternlateral pnrtal befnre (All
and after {I} resectinn at the nstenphytes tn the level at native bnne. avnirling excessive resectinn and instability.
nf the pnsterinr recess and the entire nlecrannn. Resectinn
at the pnsternmedial nlecrannn nstenphytes is perfnrmed
with the arthrnscnpe in the pnsternlateral pnrtal and
the shaver in the transtriceps pnrtal {Figure I]. A small.
curved nstentnme can else be used. Resectinn shnuld
be limited tn the nstenphyte itself withnut débridement
nf native bnne because excessive nlecrannn resectinn is
assnciated with valgus elbnw instability in the setting at
cnncnmitant chrnnic UCL insufficiency“ (Figure 3}. Mule
tiple studies have demnnstrated the rnle nf the prnrtimal
nlecrannn in elbnw stability. Studies vary based cm the
specific type nf resectinn; hnwever, a 1936 study demnnu
strated that resectinn nf the prnrtimal 25% nf the nlec—
rannn reduces cnnstraint by 3fl‘3‘rh in eatensinn and 59%
in 9D“ nf flexinn.“ A lflflfi study fnund nnly 3 mm nf
pnsternmedial resectinn caused changes in valgus angn—
latinn.“El An intranperative arthrnscnpic valgus stress test
must be perfnrmed tn avnid missing any underlying UCL
injury. The pnsternmedial gutter must be de'brided with
cautinn tn avnid iatrngenic injury tn the ulnar nerve. In
patients with prenperative ulnar neuritis, a cnncnmitant
ulnar nerve transpnsitinn is indicated.
Snme thrnwing athletes demnnstrate mnre advanced
arthritic changes assnciated with pnsternmedial impinge-
ment. Treatment can be challenging because nf cnntrac—
tures and the prnsrimity nf neurnvascular structures tn
the anterinr elbnw. Ussenus spur remnval and capsular
release can assist with mntinn and pain relief. A 21313
study described a stepwise apprnach tn prevent nerve
flrdmpaedie Knnwledge Update: Sparta Medicine 5
injury during capsulectnmy and débridement nf the elbnw,
including the use at blunt retractnrs tn sweep neurnvas-
cular structures nut nf the wnrlting field.“‘l Additinnally.
supine pnsitinning using an arm hnlder limits pressure
en the antecubital fnssa. allnwing critical neurnvascular
structures tn fall away frnm the surgical field.
lEllecrannn Stress Fractures
Dlecrannn stress fractures result frnm repetitive micrn-
trauma and errcessive tensile stress frnm the triceps tendnn
and pnsterinr impingement nf the nleerannn. The injury
presents as pnsternmedial nlecrannn pain during and after
thrnwing and has a prevalence nf 5.4% in baseball—related
elbnw injuries.“ The same study found that TD% tn 90%
nf these injuries nccur cnncnmita ntly with a UCL injury.
Firstrline treatment cnnsists nf rest, immnbiliaatinn, and
limiting full eatensinn tn allnw the heme tn heal.
Surgical treatment is perfnrmed in patients with
persistent pain after prnlnnged rest and in cnmpetitive
thrnwers with cnmplete fractures. The basic principles
nf fracture fixatinn apply, and cnmpressinn thrnugh the
fracture is the primary gnal. Dpen reductinn and internal
fixatinn using a cannulated screw has high success rates
in returning athletes tn their previnns level nf prelnjury
play nr higher” {Figure 9}. The mnst cnmmnn cnmpli-
catinn fnllnwing surgery is painful hardware, with 33%
nf patients requiring additinnal surgery fnr remnrral.“E
Fracture nnnuninn. althnugh rare, can be seen in ynung
patients with undiagnnsed chrnnic elbnw pain nr in these
El 1016 American AeadMy nf Drthnpaedie Surgetms

Figure 9 Lateral radiegraph demenstrates healed
elecranen stress fracture fellewing fixatien
with a partially threaded, cannulated screw.
treated nensurgically. In such cases, surgical fixatien with
a cannulated screw has been shewn te be an excellent
treatment eptien.“
Summaryr
Elbew injuries are a premine nt phenemenen ameng ever—
head athletes. As athletes heceme cempetitive at yeunger
ages, the incidence ef these types ef injuries will centinue
te grew. Censequently, research needs te be directed ter
ward impreving en and develeping new treatment meth-
eds fer the va rieus pathelegies asseciated with cempetitive
threwing. Currently, arthrescepic management is a viable
treatment eptien fer many ef these injuries, previding
premising functienal eutcemes and minimal merbidity.
As surgical techniques evelve and surgeens beceme famil-
iariaed with the arthrescepic methed, the applicatiens ef
clbew arthrescepy will centinue te expand.
Key Study Feints
I Elhew arthrescepy, altheugh technically challeng-
ing, is an impertant reel in an elbew surgeen’s
armamentarium.
1* Knewledge ef threwing hiemechanics is crucial fer
understanding injuries seen in everhead athletes.
1* Injury te the UCL must be ceusidered in an ever-
head athlete with elhew pain.
Eb Ifllti American Academy ef flrdtepaedjc Surgeens
Chapter 6: Ell'revrr Arthrescepy and the Threwer's Elhew
Annotated References
I. Andrews JR, Earsen WE: Arthrescepy ef the elbew. Ar-
threscepy 1935;1{2}:9?—101 Medline DUI
it. Dedsen CC, Nhe 5], Williams E] III, Altchelt DW: Elbew
arthrescepy. I Am Acad firthep Surg lflflflflfijlflltfiT’d-
535. Medline
3. Ahmad CS, ElAttrache NS: Treatment ef capitellar es-
teechendritis dissecans. TechI Shenlder Elbert! Sung
lDflE;?:169—l?4. DUI
4. Bennett Jl'vl: Elhew arthrescepy: The basics. I Hand Surg
Am 2013;33lllflfi4—161 Medline DUI
E
This article fecuses en the basic surgical setup and tech- "fl
nique fer elhew arthrescepy. The anther discusses current
a,
1]
indicatiens and centraindicatiens fer the precedure, as F”
well as cemmen cemplicatiens. ii
fit
5. Eyrarn IR, Kim HM, Levine WM, Ahmad C5: Elhew
3.
a!
arthrescepic surgery update fer sperts medicine cen-
ditiens. Am I Sparta Med 2013;41l9l:2191-22fl2.
Medline [Hill
This article prevides an update en the current indicatiens,
medern techniques, and eutcemes fellewing elhew ar-
threscepy. The anthers describe the meat cemmen surgical
techniques te treat the mest cemmen pathelegies within
the elbew jeint. The irupertauce ef apprepriate indicatiens
and preper technique are highlighted.
6. Field LD, Altchelt 13W: Evaluatien ef the arthrescepic
valgus instability test ef the elbew. Am ,i' Sperts Med
1995;24llltlTr'T—lfll.Mcdline DUI
T. Baker CL Jr, Jenes GL: Arthrescepy ef the elbew. Am
,i' Sperts Meal 1999;2Tl2]:251-264. Medline
3. Kelly EW, Merrey BF, G‘Driscell 5W: Eemplicatiens
ef elhew arthrescepy. } Hesse jer'm Surg Am 2001;33-
Aill:25-34. Medline
9. Saveie FH III, Field LD: Eemplicatiens ef elbew arthres-
cepy, in Saveie FH, Field LD, eds: AANA Advanced Ar-
Ibrescepy: The Wrist and Elia-1w. Philadelphia, Saunders!
Elsevier, lfllfl, pp 14E-15fl.
The testheelc cevers basic and cemples elbew pathele-
gies that can be treated using arthrescepy. A thereugh
review ef arthrescepic indicatiens, surgical techniques,
eutcemes, and cemplicatiens are reviewed. The future ef
elbew arthrescepy is alse discussed.
1D. Nelsen GM, Wu T, Galata Ltvt, Yamaguchi K, KeenerJD:
Elbew arthrescepy: Early cemplicatiens and asseciated
risk facters. I Sheulder Elbew 3mg 2fl14;23{2l:2?3-2T3.
Medline DUI
This case series ef 417ir elhew arthrescepies evaluated
early cemplicatiens fellewing the precedure and re-
viewed asseciated risk facters. The study feimd an everall
Drrhepaedic Knewledge Update: Sparta Medicine 5
 Sectien 1:1}pperExtremity
cemplicatien rate cf 14%. Mes: cemplicatiens were miner
and transient in nature. l'viajer cemplicatiens. the mest
cemmen ef which was deep infectien. eccurred in 5% cf
cases. Lewl ef evidence: IV.
11. Marti D. Spress C. Jest E: The first 100 elhew arthresce-
pies ef ene surgeen: Analysis ef cemplicatiens. I Shealder
HittersI 5mg 2313;12j4}:56?—5 T3. Medline DUI
This case series ef 1'30 censecutive elbew arthrescepies
analysed cemplicatiens seen fellewing elbew arthrescepy.
The everall cemplicatien rate was 5%. with ne majer
cemplicatiens eccurring. Ne asseciatien was seen between
cemplicatiens and the cemplexity ef the precedure er the
surgeen's learning curve. Level ef evidence: IV.
12. Saveie FH III. 1|Itl'anflice W. U’Brien M]: Arthrescepic
tennis elhew release. I Shenl‘der Elbert! Sarg 115110519112.
1: Upper Extrem tty
Suppljfil-Se. Medline DUI
This review details surgical technique fer treating lateral
epicendylitis using elbew atthrescepy. The results ef re-
cent studies evaluating functienal eutcemes are discussed.
The anthers cenclude that arthrescepic release ef lateral
epicendylitis is an excellent eptien fer patients whese
nensurgical treatment has failed.
13. Hirsch] RP. Ashman ES: Elbew rendinepathy: Tennis el-
bew. Cite Sperts Med 2333;22j4j:313- 335. Medline DUI
14. |Ceenrad KW. Heeper 1WK: Tennis elbew: Its ceurse. natu-
ral histery. censervative and surgical management. I Ilene
faint 5mg Arr: 13T3;55[E]:1 1??—1 132. Medline
1.5. Kim DH. Gambardella RA. Elattrache H5. Yecum LA.
jehe FW: Arthrescepic treatment ef pesterelateral elhew
impingement frem lateral synevial plicae in threwing ath-
letes and gel fers. Art: I Sperts Med 2936;34j3j:433-444.
Medline DUI
16. Latterma an E. Remee AA. Anbari .31. et al: Arthrescepic
debridement ef the extenser carpi radialis brevis fer re-
calcitrant lateral epicendylitis. j Shealder Elbert: Snrg
201D;19{5}:551-556. Medline DUI
This retrespective review cf 36 patients with lateral epi-
cendylitis treated with surgery assessed the eutceme ef
arthrescepic release ef the ECRE with a mean fellew—up
ef 3.5 yea rs. The results shewed substantial imprevement
in pesteperative pain and a mean return te I'ull activity ef
7-" weeks. He majer cemplicatiens were identified. Level
ef evidence: III.
1?. Selbeim E. Hegna J. fiyen J: Arthtescepic versus epen
tennis elhew release: 3— re 6-year results ef a case-centrel
series ef 305 elbews. Arthrescepy lfllfiilfljflmfl-ESE.
Medline DUI
This case-centrel study cempared the eutceme ef ar-
threscepic and epen treatment eF lateral epicendylitis in
3!] patients at a minimum fellew—up cf 3 years. Patients
were evaluated using the QuickDASH scale. Substantially
better sceres were reperted in the arthrescepic greup.
Level ef evidence: III.
Urrltepaedic Knewledge Update: Sperts Medicine 5
13. Grewal R. MacDermid JC. Shah P. King '3]: Functienal
eutceme ef arthrescepic extenser carpi radialis hrevis
tenden release in chrenic lateral epicendylitis. } Hand
Surg Am 2339;34l51:349-351 Medline DUI
This case series cf 36 patients with chrenic lateral epicen-
dylitis treated with athrescepic release reperted en pest-
eperative Functienal eutcemes. Thirty patients impreved
with surgery: mest reperted geed te excellent results.
Werlters’ cempensatien and heavy laher were asseciated
with substantially werse eutcemes. Level ef evidence: IV.
19. Jenes Iii]. Usbahr DC. Schrumpf MA. Dines J5. Al-
tchelt DW: Ulnar cellateral ligament recenstructien in
threwing athletes: A review ef current cencepts. FLAGS
exhibit selectien. I Berra jetnt Snrg An: 2312:94t31m49.
Medline DUI
This review article details the anatemy and functienal
biemechanics ef the UCL. Werlt—up and management ef
the th rewing athlete with UCL injury is described, and a
thereugh review ef surgical techniques and clinical eut-
cemes was cenducted.
20. Patel RM. Lynch T5. Amin NH. Calahrese G. Grysle
3M. Schickendantx MS: The threwer’s elbew. Urthep
C'It'n Netti: Arr: 2314;45{3j:355-3?6. Medline DUI
This cemprehensive everview includes the functienal anat—
emy ef the elbew. the biemechanics ef th rewing. and the
varieus pathelegies incurred with repetitive threwing in
everhead athletes. Clinical ptesentatien. werlc-up. and
management ef the mest cemmen injuries are cevered
in detail.
21. IL‘allaway GH. Field LD. Deng IH. et a1: Eiemechanical
evaluatien ef the medial cellateral ligament ef the elbew.
I Bette Ieirtt Surg Am 199?;T9j3l:1213-1231. Medliue
12. IEtshahr DC. Dines JS. Ereaseale NM. Deng EH. Altchelt
DW: Ulnehumeral chendral and ligamenteus everlead:
Biemechanical cerrelatien fer pesteremedial chendrelna-
lacia ef the elhew in threwing athletes. Hm ] Sperm Med
2313;33j13}:2535-2541.Medline DUI
This cad aver study evaluated the pathelegic hiemecha nics
ef an elbew with valgus laxity in six specimens subjected
te static valgus lead. Centact ferces and centact area shift
acress the pesteremedial elhew were measured hefere and
after sectiening ef the anterier bundle ef the UCL. The
results shew abnermal centact acress the pesteremedial
elhew secendary te valgus laxity.
13. Fleisig U3. Andrews JR. Cutter GE. et al: Risk ef seri-
eus injury fer yeung baseball pitchers: A. Ill-year pre—
spective study. Aer I Sperts Med 2311:39t2):253-25T.
Medline DUI
This cehert fellewed 431 yeuth pitchers ever 13 years te
quantify the cumulative incidence eI threwing injuries.
The everal] incidence ef injury was feund te he 5%. A sub
stantial increase in risk ef injury was seen in athletes pitch-
ing mere than 133 innings per year. Level ef evidence: III.
El 1016 American Academy ef Urrhepaedic Surge-ens

24. Dlsen 5] II, Fleisig GS, Dun S, Loftice J, Andrews JR:
Risk factors for shoulder and elbow injuries in adolescent
baseball pitchers. Am] Sports Med lflflfiflflfijflifl #11.
Medline DUI
25. Bruce JR, Andrews JR: Ulnar collateral ligament inju-
ries in the throwing athlete. J Am Acad firthop Strrg
2fl14:22{5j:315-325.Medlitte DUI
This review provides a comprehensive overview of UEL
injuries in overhead athletes and the treatments used for
these injuries.
26. Will: KE, Macrina LC, Cain EL, Dugas JR, Andrews
JR: Rehabilitation of the overhead athlete's elbow. Sports
Health 2012;4{Sj:4fl4-414. Mcdiinc DUI
This review article discusses the basic principles behind
rehabilitation following elbow injury. The authors review
the various phases of a standard rehabilitation protocol
and describe specific nonsurgical and postoperative re—
habilitation guidelines for common elbow injuries and
procedures.
2?. Rettig AC, Sherrill E, Snead DS, Mendler JC, Mieling P:
Nonnperative treatment of ulnar collateral ligament inju-
ries in throwing athletes. Arr: J Sports Med lflfllfiSHJflS-
1?. Medlinc
23. Dodson CC, Slenker H, Cohen SB, Ciccotti MG, DeLuca
P: Ulnar collateral ligament injuries of the elbow in pro-
fessional football quarterbacks. J Shoulder Elbow Sarg
Efllfl;19{3l:12?fi-123fl.Medline DUI
The article reviewed 11] cases of UCL elbow injury in
NFL quarterbacks, describing the type and mechanism
of injury, player demographics, method of treannent, and
return tn play. In nine athletes, nonsurgical management
resulted in successful return to play at an average of 16.4
days. Level of evidence: I‘v'.
29. Podesta L, lErow SA, 1|vlolhmer D, Bert T, Yocum LA:
Treatment of partial ulnar collateral ligament tears in
the elbow with platelet-rich plasma. Am J Sports Med
Efl13;41{?l:1639-1694.Medline DUI
This case series reported on the functional outcomes of
S4 overhead athletes with partial-thickness UCL tears
treated with PRP. At an average follow-up of PD weeks,
33% of athletes had returned to their previous level of play
at an average time of 11 weeks. The authors concluded
that PRP is an effective treatment option for partial UCL
tears. Level of evidence: IV.
3t]. Savoie PH 111, Trenhaile SW, Roberts J, Field LD, Ramsey
JR: Primary repair of ulnar collateral ligament injuries of
the elbow in young athletes: A case series of injuries tn
the proximal and distal ends of the ligament. Am J Sports
Med lflflS:36{6]:1066—1W2. Medline DUI
31. Cain EL Jr, Andrews JR, Dugas JR, et al: Clutcome of
ulnar collateral ligament reconstruction of the elbow
in 1231 athletes: Results in P43 athletes with minimum
1-year follow-up. Am J Sports Med 2010;33i11jtl4-Efi-
14-34. Medline D01
Eb Ifllti American Academy of flrfltopaedic Surgeons
Chapter IS: Elbow Arthroscopy and the Thrower's Elbow
This case series evaluated the functional outcomes of T43.-
athletes treated with surgical UCL reconstruction using
a modified Jobe technique. At a minimum follow-up of
1 years, results demonstrated an 33% rate of return to
previous level of competition less than 1 year after surgery.
Level of evidence: IV.
32.. Bowers AL, Dines JS, Dines Dlvl, Altchek DW: Elbow
medial ulnar collateral ligament reconstruction: Clinical
relevance and the docking technique. J Shoulder Elbow
Sarg lfllflfl BjSuppl 21:11fl-11Ti. Medline [1-01
This case series documented the treatment course of .11
overhead athletes with UCL insufficiency. A modified
version of the docking technique for UCL reconstruction
was used to treat the injury. At follow-up, 90% of athletes
had excellent results. No complications occurred. Level
of evidence: I‘v".
E
SS. Watson IN, McQueen P, Hutchinson MR: A system-
"fl
a,
1]
atic review of ulnar collateral ligament reconstruction
techniques. Am J Sports Med 2D14;42{1flj:251fl-251£.
F”
E's
Medline DUI fit
3.
This systematic review of 21 studies reported on outcomes a!
following various UCL reconstruction techniques. The
overall complication rate was 13.6%.; the most common
complication was ulnar nerve neuraprascia. The overall
rate of return to play was 13.9%. Level of evidence: W.
34. Dines JS, ElAttrache NS, Conway JE, Smith W, Ahmad
CS: lElinical outcomes of the DANE TJ technique to treat
ulnar collateral ligament insufficiency of the elbow. Am
J' Sports Med 200?;35j12}:2fl39-1fl44. Medline DUI
35. Dsbabr DC, Swaminathan SS, Allen AA, Dines JS, Cole-
man SH, Altchelt DW: IIEombined flexor-pronator mass
and ulnar collateral ligament injuries in the elbows of older
baseball players. Ara J Sports Med lfllflflflfljfifl-TSR
Medline DD]
This case series of 13'? baseball players undergoing UCL
reconstruction evaluated the athletes for concomitant
fleaor—pronator mass injury, with 3 players undergoing
flesor-pronator debridement. Athletes older than 30 years
were substantially more likely to sustain combined UCL
and fleaor—pronator mass injuries. Level of evidence: I'v'.
36. Jones KJ, Wiesel BE, Sanka: WM, Iflanley TJ: Arthroscopic
management of osteocbondritis dissecans of the capitel-
lum: l'vlid—term results in adolescent athletes. J Pediatr
Drrhop 2010:3flj1]:S-13. Medline DUI
This case series of 25 adolescent athletes undergoing ar-
throscopic treatment of capitellar DCD evaluated func-
tional outcomes. Patients were treated with arthroscopic
dEbridement, drilling, andior bone grafting. At a mean
follow-up of 4 years, patients were found to have substan-
tially improved range of motion and a high rate of return
to sports.Level of evidence: I‘r'.
3?. Talcahara l‘vi, l'viura bl, Sasalti J, Harada M, Ggino T:
Classification, treatment, and outcome of osteochondritis
dissecans of the humeral capitellum. J Boasjairir Sarg Am
1|]fl?;3 9i=1 EDS-1 214. Medline DUI
Drrhopaedic Knowledge Update: Sports Medicine 5
 Section 1:UpperEartrernit'jr
38. Iwasalti H, Kato H, Ishiltawa _], Masulto T, Funaltoshi
T, Minami A: Autologous osteochondral mosaicplasrv
for osteochondritis dissecans of the elbow in teenage
athletes. I Bone Joint Snrg An: 2UD9:91i1fli:2359-2366.
Medline DUI
This study reported on the functional outcomes of 15‘
adolescent competitive athletes undergoing mosaicplast].r
for elbow QED. At a mean follow—up of 45 months, 13
athletes had excellent or good clinical results, and all
but I returned to their previous level of play. Level of
evidence: IV.
39. Yamamoto Y, Ishibashi Y, Tsuda E, Sato H, Toh 5: Usteo-
chondral autograft transplantation for osteochondrifis dis-
secans of the elbow in juvenile baseball players: Minimum
2-year follow-up. Am I Sports Med 2i] fl6:34{5}:T14-T2l}.
Medline Dfli
1: Upper Eatrem ity
4|]. Mivalce J, Masatomi T: Arthroscopic debridement of
the humeral capirellum for osteochondriris dissecans:
Radiographic and clinical outcomes. 1 Han-:1r Snrg Ans
lfll’lfifilflhlflffl-HES.Medline DUI
This retrospective review reported on outcomes of arthro-
scopic débridement of the capitellum in 1'36 adolescent
patients diagnosed with 0CD. At an average follow-up
of 13 months, 34% of patients were pain free and 35%
had returned to their previous level of play. La rge lesions
or an open proximal radial phvsis at the time of surges]:r
were associated with poor outcomes. Level of evidence: III.
41. Kamineni S, ElAttrache N5, D’driscoll SW, et al: Medial
collateral ligament strain with partial posterornedial olec—
ranon resection. A biomechanical studv. I Bonejor'nt Surg
Am lflfl4;36-A{11}:2424-243i]. Medline
42. An KN, jl'viorreyr BF, lIZhao ET: The effect of partial removal
of proximal ulna on elbow constraint. Cffn Drtbop Refer?
Res 1935,2fl9:1?i}—2?9. Medline
43. Kamineni S, Hirahara H, Pomianowslti S, et al: Partial
poeteromedial olecranon resection: A. kinematic study.
J Bone joint Snrg An: lflflfifijarea [11215-1011. Medline
flrrhopaedie Knowledge Update: Sports Medicine 5
44. Blonna D, Woli, Fitasimmons J5, fl'Driscoll SW: Pre-
vention of nerve injurv during arthroscopic eapsulectomyr
of the elbow utilising a safetv~driven strategv. ] Bone joint
Surg Am 2013;95i15]:13T3-1331. Medline DUI
This retrospective review reports on the incidence of nerve
injurvr in a series of Sill arthroscopic elbow contracture
releases. Twenty—five patients {5%} had nerve palsies
associated with prolonged tourniquet time, ulnar nerve
transposition, or retractor use. All deficits had resolved
at 2-year follow-up. Level of evidence: III.
45. Furushima K, Itoh Y, Iwabu S, Yamamoto ‘1’, Huge R,
Shimiau M: Classification of olecranon stress fractures in
baseball players. An: 1 Sports Med IOI4;42{6}:1 343-1351.
Medline DUI
This case series of EDIE] baseball players diagnosed with
olecranon stress fractures evaluated the orientation of
the fractures using various imaging modalities. A novel
classification system was presented for these fractures
based on the origin and direction of the fracture plane.
Level of evidence: IV.
46. Paci JM, Dugas JR, Gov JA, et al: Cannulated screw fix-
ation of refractoryr olecranon stress fractures with and
without associated injuries allows a return to baseball.
Am I Sports Med 2013:41l2l:3flE-312. Medline DUI
This case series reported functional outcomes in 13 pa-
tients treated with open reduction and internal fixation
for an olecranon stress fracture. All 13 fractures went on
to union, and 94% of athletes returned to their previous
level of play. fit an average follow-up of 6.2 years, six pa-
tients had undergone removal of hardware, two of which
for infection. Level of evidence: IV.
4?. Rettig AC, 1|ifii'urth TR, Mieling P: Nonunion of olecranon
stress fractures in adolescent baseball pitchers: ii. case se-
ries of 5 athletes. Am I Sports Med EU Dd:34{4}:653—656.
Medline DUI
El 1016 American Aeademv of Cirrhopaedic Surgeons
Chapter 1
Acute/Traumatic Elbow Injuries
Iohn P. Haverstoclt, MD, FRCSC lGeorge S. Athwai, MD. FRCSC
Abstract
Fractures and dislocations around the elbow range from
simple isolated injuries to complex injuries of multiple
bony and ligamentous stabilizers. Ililrthopaedic surgeons
and sports medicine physicians may encounter several
patterns of elbow injuries. Thorough knowledge of
classic studies and recent evidence for the diagnosis
and treatment of radial head fractures, simple elbow
dislocations, complex elbow instability, triceps and
biceps injuries is necessary for optimal outcomes.
Keywords: elbow trauma: acute elbow injury:
elbow dislocation: radial head fracture: terrible
triad: PLHI: posterolateral rotatory instability:
coronoid fracture; posteromedial rotatory
instability; complex elbow instability: triceps
rupture; biceps rupture
Introduction
The elbow is a complex assembly of joints that requires
prompt diagnosis and treatment after acute injury to
maximize outcomes and avoid instability, stiffness, and
pain. Physical examination in combination with radio
graphs, and frequently advanced imaging, is required for
adequate assessment of complex fractures or soft-tissue
injury patterns.
Most physical examination special tests are more ef-
fective after initial inflammation and pain have settled;
however, the elbow extension test can be used to help rule
Dr. Athwai or an immediate family member has the po-
tential to receive royalties from imascap; serves as a paid
consultant to DePug Smith 5 Nephew, and Tornier; and
has received research or institutionai support from DePug
Exactech. Smidi s Nephew. Tomiec and simmer. Neither Dr.
Haverstocir nor any immediate family member has received
anything of value from or has stocir or stock options held
in a commercial company or institution related directly or
indirectly to the subject of this chapter:
@ lfllfi American Academy of Drthopaedic Surgeons
out fracture in the acute setting. It is a sensitive screening
tool {96.8%} to identify patients who would benefit from
further radiographic assessment. The elbow extension test
is performed by asking the seated patient with exposed E
and supinated forearms to flex his or her shoulders to "fl
fill“ and fully extend and lock both elbows. In a study of o,
1]
patients who were unable to perform the elbow extension F”
”E;
test, almost 5fl% had sustained a fracture.‘ The negative fit
predictive value for fracture in adults and children able 3.
a!
to extend the elbow was 93.4% and 95.3%, respectively.
The elbow is a commonly injured joint in the upper
extremity. At the lflll Summer Diympics Games more
than one-half of elbow injuries occurred in judo and
weightlifting; elbow injuries in throwing athletes were
less common} Surveillance of National Football League
injuries over a 10—year period revealed that the elbow
was commonly injured {53% of 359 upper extremity in-
juries]; 76% of elbow injuries occurred in offensive and
defensive lineman, and most were ligament and instability
problems.El
Elbow stability depends on the bony and soft-tissue
stabilizers, which must be assessed with every elbow in-
jury. Primary stabilisers include the nlnohumeral joint,
the lateral ulnar collateral ligament (LUCL) and the an-
terior bundle of the medial collateral ligament {MCL}.
Secondary stabilizers include the radial head, the common
extensor origin, and the common flexor origin, which
become increasingly important after injury to the primary
stabilizers.4
Radial Head Fractures
Radial head fractures, the most common fracture around
the elbow, were classified by Mason in l954 and modified
further in 19915 Type 1 fractures are displaced less than 2
mm without a mechanical block to forearm rotation and
can be effectively treated nonsurgically. Type 2. fractures
are displaced greater than 2 mm, may block forearm
motion, and are not substantially comminuted. The treat-
ment of type 2 fractures is controversial; however, most
authors agree that with the best available evidence and
without a block to rotation, this group can be effectively
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 1:1}pperExn'emity
treated nonsurgically. In patients with a block to forearm
rotation that can be attributed to the fracture, surgical
intervention is indicated. Type 3 fractures are severely
comminuted and typically require surgical intervention
to restore elbow and forearm function. In type 3 frac—
tures associated with instability, radial head excision is
contraindicated. Although type 3 fractures are highly
comminuted and typically indicated for arthroplasty, in
the younger, active athletic population an attempt at open
reduction and internal fixation should be considered.
Injuries commonly associated with radial head frac—
tures include ligamentous injuries, and chondral injuries
to the capitellum. When complete loss of cortical con-
tact of at least one fragment from a radial head fracture
1: Upper Extremity
occurs, one study reported that 91% of these fractures
were associated with complex elbow instability patterns."
In a series of SD surgically treated Mason type 2 and 3
fractures, 10 had sustained chondral injury? Chondral in-
jury to the capitellum was most common in higher-grade
radial head fractures.
Treatment of radial head fractures depends on the
character of the fracture, blocks to pronation and supi-
nation, and associated injuries {elbow dislocation, MEL,
and Essex~Lopresti injuries}. Controversy exists regarding
the best memod of treating type 1 fractures, and a large
prospective trial is underway" Stable, displaced partial
articular fractures and those with minimal comminution
and displacement can be treated nonsurgically as long
as range of motion recovers and no associated elbow or
forearm stability exists-911”
The nonsurgical treatment of minimally displaced ta-
dial head fractures without a block to rotation includes a
brief period of immobilization preceding range of motion
and active therapy. A prospective randomized controlled
trial of 130 patients with simple radial head fractures
reported that immobilization for 2 days with a sling fol—
lowed by active mobilization had superior results in mo-
tion, strength, and functional outcomes compared with
immediate mobilization and immobilization for 3 days.“1
In addition, a fragment displaced more than 4 mm or
angulated more than 3D” impaired outcome.
Radial head fractures with more than three fragments
are often not amenable to open reduction and internal
fixation because of small fragment size, comminution,
and osteopeniag,12 however, in the younger, active pop—
ulation, an initial attempt at fixation is appropriate. To
maximize elbow stability, radial head arthroplasty is an
option, which is especially important for complex in—
atahility patterns.” The early results of metallic smooth
stem and bipolar radial head implants have been good,
with minimal posttraumatic arthritis and high rates of
good to excellent patient-rated outcomes at follow-up.“
flrrhopaedic Knowledge Update: Sports Medicine 5
Simple Elbow Dislocations
Simple elbow dislocations include those without fracture,
in which the medial and lateral ligament complexes are
ruptured or avulsed. Elbow dislocations most often occur
in adolescent males participating in football, wrestling,
and basketball; or in females participating in gymnastics
and skating.” A review of video footage of 62 elbow
dislocations showed that the typical injury occurs with
the arm in near-full extension with a valgus force, which
suggests MCL rupture is common, although numerous
mechanisms are described.”
Treatment of simple elbow dislocation includes closed
reduction beginning with stabilization of the humerus,
traction, correction of varnsfvalgus angulation, and flex-
ion. Alternatively, the physician can use one hand to grasp
the patient’s wrist to apply traction and use his or her
other hand to grasp the distal humerus, while using the
thumb to push the olecranon anteriorly to obtain reduc-
tion. An examination for stability should be documented
to guide rehabilitation by gradually extending the elbow
from flexion with the forearm in pronation, neutral, and
supination, noting the angle where subluxation begins.
Radiographs obtained before and after reduction should
be scrutinized for radial head fractures, coronoid frac-
tures, intra—articular fragments, or a nonconcentric re-
duction. These occult findings can result in substantial
instability, stiffness, or pain if missed.
Therapy for elbow dislocations with a concentrically
reduced joint must begin within “F to 1|} days. Dverhead
motion protocols have been shown to decrease the “drop
sign," a radiographic finding of ulnohumeral subluxation
that is worsened by gravity and extra forearm weight
{larger arms and elbow hinge braces}.” Isometric exercises
and protective splinting with forearm rotation {pronation
for lateral collateral ligament [LCL] insufficiency and
supination for MEL insufficiency} can facilitate protected
range of motion. Therapy using this protocol allows heal-
ing in the reduced position and decreases the incidence of
recurrent instability.lil Elbows with both MEL and LCL
injuries should undergo rehabilitation with active motion,
neutral pronationl'supination of the forearm, and with the
humerus oriented vertically or horizontally to minimize
forces that promote rotational subluxation1l {Figure I}.
A review of Hi} patients at a mean follow—up of 33
months following simple elbow dislocation revealed that
although outcomes are generally good with appropriate
treatment, 62% have residual pain, 56% report subjective
stiffness, and 3% have subjective instability.m Addition-
ally, a reduced elbow flexion-extension are predicted
poorer overall satisfaction, with reduced flexion influ-
encing patient outcome more than reduced extension.
El 1016 American AcadMy of Unhopaedic Surgeons

In elbows that remain unstable after successful reduc-
tion attempts or become unstable subacutely, surgical
treatment should be considered. In a series of 15 patients
with persistent instability following simple elbow dislor
cation, 11 were treated with LUCL repair alone and 3
required the addition of hinged external fixation.21 Elf
those treated with LUCL repair alone, 5 experienced
resubluxation: 1 required later external fixation and 4
were treated with physical therapy alone, all of whom
eventually achieved a concentric and stable reduction.
Patients in whom persistent posterolateral rotatory
instability {PLRI} develops have several treatment options.
If PLRI is identified subacutely within IE weeks from in-
jury, an attempt at nonsurgical management is reasonable
with splinting at 90° in full pronation. Extension range of
motion can be blocked to 45" to El)“, and increased 10“
per week. In patients whose nonsurgical management is
unsuccessful or who present delayed with symptomatic
instability, surgical intervention to repair or reconstruct
the LUCL is indicated.
Posterolateral Ftotatory Instability
lIIZ'lriginally described in 1991, PLRI occurs following
injury to the LUCL, allowing rotatory subluxation of
the ulnohumcral joint and dislocation of the radiohu—
meral joint with a combination of extension, valgus,
and supination.fl
The diagnosis of I’LRI can be difficult because symp-
toms of painful locking or snapping and apprehension
are hard to elicit. The lateral pivot—shift test is best per—
formed with the patient lying supine with the arm over-
head, maximal external rotation at the shoulder, and with
the examiner grasping the wrist and forearm to provide a
valgus and supination force in full extension. A positive
test result presents as subluxation in extension, and as
the elbow is flexed, it pops or slides in to reduction at
3D“ to 4i)“. Although poorly tolerated by patients who
are awake, the test is reproducible at various levels of
training with full muscle rela xationfii' The posterolateral
drawer test, chair sign, and the inability to do a push-up
with the forearms in supination are also useful special
tests. Terminal forearm supination {hypersupination}
by the examiner while palpating the radiocapitellar joint
can reveal subtle instability in patients both awake and
under anesthetia.
PLRI can be treated in the acute setting as described for
simple elbow dislocations, with rehabilitation performed
with the arm in pronation. For those patients with ongo'
ing symptoms or instability, repair or reconstruction of
the LUCL with tissue plication or tendon graft is recom—
mended“ {Figure 2).
IE: lfllfi American Academy of flrrbopaedic Surgeons
Chapter 1': AcutefI'raumatic Elbow Injuries
I:
'oi
'om
Figure 1 Lateral radiograph of the ulnohumeral joint 1
demonstrates the drop sign, which indicates a a:
m
nor-congruent reduction. This finding usually H
m
H
occurs because of periarticular muscle pain—
related atony and hemarthrosis. If only axial E.
a?
distraction {no medial or lateral translation of
the joint} exists, the elbow can be treated with
isometric exercises and overhead rehabilitation
can be considered. The patient should be
followed with weekly radiog ra phs to ensure
improvement. {Reproduced with permission
from Pipicelli JG. Chinchalltar SJ. Grewal Ii. King
(31: Therapeutic implications of the radiographic
“drop sign" following elbow dislocation. J Hand
Ther 2u12;25[3]:346-353. quiz ass. http:i'idx.dol.
orgi'1fl.1fl16i'j.jht.2fl12.fl3.flfl3.}
In a study of 19 patients with acute I’LRI treated by
LCL repair using nouabsorbable, braided suture or a su-
ture anchor,” Mayo Elbow Performance Score was 36.9
of 1th.], with 12 excellent results, 5 good results, and 1
fair result. Reported complications included heterotopic
ossification in five and knot irritation in one. In a study
of a technique describing the use of tensionable suture
anchors to fine-tune the tension of collateral ligament
repair, good outcomes in two patients were reported.“
1'I'iilii'ben treating chronic PLRI, the best results are ob-
tained with ligament reconstruction with tendon graft.”
However, LUCL reconstruction can also fail. A 21114
study reported that revision of failed LUCL reconstruc-
tion is challenging and that the outcomes are guarded:
one half of patients at follow-up had persistent instability
and poorer elbow scores.“
Complex Elbow Instability
Complex elbow dislocations include those with associ-
ated fractures and are typically classified into three broad
groups: radial head fracture-dislocations {including terri-
ble triad injuries], varus posteromedial rotatory instabil-
ity ([PMRI] with anteromedial coronoid fractures} and
Drtbopaedic Knowledge Update: Sports Medicme 5
 Section 1: Upper Extremity
1: Upper Extremity
Figure 2 Illustration deoicts the lateral collateral
ligament complex, including the primary
stabilizer, the lateral ulnar collateral llgament,
running from the geometric center of the
capitellum to the crisis supinato rus. Suture
marks indicate a transosseous repair or a
suture anchor proximally, which can be used
to repair acute injuries. {Heprod uced from
Mehta. 1A. Bain GI: Fosterolateral rotatory
instability of the elbowJ Am Aced' flrthop 5mg
20-04;11[E]:dfl5-415.l
fracture-dislocations of the proximal radius and ulna
{including transolecranon and Monteggia—type injuries).
flutcomes following treatment of complex elbow insta-
bility are guarded and poor general health, lack of coopa
eration, obesity, delayed surgery, and high-energy trauma
are all poor prognostic factors.”
Terrible Triad
A terrible triad injury is named for the historically poor
results seen after an elbow dislocation combined with
radial head and coronoid fractures. A more complete
understanding of the primary and secondary stabilizers
of the elbow and treatments that allow early range of
motion following surgical stabilization has substantially
improved outcomes. Biomechanical and clinical research
has resulted in the development of successful surgical
treatment protocols that also have improved patient
outcomes.
Diagnosis is often clear using plain radiographs, al—
though subtle avulsions of the coronoid can be difficult to
detect and spontaneous reduction of the elbow dislocation
is possible. {in radiographs, these areas should be assessed
carefully, as well as the shape of the posterolateral capital-
lum, where an Usborne-Coterill lesion can indicate elbow
instability, as would a Hill-Sachs lesion on the humeral
flrdsopaedic Knowledge Update: Sports Medicb'ie 5
head.“ It is recommended that all patients with radio-
graphic findings of a possible coronoid fracture should
undergo advanced imaging using CT to fully characterize
the fractures and instability pattern.
Strict indications for the successful nonsurgical treat-
ment of terrible triad injuries have enabled good results.
Nonsurgical treatment is only advised in patients with a
concentric joint reduction, a radial head fracture without
block to rotation, a smaller coronoid fracture {Regan-
Morrey type 1 or 1}, and a stable arc of motion to a
minimum extension of 30” to 45", allowing active range
of motion within 1i} days.3‘=31
Surgical treatment should be considered for most pa-
tients with terrible triad injuries. A stepwise approach
to fixation results in good results with minimization of
complications.“ Typically, a posterior skin incision with
full—thickness fascia-cutaneous flaps is advised for versatil—
ity and to avoid injury to the superficial cutaneous nerves;
however, a direct lateral slcin incision is also acceptable.
If the radial head fracture is not reconstructable, the
coronoid fracture can usually be accessed via the lateral
approach following radial neck osteotomy in prepara-
tion for radial head arthroplasty. lIZlzherwise, a medial
approach can be suitable for exposure, depending on
the fracture configuration. Irrespective, repair of a type
2 or 3 coronoid fracture should be performed to stabilize
the elbow to varus loading, which is encountered with
shoulder abduction during daily activities.“
Coronoid fracture fixation is accomplished with so-
tures, screws, or plates, depending on the size, approach,
and comminution of the fragment. During the surgical
approach, the coronoid fragment will appear larger than
measured on preoperative CT scan; cartilage is a mean 3
mm thick at the coronoid tip, with greater ulnar height
and length associated with thicker cartilage.” For smaller
or comminuted fractures unlikely to be repaired with
screw fixation, the authors of this chapter use an anterior
cruciate ligament drill guide to create two tunnels from
the dorsal ulna and secure the capsule and fragments
with a nonabsorbable suture. Larger fragments should
be fixed with screws in a dorsal to volar trajectory. The
biomechanical strength of two different screw trajecto-
ries was assessed in coronoid fixation and the posterior
to anterior screw was found to be stronger, stiffer, and
technically easier to use.3'5
In the younger, athletic population, after the coro-
noid is secured, all radial head fractures should be fixed.
However, if stable fixation cannot be obtained, radial
head arthroplasty is indicated to provide elbow stability.l1
Because the radial head is a primary stabilizer to PLRI,
especially in the context of a coronoid fracture, the or—
thopaedic surgeon should not hesitate to proceed with
fl lflld American Academy of Orthopaedic Surgeons

arthroplasty to restore stability. A review of 24 patients
treated for terrible triad injuries compared the results
for those who underwent radial head open reduction
and internal fixation with arthroplasty.” Good results
were noted for the entire group, and patients in the radial
head arthroplasty group scored higher in the Disabilities
of the Arm, Shoulder and Hand assessment. Although
these outcomes may not translate to the younger athletic
population, they stress the importance of a radial head
Stabilized using either fixation or arthroplasty.
Varus PMHI
Anteromedial coronoid facet fractures are associated
with varus PMRI.” This fracture pattern is described
in D’Driscoll’s comprehensive coronoid facturc classi-
fication,Jiil which is based on the anatomic location of
the main fragments: the tip, the anteromedial facet, and
the basal coronoid, often as noted on CT. Anteromedial
facet fractures are further subclassified based on tip and
sublime tubercle involvement.
A biomechanical study reported that PMRI increases
with the sire of the anteromedial cornnnid fracture.“ The
instability associated with small D’Driscoll subtype 1 an—
teromedial coronoid facet fractures can be improved using
LUCL repair alone, whereas larger fractures require bony
fixation in addition to LCL repair to achieve stability.
Exposure of an anteromedial coronoid fracture is pos-
sible via the approach through the floor of the ulnar nerve,
flexor carpi ulnaris splitting, or Hotchkiss over—the—top
approaches, although access to the proxirnal ulna for
plate application is limited in the over—the top approac .41
Type 2 anteromedial coronoid fractures were assessed
and a treatment algorithm created based on the fragment
size and the stability to varus and pronation stress testing
under fluoroscopy. Selective fixation of the anteromedial
cornnoid, LUCL repair, or a combination of both were
indicated for increasingly unstable patterns.“
Distal Triceps Injuries
Distal triceps tendon injuries are less common than
distal biceps tendon ruptures, and diagnosis is often
missed acutely because of edema and pain. Patients re-
port weakness and pain, but may have some active elbow
extension because of an intact lateral triceps expansion.
[in clinical examination, patients will have difficulty
with extension against gravity and a palpable defect
in the extensor mechanism may be present. Standard
radiography should be performed because avulsion of
an associated olecranon traction spur with the distal
triceps tendon can be seen on the lateral view as a sign
of proximal tendon retraction. Ultrasonography or MRI
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 3": Acutefl'raumatic Elbow Injuries
I:
1’ --._"“-.I_ _ e
'oi
1::ru
1
at
m
Figure 3 Illustration dopicts the dome—shaped triceps
H
m
H
insertion on the posterior olecranon [outlined] E.
following dissection. The distal triceps tendon a?
should be repaired to reapproximate this
footprint.
are useful to confirm and characterize the rupture lo-
cation in cases that are nuclear or to assess for other
pathology.
An anatomic cadaver study was performed to quanti-
fy tendon insertion characteristics.“ The triceps tendon
insertion is a confluence of the long, lateral, and medial
heads on the posterior surface of the olecranon in a dome
shape. At the insertion site on the olecranon, the medial
head is deep to both the long and lateral heads. The mean
triceps insertion footprint was 20.9 mm wide and 13.4
mm long {Figure 3}.
Partial triceps tendon ruptures of the medial head in-
sertion have been reported. Following an appropriate trial
of nonsurgical management for patients with persistent
pain and dysfunction, surgery can be suggested. Surgery
is typically performed open; however, an arthroscopic
repair technique has been described that uses suture an-
chors. Surgical repair for partial triceps tendon injuries
has been reported as successful at eliminating pain and
improving strength.“
Complete distal triceps tendon avulsions are debil-
itating and result in pain and weakness. Presently, in
the younger athletic population, primary repair allows
for early rehabilitation and predictably good outcomes.
Primary open repair with tra nsosseous tunnels or suture
anchors have both been described. In addition triceps
repair, the lateral triceps expansion, if disrupted, should
be repaired because it constitutes a substantial portion
of the total tendon width.” To re-create the full depth
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 1: Upper Extremiti'
of the triceps tendon insertion, a double-row repair has
been described using Keith needles and nonabsorbable,
braided sutures with anchors fer the superficial Iayer.‘*5
Repair is most successful when performed within the
first 3 weeks; all patients in a 2003 series regained 415
manual strength, but a mean of 113""r of terminal extension
was lost.“
Distal Biceps Injuries
Distal biceps tendon avulsion injuries are common and
occur most frequently in the dominant extremity of
middle-aged men. Typically, the mechanism of injury is
a sudden eccentric muscle contraction that occurs while
1: Upper Extremity
lifting heavy leads. The underlying pathophysiology is
most likely related to degenerative changes to the mo-
don at its insertion on the bicipital tuberosity. 1i.i'ascular,
inflammatory, and mechanical factors are thought to be
associated with biceps avulsion injuries.
Patients will often hear an audible snap or pop at the
time of injury and report pain and weakness to resisted
elbow supination and flexion. Physical examination usu-
ally identifies an elevated muscle belly, an abnormal hook
test result, and loss of the normal rise and fall of the biceps
muscle with forearm rotation. Recently, a study suggested
that three physical examination special tests to diagnose
complete distal biceps tendon ruptures can expedite di-
agnosis and avoid the need for MRI or ultrasonography.
Positive hook test results, passive forearm pronation, and
biceps crease interval test together had lflfl‘it- sensitivity
and specificity for a complete distal biceps rupture. If test
results were negative or equivocal, MRI was performed
to detect partial injuries.”
Partial rupture of the distal biceps tendon can also
produce pain and weakness and often results in a delay
in diagnosis. The direct radial tuberosity compression
test, in which the examiner compresses 2.5 cm distal to
the radiocapitellar joint to elicit pain with passive prona-
tion and supination of the forearm,“ was performed in
patients with a presumed partial rupture. MRI can assist
with the diagnosis by visualizing the biceps insertion. The
flexed, abducted, supinated view is a method of patient
positioning in the MRI unit, with the shoulder fully ab-
ducted so the arm is beside the head, the elbow flexed to
PD“, and the forearm fully supinated. These images along
the long axis of the tendon from the musculotendinous
junction to the insertion ease interpretation and reduce
errors due to volume averaging.”
Nonsurgical management can be considered in patients
with acute distal biceps tendon injuries. Good results have
been reported with nonsurgical management and historic
reports suggested a 4fl‘i'rfi loss of supination and MPH:- loss
firthopaedic Knowledge Update: Sports Medicine 5
of flexion strength.” In a more recent, larger study of 13
patients treated nonsurgically at a median of 33 months,
supination strength recovered to 63% and flexion strength
to 93% compared with the uninjured side.“
In the only prospective randomised controlled trial,
the outcomes and complications of single— versus dou—
ble-incision distal biceps tendon repair were compared.“
At 2-year follow-up, no clinically substantial differences
were reported in the Disabilities of the Arm, Shoulder
and Hand score, the Patient-Rated Elbow Evaluation
score, the American Shoulder and Elbow Surgeon elbow
score, or elbow range of motion. Additionally, no differ—
ences were found in supination, pronation, or extension
strength; however, the double—incision repair group had
substantially greater flexion strength at follow-up. Fur-
thermore, the complication rate was significantly higher
in the single—incision group. Most complications were
transient neurapraxias of the lateral antebrachial cota-
neous nerve.
Excellent clinical outcomes and advances in fixation
techniques have enabled a resurgence of single-incision
technique; however, some concern exists that supination
strength may not be fully reestablished. Single—incision
repairs place the insertion of the distal biceps tendon
more anteriorly and midline than the native insertion};1
The radial tuberosity is oriented at a mean of 56" ulnar
to the midsagittal plane of the radius {ra age, 43“ to 6?“).
l[Zine study showed that the anatomic insertion on the
radial tuberosity could not be re-created using an ante-
rior incision, and that this may be responsible for supi-
nation weakness.“ A recent systematic review of repair
techniques for distal biceps tendon ruptures found that
bone tunnel [10.4%] and cortical button {fl} methods had
substantially lower complication rates compared with so-
rare anchors {16.4913} and intraossous screws {44.3%}55-5‘
{Figure 4).
Irrespective of the approach or type of fixation used,
surgeons should be confident in their knowledge of the
anatomy and the best exposure to minimize injury to the
lateral antebrachial cutaneous nerve of the forearm, the
posterior interosseous nerve, and the rec orrent branch of
the radial artery. Repairs are easiest in the first 2 weeks
following avulsion before scarring of the tendon track
has occurred. In sobacute and chronic cases, a primary
repair should still be attempted even if up to 5'0” to 100”
of elbow flexion is required to reduce the tendon to the
tuberosity. Repairs in extreme flexion eventually lengthen
and still yield good results.” In chronic cases in which
primary repair is not possible, aotologous or allograft
distal biceps tendon reconstruction is an option that yields
satisfactory outcomes.
fl lflld American Academy of Orthopaedic Surgeons

Figure 4 illustration depicts an axial schematic of the
forearm at the level of the radial tuberosity.
A, Drill placement from an anterior approach
with the forearm in full su pination. The results
indicate a limited ability to repair the tendon to
its anatomic footprint. B, Drill trajectory for the
double-incision with the forearm in pronation,
re-creating the anatomic insertion of the biceps
brachii tendon.
Summary
Acute elbow injuries require a thorough physical exam-
ination and often advanced imaging to determine the full
extent of injury and instability patterns. Examination un-
der anesthetia and intraoperatively helps to determine the
plan of sequential repair of primary and secondary stabi-
lizers and dictates postoperative rehabilitation. Achieving
a concentric reduction and allowing early range of motion
is critical to maximizing outcomes of acute elbow injuries.
Hey Study Points
1* Primary stabilizers of the elbow include the ulnohu-
meral joint, LUCL, and the anterior bundle of the
MCL. Secondary stabilizers include the radial head,
the common flexor and extensor origins, and the
joint capsule. These structures should be assessed
with every elbow injury.
I Simple elbow dislocations benefit greatly from an
early rehabilitation protocol started within “.7 to
1D days and routine imaging to ensure concentric
reduction.
1* PLRI of the elbow can be difficult to diagnose, and
patients presenting with locking or snapping should
be assessed for subtle instability findings.
IE! lfllfi American Academy of flrchopaedic Surgeons
Chapter 5': Acutea'Traumafic Elbow htjuries
Hey Study Points i'ror'rtirnierii
r Complex elbow fractures and instability cases
should be assessed with CT to fully delineate the
bony injury and plan fixation strategies.
' 1‘vi'arus PMRI typically requires fixation of the an-
teromedial eoronoid facet, andfor repair of the
LUCL to regain stability.
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't:
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 Section 1: Upper Exuemiry
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1: Upper Extremity
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Drthopaedic Knowledge Update: Sports Medichie 5
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D lfllri American Academy of Orthopaedic Surgeons

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anchnrs. Tee}: Hand Up Entree: Snrg 2011;16i4]:125-219.
Medline DUI
A technique fer the use nf tensinnable suture anchnrs fer
the repair nf cnllateral ligaments is described.
2?. Sanches- Snteln J, Mnrrey BF, U’Driscnll SW: Ligamentnus
repair and recnnstructinn fnr pesternlateral rntatnry insta-
bility cf the elbnw. } Bessejnfnt Sa-rg Er 1fl05:3?{1}:54— 61.
Medline
23. Baghdadi TM, I'vlnrrey BF, U’Driscnll SW, Steinmann SP,
Sanchez—Enteln J: Revisinn allngraft recnnstructinn cf the
lateral cnllateral ligament cnmplea in elbnws with previnus
failed recnnstructinn and persistent pnsternlateral rntatnr
ry instability. Elie Urn'rnp Refer. Res 2fl14:4?2{?}:2061-
206 ?. Medline DUI
A case series dncumented the nutcnmes nf elbnws treated
with revisinn allngraft reennstructinn cf the LCL fnr
persistent PLRI after failure nf index surgery. Level nf
evidence: IV.
29. IGiannicnla G, Pnlimanti D, Bullitta G, Seacchi M: Heg-
ative prngnnstic factnrs in cnmpleic elbnw instability: A
prnspective study nn TE patients. _,I Urtfenp Traumatnf
2013;14j5uppl I}:533.
A cnhnrt nf T3 patients with cnmples: elbnvvr instability
was reviewed tn determine negative prngnnstic factnrs.
Level nf evidence: III.
3D. Jenn IH, Micic ID, Yamamntn N, Mnrrey BF: Us-
bnrne-cntterill lesiun: An nssenus defect nf the capitel-
lum assnciated with instability nf the elbnw. AJR Am
I Rneutgennf 2033;191Ij3}:?2?—?23. Medline DUI
31. Guittnn TU, Ring D: Nnnsurgically treated terrible triad
injuries nf the elbnw: Repnrt nf four cases. ,I Hand Surg
Am lflIiI;35{3j:4-E4-4ET. Medline DUI
Case series repnrted nu fnur patients with terrible triad
injuries treated nnnsurgically. Level nf evidence: IV.
32. Chan K, IvIaeDermid JC, Faber E], King G], Athwal
[35: Can we treat select terrible triad injuries nnnnper-
ativelyi‘ Cfirr Urtl'snp Refer Res lflI4;4?2{?}:Ei}92-1fl99.
Medline DUI
Specific indicatinus fnr nnnsurgical treatment nf terrible
triad injuries and the results nf titatment were repnrted
fnr 11 patients. Level nf evidence: IV.
IE! lfllii American Academy nf Urthnpaedic Snrgenns
Chapter I": Acutei'Traumafic EIb-nw Injuries
33. Pugh Dlvl, 1|iilli'ild ll, Schemitsch EH, King G], McKee
MD: Standard surgical prntncnl tn treat elbnw dislnca—
tinns with radial head and cnrnnnid fractures. j Enne Inn-rs
Surg Am 20fl4;36—A{E}:I 1 22—1130. IvIedline
34. Hartaler RU, Llusa—Perea lid, Steinmann 5P, Mnrrey
BF, Sanchez-Enteln J: Transverse cnrnnnid fracture:
When dnes it have tn be fixed? {Ilia Urtiinp Refer Res
2014;4?2{?}:2063-20?4.Medline DUI
This binmechanical cadaver study assessed the effect nf
a 30% cnrnnnid fracture and fiaatinn nn elbnw stability
with and withnut an intact radial head.
35. Rafehi 5, Lalnne E, Jnhnsnn M, King G], Athwal G5:
An anatnmic study nf cnrnnnid cartilage thickness with
special reference tn fractures. ] Shnnidev Effsnse Snrg
2fl12:21[?}:951-953.Medline DUI
I:
A CT study was perfnrrned tn determine the thickness nf 'n
'nm
cartilage an the cnrnnnid tip. 1
s:
”'1
36. Mnnn JU, Enbits I'vIE, An KN, U’Driscnll 5W: Uptimal
H
m
H
screw nrientatinn fnr finatinn nf cnrnnnid fractures. J Ur- E.
tfmp Trauma lflfl?:23{4l:2??—lflfl. Medline DUI a?
This binmechanical study assessed nptimal screw nrien-
tatinn fnr the finatinn nf cnrnnnid fractures.
3?. Leigh WE, Ball EM: Radial head recnnsttuctinn versus
replacement in the treatment nf terrible triad injuries nf
the elbnw. ] Sbnufder Eibnse Surg EDI 2:2H1fllfl 33 6—1 341.
Medliue DUI
The results fnllnwing surgical repair nf terrible triad in-
juries were reviewed in 23 patients. Level nf evidence: III.
33. Dnnrnberg 1N, Ring DU: Fracture nf the anternmedi-
al facet nf the cnrnnnid prncess. j Hesse jnfns Snrg An:
Iflfl6:33{1fll:2215-2224.Medline DUI
39. U’Driscnll 5W, Jupiter JB, Cnhen M5, Ring D, McKee
MD: Difficult elbnw fractures: Pearls and pitfalls. Instr
Unnrse Leer lflfl3:52:1 13—134. IvIedline
4D. Pnllnck 1W, Ernwnhill J, Ferreira L, Mcnald UP, Jnhn—
snn J, King I133: The effect nf anternmedial facet fractures
cf the cnrnnnid and lateral cnllateral ligament injury nn
clbnw stability and kinematics. ] Hesse faint Surg Am
2Dfl9;91{fij:1443-1453.Medline DUI
A binmechanical study assessed the effect nf varinus sizes
nf anternmedial cnrnnnid facet fracture and the influence
nf LCL repair nn elbnw stability.
41. Huh J, Krueger {3A, Medvecky M], Hsu JR; Skeletal Trau—
ma Research lEll-:Imsnrtium: Medial elbnw espnsure fnr cnr-
nnnid fractures: FED-split versus nver-the-tnp. j Urtfsnp
Trauma 2013:2Tllllfl30-7’34. Medline DUI
A cadaver dissectinn cnmpared the eapnsure nbtained
by the flexnr' carpi ulnaris-splitting versus the Hntchkiss
nver-the-tnp apprnach.
42.. Rhynu II-I, Kim KC, Lee JH, Kim 53’: Strategic ap-
prnach tn U'Driscnll type 2 anternmedial cnrnnnid facet
Urthnpaedic Knnwledge Update: Spnrts Medicine 3
 Seeders 1: Upper Extremity
fracture. I Shenlder Elbew Sarg 2fl14:23{?]:924-932.
Mcdline DUI
The authers suggested a strategic appreach te dealing
with fractures ef the anteremedial cereneid facet based
en the |IiZiI‘IIriscell classificatien and the degree ef lateral
seft-tissue injury. Level ef evidence: IV.
43. Keener JD, Eha filr. D, Kim HM, Galats LM. Yamaguchi K:
Insertienal anatemy ef the triceps brachii tenden. ] Sherif-
der Elbert: Sui-g 201 fl:19(3}:399-4 :15. Medline DUI
A cadaver dissectien study detailed the triceps tenden
anatemy and the lateral triceps expansien.
44. Athwal GS, McGill RJ, Rispeli DIM: Iselatcd avulsien
ef the medial head ef the triceps tenden: An anatemic
study and arthrescepic repair in 2 cases. Artbreseepy
1: Upper Estrem ity
2fl09;25(9}:933-933.Medline DUI
The anthers described the insertien ef the triceps tenden
and an arthrescepic repair technique fer iselated medial
head triceps avulsiens. Level ef evidence: IV.
45. Kekltalis ET. Mavregenis AF, Spyridenes S, Papagelepeu-
les P]. Weiser 11W. Setereanes DIG: Triceps brachii distal
tenden reattachment with a deuble-rew technique. Ur-
tfiepedies 2013;36llifllfl-116. Medline DUI
The anthers described a technique fer a deuble-rew repair
ef the triceps tenden using Keith needles and suture an-
chers, and the results fer a series ef patients were reviewed.
Level ef evidence: IV.
46. van Riet RP. Merrey BF, He E, U’Driscell SW: Surgical
treatment ef distal triceps ruptures. I BDHE jeint Surgrilm
2fl03;35—A{10}I:1961—1961 Medline
4?. Devereaust MW, ElMaraghy AW: Impreving the rapid
and reliable diagnesis ef cemplete distal biceps tenden
rupture: fl. nuanced appreach te the clinical examinatien.
An: }' Sperts Med 2fl13g41[9}:1993 4004. Medline DUI
The physical examinatien fer distal biceps tenden ruptures
and an evidence—based diagnesitic algerithm are described.
Level ef evidence: II.
43. Abbeud JA, Ricchetti ET, Tjeumaltaris FP, Earteleezi All,
Hsu JE: The direct radial tuberesity cempressien test: A
sensitive methed fer diagnesing partial distal biceps ten—
den ruptures. Carr Urtbep Peter 20] 1;22{1}:?6 -3IJ. DUI
The anthers describe and validate the direct radial mber-
esity cempressien test te diagnesc partial biceps tenden
injuries. Level ef evidence: II.
49. Uiuffre EM, Mess M]: Uptimal pesitiening fer MRI ef
the distal biceps brachii tenden: Pleated abducted supi-
nated view. EUR Am I Reentgenef 2004;131{4}:944—946.
Medline DUI
Si}. Merrey BF, fishery LL An KN, Debyus JH: Rupture ef
the distal tenden ef the biceps brachii. A biemecbanical
study. I Benejeint Serg Am 1535:6?{3]:413-421. Medline
Urthepaedic Knewledge Update: Sperts Medicine 5
. Freeman CR. McCennick KR. Maheney D. Earata M, Lu-
bahn JD: Neneperative treatment ef distal biceps tenden
ruptures cempared with a histerical centre] greup. I Hens
jeint Surg Am 1009;91{1{}]:2329-2334. Medline DUI
The results ef surgical and nensurgical treatment are
cempared: nensurgical treatment results in ELISE ef the
supinatien strength that surgical treatment dees; fleetien
strength is the same. Level ef evidence: IV.
52. Grewal II... fithwal GS, MacDermid JC, et al: Single versus
deuble-incisien technique fer the repair ef acute distal
biceps tenden ruptures: A randemiaed clinical trial. I Bene-
j'eirtt Surg Am 1012:94{13J:1156—11?4. Medline DUI
This is the enly prespective, randemiaed centrelled trial
te evaluate the eutcemes ef distal biceps tenden repair
using a single- versus deuble-incisien technique. Level
ef evidence: I.
53. Schmidt CC, Dias VA, Weir DM, Latena CR, Miller
MC: Repaired distal biceps magnetic resenance imagi
anatemy cempared with eutceme. I Seeefder Elbert: 3mg
2D12;11{12J:1623-1631.Medline DUI
A substantial decrease in strength at EU“ ef supinatien
appears te be an effect ef an anterier tenden reattachment
lecatien. Level ef evidence: III.
54. Hansen '3, Smith A, Pelleclc JW, et al: finatemic repair
ef the distal biceps tenden cannet be censistently per—
fermed threugh a classic single-incisien suture anchet
technique. I Shenider Elbew Sarg 2014:23{12]:1393-
1904. Medline DUI
This retrespective review ef single-incisien distal biceps
repairs with CT was perfermed te determine if the ana-
temic insertien en the radial tuberesity can be re-created.
Level ef evidence: IV.
SS. Watsen IN. Meretti VM. Schwindel L. Hutchinsen
MR: Repair techniques fer acute distal biceps tenden
ruptures: A systematic review. I Berte- jefrrt Surg Am
lfll4;96{24}:2036-2fl9fl.Medline DUI
The anthers cenducted a systematic review ef techniques
fer distal biceps tenden repair with a feces en cemplica-
tien rate. Level ef evidence: IV.
56. Schmidt CC. Jarrett CD, Brewn ET: The distal biceps
tenden. JI Hand Surg Am 2G13:3S{4]:311-321, quiz 32.1.
Medline DUI
5?. Merrey ME, fibdel MP, Sanchez-Setele J, Merrey BF:
Primary repair ef retracted distal biceps tenden ruptures in
extreme flesien. ] Sbeelder Elbew Snrg 2fl14;13{51:6??-
SSS. Medline DUI
This retrespective case-centrel study examined the eut-
cemes ef distal biceps repairs requiring repair in greater
than 60” cf flexien. Level ef evidence: III.
U lflle American Academy ef Urthepaedic Surge-ens
Chapter 3
Chronic/Overuse Elbow Disorders
Champ L. Halter III, MD Champ I.. Halter Ir, MD
Abstract
fiveruse disorders of the elbow are common and can
be a substantial cause of pain and disability to the
athlete. Despite increased understanding of the causes
and pathoanatomy of elbow tendinopathy, a lack of
consensus remains regarding optimal management.
Many different nonsurgical and surgical interventions
have been reported with varied outcomes. Irrespective
of the methods chosen, nonsurgical treatment typically
allows safe return to sport. Surgical intervention is re-
served only for the few cases with recalcitrant symptoms.
Keywords: medial epicondylitis: lateral
epicondylitis; tendinopathy
Introduction
Elbow tendinopathy is the most common cause of elbow
pain. Competitive and recreational athletes, laborers,
and office workers engaged in repetitive upper extremity
activities are all susceptible to this painful, sometimes
disabling condition. It remains a substantial cause of
activity restriction, with lost time from sports, recre-
ation, and occupation. Despite increased understanding
of the causes and pathos natomy of elbow tendinopathy,
a lack of consensus remains regarding its optimal man-
agement. Multiple treatment options have been described,
with most patients ultimately responding to nonsurgical
care over an extended period. Many different surgical
Dr. Champ L. Halter ill or an immediate family member has
stoclr or stoclr options held in Arthreir. or. {Champ t. Salter,
it; or an immediate family member has received royalties
from Arthreir; serves as an unpaid consultant to Arthreir
and Smith d Nephenc has stoclr or stool: options held in
Arthrex; and serves as a board member, owner, officer; or
committee member of the American Orthopaedic Society
for Sports Medicine.
fl lflld American Academy of Drrhopaedic Surgeons
procedures have been described for those patients with
recalcitrant symptoms despite appropriate nonsurgical
treatment. lDptimal management of elbow tendinopathy
requires a thorough understanding of the pathophysiol-
ogy, clinical evaluation, available treatment options, and I:
'oi
'om
reported outcomes. 1
in:
m
H
m
H
Medial Epitondylitis E.
a?
Elbow tendinopathy of the flertor pronator origin aris-
ing from the medial cpicondylc is commonly referred to
as medial cpicondylitis. Although lateral cpicondylitis is
diagnosed up to T to 10 times more frequently, medial
elbow tendinopathy can cause substantial disability to
athletes and those individuals with repetitive occupational
requirements."1 Athletes who are particularly susceptible
to the development of medial epicondylitis include base-
ball players, golfers, and those involved in racquet sports
such as tennis.El Medial epicoudylitis primarily affects
patients in the fourth or fifth decades of life.
Pathophysiology
The primary etiology appears to be repetitive overuse of
or stress to the flercor pronator muscle origin. In the late
cocking and early acceleration phases of the overhand
throwing motion, high medial tensile forces and lateral
compression forces are generated at the elbow. The etc-
treme valgus forces are transmitted medially to the ulnar
collateral ligament and the flexor pronator muscle group,
which acts as an important secondary and dynamic stabi-
liner of the elbow. The repetitive stress and loading over
time can result in tendon degeneration and tendinopa-
thy in throwers. Similarly, overuse injuries are common
in golfers, especially those who have poor technique. A
recent electromyographic {EMG} analysis of amateur
and professional golfers demonstrated substantially in-
creased activity in the pronator teres in the trailing arm
of the amateur golfers during the forward swing phase
and a trend toward increased activity of the pronator
teres during the acceleration phase compared with the
professional golfers.“l In tennis players, EMG analysis has
showed substantially increased activity of the pronator
Drthepaedic Knowledge Update: Sports Medicine 5
 Sectinn 1: Upper Extremitl'
teres and flexnr carpi radialis during the acceleratinn
phase ef the everhand serve?
Repetitive nveruse results in micrnscnpic tears nf the
flexnr prnnatnr nrigin with subsequent tendinnus repair
and replacement with immature reparative tissue. His-
tnlngically, the tissue is characterised by the absence nf
inflammatnry cells and the presence nf fibrnblasts, disnr-
ganieed cellagen, and vascular hyperplasia. This tendnn
degeneratinn has been termed anginfibrnblastic tendinn-
sis.3-5~I In medial epicnndylitis, the pathnlngic tendinnsis
tissue mnst cnm mnnly invnlves the prnnatnr teres and the
flexnr carpi radialis. In nne study nf surgical treatment
nf 50 elbnws, the degenerated tissue was lncalized at
the flexnr carpi radialis—prnnatnr teres interval in 56%
t
nf cases, the flexnr carpi ulnaris in 12%, and diffuse
1: Upper Extrem
changes were nnted in the cnmmnn flexnr nrigin in the
remaining 32%.}
Evaluatiun
Patients with medial elbnw tendinnpathyr tend tn repnrt a
gradual nnset nf elbnw pain lncalized tn the medial epi-
cnndyle and ever the flexnr prnnatnr muscle mass. Pain is
increased with the nffending activity such as thrnwing nr
playing gnlf. Physical examinatinn typically reveals ten-
derness ever the flexer prnnatnr nrigin antericr and distal
tn the medial epicnndyle. Pain nu resisted prnnatinn nf the
fnrearm has been found tn be the mnst sensitive physical
examinatinn finding.” Pain can alsn be reprnduced frnm
resisted wrist flexinn. Grip strength can be decreased as
well. The examinatien cf the athlete with medial elbew
pain shnuld alsn include a cnmplete evaluatinn nf the
integrity nf the ulnar cnllateral ligament and assessment
fer ulnar neuritis, hnth uf which can cnexist with medial
epicnndylitis. Ulnar neuritis has been repnrted in up tn
60% nf patients ultimately requiring surgery fnr medial
epicnndylitisfi‘f'11
Plain radingraphs are typically nnrmal, althnugh cal—
cificatinns can snmetimes be seen adjacent tn the medial
epicnndyle. Althnugh primarily a clinical diagnusis, ad-
vanced imaging can help evaluate fnr suspected assnciated
cnnclitinns. Cine study evaluated the MRI findings nf 13
patients with a clinical diagnnsis nf medial epicnndyli-
tis.”- Cnmpared with age-matched cnntrnl patients, the
must specific MRI findings fnr medial epicnndylitis are
the presence nf intermediate tn high T2hweighted signal
intensity nr high Til-weighted signal intensity within the
cnmmun flexur tendnn and the presence ef paratendinuus
snft—tissue edema. Annther study fnund a sensitivity nf
95% and specificity nf 92% for ultrasnnngraphy in the
diagnusis cf clinical medial epicnndylitis.13 The must
cnmmnn pnsitive ultrasnnngraphic findings in patients
with medial epicnndylitis were fncal hypnechnic reginns
firthupaedic Knnwledge Update: Spnrts lvledichie 5
demnnstrating tendinnpathy, fncal anechnic areas indicat-
ing partial cummen flexer tendnn tears, cnrtical irregular-
ities, and tendnn thickening. The use nf ultrasnnngraphy
in the nffice setting is increasing recently, especially in the
treatment cf medial and lateral elbow tendinnpathy with
injectinns and nther prncedures.
Treatment
Althnugh the existing literature is replete with repnrts
nf widely varied nnnsurgical treatment nptinns fnr later-
al epicnndylitis, relatively little is dedicated specifically
tn medial epicnndylitis. Reperted nnnsurgical treatment
nptinns include rest, activity mndificatinns, cnunterfnrce
bracing, physical therapy, nral and tnpical NSAIDs, and
injectinns with cnrticnsternids in additinn tn the mere
recent use nf platelet-rich plasma {PRP} and autulugnus
blnnd. Althnugh cnmmnnly used in clinical practice, a
randnmized dnuble-blind study cnmparing an injectinn nf
methylprednisulune with an injectiun cf saline in patients
with medial epicnndylitis fnuud nnly shnrt—term benefit
in pain relief at 5 weeks fnr patients in the methylpred-
nisnlnne grnup. He substantial differences were fnu nd re-
garding pain relief at 3 mnnths nr 1 year after injectinn.”
One case series investigated the use nf dry needling and
injectinns cf autnlngcus blend under ultrasnnngraphic
guidance in 2G patients with medial elbnw tendinnpa—
thy.” At final fnllnw—up nf 1D mnnths, 3 patients were
cnnsidered tn have unsuccessful results and the remaining
patients demnnstrated substantial decreases in their visual
analug scale WAS} pain sceres and medified Hirsch] pain
scnres. Althnugh the use nf PRP has been studied in the
treatment nf lateral epicnndylitis, tn date, nn repnrts are
available en the treatment nf medial elhuw tendinnpathy.
Successful nnnsurgical treatment has been repnrted in
35% tn 90% nf cases.3-" Surgical treatment is reserved
fnr these patients with refractnryr symptnms even after
at least 5 mnnths nf nnnsurgical care. In cnntrast tn the
numernus repnrts nf surgical treatment nf lateral elbnw
mndinupathy, few repnrts regarding surgical management
nf medial epicnndylitis are published. Althnugh percuta—
nenus and npen flexnr releases” have been described, the
current cnnsensus fnr surgical treatment is npen resectinn
nf pathnlngic tendinnsis tissue frnm the flexnr prnnatnr
nriginf‘rfl'h'fi {Figure 1}. The success nf débridement is
substantially influenced by the presence nf cnncurrent
ulnar neuritisfi-m Overall, 3?% gnnd tn excellent results
were repnrted in 30 patients treated with flexur prnnatnr
nrigin débridement at a mean fnllnw—up nf 7*" years; hnw-
ever, the status nf the ulnar nerve cnrrelated with the
eutcume.“ Geed te excellent results were feund in 96%
nf patients with nn nr assnciated mild ulnar neurnpathy
cnmpared with nnlyr 4fl% gnnd tn excellent results in
fl lfllfi American Academy nf Orthnpaedic Surge-ens
 Chapter 3: Chroniol'flveruse Elbow Disorders

fincuanaa .iaddn :1
.1: -_ L h l

Figure 1 Photographs demonstrate open treatment of medial epicondylitis. A. The planned incision is marked. progressing
distally from the medial epicondyle. The medial epicondyle. the olecra non, and the position of the ulnar nerve
are outlined on the sltin. B. A portion of the flavor pronator origin is detached from the medial epicondyle and
reflected distally. A good cuff of tissue remains prosimally for later repair. E. The tendinosis tissue is removed from
the undersu rface of the flesor pronator tendons. The ulnar nerve is identified and either simply deco mpressed.
or tra nsposed. based on the presence and severity of preoperative ulnar nerve symptoms. D. The fleitor pronator
mass is securely repaired back to the medial epicondyle with heavy suture. {Reproduced from Eia lter EL Ill. Aldus
J, Halter EL Jr: Dpen treatment of medial and lateral epicondylitis. in Flatovv E, Colvin AC, eds: Atlas of Essential
Elrlhopaedfc Procedures. Rose mont, IL, American Academy of Drtho paedic Surgeons. 1'01 3, pp 39-42.}

those patients with moderate to severe ulnar neurop-
athy. Currently, no studies have evaluated the results of
ulnar nerve decompression versus anterior transposition
in patients with associated ulnar neuritis. Most case series
detail high rates of pain relief and success with various
outcome measures. |liilverall rate of return to the same
level of spurt ranges from 69% to 95%.3-*" A recent case
series of 22 elbows treated with open flescor pronator
tendinosis resection detailed 93% improvement in mean
VAS scores for pain, 94% improvement for pain at rest,
and 33% improvement for pain with heavy activity at a
mean follow-up of 36 months? The patient’s perception
of their arm function as measured by the Disability of the
Arm, Shoulder and Hand (DASH) scores substantially
improved to the levels of the general, healthy population
{mean improvement, 51.6 to 3.0}, with 90% of patients
overall satisfied with their outcome.
Lateral Epicondylitis
Lateral elbovi.r tendinopathya or tennis elbow, is the most
common cause of lateral elbow pain in the adult popula-
tion. Although it can occur in up to 5D% of recreation-
al tennis players, lateral elbow tendinopathy frequently
affects other athletes and workers whose occupation
requires repetitive wrist extension activities.” The dom-
inant arm is most commonly involved with an equal in-
cidence in men and women in the general population.

El lfllfi American Academy of flrchopaedie Surgeons Drthopaedic Knowledge Update: Sports Medichae S
 Section 1: Upper Extremitl'
Acute onset of symptoms can be seen in young athletes,
whereas chronic, recalcitrant symptoms typically occur in
older patients. It primarily affects patients in their fourth
or fifth decades of life.‘3~“'
Pathophysiology
The primary etiology for lateral elbow tendinopathy ap-
pears to be repetitive overuse or stress to the wrist ex-
tensor origin. The extensor carpi radialis brevis {HERB}
is most commonly affected, although portions of the
extensor digitorum communis can also be involved. Sev-
eral authors have promoted the most commonly accepted
theory of the pathogenesis of lateral epicondylitisfi?!”
Repetitive overuse results in microscopic tears of the
1: Upper Extremity
ECRB. Attempted repair and failure of healing results
in degenerative changes in the tendon characterised by fi-
broblasts, disorganized collagen, and vascular hyperplasia
with an absence of inflammatory cells. The degenerated
angiofibroblastic tendinosis tissue is similar histologically
to that found in medial elbow tendinopathy. One study
noted increased rates of cellular apoptosis and autophagic
cell death in surgical specimens of ECRE tendon with
associated collagen deterioration and breakdowns”-fl A
recent cadaver study demonstrated impingement of the
ECRB origin on the lateral edge of the capitellum during
extension as a potential anatomic contribution to the
development of lateral epicondylitis.21
Evaluation
Patients with lateral elbow tendinopatby report lateral
elbow pain that can radiate down the forearm. Occasions
ally, the patient may recall a specific injury to the area, but
the history is typically of a gradual, progressive nature.
Symptoms include weakness of grip strength affecting
work activities, sports performance, and sometimes even
activities of daily living. Difficulty picking up objects and
shaking hands may be noted. Un examination, point
tenderness is located at and just anterior and distal to the
lateral epicondyle. Pain is reproduced on resisted wrist
extension, which can be greater with the elbow extended
than with the elbow flexed. The differential diagnosis for
lateral elbow pain includes synovial plica, radiocapitellar
arthritis, posterolatera] rotatory instability, radial tunnel
syndrome, osteochondritis dissicans of the capitellum,
and cervical radiculopathy.
Plain radiographs are typically normal, although cal—
cifications can sometimes be seen adjacent to the lateral
epicondyle. Although primarily a clinical diagnosis, ad—
vanced imaging can be useful in patients with symptoms
refractory to treatment and those with atypical symp-
toms or presentation. MRI may demonstrate increased
Til-weighted signal and extensor tendon thickening. MRI
firthopaedic Knowledge Update: Sports Medicine 5
findings have been shown to correlate well with surgical
and histologic findings.“ However, one study noted that
severity of MRI signal changes consistent with tendon de-
generation did not correlate positively with patient symp-
toms.23 Ultrasonography has been described as a useful
diagnostic tool and as an adjunct to treatment of lateral
epicondylitis. fine study reported on 62 elbows with lat-
eral epicondylitis that underwent ultrasonographic assess-
ment of the common extensor tendon at diagnosis and
after 5 months of physical therapy.“ Pain and functional
disability were assessed using a validated tennis elbow
questionnaire. The presence of a large intrasubstance tear
was found to be predictive of a poor outcome and less
likely to respond to noninvasive treatment.
Treatment
In 1936, it was proposed that tennis elbow have only
one type of treatment}:T However, the increasing litera-
ture of myriad proposed nonsurgical treatment options
with sometimes conflicting results, different outcome
measurements, and varied levels of evidence makes di-
rect comparison difficult. A recent systematic review of
randomised controlled trials of nonsurgical treatment
concluded no conclusive evidence exists of one preferred
method of nonsurgical treatment of lateral epicondyli-
tis.” An assessment of all nonsurgical treatment options
must also consider the favorable natural history of the
condition with resolution of approximately Sfl‘if- of cases
within 1 year.” In general, nonsurgical treatment options
have included benign neglect, rest, activity modification,
physical therapy, bracing or splinting, oral and topical
medications including NSAIDs, extracorporeal shock-
wave therapy, and injections of corticosteroid and newer
biologic alternatives. Irrespective of the type of nonsur‘
gical care, almost 90% of patients ultimately respond
successfully, sometimes after an extended period. Poor
overall improvement has been noted in patients whose
employment involves manual labor, who have dominant
arm involvement, and who have higher levels of baseline
pain.”
Initial treatment includes active rest and refraining from
the repetitive offending activity. Modifications to improper
technique, if contributory, must also be made. Physical
therapy with stretching in conjunction with modalities
including iontophoresis, friction massage, ultrasonograu
phy, and electrical stimulation can be instituted, although
the efficacy of these modalities remains unproved. The
addition of eccentric extensor strengthening has been in—
vestigated based on prior success with patellar and Achilles
tendinopathy.-15' A recent systematic review evaluating the
utility of eccentric extensor strengthening supported its
inclusion as part of a multimodal treatment program for
fl lflld American Academy of Orthopaedic Surgeons

improved outcomes in patients with lateral epicondylitisfiml
Forearm counterforce straps and wrist extension splints
are two common orthoses prescribed as part of a non—
surgical treatment regimen. Few studies have evaluated
the use of orthoses, especially in comparison with other
treatment modalities; however, the authors of a 2'31!) ran—
domized trial compared a counterforce brace with a wrist
extension splint and found greater pain relief in the wrist
extension splint group after 6 weeks of treatment despite
no functional differences between the groups}1
Although the pathology of elbow tendinopathy does
not support an inflammatory component, both oral and
topical NSAIDs are commonly prescribed. In a EH13
|Cochraue review, 15 clinical trials were examined to de—
termine the benefits and disadvantages of both oral and
topical l_”*~lS.e5tI[ZIIs.3*1 Although firm conclusions were not
drawn from the available evidence, data suggest that top—
ical NSAIDs are more effective than placebo in providing
short-term pain relief in patients with lateral epicondylitis,
with a small risk of a transient skin rash. Conflicting
evidence regarding the use of oral HSAIDs precluded
any recommendations, although gastrointestinal side
effects were noted in several studies.”- Tbe use of other
topical agents has been described, including compound-
ing creams and nitric oxide. A prospective, randomised,
double—blinded clinical trial compared patients receiving
therapyr and a glyceryl trinitrate transdermal patch with
those receiving therapy and a placebo patchf‘3 Patients in
the glyceryl trinitrate group demonstrated substantially
decreased elbow pain, reduced epicondyle tenderness, and
improved wrist extensor strength compared with the pla—
cebo group. At 6 months, 31% of the treated patients were
asymptomatic with activities of daily living versus 60%
of those treated with rehabilitation alone. These results
were not maintained in a follow-up study at 5 years after
discontinuation of treatment, with no differences seen
between groups, although both had improved compared
with baseline.“ Extracorporeal shockwave therapy has
been proposed as an effective treatment option, but evi-
dence remains mixed with one systematic review finding
that most trials showed no benefit over placebo.35
Multiple injection therapies have been described, in-
cluding the use of glucocorticoids, PEP, autologous blood,
autologous tenocytes, sodium hyaluronate, botulinum
toxin, polidocanol, and glycosarninoglycan polysulfatefif
The use of glucocorticoid injections are common in clin"
ical practice despite the lack of inflammation seen in
chronic elbow tendinopatby. Randomised studies com—
paring glucocorticoid injection with naproxen or place-
hoEll or with physiotherapy or a wait-and-see approach“
demonstrated substantial improvements in pain and
function with glucocorticoid injection compared with
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 3: Chronicfflveruse Elbow Disorders
other treatment arms at short-term evaluation of 4 to
6 weeks. No benefit remained at 12-month follow-up.
A recent network meta—analysis of injection therapies
in the treatment of lateral epicondylitis found no sub-
stantial benefit of glucocorticoid injections versus pla-
cebo in outcomes greater than 3 weeks.” Potential side
effects from steroid injections include subcutaneous fat
atrophy and skin dEpigmentation. In this same network
meta-analysis, botulinum toxin was found to have a mar-
ginally significant reduction of pain intensity compared
with placebo. Several high-level studies have evaluated
the use of PRP injections. In one study, an injection of
leukocyte-rich PRP was compared with an injection of
corticosteroid using a peppering technique in a random-
ized controlled trial of ICE] patients.“ Outcomes were I:
'oi
'om
determined by PAS pain scores and DASH scores. The 1
PEP cohort demonstrated substantial improvements in an:
m
H
pain and function at 6 months and at 1 year compared m
H
with baseline and the corticosteroid cohort. These re- E.
a?
sults were maintained in a follow—up study at 2 years:
PEP-treated patients demonstrated 69% improvement
in pain versus 36% improvement in the corticosteroid
cohort. Similarly, the PRP cohort maintained substantial
differences in improvement in function: almost 63% in
the DASH outcome measurement versus only 15% in
the corticosteroid group.“ In a multiccnter randomised,
controlled trial of 23C! patients, a leukocyte-rich PRP
injection was compared with a control group of needliug
without PEP.” Substantial differences were not noted
until final follow-up at 14 weeks when 34% of the PRP
group was determined to have successful treatment coma
pared with 53% of the control group. A 2013 a systematic
review of the use of PRP in the treatment of lateral epicon-
dylitis suggests PRP has been shown to be of benefit over
corticosteroid treatment,“ and a network meta-analysis
concluded PRP and autologous blood injections were all
substantially more efficacious than placebo.“ Import-
ant questions remain regarding the cost-effectiveness of
PP. P, optimal preparation, and the timing and frequency
of intervention, although these early results of biologic
enhancement of healing appear promising.
Surgical treatment is recommended in patients with
recalcitrant symptoms even after 6 months or more of
nonsurgical care. Numerous reports of surgical man-
agement have been published with a wide variety of
techniques used; the most common currently include
percutaneous extensor tendon release,“~” open tendino-
sis resectionfldfidi‘r‘H and arthroscopic resection.” Most
studies detail high rates of success with limited follow-up.
A paucity of well-designed controlled studies support one
technique over another; therefore, the type of procedure
used should be based on surgeon comfort and experience.
Drthopaedic Knowledge Update: Sports Medicme S
 Section 1: Upper Extremity
1: Upper Extremity

r “'- 1.n I'-

ggefiasedEEFI-IB __ 1;; . ‘I

El

Figure I Arthroscopic images of treatment of lateral epicondylitis obtained from the proximal anteromedial portal- A, The
capitellum, radial head, and capsular tears are visualized. B, After capsular déhridement, the deep extensor carpi
radialis longus is exposed. C. The diseased extensor carpi radialis brevis origin is resected off its origin using a
radiofreci uency probe. {Heprod uced from Baker EL Jr: Arthroscopic release for lateral epicondylitis. in Ta mag uchi
it, King GJW, McKee MD, D'Driscoll SWM, eds: Advanced Reconstruction: Elbow. Hosemont, lL, American Academy
of lElrthopaedic Surgeons, IDDT, pp lE-EDJ

Currently, open treatment includes resection of the ECRE
tendiuosis tissue with or without repair of the extensor
tendon origin. {line study reported an overall improvement
rate of 93% in a cohort of 33 elbows, with 35% of patients
returning to full activities including sports."r A long—term
follow-up study of the Nirschl open tendinosis resection
technique reported 34% good to excellent results based
on outcome measurements, with 93% of patients available
at 10-year follow-up returning to sports.” Proponents of
arthroscopic resection similarly detail high rates of suc—
cess with additional benefits of identifying and treating
concurrent intra-articular pathology. Elf (ill patients at a
mean follow-up of 13D months,” none reported pain at
rest, with overall high function demonstrated using the
Mayo Elbow Performance Index; 23 {THE} reported pain
as “much better,” 5 (Zfl‘ihl as “better,” and 1 [3%] as the
same. Twenty-six patients {3?‘lisl were satisfied with the
procedure and 23 {93%} stated they would undergo the
surgery again if necessary. Arthroscopic resection of ten-
dinosis tissue was determined to he an effective treatment
of recalcitrant lateral epicoudylitis. High rates of early
success are maintained at long-term follow-up {Figure 2}.

flrdsopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons

A Zflflfi study compared 13 percutanenus releases, 41
arthroscopic procedures, and 33 open Hirsch] procedures,
all with a mean follow—up of 43 months.43 No significant
differences were reported among the groups regarding
complications, recurrences, failures, VAS pain scores, or
preoperative or postoperative Andrews-Carson scores.
The rate at which these patients returned to their activities
of daily living and work without discomfort could not be
measured. Each method is considered a highly effective
way to treat recalcitrant ECRE tendinosis.
Summary
Elbow tendinopathy is a common cause of pain and dis—
ability resulting from repetitive overuse activities. Honsur-
gical treatment is successful in most cases, with surgical
intervention reserved for those patients with continued
symptoms after 6 months or more of treatment. Many
treatment options are available, but currently, no con-
sensus exists regarding optimal management. Additional
well-designed comparative studies are needed to better
evaluate an ideal treatment algorithm with comparison
with the natural history of the condition.
Itey Study Points
1* Uveruse disorders of the elbow are common and
can be a substantial cause of pain and disability,
resulting in loss of time from worlt and spurt.
- Elbow tendinnpathy is not an inflammatory con-
dition but rather tendon degeneration resulting
from continued microtrauma and failed attempts
at healing.
' Many nonsurgical treatment options are available;
rest and activity modification are paramount.
I The current literature provides no definitive rec-
ommendations regarding efficacy of nonsurgical
interventions.
e Regardless of treatment type, most symptoms
improve.
Annotated References
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ID lfllli American Academy of flrthopaeclic Surgeons
Chapter 3: Chronictflveruse Elbow Disorders
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tendon origin resection technique for the treatment of
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Mari 2fl14;42{?l:1?31-1?3?. Medline DflI
The authors of this case series noted substantial improve-
ments in 1|tAS and DASH scores and improvements in grip
strength using their tendinosis resection technique in 22
elbows at a mean 3-year follow-up. Level of evidence: IV.
10'. Kurvers H, Verhaar J: The results of operative treat-
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1995;??[9J:13?4—13?9. Medline
11. Vangsness CT Jr, ae FW: Surgical treatment of medial
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12.. Kiiowslti 11, De Smet AA: Magnetic resonance imaging
findings in patients with media] epicnndylitis. Sitsfstai
Radio! 20fl5;34{4]:196-1fl2. Medline DUI
13. Park GT, Lee SM, Lee MY: Diagnostic value of ultraso-
nngraphy for clinical medial epicnndylitis. Arcfr Phys Med
Rehabii lflfl3;39{4j:?33-?41. Medline DUI
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roids for medial epicnndylitis: A prospective study of sixty
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Drrhopaedic Knowledge Update: Sports Medichse S
 Sectian 1: Upper Extremity
15. Suresh SP, Ali FEE, Janes H, Cannell DA: Medial epicen-
dylitia: Is ultrasaund guided autc-lagaus bland injectian an
effective treatment? Hr]Sparta Med1flfl6;4l}{11}:935-939,
discussian 939. Medline DUI
16. Schipper UN, Dunn JH, Uchiai DH, Danavan J5, Nirschl
RP: Hirsch] surgical technique far cancarnitant lateral
and medial elhaw tendinasis: A retraspecn've review at SS
elbows with a mean fallaw-up at 11 .1 years. Am 1 Sparta
Med1fl11:39{5l:911-916. Medline DUI
The authars at this case series repartcd substantial II'I'I—
pravements in Hirsch] tennis elbaw scares, American
Shaulder and Elhaw Surgeans scares, and 3.5% gaacl ta
excellent results with apen cambined medial and lateral
tendinasis resectian at lung-term fallaw-up: 96% at pa-
tients returned ta spurts. Level af evidence: IV.
1: Upper Extremity
11'. Hirschl RP: Elbaw tendinasisi'tennis elbaw. Cilia Sparta
Med 1991;11l4}:35 1-STIJ. Medline
13. Baker CL Jr, Baker CL III: Lang-term fallaw-up af arthro-
scapic treatment at lateral epicandylitis. Am I Sparta Med
1flfl3;36{1}:154—160.Medfine DUI
19. Dunn JH, Kim J}, Davis L, Nirschl RP: Ten- ta 14-year
fallaw—up at the Hirsch] surgical technique far lateral
epicandylitis. Am J Sparta Med 1DDS;SS{1]:1SI-1SS.
Medline DUI
11]. Chen], Wang A, Kn J, Eheng M: In chranic latetai epi-
candylitis, apaptasis and autaphagic cell death accur in the
extensar carpi radialis brevis tendaa. j Shaat'der Ethan!
Stttg 101D;19l3}:355-361. Medline DUI
Ten lateral epicandylitis surgical specimens were examined
histalagically. Increasing rates af tenacyte apaptasis and
autaphagic cell death were nated with assaciated increas—
ing callagen degradatian.
11. Bunata RE, Brawn DS, Capela R: Anatamic factars re—
lated tn the cause at tennis elbaw. I Harte Jlair-rt Snag Arr:
1flfl1;39{9}:1955-1963.Medline DUI
Patter HG, Hannafin JA, Marwessel EM, DiCarla EF,
U’Brien S], Altchelc DW: Lateral epicandylitis: Carrelatian
af MR imaging, surgical, and histapathalagic findings.
Radialagy 1995:196l1}:43'46. Medline DUI
13. Waltan M], Mackie K, Fallan M, et a]: The reliability
and validity af magnetic resanance imaging in the assess-
ment af chranic lateral epicandylitis. ] Hand Sari-g Am
1fl11;35l3J:4?5-4T9. Madlirle DUI
There was substantial interabserver reliability and in—
traabserver agreement in the MRI evaluatian af11 elbaws
with clinical lateral epicandyiitis. A negative carrelatian
with tendinasis severity an MRI was seen with patient
aymptams as repartcd by quick DASH and maximum
pain levels.
14. Clarke AW, Ahmad M, lCurtis M, Cannell DA: Lateral
elbaw tendinapathy: Carrelatian af ultrasaund findings
Drthapaedic Knawledge Update: Sparta Medichie S
with pain and functianal disability. Am I Sparta Med
1fl1flt33lfilfl109-1114.Medline DUI
In this cahart study, 61. elbaws with lateral epicandy-
litis were evaluated ultrasanagraphically and with Pa-
tient—Rated Tennis Elbaw Evaluatian {PRTEE} scares.
After 6 manths at physical therapy, PRTEE scares were
again determined. Large intrasubstance tears and lateral
callateral ligament tears seen an initial ultrasanagraphy
were predictive at a paar autcame with this farm at nan-
surgicai treatment. Level at evidence: II.
15. EyriaxJH: The pathalagy and treatment af tennis elbaw.
j Banefaint Sarg Am 1936;113:911-940.
1S. Sims SE, Miller E, Elfar JC, Hammett WC: Nan-surgical
treatment af lateral epicandylitis: A systematic review at
raadamiaed centralled trials. Hand (N 1’} 1i] 14,9{4l:41 9-
446. Medline DUI
In a systematic review at SS randamired, cantralled trials
evaluating nansurgical treatment aptic-ns far lateral epi-
candylitis, the authars determined na canclusive evidence
at ane preferred aptian. IZarticaateraid injectians can pra-
vide shart-term pain relief with lang-term advantages.
Level af evidence: II.
1?. Smidt N, van der Windt DA, Assendelft W], Devillr‘i
WL, Karthals-de Ens IE, Banter LM: Earticasteraid in-
jectians, physiatherapy, at a wait-and-sec palicy far lat-
eral epicandylitis: A randamised cantralled trial. Lancet
1Dfl1;359{93fl1}:651—SS1.Medline DUI
13. Haahr JP, Andersen JH: Pragnastic factars in lateral epi-
candylitis: A ra ndamiaed trial with ane—year fallaw—up in
166 new cases treated with minimal accupatianal inter—
venn'an ar the usual appraach in general practice. Rheuma-
tal‘agy (Uxfardj 1flfl3;41{1fll:1116-1115. Medline DUI
19. Tyler TF, Thamas GC, Nichalas S], McHugh MP: Ad-
diticin at isalated wrist extensar eccentric exercise ta
standard treatment far chranic lateral epicandylasis: A
praspective randamiaed trial. ] Sbaatder Elhata Sta-g
1fllfl;19{5}:911-911.Medline DUI
In a small trial at 11 elhaws, patients with lateral epicen-
dylitis were randamiaed ta treatment graups at standard
physical therapy and standard physical therapy with the
additian af eccentric wrist extensar exercises. Patients
in the eccentric exercise graup impraved substantially in
all autcame measures at VAS, DASH, tenderness, and
strength campared with cantral patients.
30. Cullinane FL, Baacack MG, Trevelyan FE: Is eccentric
exercise an effective treatment far lateral epicandyli-
tisi'l A systematic review. CH1: Rehahii 1D14;13{1}:3-19.
Medline DUI
In a systematic review at eight randamiaed trials evaluat-
ing eccentric exercise, the authars reparted mast studies
demanstrated impraved clinical autcc-mes with the addi-
tian af eccentric exercise campared with these treatment
pragrams withaut eccentric exercise.
D 111115 American Academy at Drthapaedic Surge-ans

31. Garg R, Adamson G], Dawson PA, Shankwiler JA,
Pink MM: A prospective randomized study compar-
ing a forearm strap brace versus a wrist splint for the
treatment of lateral epicondylitis. ,l Shoulder Elbflw Sarg
2313;19H]:503-512.Medline DDI
In a randomised clinical trial of 44 elbows, patients receiv—
ing a wrist splint compared with a forearm counterforce
brace demonstrated improved pain relief after I5 weeks,
although no functional differences were seen between
groups based on American Shoulder and Elbow Surgeons
or Mayo Elbow Performance scores.
32. Pattanittnm P, Turner T, Green S, Buchbinder E: Non-ste-
roidal anti-in flammatory drugs {NSAIDs} for treating
lateral elbow pain in adults. l|.'3o.r:.l:rrarse Database Syst Ree
lfllSfitflflflflfififlfi. Mcdline
A Cochrane review concluded that topical NSAIDs ate
more effective than placebo in providing short-term pain
relief in patients with lateral epicondylitis, with a small
risk of a transient skin rash. Eonflicting evidence regarding
the use of oral NSAIDs prevented any recommendations,
although gastrointestinal side effects were noted in several
studies.
33. PaoloniJA, Appleyard RC, Nelson], Murrell GA: Topical
nitric oxide application in the treatment of chronic exten-
sor tendinosis at the elbow: A randomised, double-blind-
ed, placebo-controlled clinical trial. Arr: I Sports Med
lflflS;Sl{S}:915—91ll. Medline
34. l'vlcCaIIum SD, Paoloni JA, l'vlurrell GA: Five-year pro-
spective comparison study of topical glyceryl trinitratc
treatment of chronic lateral epicondylosis at the elbow.
Br ] Sports Med 2011;45{5}:416-4lfl. Medline DUI
In this prospective follow-up study of a prior report, the
authors reported no sustained benefit .5 years after treat-
ment with a topical glyceryl patch compared with those
treated with physical therapy alone.
SS. Euchbinder E, Green SE, Tend JM, Assendelft W], Barns-
lEy L, Smidt N: Systematic review of the efficacy and safety
of shock wave therapy for lateral elbow pain. I eeumatol
2333;333:1351—1363. Medline
36. Krogh TP, Barrels EM, Ellingsen T, et al: Comparative ef—
fectiveness of injection therapies in lateral epicondylitis: A
systematic review and network meta-analysis of random-
ized controlled trials. Arr: f Sports Merl 1313;41l51fl435-
1443. Medline DUI
In this systematic review and meta-analysis of inieetion
therapies for lateral epicondylitis.. the anthers concluded
glucocorticoids were no better than placebo beyond 3
weeks, bctnlinum toxin was marginally better than place—
bo with risk of estensor paresis, and PEP and autologons
blood were substantially better than placebo; however,
most studies were associated with risks of bias.
3?. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P: Prag-
matic randomised controlled trial of local corticosteroid in-
jection and naproxen for treatment of lateral epicondylitis
IS! 2313 American Academy of flrrhopaedic Surgeons
Chapter 3: Chroniclflverusc Elbow Disorders
of elbow in primary care. BM,r 1999,319{y115),954-953_
Mcdline DUI
S3. Peerbonms JC, Sluimer J, Eruiin D], Gosens T: Positive
effect of an autologons platelet concentrate in lateral epi-
condylitis in a double-blind randomized controlled trial:
Platelet-rich plasma versus corticosteroid iniectiou with a
1-year follow-up. Am } Sports Med 231 fl:33{2}:2 SS -2 ES.
Medline DUI
This randomised, controlled trial compared leukocyte-rich
PRP and corticosteroid injections. The PEP cohort demon-
strated progressive improvement. At 1 year, the PEP cohort
demonstrated T333 success in substantial pain reduction
versus 49% in the corticosteroid group. Based on DASH
scores, the PRP cohort demonstrated substantially more
success at T333 versus 51%. Level of evidence: I.
39. Goscns T, Peerbooms JC, van Laar W, den |Eludstctl I:
'oi
31.: Ongoing positive effect of platelet-rich plasma ver- 'om
sus corticosteroid injection in lateral epicondylitis: A 1
double-blind randomized controlled trial with laycar s:
”'1
H
follow—up. Am ] Sports Med lfll];39{3}:1233—1133. m
H
E.
Medline DIG] a?
At 2-year follow-up of a randomised, controlled trial,
PEP-treated patients demonstrated 39% improvement in
pain versus 36% improvement in the corticosteroid cohort.
Similarly, the PEP cohort maintained substantial improve-
ment in function of almost 63% in the DASH outcome
versus only 16% in the steroid group. Level of evidence: I.
4D. Mishra AK, Skrepnik NV, Edwards 5G, or al: Efficacy
of platelet—rich plasma for chronic tennis elbow: A dou—
ble-blind, prospective, multicenter, randomized controlled
trial of 233 patients. rim } Sports Med 2014;42lllt463-
431. Medline DUI
In a multicenter randomized controlled trial of 233 pa-
tients, a leukocyte-rich PEP injection was compared with
a control group of needling without PEP. Substantial dif-
ferences were not noted until final follow-up of 24 weeks
when 34% of the PEP group was determined to have
successful treatment compared with 63% of the control
group. Level of evidence: II.
41. Ahmad Z, Brooks E, Eang SN, et al: The effect of plate-
let-rich plasma on clinical outcomes in lateral epicondyli-
tis. Arthroscopy 1313;19{11):13Sl-1362. Medline DUI
In a sysmmatic review of the clinical efficacy of PEP in the
treatment of lateral epicondylitis, the authors concluded
limited evidence in the use of PEP. Recommendations
regarding future studies involving its use were made. Level
of evidence: III.
41. Eaumgard SH, Schwarts DE: Percutaneous release of
the epicondylar muscles for humeral epicondylitis. Am
] Sports Med 1932;10l4}:233-236. Medline DUI
43. Saabo SJ, Savoie FH III, Field LII}, Eamsey JE, Hose-
manu CD: Tendinosis of the extensor carpi radialis
brevis: An evaluation of three methods of operative
treatment. I Shoulder Elbow Serg 2336;15{61:?21-?l?.
Medline DUI
Drthopaedic Knowledge Update: Sports lvledichte S
Chapter 9
Hand and Wrist Injuries
Ieifrcy Taylor Iobe. MD A. Hobby lEhhabra. MD
Athletes commonly sustain injuries to the hand and
wrist. An understanding of both common and uncom-
mon injuries, diagnostic modalities and treatments of
the athletes’ hand and wrist, along with the most recent
published data and treatment methods, are important
to maximize treatment outcomes.
Keywords: hand and wrist injuries: hand
fractures: carpal fractures; wrist instability: finger
dislocations; return to play; skier's thumb; mallet
finger; central slip: flexor pulleyr rupture: hook of
hamate fractu re; triangular fibrocartilage complex:
scapholunate ligament: Bennett fracture: sagittal
band: extensor carpi ulnaris tendinitis: flexor carpi
radialis tendinitis; extensor carpi ulnaris instability:
jerseyr finger; intersection syndrome: de Quervain:
ganglion; ulnar tunnel syndrome; ulnar artery
thrombosis
Introduction
Hand and wrist injuries in the athlete are frequently en-
countered by orthopaedic surgeons. Although treatment
of many of these injuries is effective, management of these
injuries can present a challenge to the physician. An un-
derstanding of diagnosis and treatment of com mon hand
and wrist injuries in the athlete, along with guidelines for
rerurn to play will help the physician provide optimal care
for a specific injury.
Dr. Chhahra or an immediate famiiy member has received
nonincome support {such as equipment or services). com-
merciaiiy derived honoraria. or other non—research-reia ted
funding [such as paid traveiJ from DePuyiSynthes. Neither
or. .iohe nor any immediate famiiy member has received
anything of vaioe from or has stock or stock options heid
in a commerciai company or institution reiated ciirectij.»r or
indirectiy to the subject of this chapter.
fl lflld American Academy of Drrhopaedic Surgeons
Not only are the hands used in almost every sport for
sport-specific ta sits, but they are also instinctively used to
protect the body from the initial impact of a fall or con-
tact with another person. Hand injuries are common in I:
'oi
'om
athletes and occur in almost every sport played. Neglected 1
injuries can have detrimental consequences; therefore, it in:
m
H
is important to quickly and accurately identify and treat m
H
hand injuries.‘ E.
a?
Metacarpal and Phalangeal Fractures
Metacarpal and phalangeal shaft fractures are the most
common fractures and are frequently encountered in
athletes. Most injuries can he treated nonsurgically in
the general population, but athletes require special con-
sideration. When treating hand fractures, “Deformity
follows nndertreatment, stiffness follows overtreatrnent,
and deformity and stiffness follow poor treatment."1
Distal phalanx fractures {tuft fractures} are the most
common hand fractures and require only short periods
of immobilization lid to 14 days]. The nail bed should
be inspected because this is a common associated injury.
Substantial nail bed injuries require meticulous repair
technique to avoid nail plate abnormalities.
More proximal fractures in the phalanges and meta-
carpal bones can usually be treated with approximately
3 weeks of immobilization followed by early protected
range of motion to prevent stiffness if minimal displace-
ment and no rotational deformity exist. Early edema
control, along with motion and elevation, should be in-
eorporated into therapy. Fractures of the metacarpal head
are rare intro-articular fractures, most commonly occur-
ring in the index finger. Surgery with Kirschner wires or
minifragment plate and screws is required if more than
1 mm of intrauarticular stepuoff exists. These injuries are
commonly associated with fight bites, which should he
treated with appropriate irrigation and debridement and
a course of antibiotics.
Metaearpal neck fractures jboxer’s fractures} usually
occur in the ring and little fingers, although other meta-
carpal bones can be involved. Lateral radiographs are
necessary to evaluate the amount of angular deformity;
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 1: Upper Extremitl'

15“ of deformity can be tolerated in the index and middle

finger metacarpals, 3G” to 4D” in the ring finger, and 5CI“
to 6E!" in the little finger. The interossei are the deform—
ing forces that cause dorsal angulation. Traditionally, an
ulnar gutter splint has been applied for 2 to 3 weeks, but
data from lflfl? showed no difference in Disabilities of
the Arm, Shoulder and Hand scores with buddy taping
alone.2 Malunion is common after metacarpal neclt frac-
tures, but is rarely a functional deficit in the athlete}3
In rare circumstances, open reduction and internal fixan
tion {GRIP}, closed reduction and percutaneous pinning
[CRPP], or an intramedullary technique can be considered
if malunion is not tolerated, such as for a tennis player in
whom the metacarpal head prominence in the palm can
1: Upper Extremity

make gripping a racquct difficult.

For metacarpal shaft fractures, less angular deformity
is tolerated than for metacarpal neck fractures: 10" for
the index and middle fingers, and 3f)“ for the ring and
little fingers. Malrotation is unacceptable because 5“ of
malrotation results in 1.5 cm of digital overlap. Short-
ening is acceptable up to 5 mm, but F“ of extensor lag
occurs with eyeryr 2 nun of shortening. DRIP is commonly
performed in athletes with metacarpal shaft fractures if
surgical criteria are met, but CRPP can be considered.“-"
Metacarpal base fractures are uncommon, usually
stable, and minimally displaced. Displaced fractures at the
base of the metacarpal can result in arthrosis. Fourth and
fifth carpometacarpal {CMC} fracture-dislocations are
unstable injuries and require pinning of the CMC joint.
Proximal phalanx shaft fractures result in solar an-
gulation because the proximal fragment is flexed by the
interossei, and the distal fragment is extended by the
central slip. Middle phalangeal shaft fractures can have
yolar or dorsal angulation, depending on the location
of the fracture. Malrotation is unacceptable, and only
lfl" of angulation in any plane is tolerable. CRPP can be
considered, but DRIP with a plate in the athlete may be
a better option. Dbliquefspiral fractures can be treated
with interfragmentary lag screws if the fracture line is
twice the bone diameter?
Phalangeal head fractures can be unicondylar or bi-
condylar. The collateral ligament attachment provides
blood supply. Surgery must be considered with displaced
unstable fractures, usually with DRIF with interfragmen-
tary screwsf‘
Athletes can return to play with appropriate protection
after the fracture is stable and sport-specific range of
motion is obtained. Recent data have shown successful
early return to play {less than 1 month} after DRIP for
metacarpal and phalangeal fractures with appropriate
protection? Contact sports are not allowed without pro—
tection {casting or splintingj until 5 to 3 weeks after injury
Figure 1
{Reproduced from Erewal R, Faber Hi], Graham
Tl, Rettig LA: Hand and wrist injuries, in flibler
WEI. ed: Orthopaedic Knowiedge Update:
Sports Medicine. ed 4. Basement. IL, American
Acade my of flrthopaedic Surgeons, 2M9, pp
59-30.}
to ensure adequate healing.
Bennett fractures are intra-articular fractures that in-
yolye the base of the thumb and occur when an axial load
is applied to the flexed and adducted thumb {Figure 1].
The abductor pollicis longus displaces the metacarpal
base proximally, and the anterior oblique ligament pulls
the Bennett fragment to the base of the second meta-
carpal. Bennett fractures are surgical injuries and require
CRPP or DRIP if the fragment is large enough. Extra-
articular thumb metacarpal base fractures can tolerate up
to 30° of angulation as a result of EMC joint hypermobil-
ity and most cases can be treated nons urgically, but DRIP
or CRPP should be considered in the high—level athlete
for earlier rehabilitation and return to play.
Finger Dislocations
Dorsal dislocations of the proximal interphalangeal [PIP]
joint are the most common finger dislocation. Simple dis-
locations are usually reducible with hyperextension of the
middle phalanx followed by distal translation. The yolar

firthupaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons

Figure 2 Phetugraph demonstrates pin and rubber band
tractien used tc- treat middle phalanx pilen
fractures.
plate can bleclt reductien. If stable after reductien, buddy
taping and range ef metien are initiated. If unstable, :1
dersal bleclcing splint is applied. Avulsinn fractures ef
the velar plate sheuld be menitered carefully because a
fies-den centracture can develepfi‘ Early return te play is
pessible with buddy taping based en cum fnrt and stability
after reductien.
Dersal fracture-dislecatieus eften invelve fracture ef
the velar base ef the middle phalanx. The Hastings clas-
sificatien summarises these iniuries and guides treatment,
and is based en the size ef the middle phalanx articular
fragment. Fer Hastings type I fractures, less than 39%
ef the articular surface is censidered stable. Type II frac-
tures have sass te sass articular invelvement and are
censidered tenueus. Type III fractures have mere than
5fl% articular invelvement and are censidered unstable.
If reducible, types I and [I can be treated with a dersal
extensien bleck splint, carefully decreasing the ameunt
ef flexien by 10" every week. Unstable fractures must be
treated surgically using DRIP er hemihamate arthrnplas-
tyfiW Chrenic fracture—dislecatieus are treated using velar
plate arthreplasty er hemihamate arthreplasty.11 Pilen
fractures ef the base ef the middle phalanx are treated
using leugitudinal tractien (pin and rubber band tractien}
and immediate metien.11 |Heed results have been ebtained
using pin and rubber band tractien”I [Figure 2}.
Velar PIP dislecatieus are less cemmen and are assew
ciated with a central slip disruptien. After reductien, the
PIP sheuld be splinted in extensien fer 6 weeks te prevent
a beutenniiere defermity and allew healing ef the central
slip. If the dislecatiun is still unstable after reductiun,
pinning fer 3 weeks is required.
Retatery subluxatien-dislecatiens ef the PIP alse can
IE! Efllli American Academy ef flrthepaedic Surgeens
|Iiiihapter .9: Hand and 1|i'lfrist Injuries
I:
Is
I:m
Figure El Radiegraphs shevv a retatery subluxatien ef the 1
proximal interphalangeal jeint. A. Lateral view. s:
m
B, Dhlique vievv. IE, PA view. H
m
H
E.
a?
eccur, leaving the central slip intact, but the cendyle but-
tenheles threugh the central slip and lateral band {Fig-
ure 3]. These injuries eften require surgical interventien
fer reductien.
Skier's Thumh
Injury re the ulnar cellateral ligament ef the thumb
metacarpephalangeal iMCP) jeint is referred te as ski-
er‘s thumb, er gamekeeper‘s thumb. A cempetent ulnar
cellateral ligament is critical fer effective pinch.
It is impnrtant re ebtain radiegraphs befere stressing
the MCP jeint te aveid displacing an etherwise nendis-
placed fracture. Physical examinatien is perfermed with
a valgus stress applied re the thumb in beth extensinn
{testing the accessery ligament} and fill!"u flexien {preper
ligament}. The ulnar side ef the jeint sheuld be palpated
fer a Stener lesien {beth the preper and accessery liga-
ment are retracted and lie en the adducter apeneuresis}.
The adducter apeneuresis interpesitien prevents direct
ligament healing witheut surgery. Mere than 35” pi lax-
ity alene er mere than 15“ ef laxity cempared with the
centralateral side is censidered a pesitive test result. Stress
radiegraphs are useful fer identifying Stener lesiens, as
are Mills and ultraseuegraphs.”
Incemplete acute tears and nendisplaced av ulsien frac-
tures are treated with a thumb spica cast fer 4 weeks, fel-
lewed by remevable pretective splinting fer 3 mere weeks
with active range-ef—metien exercises. Cemplete tears
require epen repair with suture anchers er bene tunnels
placed at the site ef the avulsien, which mest cemmenly
is the preximal phalanx. Altheugh cemplete minimally
retracted tears can heal with nensurgical treatment, the
tear will net heal in the setting ef a Stener lesien because
Drthepeedic Knewledge Update: Sperts Medicine 5
 Section 1: Upper Extremitl'

of adductor aponeurosis interposition. Strenuous activity

is avoided for 3 months, with unrestricted return to sport
usually at 2 to 3 months. Recent data have reported good
long-term outcomes following repair with two suture an—
chors in collegiate football players. Skill position players
were repaired acutely; lineman were able to complete the
season with bracing or casting before undergoing repair.I ‘

Extensor Tendon Injuries

Mallet Finger
l'vlallet finger occurs when the extensor tendon attachment
to the distal phalanx becomes incompetent, resulting in "I— I

inability to extend the distal phalanx. This can be either

------

a soft—tissue or a bony avulsion. Soft—tissue mallets are

1: Upper Extremity

treated with S to 3 weeks of extension. A slight residual

extensor lag of approximately lfl‘” should he expected
after treatment. A bony mallet should be assessed with
lateral radiographs, both without external force and with
the joint held in extension tn assess if the fracture reduces
appropriately. Bony mallet injuries also are treated with IS
weeks of extension splinting. If the distal interphalangcal
[DIP] joint is subluxated or the fragment is large and re-
sults in substantial articular incongruity, DRIP or dorsal
block pinning should be considered [Figure 4}. Chronic
mallet fingers result in swan neck deformities. Recent data --L'.-

have shown good outcomes with splinting for soft—tissue
mallets that were treated within 6 weeks of injury.” Pre-
viously, splinting at night for 1 month after cessation of
fullvtime splinting has been performed, but recent data
reported equivocal outcomes without night splinting.”
Central Slip Injury {Acute Boutonniere Deformity]
A houtonniére deformity is the result of a central slip
rupture, triangular ligament attenuation, and volar mi-
gration of the lateral bands. Dn examination, the PIP
joint is passively placed in extension; if the patient can
maintain PIP extension, the triangular ligaments are likely
intact and splinting usually provides good outcomes. The
Elson test is used to assess a central slip rupture. The PIP
is flexed to 9D“ and blocked while extension of the PIP
is attempted and the DIP is assessed. The test result for
a central slip injury is positive if the DIP becomes rigid
or actively extends to neutral. Radiographs may show
an avulsion fracture. A closed acute houronniii-re injury
is treated with extension splinting of the PIP for 6 weeks
followed by 5 weeks of night splinting. Surgery is indi—
cated if closed treatment fails, for open injuries, for large
displaced avulsion fractures, or in the setting of an un—
stable volar PIP dislocation {Figure 5}. For large fracture
fragments, IKiln]: can he performed or the fragment can
be excised and the tendon repaired with suture anchors.“
Figure 4 Late ral radiog ra ph demonstrates the pinning
technique for a bony mallet finger. The ohlitjue
pin is used to block the fragment and provide
anatomic reduction.
Sagittal Band Injury
If an extensor lag of the finger is present, laceration or
rupture of the sagittal band should he considered, which
results in ulnar sublu xation of the extensor tendon. This
injury, also known as boxer’s knuckle, also can be associ-
ated with a capsular injury of the MCP joint. The middle
finger is the most commonly affected. On examination,
the patient is unable to initiate MCP joint extension, but
can maintain extension after passive finger extension.
The extensor tendon dislocates to the cnntralateral side
when the MCP joint is flexed and reduces when the joint
is extended. The mainstay of treatment of acute inju-
ries in the general population is flexion block splinting
of the MCP joint for 3 weeks, but in athletes, surgical
repair must be considered, depending on when in the
season the injury occurs and the athlete’s preferences.”
Numerous techniques can he used for repair, depending
on the local soft—tissue availability and need for recon-
struction. Patients with chronic injuries can undergo a
trial of splinting, but surgery is required more often than
for acute injuries.

firthopaedic Knowledge Update: Sports lvledich'ie 5 fl lfllfi American Academy of Orthopaedic Surgeons

Figure 5 Lateral radiograph shows central slip avulsion
and resultant Boutonniére deformity.
[Reproduced from Grewal Fl. Faber it]. Graham
TJ, Fiettig LA: Hand and wrist injuries, in itihler
WE, ed: Drthopeedic Knowledge Update:
Sports Medicine. ed 4. Easement. IL. American
Academy of flrthopaedic Surgeons, 2W9. pp
Gil-ED.)
Flexor Tendon injuries
Jersey Finger
Jersey finger is the result of a flexor digitorum profundus
avulsion from its insertion on the distal phalanx. The ring
finger is most commonly involved. Physical examination
reveals inability to flex the DIP. Ultrasonography can help
assess the level of tendon retraction in a timely fashion,
although MRI also has good results if performed soon
enough postinjury. The Leddy classification is based on
the level of retraction. In type I injuries, the flexor digi-
torum profundus is retracted to the pahn and the vincu-
la {blood supply] is compromised. Primary early repair
{within lfl days} is warranted. Type II injuries involve a
tendon that is retracted but still in the flexor sheath, at
|the level of the A2 pulley. Surgical repair is warranted and
should he performed in a timely fashion, usually within
4 weeks. Type III injuries include a bone fragment that
is caught on the A4 pulley. DRIP is performed on the
fragment that involves the tendon insertion. Type IIIA
injuries are less common and involve a bone fragment
IE! lfllfi American Academy of flrrhopaedic Surgeons
Chapter 9: Hand and Wrist Injuries
and tendon retraction to the pahn. lE'IRIF is performed,
as well as tendon repair, and should he done within 1!]
days as in type 1 injuries.”
Pulley Rupture
Flexor tendon pulley ruptures occur when a sudden ex-
tension force is generated on a flexed finger. This is most
commonly seen in rock climbers when they slip and fre-
quently affects the ring and middle finger. The patient will
have acute pain over the flexor tendon. Dn examination,
bowstringing may be visible if the A2 or A4 pulleys are
involved and the patient will have difficulty making a
full fist. Dynamic ultrasonography and MRI are useful
in diagnosis.
Single-pulley ruptures should he immohiliaed for If] I:
I:
I:re
to 14 days, followed by therapy for motion and taping 1
or rings to support the pulleys. Multiple ruptured pulleys s:
”'1
H
should he treated surgically. Repair can be performed re
H
with extensor retinaculum sutured to the remnant of the 3.
a?
pulleys. If no pulley edges remain for suturing, a triple
loop repair is performed using tendon autograft [Fig-
ure 6}. Return to sport is permitted at e? to 3 weeks with
continued pulley protection. Full sports participation
begins at 3 months. Taping or pulley ring use should he
continued for at least 6 months.”
Scaphoid Fractures
Scaphoid fractures are a common problem encountered
by orthopaedic hand surgeons. A high index of suspicion
is necessary to make the diagnosis because radiographs
are often negative at initial presentation. Any history of
wrist trauma and tenderness should increase suspicion.
On physical examination, tenderness over the anatomic
snuffhox prevents the surgeon from ruling out a scaphoid
fracture. Resisted pronation also elicits pain on exam-
ination. In addition to standard wrist radiographs, a
scaphoid view should he obtained, with the wrist in 30"
of extension and 1D“ of ulnar deviation. In the athlete, an
MRI is useful if radiographs are inconclusive. This can
allow earlier return to play if no fracture is identified.
MRI is also used to assess osteonecrosis of the proximal
pole of the scaphoid, a common complication of these
injuries, and can help assess for a scapholunate ligament
injury, another common cause of radial-side wrist pain
in the athlete after a fall.
Scaphoid fractures are often a missed injury. Fractures
treated less than 28 days from injury result in a 5 “if. non-
union rate. If treatment is delayed longer than 23 days,
the nonunion rate increases to 23%. It is imperative that
the surgeon educate all trainers and other athletic staff
about scaphoid fractures; any suspected injury should be
promptly evaluated and treated.
Drthopoedic Knowledge Update: Sports Medicine 5
 Sectien 1: Upper Extremiqr
1: Upper Extremity
Figure E- Photograph demenstrates an A2 pulley
recenstructien with a triple-lee ped tenden
graft.
Scapheid fracture treatment depends en the lecatien
and displacement ef the fracture, as well as the skills re-
quired fer the spert andfer pesitien. If clinical suspicien
is high fer fracture, but the radiegraphs are negative,
the athlete sheuld be placed in a shert arm thumb spica
splint and an MRI sheuld he ebtained. Nendisplaced
fractures ef the scapheid waist can be treated with thumb
spica casting in feetball lineman with frequent fellew-up
repeat radiegraphs, hut percuta neeus cempressien screw
fisatien is strengly censidered fer mere skilled pesitien
players such as receivers. IEasting generally lasts fer at
least 3 menths er until healing is cenfirrned en sequen-
tial radiegraphs er a CT scan. Displaced scapheid waste
fractures are treated using GRIP with a cempressien
screw. Prereimal pele fractures are treated using DRIP
with cempressien screw fixatien in all cases because ef
the high rate ef esteenecresis and nenunien fer these
fracture patterns. Other surgical indicatiens include 15"
humpback defermity, cemminuted fractures, and dis-
placement greater than 1 mm. In general, surgical fixa-
tien decreases the time te unien, thus allewing a quicker
return re spert. Athletes are net allewed re return re
firthepaedic Knewledge Update: Sperra Mediehte 5
unpretected play until evidence ef radiegraphic unien is
eenfirrned. Healing is assessed by tenderness en clinical
examinatien and using radiegraphs and CT scans. CT
is the mest reliable imaging study fer assessing unien.‘
Arthrescepically assisted reductien and fixatien has been
perfermed in athletes, but substantial fluerescepy is alse
required fer this precedure.m
Heel: ef Hamate Fractures
Heek ef hamate fractures are eften a seurce ef chrenic
ulnar-side hand pain in baseball players, heckey players,
gelfers, and these whe play racquet sperts. Patients pres-
ent with vague ulnar-side pain in the palm. Tenderness
is elicited ever the hamate, and ulnar nerve symptems
may be present. The fracture can alse cause Heater tenden
irritatien er rupture. Standard hand radiegraphs usually
will net reveal the fracture, se a carpal tunnel view is
necessary. Because diaguesis is difficult, a CT scan sheuld
he ebtained if a fracture is suspected.
Acute injuries can be treated with IS weeks in a shert
arm cast; hewever, the risk ef nenunien is high. Surgical
excisien ef the fragment is the mest reliable eptien fer a
pain—free eutceme in athletes. DRIP has been described,
but hardware preminence is a cemmen cemplicatien. Af-
ter fragment excisien, range ef metien and strengthening
can begin immediately. Baseball players are eften able
re return re play by ti weeks after surgery. [In return re
sperrs, a gleve with a denut-shaped pad can he wern fer
prerectien until the scar is ne lenger tender.11
Differential Diagnesis ef Wrist Pain in the Athlete
Radial Wrist Pain
lntersectien Syndreme
Intersectien syndreme is acute bursitis at the intersectien
ef the first and secend extenser cempartment tendens in
the ferearm. This injury is mest cemmenly seen in rewers
and gelfers. It presents with tenderness 5 cm prettimal
re the radial styleid, and must he differentiated frem de
Quervain tenesynevitis, which is mere distal. A charac—
teristic crepirus is lecared at the site ef intersectien. Treat-
ment censists ef splinting in a thumb spica hrace, activity
medificatien, HSAIDs, and semetimes, stereid injectiens.
Surgery is rarely indicated, and is reserved fer these in
whem nensurgical treatment has been unsuccessful fer
at least 3 menths. Surgery includes hursal débridement
and secend estenser cempartment release.
de Quervain Tenesynevitis
de Quervain tenesynevitis is an everuse syndrerne that
invelves inflammatien ef the tenesynevium ef the first
extenser cempartment tendens and is seen in racquet
fl lfllfi American Academy ef Urrhepaedic Surge-ens

sport athletes and golfers. Symptoms include dorsoradial
wrist pain and swelling, with crepitus over the tendons
detected with thumb circumduction. Individuals with de
Quervain tenosynovitis will have tenderness over the first
dorsal compartment and a positive Finldestein test result.
Pain is also elicited with resisted thumb MCP extension.
Treatment is similar to intersection syndrome, but with
a lower threshold level for surgical intervention. At the
time of surgical release of the first dorsal compartment,
careful inspection for a separate subsheath that contains
the extensor pollicis brevis tendon is needed.” In 2011,
a novel four—point steroid injection teclmique for recal—
citrant cases in high-resistance athletes was described
that yielded better outcomes than the standard two-point
injection technique.m
Volar Wrist Ganglions
Volar wrist ganglions can cause pain on the radial aspect
of the wrist, usually emanating fmm the joint via a tear
in the radioscaphocapitatc ligament. Pain is caused by
compression of the surrounding structures. If the cyst
is appreciable on physical examination, it will transillu-
minate. Usually, no correlation is found with underlying
pathology, although other diagnoses, such as a radial
artery aneurysm, should be excluded before undertaking
surgical excision. The cyst should be excised if painful,
although Zfl‘l’h recur. A volar cyst [versus a dorsal cyst}
should not be aspirated or injected with steroid because
of the proximity of the radial artery and potential for
injury to this structure.”
Flexor Carpi Hadialis Tenclinitis
Athletes engaging in forceful, repetitive wrist flexion can
develop inflammation of the wrist flexors, especially the
flexor carpi radialis. Symptoms include volar radial and]
or ulnar wrist and forearm pain, and are elicited with
resisted wrist flexion and radial or ulnar deviation. Lo—
caliaed tenderness is present over the involved tendon.
Splinting and steroid injections into the tendon sheath are
the first line of treatment. Surgical release of the flexor
carpi radialis sheath has good results in 313% of cases.”l
Dorsal Wrist Pain
Dorsal Wrist Ga nglions
Approximately ?fl% of dorsal wrist ganglions emanate
from the scapholunate wrist ligament. Pain associated
with a dorsal wrist ganglion should increase concern for
a scapholunate ligament injury. Ganglions not associat—
ed with pain may be observed. They can be aspirated if
painful, but have recurrence rates of 20% to 50%. Steroid
injection of the cyst has no benefit. Surgical excision is
usually successful at relieving symptoms, although up to
IE! Efllfi American Academy of flrthopaedic Surgeons
Chapter 9: Hand and Wrist Injuries
20% of ganglious recur. Arthroscopic excision allows
direct visualization of the scapholunate ligament as well
as the remainder of the wrist joint, and debridement of
the capsular stalk at the base of the cyst. Arthroscopic
excision has a slightly lower recurrence rate than open
cxcisiond-u"
Scapholunate Ligament Injuries
Scapholunate ligament injuries also cause dorsal wrist
pain. As with scaphoid fractures, scapholunate ligament
injuries are often missed on initial presentation and are
challenging for the orthopaedic hand surgeon to treat if
they present in a delayed fashion. Examination will reveal
tenderness at the scapholun ate interval, as well as a posi-
tive scaphoid shift test result. 1Fl'lfrist radiographs should be I:
11
't:m
obtained and include a clenched list view to evaluate for 1
widening between the scaphoid and lunate. More than 3 s:
m
H
mm of widening {the Terry Thomas sign] suggests a liga- m
H
ment tear. On the lateral view, an increased scapholunate E.
a?
angle may be appreciated {greater than 90“]. Dynamic
widening of the interval is appreciated when the widening
only occurs with the clenched list view {Figure 7"}. Static
widening can be seen on all views, is usually associated
with a chronic injury, and will result in arthritis over
time. MRI can be helpful in the diagnosis, although it
only has ?fl% to 31% accuracy.” Arthroscopy is the gold
standard in diagnosis“ {Figure 3}. Acute tears should
undergo surgical treatment acutely when possible, with
open reduction of the scaphoid and lunate with dorsal
wrist capsulodesis or ligament repair and percutaneous
pin fixation. Numerous reconstruction techniques have
been described for static chronic injuries more than 6
weeks post-injury. More recent data have shown better
radiographic outcomes with ligament reconstruction over
wrist capsulodesis for chronic injuries'”
Ulnar Wrist Pain
Extensor Earpi Ulnaris Tenclinitis
Exten sor carpi ulnaris {ECU} tendinitis is seen in racquet
sport athletes and baseball players. The sixth extensor
compartment is a unique fibro-osseous compartment that
holds the ECU tendon tight against the ulnar groove.
As the forearm is supinated, the sheath prevents ulnar
translation of the tendon. Tenderness is elicited directly
over the ECU tendon on examination. Radiographs are
obtained to rule out fractures of the ulnar styloid and
other bony pathologies. MRI sometimes shows splits
in the tendon or increased signal intensity in the tendon
on T2-weighted images. Nonsurgical management is
preferred using HSAIDs, splints, and restricted activity.
Steroid injections can help relieve pain. If nonsurgical
management fails, the ECU tendon can be débrided. The
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 1: Upper Extremity
1: Upper Estrem ity
A
Figure 3’ FA radiographs demonstrate dynamic widening
of the scapholunate interval. A, Clpen fist view
shows normal space between the scaphoid and
lunate. B. Clenched fist view shows less than 3
mm of wicl ening. corresponding to a complete
scapholunate ligament tear. {Reproduced from
Eurrus MT, Dacus AH: Carpal instability, in [layer
MI, ed: AACIE Comprehensive flrthopaeci'ic
Review, ed 2. Hosemo nt, IL, American Academy
of Clrthopaedil: Surgeons. 21114. pp toss-toss.)
retinaculum of the sixth esctensor compartment must be
repaired carefully to prevent instability.
E-CU Tendon Sublustation
ECU tendon sublurcation is most commonly seen in tennis
players, usually resulting from a hypersupination andfor
ulnar deviation injury. Du examination, the ECU ten-
don painfully snaps out of the groove with supination
and ulnar deviation. The displaced tendon is palpable.
Acute treatment is with a long arm cast in pronation
and slight radial deviation. Chronic instability requires
compartment reconstruction performed with direct repair
supplemented using a radial-based sling of retinaculum
or a free graft from the retinaculum. The ulnar groove
can also he deepened to further stabilise the tendon. This
is strongly {almost Sfl‘iis} associated with triangular fi-
brocartilage complex [TFCQ tears.“ Wrist arthroscopy
should be considered at the time of surgery if a TFEC
teat is suspected.
Ulnar Tunnel Syndrome
Ulnar tunnel syndrome consists of entrapment of the
ulnar nerve in the Guyon canal at the wrist. Also known
as handlebar palsy in cyclists, it can be associated with
carpal tunnel syndrome. Depending on the location of
the compression, patients can have motor or sensory
C'Irthopaedic Knowledge Update: Sports Medicine 5
Figure B Arthroscopic view of the rnidcarpal space-
The probe in the scapholunate interval
demonstrates scapholunate ligament tearing.
{Reproduced from Burrus MT, Dacus AR:
Carpal instability, in Boyer l'vll, ed: M05
Comprehensive Drthopaedic Reviews ed
2. Rose mont, IL, American Academy of
Orthopaedic Surgeons, 211114, pp 1D55-1DE-4J
symptoms or both. Paresthesias are noted in the ring
and little fingers, and the intrinsic muscles are often weak.
This condition is often caused by a mass lesion such as
an ulnar artery thrombosis or aneurysm, book of hamate
fracture, ganglion {most common] or lipnma, inflamma-
tory arthritis, bone anomalies, or continuous pressure.31
Nerve conduction velocity studies and electromyogtaphy
can support the diagnosis, and MRI can be helpful if a
mass lesion is suspected. Nonsurgical therapy includes
wrist splints and avoidance of aggravating activities. Sut-
gery involves nerve decompression and removal of any
masses or lesions. If the patient has concomitant carpal
tunnel syndrome, release of the carpal tunnel is sufficient
for release of the ulnar tunnel as well.
Ulnar Artery Thrombosis
Ulnar artery thrombosis, also known as hypothenar ham-
mer syndrome, can occur in baseball catchers because
of repetitive impact to the ulnar artery while catching.
Symptoms include pain, cramping, and sensory distur—
bance. The Allen test should be performed if diagnosis
is suspected, with delayed reperfusion appreciated while
occluding the radial artery. Ulnar artery reconstruction
with interposition vein grafting is required.33
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 9: Hand and 1|i'lfrist Injuries

TFEC Injury Summary

The TFCC is the primary stabilizer bf the distal radibul-
nar jbint and is cbmpbsed bf a central disk and peripheral
disk—carpal ligaments that are mbre vblarly based. TFCC
tears can be degenerative br acute.
Injury tb the TFCC causes pain br perceived instability
that can prevent athletic participatibn. Peripheral injury
has the best likelihbbd bf healing because this pbrtibn
has the best blbbd supply. Tenderness bvcr the fbvea bf
the ulna {a pbsitive fbvea sign} is evident bn examinatibn.
Radibgraphs are bbtained tb assess ulnar variance and
rule but ulnar stylbid fractures. MRI helps determine a
diagnbsis, althbugh studies have shbwn magnetic resb-
nance arthrbgraphy tb be mbre helpful.“ Wrist arthrbs—
cbpy cbnlirms the diagnbsis {Figure 9}. Classificatibn is
based en the lbcatibn bf the tear and chrbnicity. Type 1
Hand and wrist injuries bf the athlete prbvide a substan-
tial challenge tb the treating physician because bf the sheer
number and diversity bf injuries seen in this patient pep-
ulatibn. Furthermbrc, many injuries are initially missed,
presenting the challenge bf treating a chrbnic injury in
an athlete. The cbmplexity bf the hand and wrist can
make diagnbsis difficult; thus, it is imperative tb have a
deep understanding bf all types bf injuries that can bccur
in the hand and wrist. With the apprbpriate knbwledge
base, brthbpacdic hand surgebns can usually cbnlirm the
diagnbsis bf athletic injuries bf the hand and wrist and
prbvide the apprbpriatc therapy tb allbw the athlete tb
return tb his br her spbrt as quickly and safely as pbssible. I:
'bi
'bm
1

tears are traumatic {Table 1]; type 2 tears are degenera— s:

”'1
H

tive. Treatment cbnsists bf rest, splinting, NSAIDs, and m

H

sterbid injectibns versus arthrbscbpic surgical debride- E.

a?
ment br repair.
Ulnar-side peripheral tears shbuld be repaired; central
and radial tears can truly be debridedfij Ulnar tears that
are repaired within 3 mbnths regain Edit: bf mbtibn and
strength.35 The surgebn shbuld be aware that a knbt tied
in the fiber bf the EEU sheath can cause ECU tendinitis.
If a central tear is débrided, a 2-mm peripheral rim bf the
TFCC shbuld be preserved after debridement tb maintain
a stable jbint. Partial-thickness tears bf the ulnar fuvea
db well with repair and patients whb play racquet spbrts
are bfteu able tb return tb spbrt. Hewever, athletes whn
bear weight thrbugh the wrist have less favbrable return-
tb-spbrt butcbmes.“ If ulnar variance bf mbrc than 2 mm
exists, resulting in symptomatic ulnbcarpal abutment, an
ulnar shbrtcning prbcedure shbuld alsb be pcrfbrmed.
Excellent results have been achieved with ulnar shbrtening
bstebtbmy because this stabilizes the distal radibulnar Figure 9 Arthrbscbbit view bf the triangular
fibrbcartilage cbm pleat (TFCE) seen frbm the
jbint, reduces the effect bf ulnbcarpal abutment, and de— radial side bf the wrist. The TFCE is detached
creases fbrces bn the TFCC.” from the radius.

Table ‘1

Palmer Classificatibn bf Class 1 (Acute) Triangular Fibrbcartilage Cbmplerc Tears

Type Lbcatibn Characteristics
1A Ce ntral Traumatic tears bf articular dislt
IB Ulnar Ulnar avulsibn
1C Ublar distal Distal traumatic disruptibn bf the ulnblunate br ulnbtricjuetral ligaments
1D Radial Traumatic avulsibn frbm sigmbid nbtch bf radius
{Heprbduted frbm t‘ibldfarb CA: Wrist erfllrbscbpy, in Buyer Ml, ed: AAflS Cbmprehensive flflbbpaedic Review, ed 2. Basement, IL, American
Academy bf Orthbbaedlc Surgeuns, IDH, pp net-tree.)

IE! lfllfi American Academy bf Urchbpaedic Surgebns Drthbpaedic Knuwledge Update: Sperrs lvledichie .‘i
 Sectien 1: Upper Extremity
Hey Study Feints
I Metacarpal and phalangea] fractures are at risk ef
defermity and functienal less if net treated appre-
priately. The handffingers are at high risk ef stiffness
if immehiliaed fer extended perieds ef time.
Directien ef finger PIP ieint dislecatien is important
in guiding treatment.
l Acute pain in the snuffbesr regien in an athlete
sheuld he treated aggressively with immehiliaatien
fer 3 weeks and then reassessment te rule eut a
scapheid fracture. Uccult scapheid fractures may
net be visible en radiegraphs until 3 weeks pastin-
iury. Per early evaluatien and diagnesis, an MRI
1: Upper Extremity
is beneficial in the diagnesis ef an eccult scapheid
fracture if return te play is critical fer a high-level
athlete. Untreated scapheid fractures can have dire
censequences te the patient.
I Advancements in wrist arthrescepy have lewered
the recurrence rates ef dersal wrist gangliens.
l Ulnar-side peripheral tears ef the TPCC sheuld be
rcpaired as eppesed te debrided.
Annetatecl References
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Grrlhep Cfirr- Hersh Arr: 19?fl;1[2}:261-2?4. Medline
. van Aalren J, Kampfen 5, Eerli l'vl, Fritschy D, Della Santa
D, Fusetti C: Clutceme ef bexer’s fractures treated by a
seft wrap and buddy taping: A prespective study. Heard
as v; 200?:2i41:212—11?.Medline net
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carpal fractures: lvlechanisms, lecatiens, and radiegraphic
para meters. 1 Hand Sari-g Am. ae1e;ss{s}:1ass-1ass.
Medline DUI
The anthers reviewed Ifll ring and little finger metacarpal
fractures and reperted that punching iniuries usually cause
a neck fracture ef the little finger versus a shaft fracture ef
the ring finger. The isthmus ef the ring finger is narrewet.
Level ef evidence: IV.
. Reth J], Auerbach DM: Fixatien ef hand fractures with
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Medline DD]
. Hardy MA: Principles ef metacarpal and phalangeal
fracture management: A review ef rehabilitatien cen-
cepts. I Drrhep Sparta Phys Ther 2Ufl4;34{12}:?31—T99.
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firthnpaedic Knewledge Update: Sperts Medicine 5
E. Eirre M, Shin AT: Treatment ef acute scapheid fractures
in the athlete. Carr Sperts Med Rep lfl‘flfiriffi l:242-243.
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Kedama N, Tal-temura T, Ueba H, Imai 5, Matsusne
Y: Dperative treatment ef metacarpal and phalangeal
fractures in athletes: Early returu te play. I Drrfrep Sci
2014:19i51fl29-T36.Medline Ill-DI
0f lfll metacarpal er phala ngeal shaft fractures, 2G were
treated with DRIP se athletes ceuld return fer impert-
ant event. All 2i] returned by 1 menth and eventually
achieved unien with excellent range ef metien. Lewl ef
evidence: III.
Arera FL, Angermann P, Fritz I}, I-Iennerhichler A, Gabi
M, Lute M: [Derselateral dislecatien ef the preximal in-
terphalangeal ieint: Elesed reductien and early active me-
tien versus static splintingl.[Article in German] Haedcfrrr
Mikreclar'r Plasr Elvin: 2f! fl?;39{3}:215-223. Medline DUI
Elfar J, Mann T: Fracture-dislecatiens ef the presti-
mal interphalangeal jeint. ] Aer Acird Drtbep Srrrg
1fl13:21[2}:33—93.Medline net
The authers reviewed dersal, velar, and pilen PIP
fracture-dislecatiens in this review article. Acceptable
eutcemes were achieving a well-aligned jeint and reestab-
lishing metien. Anatemic articular cengruity is preferable
but net abselutely necessary fer geed eutcemes.
If]. Pagenis T, Ditsies K, Teli P, Givissis P, Christedeuleu A:
Impreved certicestereid treatment ef recalcitrant de Quer-
vain tenesynevitis with a nevel I'-lr-peint injectiee technique.
Aer }' Sperrs Med 2011,39{2]:393-4fl3. Medliue DID]
The authers cempared twe similar grenps ef 14 athletes
treated with ene- te twe-peint injectien technique ver-
see their new feur-peint technique. Symptem relief was
better in the fenr-peint greup at 1 and 51 weeks. Level
ef evidence: II.
11. Williams RM, Kiefhaber TR, Semmerltamp TG, Stern
PJ: Treatment ef unstable dersal preeimal interphalan-
geal fracturefdislecatiens using a hemi-hamate autegraft.
1 Head Serg Arrr lflfl3;13{5]:355-365. Medline DUI
12. Nilssen JA, Eesberg HE: Treatment ef preJtiInal iri-
terphalangeal jeint fractures by the pins and rubbers
tractien system: A fellew—up. j Pleat Sarg Hand Snug
2014:43l4}:259-264.Medline DUI
Petty-twe patients with cemplea: PIP jeint fractures were
treated with a pins-and-rnbber band system. The device
was easy te apply and well telerated. Vela: lip fractures
had the best eutceme. flsteearthritis and less ef metien
are still cemmen. Level ef evidence: III.
13. Kiral A, Erlcen HY, Altmaa I, ‘r'ildirim C, Erler K: Pins
and rubber band tractien fer treatment ef cemmiriuted
intra—articular fractures in the hand. I Hand Surg Aer
2fll4;39[4}:69fi~?fl5.Medliue DUI
This retrespective review ef 33 patients treated with
pins-and—rubber band system at the PIP, DIP, thumb
fl lfllfi American Academy ef Orthepaedic Surge-ens

interphalangeal, and thumb MCP jeints reperted satis-
factnry results. Level nf evidence: IV.
14. Heyrnan P: Injuries tn the ulnar cnllateral ligament nf the
thumb metacarpnphalangeal jnint. I An: Aced Urthnp
Snrg manganese-see. Medline
1.5. Werner BC, I-Iadeed MM, Lyens ML, lILIrluck 15, Didnch
DR, Chhabra AB: Return tn feetbaIl and leng-term clin-
ical eutcemes after thumb ulnar ceIlateral ligament su-
tnre anchnt repair in cnllegiate athletes. I Hand Snrg Ans
lfl14:39[1i}}:1992-1993.I'vIetlline DUI
The anthers reperted en a twe-suture anchnr technique ef
ulnar cellateral ligament repair perfermed en 13 cellegiate
fnnthall players. All returned tn at least their eriginal level
ef play. Skilled players returned in 7' weeks, nnnskilled
returned in 4 weeks. Level ef evidence: IV.
IE. Altan E, AIp NB, Baser R, Yalctn L: Seft-tissue mallet
injuries: A cemparisen ef early and delayed treatment.
mane Snrg An: 2014;39i1fl]:1932-1935. means: DUI
1?. Gruber J5, Bet AG, Ring D: A prespective tandem-
ized cnntrnlled trial cemparing night splinting with nn
splinting after treatment nf mallet finger. Hand {N Y}
1fl14;9{2}:145-15i}.Medline DUI
In this study, 51 patients were enrelled in a prespective
trial tn either receive night splinting after 6 tn 3 weeks nf
cnntinuens splinting fer mallet fingers er ne splinting. Ne
difference in extenser lag was reperted between the twe
grnnps at final eutcnme. Level ef evidence: II.
13. Lin JD, Strauch R]: Clesed seft tissue extenser mechanism
injuries (mallet, beutenniere, and sagittal band}. I Hand
Snrg Arn 2fl14;39{5}:1fl05-1011. Medlitle DUI
The anthers summarise mechanism and treatment nf
clesed seft-tissue injuries in aene I, III, and V extenser
mechanism injuries. Level nf evidence: V.
15'. Freilich AM: Evaluatien and treatment ef jersey finger and
pulley injuries in athletes. Elfin Spnrts Med 2U15;34{1}:I 51—
155. Medline DUI
The anther discussed fleanr tenden injuries and pulley
injuries in the athlete. Level ef evidence: V.
ll}. Geissler WE: Arthrescepic management ef scapheicl
fractures in athletes. Hand Ciin lflflfljlfijdjfiEE-JEQ.
Medline DUI
This article discussed the indicatinns and treatment strat-
egy fer arthrnscnpic management nf scaphnid fractures
and nenuniens in athletes. Level ef evidence: V.
21. Bacheura A, Wreblewski A, Jaceby SM, Usterman
AL, *3q RW: Heels ef hamate fractures in cempet-
itive baseball players. Hand (N I? 2013;3{3}:3i}2—3fi1
Medline DUI
The anthers presented their experience with hnnk ef ha-
mate fractures in baseball players treated surgically. Ulnar
tunnel decnmpressinn with hnnk excisien prnvides gned
IE! lfllfi American Academy ef Urthnpaedic Snrgenns
Chapter 9: Hand and Wrist Injuries
eutcemes. Mean return tn play was 5.? weeks. Level ef
evidence: IV.
12. Stein AH Jr, Ramsey RI—I, Key JA: Stennsing tendnvaginitis
at the radial styleid prncess {DeQuervain's disease}. AMA
Arcfr Snrg 1951;63i2}:215-228. Medline DUI
2.3. Liddet 5, Ranawat V, Ahrens P: Surgical eacisien nf wrist
ganglia,-I literature review and nine-year retrespective study
ef recurrence and patient satisfactien. Urinep Rev {Fania}
2i] flflglflltefi. Medline DUI
The anthers fnllnwed up 1'1?r patients whn underwent velar
er dersal wrist ganglia excisien. An everall recurrence
ef 41.3% was reperted; it was cencluded that surgery
may have better results with a hand specialist. Level ef
evidence: IV.
24. Sauvé P5, Rhee PC, Shin AT, Lindau T: Eaaminatien I:
'e
ef the wrist: Radial-sided wrist pain. I Hand Snrg Arr: 'e:m
2fl14;39{19j:2fl39-1D92.Mcine DUI
1
a:
m
H
The anthers previded a thereugh review ef causes uf m
H
radial-side wrist pain. Level nf evidence: V. E.
a?
15. Fernandes EH, Miranda CD, Des Santns JE, Falnppa F:
A systematic review nf cnmplicatinns and recurrence rate
ef arthrescepic resectinn nf velar wrist ganglien. Hand
Snrg 2014;19i3}:4?5-43i]. Medline DUI
Uf 232 wrists treated with arthrescepic velar wrist gan-
glinn eacisien, 14 had recurrence. Recurrence rates in the
papers reviewed ranged frem fl tn 20%. The prncedure
was reperted as technically difficult, and had higher rates
nf assnciated cnmplieatiens than epen excisinn. Level ef
evidence: III.
16. Kang L, Akelman E, Weiss AP: Arth rescnpic versus npen
dntsal ganglien excisinn: A prnspective, randnmised enm-
parisen ef rates ef recurrence and ef residual pain. I Hand
Snrg Arn 2003:33i4]:4?1-4?§. Medline DUI
2?. Spaans A], I'innen Pv, Prins I-I], Kerteweg MA, Schuur—
man AH: The value nf 3.fl-tesla MRI in diagnesing
scapheIunate ligament injury. I Wrist Snrg 3fl13;2[1}:69-
T2. Medline DUI
The anthers reviewed the sensitivity and specificity ef
3.0-T MRI in the diagnnsis nf TFCE‘ tears by cemparing
the imaging findings with arth rescnpic findings. Level nf
evidence: II.
23. Schadel-Htipfner M, Iwinska-Zelder J, Braus T, Behringer
G, Klese K], Getaen L: I'vIRI versus arthrescepy in the
diagnesis ef scapheIunate ligament injury. ,I Hand Snrg
Hr lflfliflfilIHT-ZI. Mcdlinc DUI
29. Pappen IP, Easel J, Deal DH: Scaphnlunate ligament
injuries: A review ef current cnncepts. Hand {N ‘1’}
2fl13;3{2}:146-156.Medline DUI
The anthers reviewed classificatien ef and treatment ep-
tiens fer scapheIunate injuries, fecusing en stages in which
tecnnstrnctinn prncedures may wnrk as eppnsed tn salvage
precedures. Level ef evidence: V.
Urthnpaedic Knnwledge Update: Sperts Medicbie 5
 Sectiun 1: Upper Extremity
30. Ruhman EM, Agel J, Putnam MD, Adams JE: Scaphulu-
nate interusseuus ligament iniuries: A retruspeetive review
uf treatment and uutcumes in 32 wrists. I Hand SurgAm
2fl14;39{1fl]:102D-2026.Medliue DUI
The authurs reviewed 1? acute and SD chrunic scaphulu—
nate tears treated surgically. Chrcnic injuries had better
radiugraphic uutcumes with ligament recuustructiun cum-
pared with capsuludesis. Acute repair within 6 weeks was
preferred. Level uf evidence: III.
31. MacLenuan A], Hemechelt NM, Waitayawiuyu T, Trum—
hle TE: Diagncsis and anatumic recunstructiun uf extensur
carpi ulnaris suhlui-tatiun. ] Hand SurgAm lflfl3;33{1}:59-
64. Medline DUI
31. Jayakurnar P, jayaram V, Hairn D5: Cumpressive neurup-
athies related te gangliuns cf the wrist and hand. Hand
t
Strrg 2fl14;19{1]:113-116. Medlirte DUI
1: Upper Etttrem
The anthers discussed the pathuanatc-my uf wrist and
hand gangliuns that cause cumpressive neurupathies. Mu-
tur andl'ur sensury deficits can be encuuntered and cur-
relate tn the lueatiun cf the gangliun. Level cf evidence: V.
33. Dreiain D, Juse J: I-Iyputhenar hammer syndrume. Am
I Urtbup {Belle Mead NI} 2012;41{3}:33fl-332. Medline
Hyputhenar hammer syndreme was discussed in this
study, including the impurtance uf early diagnusis and
imaging studies. Definitive evaluatiun was made with cath—
etervdirected angiugraphy. Management uptiuns were alsu
discussed. Level uf evidence: V.
34. Berna-Berna JD, Martinez F, Reus M, Alunsu J, Duménech
G, |ICIampcus M: Evaluatiun uf the triangular fihrucartilage
Urthupaedic Knuwledge Update: Spurts Medicine 5
in cadaveric wrists by means uf arthrugraphy, magnetic
resunance {MR} imaging, and MR arthrugraphy. Acre
Radial lDflfi-‘lflfllflfi -1 [13. Medline DUI
The authurs examined the value uf arthrugraphy, MRI,
and magnetic resuuauce arthrugraphy in diagnusing
TFCE tears, and their ability tu identify the lueatiun cf
the tear. Level uf evidence: II.
35. Estrella EP, Hung LK, Hu PC, Tse WL: Arthruscupic
repair uf triangular fihrucartilage cumpletlt tears. Artistes-
cupy 10H?:23[?}:?29-?31e1. Medline DUI
The authurs reviewed 26 patients whu underwent repairs
cf partial-thickness TFCC fuvea tea rs. Patients were mere
lilcely tu return tu racquet spurts and less likely tu return
tu spurts that required weight bearing thruugh the hands.
Lewl uf evidence: 1|v’I.
36. Ruch D5, Papaduuiltulaltis A: Arthruscupieally assisted re-
pair ef peripheral triangular fihrceartilage cumplex tears:
Facturs affecting uutcume. Arthruscupy EDGE;11{9']:112tii-
1131]. Medline DUI
3?. Wysuclci KW, Richard M], Cruwe MM, Leversedge F],
Ruch D5: Arthreseupic treatment uf peripheral triangular
fihrueartilage CUIIIPIEII’. tears with the deep fibers intact.
1 Hand Sat-g Am 2012:3Tl3}:5fl9-515. Medline DUI
33. Cunstantine K], Tumainu MM, Herndun jH, Entere-
anus DIG: Cumparisutt uf ulnar shuttening usteuturuy
and the wafer resectiun prueedure as treatment fur ulnar
impactiun syndrumeJHaud Surg Am lflflflglillifij-fil}.
Medline DUI
U zeta American Academy at Urthupaedic Surge-ans
Hip and Pelvis
Chapter 10
Athletic Hip Injuries
Richard Charles Mather III, MD, MBA Michael S. Ferrell, MD
abstract
Indications for hip arthroscopy are rapidly expanding
and include pathology in the central, peripheral, and
peritrochanteric compartments. The anterolateral and
anterior portals are the primary portals with several
described accessory portals. The most common surgical
complications include iatrogenic chondrolabral injury,
transient neurapra xia, and the inadequate resection of
femnroacetabular impingement. The acetabular labrum
is a critical structure and should be repaired or recon-
structed whenever possible to preserve its function,
especially that of creating negative pressure seal to the
femoral head. Hip microinstability is proving to be a
source of chronic hip pain and disability with several
soft-tissue structures, including the ligamentum teres,
playing key roles in maintaining stability. Appropriate
capsular management, including capsular repair and
plication in indicated cases, is proving to be a key step
in preserving or establishing hip stability and optimizing
surgical outcomes. Tears of the ligamentum teres are
a source of pain in the hip and require a high index
of suspicion to make the diagnosis. Ddhridement of
partial—thickness ligamentum teres tears has demon—
strated good clinical outcomes. Ligamentum teres re-
construction in instability cases may prove to be a useful
adjunct along with capsular plicatinn in certain setting
but is still unproved at this point.
Dr. Mather or an immediate family member serves as a paid
consuitant to ENG Heaith Consuiting, Pivot Medicai, Smith
.5 Nephevn and Stryirec has stock or stocir options held in
forfMDL' and serves as a board member; owner. officer; or
committee member of the Arthroscopy Association of North
America, the American Academy of Orthopaedic Surgeons,
and the North Caroiina Urthopaedic Association. Neither
Dr. Ferreii nor any immediate famiiy member has received
anything of value from or has stuck or stock options held
in a commerciai company or institution reiated directiy or
indirectiy to the subject of this chapter.
fl lflld American Academy of Drthopaedic Surgeons
Keywords: hip arthroscopy; Iahral tears:
ligamentum teres: hip instability
Introduction
Hip arthroscopy has been one of the most rapidly devel-
oping fields in orthopaedic surgery over the past decade.1
As improved equipment and evolving techniques have
made the procedure safer and relatively easier to perform,
indications have continued to expand. Furthermore, as
the understanding and appreciation of femoroacetahular
impingement {FAD—the most common indication for hip
arthroscopy—have evolved, the diagnosis has become
better recognized and surgical outcomes have improved.1
The current indications for hip arthroscopy address
pathology in the central, peripheral, and peritrochanter-
ic compartments of the hip joint. Central compartment
pathology includes labral tears, loose bodies, ligamentum Pr'
teres {LT} tears, chondral defects, and pincer lesions as— 3.
'U
sociated with FAI. Peripheral compartment pathology to
3
EL
includes cam lesions associated with FA], capsular laxity '13
1
associated with hip instability, loose bodies, and recalci- ul-
El-
trant internal snapping hip secondary to chronic iliopsoas
bursitis. Peritrochanteric compartment pathology includes
recalcitrant trochanteric bursitis, tears of the gluteus me-
dius and minimus, and painful external snapping hip.
Successful surgical outcomes in these compartments have
expanded the application of endoscopic techniques to
other conditions, including proximal hamstring repairs
and sciatic nerve decompression in the deep gluteal space.
The portals for hip arthroscopy have evolved to im-
prove access and safety {Figure 1}. In general, the central
and peripheral compartments can be accessed through
two or three portals. The anterolateral portal is typically
the first portal established, using anatomic landmarks
and fluoroscopy to determine the appropriate trajectory
with which to enter the joint. Typically, this portal is 2 cm
anterior and 2 cm distal to the greater trochanter and has
the objective of entering the joint parallel to the sourcil
without violating the labrum. The anterior portal typi-
cally is made next, using a spinal needle for localization
via an inside-out technique through the anterior triangle,
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 2: Hip and Pub-Pia
V __
asis
use ‘3 AP Q Iatrogenic chondrolahral injury
® @PMAF-
onus
fl esp ®AL ® PAL“
@PL
# flsteonecrosis
Illustration shows the positions of the portals
for hip arth roscopy. The anterolateral portal
{at} is a mainstay of hip arthroscopy access
and visualization. and most surgeons use
some variation of an anterior portal [AP] for
instrumentation. Several accessory portals
also have been described. DALA = distal
anterolateral accessory portal; MAP = mid-
anterior portal; ASIS = anterior superior iliac
spine; PMAP = proximal midanterior portal:
FA LA = proximal anterolateral accessory
portal: PL = posterolateral portal: P5P -
posterosuperior portal.
as in other joints. The key landmark is a line parallel to
-E
2
the femur extending distal from the anterior superior iliac
to spine {ASIS}. Remaining lateral to this line will minimize
o.
1:
I:
as
the risk to the femoral neurovascular bundle, and the
E- more lateral the portal is, the farther away it is from
I
H the lateral femoral cutaneous nerve. The position of the
anterior portal varies and can be placed farther distal
and lateral to facilitate anchor placement, particularly
for two-portal approaches.
Additional portals include the distal anterolateral por-
tal, which is typically 4 to 5 cm distal to the anterolateral
portal. This portal provides a safe trajectory for anchor
placement in the acetabulum and provides easy access
for cam resection in PAL The Dienst portal is placed
a few centimeters proximal to the anterolateral portal
and offers a different trajectory into the central and pe-
ripheral compartments. The trochanteric space can be
accessed via the same anterolateral portal as well as via
a posterolateral portal, which is 2 cm posterior and 2 cm
distal to the greater trochanter. A third portal distal to
the vastus ridge insertion of the vastus lateralis provides
a good viewing angle for gluteus medius and minimus
repairs while working through the anterolateral and pos-
terolateral portals.
Hip arthroscopy has a unique set of complications
that differ from those of other joints because of the
firthopaedic Knowledge Update: Sports Medicine 5
—_
Complications Associated
With Hip Arthroscopy
hleurapraxia
FAI underresection
Sequela of FAI overresection, including iatrogenic
instability and femoral neck fracture
Heterotopic ossification
Deep vein thrombosis
Pulmonary embolism
Abdominal compartment syndrome
FAl - femoroacetahular lmpl ngement.
steep learning curve associated with the procedure, the
techniques required to access the deep, highly congru—
ent joint through its thick soft-tissue envelope, and the
longer surgical times [Table 1}. Iatrogenic chondrolabral
injury can occur while the surgeon is gaining access to
the central compartment; it was the most reported com-
plication in one systematic review.3 Another common
but transient complication following hip arthroscopy is
neurapraxialan with incidence approaching 5fl% in one
series.‘1 The lateral femoral cutaneous nerve iLFCN} is
most commonly involved. It is unclear whether LFCN
neurapraxia is related to direct injury from portal place-
ment, traction from the portals and cannulas, swelling
associated with arthroscopy, or a combination of causes,
but LFCH neurapraxia is now considered by many hip
arthroscopists to be a sequela of hip arthroscopy rather
than a complication. Permanent injury is less than 5%,
however. Pudendal neurapraxia also can occur, even with
short traction times, especially in stiff, prearthritic hips.
Traction injuries related to the post, which are substantial
but avoidable, also include skin and soft-tissue necrosis.
Inadequate resection in FAI surgery, more commonly
on the femoral side, is the most common reason for revi-
sion hip preservation surgery? Fluoroscopy, hip rotation,
and the performance of a T—capsulotomy allow visual-
ixation of the cam lesion in its entirety and minimise the
risk of an inadequate resection. The most common reason
for reoperation following hip arthroscopy is conversion
to a total hip arthroplasty {THAI} Whether conversion
to THA is a complication related to hip arthroscopy or
merely a progression of the natural history of FA] remains
unclear.
Rare but catastrophic hip arthroscopy complications
include femoral neck fracture, abdominal compartment
fl lflld American Academy of Orthopaedic Surgeons

A
Figure 2 A. Arthroscopic view shows an acetabular labral tear. which is a common finding at arth roscopy and typically
occurs anteriorly andror ante rolaterally. E, Arthroscopic view shows aceta hular labral repair. which is essential to
restore the multiple functions of the lab rum. {Courtesy of F. Winston Gwath mey, MD, Charlottesville. VA.)
syndrome, iatrogenic instability including hip dislo—
cation, thromboembolic disease, and fatal pulmonary
embolism?”
Acetobular Labral Tears
Acetabular labral tears have been shown to be a substan-
tial source of pain and disability and comprise the most
common pathologic finding at the time of hip arthros—
copy11 [Figure 2}. The acetabular labrum is a triangular
fibrocartilaginous ring, which is attached firmly to the
acetabular rim and encompasses nearly the entire ace-
tabulum, except for the most inferior aspect, which is
bridged by the transverse acetabular ligament. The 1a-
brum deepens the acetabulum, increases coverage of the
femoral head, and plays a role in shock absorption, joint
lubrication, and pressure distribution. Its most critical role
may be the creation of a negative pressure seal with the
femoral head, which aids in joint stability. Removal of the
labrum has been shown to lead to a shift in the femoral
contact point toward the acetabular rim, a decrease in
intra-articular fluid pressurization, and a loss of lateral
restraint to femoral head motion. It also has been shown
to increase contact stresses between the articular cartilage
of the femoral head and the acetabulum by 92%.”"4
The labrum is injured most often in FAI and acetabular
dysplasia. Hip trauma leading to a labral tear generally
involves a high-energy contact mechanism, which results
in a frank dislocation or subluication. Traumatic hip in—
stability is frequently associated with chondral lesions to
IE! Efllfi American Academy of flrthopaedic Surgeons
Ehapter til: Athletic Hip Injuries
the femoral head and acetabulum analogous to those seen
in a shoulder dislocation. Sports that require a great deal
of hip torsion can lead to capsule attenuation and laxity
secondary to repetitive microtrauma. Attenuation of the
capsule leads to mieroinstability of the joint, in which
the femoral head suhluicates anteriorly and rides on the H
anterior superior labrum.” Microinstability can also oc- E
'U
cur outside of sports in patients with collagen disorders to
3
EL
such as Ehlers—Danlos syndrome, Marfan syndrome, and '13
1
Down syndrome. Degenerative labral tea rs are analogous ul-
El-
to degenerative meniscus tears in the knee and are fre-
quently associated with diffuse articular changes in an
arthritic joint. Degenerative labral tears are thought to
be extremely common in the aging hip and likely occur
early in the arthritic process.
Iliopsoas impingement on the anterior hip joint recently
has been suggested as an additional mechanism for labral
tears. The authors of a 2011 study”i described an atypical
labral tear pattern in a series of patients in which the
labral tear occurs on the anterior acetabulum directly
beneath where the iliopsoas tendon crosses the hip joint,
unlike the common location in FA] and dysplasia, which
is more superior on the anterior acetabulum. The pre-
sentation was similar to that of FAI, with groin pain in
flesion, adduction, and internal rotation. These patients
were successfully treated with an iliopsoas lengthening
and a labral débridement or repair.
in the pediatric literature, several case series describe
labral tears in association with avulsions of the rectus
femoris. The reflected head of the rectus femoris is near
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 2: Hip and Pelt-fie
the anterior labrum and inferior to the A515. It is theo-
rized that a traction injury of sufficient energy can tear
the labrum in this location.”
Several labral tear classification systems exist based
on tear morphology, histology, and location. Tear pat-
terns based on morphology have been described.” Stable
tear patterns include radial, fibrillated, and longitudinal
peripheral tear patterns. Radial flap tears occur with an
intra—articular free—edge disruption. Radial fibrillated
tears are degenerative tears with fibrillated free margins.
Longitudinal peripheral tears are stable labral separations
from the acetabular margin. Unstable tears include the
bucket-handle tear. Two types of labral tears based on
histology have been described.” Type I tears occurred at
the junction between the fibrocartilaginous labrum and
the articular hyaline cartilage. Type .1 tears occurred in
various pla ucs within the substance of the labrum. Labral
tear classification based on location is described by the
tear position in relation to the acetabulum. Anterior labral
tears have been prevalent in most of the studies because
of their association with FA].
The diagnosis of a labral tear often can be made clini-
cally. Patients may report mechanical symptoms, such as
clicking and catching, as well as groin pain in positions
of hip flexion. It is not uncommon to feel pain laterally or
posteriorly with anterior labral tears. Pain with prolonged
sitting is another common symptom. Physical examina-
-E
2
tion findings can include pain in the provocative position
tn of flexion, adduction, and internal rotation if the tear is
:1.
1:
I:
rt:
anterior or pain in flexion, abduction, and external rota-
E- tion if the tear is lateral. Table 2 describes the tests used
I
H to detect a labral tear. Imaging includes plain radiographs
and magnetic resonance arthrography. The most valuable
diagnostic sign is a positive response to an intra-a rticular
joint injection that brings complete pain relief, even for
a brief period. This assessment is especially helpful in
patients with atypical referred pain locations to confirm
the joint as the source of pain.
Treatment options for labral tears include debridernent,
repair, and reconstruction, with the goal of restoring or
preserving the function of the native labrum {Figure 3}.
Débridement is reserved for tear patterns that are stable
and in which the function of the labrum will be main-
tained. Repair is appropriate for unstable tear patterns,
in which excision would render the labrum incompetent.
Several studies have shown improved results with repair
versus débridement in groups treated with an open sur-
gical hip dislocation as well as an arthroscopic repair.
A comparison of labral débridement versus repair in
open surgical hip dislocation for FAI showed substantial
improvement in clinical outcomes, with Sfl% excellent
results in the labral repair group versus 23% excellent
firthopaedic Knowledge Update: Sports Medicine 5
—_
Tests for Labral Tears During
the Physical Examination
Anterior tears Flexion, adduction,
internal rotation
{FADIRJ test
Dynamic internal
rotation impingement
test
Lateral tears Flexion, abduction,
external rotation
{FABER} tIE'St
Dynamic external
rotation impingement
test
Hip instability Extension and external
rotation test
External rotation log-roll
test
Liga ITIE'I'TI‘UITI tE'l'E'S tE'EII'S Liga mentum te res test
results in the débridement group.m In addition, radio-
graphic signs of osteoarthritis were significantly more
prevalent in the débridement group at final follow—up.
Furthermore, superior clinical outcomes and patient
satisfaction were seen with arthroscopic labral repair
versus labral débridement, with 6TH: good or excellent
results in the debridetneut group versus 90% in the repair
group.“ Labral repair and débridement were compared
in a randomised controlled trial and significantlyr great-
er improvement in the hip outcome score in the repair
group was found, although both groups demonstrated
improvement from the preoperative states"1 In addition,
Tide of the patients in the repair arm self-rated their hips
as normal versus 23% in the débridcment arm. Labral
reconstruction traditionally has been reserved for revi-
sion cases in which the primary labral repair has failed.
Reconstruction may be considered in young athletes with
an irreparable tear or a hypoplastic labrum that renders
the labrum incompetent, especially in a high-demand
sport that requires cutting and pivoting at high speed or
repetitive rotational maneuvers or for patients at risk of
instability. lGood outcomes and high patient satisfaction
were seen with labral reconstruction using iliotibial band
autograft; better results occurred in younger patients with
no joint space narrowing less than 2 mm.3
fl lfllii American Academy of Orthopaedic Surgeons

Figure 3 arthroscopic views show hamstring allog raft Ia brum reconstruction for iatrogenic instability after hip arth roscopy.
A. Point A shows a normal labrum. Point B shows labral insufficien cy. Point C shows an iatrogenic cartilage injury
of the femoral head. B. Restoration of the suction seal after hamstring allograft labral reconstruction is shown.
Hip Instability
Hip instability has been increasingly recognized as a
pathologic entity and a source of chronic pain and dis-
ability over the past decade, especially in cases of more
subtle atraumatic instability. Unlike these in the shoulder,
the major stabilizers in the hip are the static restraints
and include both nsseous and soft-tissue structures. The
nsseous components consist of the highly constrained fem-
oral head inside the concentric acetabulum. The degree
of acetabular coverage and the femoral and acetabular
version are key determinants of stability. It is in the set-
ting of diminished acetabular coverage and alterations
in normal version that the hip joint increasingly relies on
soft-tissue structures to maintain stability.“
The soft-tissue static restraints include the labru m, the
capsule, and the ligaments. The labrum is a triangular
fibrocartilaginous ring encompassing the acetabulum at
all but its most inferior aspect, which is spanned by the
transverse acetabular ligament. The labrum deepens the
acetabulum, increases the coverage of the femoral head,
and enables the joint to have a negative suction seal,
which increases stabilityflf'“ Three primary ligaments
span the joint and blend with the capsule {Table 3}. The
strongest is the iliofemoral ligament lIFL}, which is an
inverted Y-shaped ligament that originates iust inferior
to the anterior inferior iliac spine and attaches distally
along the femoral intertrochanteric line. The [PL has been
shown to limit hip extension and external rotation.“ The
IE! lfllfi American Academy of flrthopaeclic Surgeons
Chapter 1D: Athletic Hip Injuries
pubofemoral ligament {PFL} is inferior to the IFL, origi-
nates on the pubis, and blends in with the [FL at its medial
attachment, extending along the femoral intertrocha nteric
line. The PFL has been shown to limit external rotation
and abduction. The ischiofemoral ligament {ISL} is locat- l‘t'
ed posteriorly, connecting the posterior acetabulum to a E
15
portion of the posterior femoral neck. The ISL provides Eu
3
EL
some support to the posterior femoral neck. Because of '13
1
their helical orientation, the three ligaments twist when tn
El-
they are taut and are thought to provide a “screw home”
mechanism to the joint when the hip is in extension. The
xona orbicularis is a circumferential structure that forms a
collar around the base of the femoral neck and is thought
to resist hip distraction. The LT appears to play a sec-
ondary role to these soft-tissue restraints, having been
shown to restrict the motion of the femoral hea .1”?
Furthermore, isolated tears of the LT have been found
in hip dysplasia, in which it may play a more prominent
role in stabilisation}E
Hip instability is thought to have traumatic and at-
raumatic origins {Table 4}. Traumatic origins include
highuenergy and low~energy mechanisms. Highuenergy
mechanisms can lead to nsseous disruptions and an un-
stable hip joint, as in a posterior acetabular rim fracture.
The classic example is the motor vehicle accident in which
the knee strikes the dashboard, resulting in a posterior
hip dislocation. High-energy mechanisms also can lead
to disruptions of the soft tissue, such as labral tears and
ligament sprains, resulting in instability in the absence
Drtbopaedic Knowledge Update: Sports Medicbte 5
 Section 2: Hip and Pelvis

-—
Hip Ligaments and Their Motion Restrictions Risk Factors for Hip Instability
lliofemoral ligament Extension and EH Acetahular dysplasia
lschiofemoral ligament Flexion and IR Abnormal femoral and acetabular version
Extension and IR Generalized ligamentous laxity
Pubofemoral ligament Abduction and ER Iatrogenic capsular insufficiency
namentum teres Flexion and ER Sports requiring extreme hip motion
Extension and IR
Ell. = external rotation. IF. = internal rotation.

Figure 4 Images depict assessment of the iliofemoral ligament. A, Coronal magnetic resonance arthrogram demonstrates a
large capsular defect after hip arthroscopy. B. Photograph shows the external rotation log-roll test for iliofemoral
Iiga me nt insufficiency. The examiner externally rotates the leg at the foot. A normal ligament will display spring
back. C, Photograph shows capsular plication of the left leg with an end point in external rotation, whereas the
rig ht leg shows the preoperative iliofemoral ligament instability.
-E
2
to
o.
1:
I:
re
of fracture. Sports with repetitive torsional movements and feelings of instability, especially in hip positions
E- can produce softatissue attenuation due to repetitive mid that rely more on softatissue restraint like hip extension
I
H crotrauma to the capsule and ligaments. A common ex- and external rotation. These patients tend to be highly
ample is the athlete engaged in a sport requiring extreme symptomatic in pain and can have difficulty with tasks as
amounts of hip motion and rotation, such as gymnastics, simple as walking. Secondary iliopsoas tendinitis, result-
ballet, and golf. Atraumatic origins also can be seen in ing from strain on the iliopsoas as it attempts to stabilize
patients with congenital soft-tissue deficiency or laxi- the anterior hip joint, can develop in these patients.
ty, such as the capsular and ligamentous laxity seen in 0n examination, these patients may show global signs
Ehlers-Danlos syndrome, Marfan syndrome, and Down of generalized ligamentous laxity. The log-roll external
syndrome. The atraumatic mechanism most recently de- rotation test may show a capsular laxity, with dimin-
scribed is a seguela of a large cam—based deformity in ished spring back during external rotation {Figure 4}.
PM. In this case, impingement of the cam lesion inside the The results of this test can be compared with those of the
acetabulum in flexion levers the femoral head posteriorly, contralateral hip. These patients also may have pain and
which can cause a posterior contreconp cartilage lesion, apprehension during hip extension and external rotation
with posterior subluxation and instability.” if the primary component of instability is anterior. This
The concept of atraumatic hip instability has led to pain and apprehension can be improved with a posteriorly
the emerging idea of hip microinstability. This type of directed force to the proximal femur in this position of
instability can occur in athletes with mild osseous hip anterior instability with external rotation and extension,
dysplasia superimposed on ligamentous laxity during a maneuver comparable to the Jobe relocation test in the
sports requiring high degrees of hip motion. In the setting shoulder.
of hip dysplasia, the individual is much more reliant on Patients with hip microinstability in whom nonsurgical
soft—tissue structures to stabilise the hip. The athlete with treatment has failed may benefit from a hip arthroscopy
hip microinstability may report mechanical symptoms to address ligamentous and capsular laxity as well as

firthopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons

labral tears. The labrtun can be repaired after addressing
any assnciated rim pathnlngy using a mattress suture,
which will restnre the suctinn seal. Several prncedurcs
have been described tn address the capsule in instability,
including thermal capsulnrrhaphy and capsular plicatien.
Thermal capsulnrrhaphy was described in 95 patients
having a mnnnpnlar radinfrequency prnbe tn reduce cap-
sular redundancy, with resnlutinn nf hip instability in
lflfl% nf his patients at 12 mnnths and imprnvement in
their mndified Harris Hip Scnres.” Tn date, nn repnrts
have been recnrded cf chnndrnlysis secnndary tn ther-
mal capsulnrrhaphy in the hip, as has been described in
the shnulder. Capsular plicatinn alsn has been described
by several authnrs as a methnd tn reduce capsular re—
dundancy. A technique has been described, in which the
medial and lateral limbs cf the [FL were tied tngether tn
reduce capsular laxity.“ Annther technique, in which the
capsule is plicated by including it in a labral repair using
dnuble-inaded suture anchnrs at the acetabular rim, has
been described.31 This secnnd technique is thnught tn
restnre nnrmal anatnmy and apprnpriately tensinn the
capsule with gnnd shnrt-term results.
The evnlutinn cf the cnncept nf capsular laxity as a
snurce nf hip instability has led snme authnrs tn stress the
impnrta nce cf capsular management and the recngnitinn
nf risk factnrs fnr instability in hip arthrnscnpy perfnrmed
tn address nther pathnlngy. This cnncept has been rein-
fnrced by recent case repnrts nf hip dislncatinns fnllnwing
hip arthrnscnpy. The authnrs nf nne study repnrted hip
subluxatinn in a patient with a dysplastic hip 3 mnnths
fnllnwing an arthrnscnpic labral resectinn and capsu—
lntnmy}3 A case nf a traumatic anterinr hip dislncatinn
was repnrted in a pnstnperative patient fnilnwing a fall
dnwn stairs that was successfully treated with a revisinn
capsular repairs“ The authnrs nf annther study repnrted
a hip dislncatinn in the recnvery rnnm in a patient whn
had undergnne an arthrnscnpic capsulntnmy fnr a cam
resectinn and rim trimming; the dislncatinn was success-
fully treated with mini-npen anterinr capsulm-rhaphy.fl
Recently, imprnved nutcnmes have been demnnstrated
in patients undergning hip arthrnscnpy with a cnmplete
capsular repair versus a matched cnhnrt that underwent
a partial repair nnly.35 The cnmplete repair grnup demnn-
Strated superinr spnrt—specific nutcnmes and had a 0%
revisinn rate cnmpared with a 13% arth rnscnpic revisinn
rate in the partial repair grnup. Current recnmmenda—
tinns fnr capsular management invnlve perfnrming an
interpnrtal capsulntnmy between the standard anterinr
and anternlateral pnrtals tn address central cnmpart-
ment Pathnlngy. This prncedure is fnllnwed by adding
a lnngitudinal capsulntnmy tn fnrm a T—capsulntnmy
dnwn the neck nf the femur in the interval between the
IE! H116 American Academy nf flrthnpaeclic Surgenns
Chapter ll]: athletic Hip Injuries
ilincapsularis and the gluteus minimus. This lnngitudinal
cnmpnnent typically is stepped just prnximal tn the snna
nrbicularis tn prntect the lateral femnral circumflex ar-
tery. This expnsure typically allnws ample visualisatinn
nf a cam lesinn. Hip rntatinn prevides visualization frnm
the medial tn lateral synnvial fnlds, which are landmarks
fer the synnvial vessels. Bnth limbs nf the T-capsulntnmy
are repaired at the cnmpletinn cf the case with several
side-tn-side stitches. The capsule can be plicated at this
stage, if indicated, by resecting a pnrtinn nf the capsule
befnre repair nr by taking bigger bites in the side-tn-
side clnsure tn tighten the capsule. In general, three nr
fnur sutures are used nn the lnngitudinal pnrtinn, and
twn nr three sutures are used cm the interpnrtal pnrtinn.
Typically, the patient is placed in a brace fnr 6 weeks
pnstnperatively tn limit extensinn and external rntatinn,
with a perind nf prntected weight bearing as indicated
fnr nther prncedures.
The Ligamenturn Teres
The LT can be a cnmmnn snurce nf hip pain and has been
fnund tn be turn at arthrnscnpy in 8% tn 51% cf ca ses.”38
It is a pyramid-shaped structure, with its brnad base at the
pnsterninferinr acetabular fnssa and its pnint attaching
tn the femnral fnvea capitis. It fnrms snme attachment tn
the transverse acetabular ligament at its base and tran-
sitinns tn a rnund and nvnid attachment tn the femur. It H
has been shnwn tn cnntain free nerve endings with both E
'U
nncinceptive and prnprinceptive innervatinn cnncentrated tn
3
EL
primarily in the center cf the ligament, cnnfirming its rule '13
1
as a pntential pain generatnr in the hip.“ In
El-
The functinn and pathnlngic rnie cf the LT remains
cnntrnversial. Currently, it is thnught tn serve as a sec-
nndary restraint tn hip stability. The first suggestinn that
the LT might play a rule in hip stability surfaced in an
early cadaver study demnnstrating that sectinning the LT
resulted in increasing amnunts nf hip abductinn and ad-
ductinn.“ A string mndel was used tn assess LT excursinn
during hip mntinns and she-wed the greatest excursinn
during hip external rntatinn and flexinn, which nccurs
in squatting, and during internal rntatinn and extensinn,
which nccurs when crnssing nne leg under the nther.“ The
LT mnved intn an anterinr and inferinr pnsitinn arnund
the femnral head during a squat.“fll This was thnught tn
prnvide a sling—like effect, analngnus tn the actinns nf
the cnnje-int tendnn in the cnracnid transfer prncedure
in the shnulder. Further, in a survey nf 161 pnstnperative
patients whn had undergnne a surgical hip dislncatinn,
which includes resectinn cf the LT, it was repnrted that
35% cf patients described pnpping and lncking, and 24%
experienced feelings nf instability!”1 The LT may play a
Drthnpaedic Knnwledge Update: Spnrrs Medicine 5
 Section .3: Hip and Pelt-fie
more important role in stability in dysplastic patients
lacking acetabular coverage. These patients may be more
reliant on primary soft—tissue restraints such as the la—
brum, capsule, and ligaments. If one or more of these
soft-tissue restraints also is compromised, increased re-
liance on the LT to maintain a concentric hip joint may
occur with certain motions.
Injury to the LT is thought to occur from one of several
mechanisms. The LT is at risk with any major hip trauma
causing a hip dislocation. It has been torn with lower
levels of trauma, however, including a case report of a
tear occurring while a patient pushed a shopping cart.“2
LT tears also can occur from repetitive mierotrauma in
sports requiring extreme amounts of hip motion such as
dance, gymnastics, and martial arts. Microtrauma to
the LT may be exacerbated in patients with ligamentous
laxity or insufficiency, in which the LT is thought to play
a larger role in instability. Finally, a degenerative tear
can occur due to abrasive wear against osteophytes in
osteoarthritis.“
The clinical assessment of LT tears traditionally has
been difficult. Patients may report an injury during a
twisting mechanism, a fall onto a flexed knee, or a hy—
peradduction mechanism. Patient reports may include
pain, mechanical symptoms, and feelings of instability
with giving way, especially during squatting and when
crossing the affected leg behind the other when stand-
-E
2
ing. Some patients may present with pain as their only
cu symptom. Physical examination findings in patients with
o.
1:
I:
an
LT tears are consistent with findings in other tests for
E- intra-a rticular pathology. These nonspecific tests include
I
H pain with flexion and internal rotation, log rolling in ex-
tension, and during the McCarthy test, in which the hip
is alternately taken from flexion to extension in internal
rotation and then external rotation. A test called the LT
test was recently described that may aid in the diagnosis.“
The LT test is performed by placing the patient supine,
flexing in the hip to T3“, abducting it 33“, and rotating it
into maximum internal and external rotation. This test
was found to have a sensitivity of 93% and a specificity
of 35%.
Imaging to identify LT pathology also has proven
difficult traditionally. The authors of one study noted
that only 2 of 23 LT tears in their series were diagnosed
preoperativelyfif In an attempt to distinguish partial LT
tears from normal anatomy, the authors of a 2012 study
found similar radiographic findings on 3-T magnetic res-
onance arthrography between the partial tear and normal
firthopaedic Knowledge Update: Sports Medicine 5
anatomy.” Their ability to diagnose LT tears ranged from
42% to east. Finally, a sensitivity of 34% and a specificity
of 53% in identifying pathology in the LT was found,
also using 3-T Il'vllR.I.“'5
Treatment options for LT tears include debridement
and reconstruction. A systematic review compared the
short-term benefit of the two modalities. ‘T The iii-patient
reconstruction group was compared with 31 patients in
the debridement group. The debridement group showed
an increase in modified Harris Hip Scores from poor
(63.?3; 95% confidence interval [CI], 4?.fl-T4.4ti} to good
(33.4; 95% CI, 35.95—93.32} and showed an improvement
in pain and function in the mean nonarthritic hip score
from 55.1 [95% CI, 6234—6125] to 36.35 {95% CI,
3166-3134}. Although having very small numbers, the
reconstruction group also showed improved subjective
and objective outcome scores despite using different graft
sources and fixation techniques. The indications for repair
versus reconstruction are not yet defined clearly.“
S u m m a ry
Hip arthroscopy continues to evolve rapidly along with
the understanding of pathology in and around the hip
joint. The indications for surgery include pathology in the
central, peripheral, and peritrochanteric compartments,
and the indications are expanding to include pathology in
the surrounding soft tissues. The acetabular Iabrum is a
critical structure and should be repaired or reconstructed
whenever possible to preserve its function, especially the
negative suction seal function. Hip instability has proven
to be a source of chronic pain and disability. Soft-tissue
structures, including the LT, play a key role in main-
taining stability, especially in the setting of abnormal
bony morphology. Appropriate capsular management,
including capsular repair and plication in indicated cases,
is proving to be a key step in preserving or establishing
hip stability and optimizing surgical outcomes. Tears of
the LT are a source of pain in the hip and require a high
index of suspicion to make the diagnosis. The LT test is
a new physical examination tool to aid in making the
diagnosis. Débridement of partial-thickness tears has
demonstrated good clinical outcomes. LT reconstruction
in instability cases may prove to be a useful adjunct along
with capsular plication in certain settings but is still un-
proved at this point.
fl 2315 American Academy of Orthopaedic Surgeons

lie-y Study Pnints
i Acetahnlar la bral tears are the mest cemmenly nnt—
ed pathnlngy at hip arthrescnpy and sheuld be re-
paired er recnnstrncted whenever pessible te restere
the labral functien nf creating a negative pressure
seal tn the femeral head.
Hip micreinstability is an increasingly recegnized
snurce ef pain and instability because nf snft—tissue
restraint incempetency in the herderline dysplastic
hip. The acetabular lahrum, the ligamentum teres,
and the jeint capsule play critical secendary reles
tn heny restraint.
Tears ef the ligamentum teres can he an imper-
tant senrce nf pain and disability, which require
a high index nf suspicinn tn diagnese but are suc-
cessfully treated with surgical débridement and
reconstruction.
Annetated References
1. Celvin AC, Harrast], Harrier C: Trends in hip arthrescepy.
I Hens Inns-t Surg Am 2fl12;94{4}:e23. Medline DUI
The anthers determined that the number ef hip arthres-
cnpy cases submitted by American Heard nf flrthnpaedic
Surgery Part 11 candidates during the perie-d item 1999 tn
Elli}? increased lfl-feld, with mest perfermed by spnrts
medicine fellnwship—trained candidates
Eerie K], Chan V, Valene FH III, Feeley ET, Vail TP:
Trends in hip arthrescepy ntiliaatien in the United States.
] Arthrepiesty 1fl13;23{3, Snpplfld-D—HJ. h'IedIine [101
The authers determined that the incidence ef hip arthres-
cepy precede res ameng American Heard Of Drthepaedic
Surgery Part II candidates increased ever fiflfl‘h’s frem EDDIE
te 2131i], with an everall cnmplicatien rate ef appreiti-
mately 5%.
HarrisJD, hrIc'Cnrmiclt Fl'vI, Abrams GD, et al: Cemplica‘
tiens and rcepcratiens during and after hip arthrescepy: A
systematic review nf 91 studies and mere than 65,306! pa-
tients. Arthrnsenpy 2fl13;19{3]:539-595. Mcdline DUI
The anthers reviewed 9'2 studies, ef which 33% are lev-
el IV evidence with shert-tenn fellew—up at a mean ef
2.0 years. The rate ef majer cemplicatiens after hip ar-
threscepy was fl.53% and miner cemplicatinns was 15%.
The renperatien rate was 6.3% at a mean cf 16 menths.
with the mest cemmen reeperatien being cenversinn tn
tetal hip arthreplasty. Level ef evidence: I‘v’.
Dippmann C, Therbnrg K, Kraemer D, Wings- 5, Hell-
mich P: Symptems nf nerve dysfunctinn after hip arthres-
cepy: An nnder-reperted cnmplicatinn? Arthreseepy
2014:3fllllflfll—EGIMndline DUI
IE! ants American Academy et' flrthepaedic Surgeens
Chapter II]: Athletic Hip Injuries
The anthers reviewed 51 censecutive hip arthrescnpy pa-
tients frem March tn |fictnber liilfl and determined that
46% repert symptems ef nerve dysfunctien during the first
pestnperative week, which decreased In 23% at 6 weeks
and 13% after 1 year. Tractinn time during surgery was
net different in patients with and witheut symptnms ef
nerve dysfunctien. Level nf evidence: I‘v'.
Clnhisy JC, Nepplc J]. Larsen EM. Zalts I, lviillis M;
Academic Netwnrlt ef Cnnservatien Hip Clutceme Re-
search {AHCHGR} Members: Persistent structural dis-
ease is the mest cem men cause nf repeat hip preservatinn
surgery. Chit firthnp Reina? Res 2fl13;4T1{12}:3T33-3?94.
Medlinc DUI
The anthers reviewed a prespective, multicenter hip pres-
ervatien database et 2,336 surgery cases tn identify 352
patients, er 15%, whe had prier surgery. Inadequately
cerrected structural disease was the mest cemmen reasen
fer secendary surgery. Level ef evidence: IIl.
Ayeni CIR, Eedi A, Lerich DG, Kelly ET: Femeral neclr
fracture after ardtrescnpic management nf femnrnacetab-
ular impingement: A case repert. ] Hesse jeinr Sin-g An:
2fl11;93{9]:e4?.Merlline Dfll
The anthers present a case repert ef a nnndisplaced,
subcapital femeral neck fracture after arthrescepic man-
agement nf femernacetabular impingement. Level ef
evidence: IV.
Fewler J, Dwens ED: Abdeminal cempartment syndreme
after hip arthrescepy. Arthrnscepy lfllfififiillfllfla-l 3i].
Medline DD]
Authers present a case repert ef abdeminal cempartment H
syndreme resulting frnm fluid extravasatinn fellnwing hip E
arthrescepy fer FAI. A distended abdemen was neted at
'U
tn
time nf drape remeval, and a decnmpressive Iaparntemy 3
EL
was perfermcd. Level W evidence. '13
1
n1-
El-
Matsuda DH: Acute iatregenic dislecatien fellewing
hip impingement arthrescepic surgery. Arrhrescepy
2fl09;25{4]:4flfl-4fl4.Medline DUI
The anthers discuss a case repert ef an iatregenic hip
dislecatien after arthrescepic hip surgery fer femernace-
tabular impingement. hinted in the repert is suprannrmal
hip distractien re extract a leese bedy. A mini-epen cap-
snlnrrhaphy was required tn restere hip stability. Level
nf evidence: 11.".
Salve JP, Treitell CR, Dnggan DP: Incidence nf veneus
thrembecmbnlic disease Fellewing hip arthrescepy. Cir-
rhepedics lfllflfifiifllmfi-i. Medline
The anthers retrespectively reviewed 31 censecutive pa-
tients nndergeing standard hip arthrescnpy and deter-
mined a 33% incidence nf clinically symptnmatic veneus
thrembnembnlic disease, which was suspected clinically
and cenfirmed with the use nf apler nltrasnnngraphy.
He patients develeped symptnmatic pnlmnnary embnli.
1G. Bushnell ED, Dahners LE: Fatal pnlmnnary emhnlism
in a pelytraumatiscd patient fellewing hip arthrescepy.
flrrhepsdics eneseemes. Medline DUI
Drthepeedic Knewledge Update: Sperrs Medicine 5
 Sectinn 2: Hip and Pel'lde
The authnrs present a case repnrt nf a fatal pulmnnary
embnlism after hip arthrnscnpy perfnrmed tn remnval
multiple intra-articular lnnse bndies fnllnwing a closed
reductinn and percntanenus fixatinn nf an acetahular frac-
ture secnndary tn a gunshnt wnund.
11. Kelly ET, Weiland DE, fichenker ML, Philippnn MJ: Ar-
thrnscnpic lahral repair in the hip: Surgical technique and
review ed the literature. Artbrnscnpy 1fl05;11{11}:145l'fi-
15fl4. Medline DflI
11. Fergusnn SJ, Bryant JT, Gan: R, Itn K: The acetahular
Iabrum seal: A pnrnelastic finite element mndel. Clair: flin-
mecb (Bridal, Anne} lfiflflfl 5{61:463-463. Medline DD]
13. Fergusnn 5], Bryant JT, |Gan: R, Itn K: The influence
nf the acetabular labrum nu hip jnint cartilage cnnsnl-
idatinn: A pnrnelastic finite element mndel. J Binmeel':
lflfli};33{fl}:953—Sfifl.Medline DUI
14-. Fergusnn SJ, Bryant JT, Gan: R, Itn K: An in vitrn investi-
gatinn nf the acetahular lahral seal in hip jnint mechanics.
I Binmecb 2Ufl3:35[2}:1?1-1?fi. Medline DUI
15. Philippnn M]: Hip arthrnscnpy in the athlete. in McGinty
JB, ed: Operative errbrnsenpy ,ed 3. Philadelphia, Lip-
pincntt Williams 8:: 1|Wilkins, lflfll.
16. Dumb BG, Shindle MK, McArthur B, Vnns JE, Magennis
EM, Kelly ET: [linpsnas impingement: A newly identified
cause nf lahral pathnlngy in the hip. HSS I 2131 1;?{2}:145-
15D. Medline DUI
-E The authnrs identified 25 patients whn underwent isnlat-
2
tn
:1.
ed, primary, unilateral ilinpsnas release with either lahral
1: dd-bridement nr repair nf a lahral tear. In this series, they
I:
rt: identified a distinct pattern nf lahral pathnlngy that nccurs
E- in the direct anterinr lncatinn thnught be secnndary tn
I
H ilinpsnas impingement. Level nf evidence: IV.
1?. Fame '3], Maizlin ZV, Shrnuder J, Grant MM, Bedi A,
Ayeni OR: The assnciatinn between avulsinns nf the re-
flected head at the rectus femnris and lahral tears: A ret-
rnspective study. J Pediatr 011p EflldfidlfilfllT-Idl.
Medline D01
The authnrs reviewed electrnnic medical recnrds nver a
lfl-year perind nf patients between the ages nf 12 and
13 years and identified 9 patients with avulsinn injuries nf
the rectus femnris muscle during spurts activities, with T
nf the 9 demnnstrating lahral tears nn magnetic resnnance
arthrngraphy. All patients were initially managed nnnsur-
gically, and 1 nf the 9' went nn tn arthrnscnpy secnndary
tn substantial refraetnry pain. Level nf evidence: IV.
13. Latge LA, Patel JV, Villar EN: The acetahular labral
tear: An arthrnscnpic classificatinn. Artbrnscnpy
1996:13i3}:269-2?2.Medline DUI
19. Seldes RM, Tan V, Hunt], Kat: M, Winiarsky R, Fit:ger-
aid EH Jr: Anatomy, histnlngic features, and vascularity
DI the adult acetabular labrum. Glir: Drtfinp Relet Res
2001;332:132—240.Mndline DUI
firthnpaedic Knnwledge Update: fipnrts Medicine 5
El]. Espinnsa N, Enthenfluh DA, Beck M, Gan: R, Leunig
M: Treatment nf femnrn-acetabular impingement: Prelim-
inary results nf labral refixatinn. J Barre Jul-int Surg Am
lDflfi;33l5}I:915—935. Medline DUI
21. Larsnn GM, Giveans MR: Arthrnscc-pic debridement
versus refiaatinn nf the acetahular labrum assnciated
with femnrnacetabular impingement. Arrhrnscnpy
1Dfl9;25{4}:369-3?6.Medline DUI
The authnrs cnmpared twn grnups that underwent ar-
thrnscnpic labral ddbridement versus lahral repair for
pincer-type nr cnmbined pincer- and cam-type FAI with
a minimum nf 1-year fnllnw-up. The lahral repair grnup
demnnstrated better mndified Harris Hip Scnres {94.3
versus 33.9} and a greater percentage nf gnnd tn excel'
lent results cnmpared with the labral débridement gen-up
{393% versus 563%]. Level nf evidence: IV.
22. Krych AJ, Tt-mpsnn M, Knutsnn Z, Scnnn J, |Cnleman
5H: Arthrnscnpic lahral repair versus selective labral de-
bridement in female patients with femnrnacetabular im-
pingement: A prnspective randnrnized study. Arthrnsenpy
1fl13;29{1]:4fi-53.Medline DUI
The authnrs repnrt nutcnmes nf 36 female patients un-
dergning arthrnscnpic hip treatment fnr pincer- nr cnm-
bined-type FAI randnmi:ed tn either lahral repair versus
Iabral débtidement between June Elli}? and June Iflflfl
with the same rehabilitatinn prntn-cnl pnstnperatively with
average fnllnw—up nf 32 mnnths. The lahral repair grnup
demnnstrated super'inr imprnvement in hip functinnal nut-
cnmes with a greater number rating their hip functinn as
nnrmal nr nearly nnrm al. Level nf evidence: I.
23. Philippnn MJ, Briggs KK, Hay GJ, Kuppersmith DA,
Dewing CB, Huang M]: Arthrnscnpic labral recnnsttun-
firm .in the hip using ilintibial hand autngraft: Technique
and early nutcc-mes. Artisrnscnpy lfllfl;lfi{fil:?5fl-?56.
Medline LII-GI
The authnrs discuss the technique nf lahral recnnstruc—
tinn fnr labral deficiency nr advanced la bral degeneratinn
using an ilintibial band autngraft and nutcnmes nf 9.5
arthrnscnpic labral recnnstructinns with mean fnllnw—up
nf 13 mnnths. This study shnwed gnnd nutcnmes and high
patient satisfactinn, with better nutcnmes for these within
1 year Item the time nf injury. Level nf evidence: IV.
24. Shindle MK, Ranawat AS, Kelly ET: Diagnnsis and man-
agement nf traumatic and atraurnatic hip instability in the
athletic patient. Elie Spnrts Med Elli-1:25{21:309-326,
iii-I. Medline DUI
25. fihu B, Sa fran MR: Hip instability: Anatnmic and clinical
cnnsideratinns nf traumatic and atraumatic instability.
Bliss Sports Med lfl11;3fl{1}:349-36?. Medline DUI
The authnrs reviewed the anatnmy cf the hip and bnw each
structure cnntributes tn hip stability. They alsn reviewed
the causes nf instability and treatment techniques.
26. Demange MK, Kakuda EMS, Pereira CAM, Sakalti
MH, Albuquerque ILFM: Influence nf the femnral head
fl 211115 American Academy nf Urthnpaedic Surge-ans

ligament en hip mechanical functien. Acre Urtep Bras
Elli—1?; 15i4]:lfl?—19l].
1?. Martin RL, Palmer I, Martin HD: Ligamentum teres: A
functienal descriptien and petential clinical relevance.
Knee Sui-g Sperts Tranmetef Arthresc 2011;2fii6]:12i}9-
1214. Medline DUI
The anthers created a string medel te examine ligamentnm
teres excursien during va rieus hip pesitiens and feund the
liga meutum teres te have the greatest hip excu rsien when
the hip was externally retated in flexien and internally
retated in extensien. a tetal ef 35f] censecutive surgical
patients were then retrespectively reviewed te identify Eli
patients with cemplete ligamentnm teres rupture. bline ef
the Eli} subjects were available fer fellew—up, and 5 ef the
9 neted feelings ef instability with squatting inte external
retatien and flexien and cressing eue leg behind the ether
inte internal retatien and extensien. Level ef evidence: IV.
23. Demb BU, Lareau JM, Baydenn H, Betser I, Millis
ME, Yen TM: Is intraarticular pathelegy cemmen in
patients with hip dysplasia undergeing periacetabulat
esteetemyi Chin Urrhep Refer lies 2i] 14:4?2i2]:e?4-Eflfl.
Medline DUI
The anthers decumented arthrescepic incidence ef
intra-articular patbelegy cf 16 patients undergeing peri-
acetabular esteetemy fer hip dysplasia and cencemitant
hip arthrescepy fer mechanical symptems censistent with
lahral pathelegy identified en MRI and feund significant
intra—articular pathelegy in all patients, te include pathelv
egy ef the labrum, chendral surface, ligamentum teres,
cam defermity, and pseas tenden.
2?. Krych A], Thempsen M, Larsen CM, Byrd JW, Kelly ET:
Is pesterier hip instability asseciated with cam and pincer
defermityi' Elie Urthep Refat Res lflll:4?fl{11j:339il-
3315?I T. Medline DUI
The anthers reviewed the recerds ef 22 athletes presenting
with a pesterier acetabular rim fracture cenfirming a
pesterier hip instability episede and identified a peten—
tial asseciatien between the eccurrence ef pesterier hip
instability and structural abnermalities asseciated with
FAI, which may centribute te a mechanism ef femereacs
etabular—induced pesterier snhlnxatien.
30. Philippen M]: The rule ef arthrescepic thermal capsu-
lerrhaphy in the hip. Elie Sperts Med 2Dfl1:2fl{4}:31?—329.
Medline DUI
31. Bayer JL, Eel-:iya JFC: Hip instability and capsular laxity.
Uper Tech Urthep 201i};lfl{4}:13?-241. DUI
The anthers describe their surgical technique fer treatment
ef hip instability including evaluatien with flnerescepy
and arthmscepy capsular plicatien.
32. Slihker w, Van Thiel (35, Uhabal JC, blhe 5]: Hip insta—
biliry and arthrescepic techniques fer cemplete capsular
clesure and capsular plicatien. Uper TechI Sperts Med
1131 2;1fl:3fll-3i}9. DUI
The anthers describe twe different techniques that previde
auatemic repair ef the capsule and aim te decrease the
IE! Eillfi American Academy ef Urthepaedic Surgeens
Chapter in: athletic Hip Injuries
capsular velume te minimise the risk ef iatregenic hip
instability after hip arthrescepy.
33. Eeuali T, Katthagen ED: Hip sublnxatien as a cum-
plicatien ef arthrescepic dehridement. Arthrescepy
2fl09;35{4]:405-4i}?. Medline DUI
The anthers reperted the case ef a 49-year-eld weman
with mederate hip dysplasia whe underwent arthrescepic
lahral resectien with remeva] ef an acetabular exesteses
in whem hip instability develeped 3 menths after sur-
gery. It was cencluded that the labrum perfermed a mere
stabilising functien in dysplastic ieints.
34. Ranawat AS, McClincy M, Seltiya JK: Anterier dislecatien
ef the hip after arthrescepy in a patient with capsular
laxity ef the hip. A case repert. I Beue jer'nt Surg Am
Zflflfifilillfl‘E’Z-IFEMedline DUI
The anthers reperted en a case ef anterier hip dislecatien
after hip arthrescepy.
35. Frank RM, Lee S, Eush—Jeseph CA, Kelly ET, Salata M],
Nhe SJ: Impreved eutcemes after hip arthrescepic sur-
gery in patients undergeing T-capsuletemy with cemplete
repair versus partial repair fer femereaceta bular impinge-
ment: a cempatative matched-pair analysis. An: I Sparta
Med 2014:42illjflfi34-2642. Medline DUI
The anthers reperted eutcemes ef as patients undergeing
hip arthrescepy fer FAI that were divided inte twe treat-
ment greups cemparing a partial T-capsnletemy repair
versus cemplete repair with minimum 2—year fellew—np.
Patients with cemplete capsular clesure demenstrated
superier spurt-specific eutcemes and ne revisien surgery
versus 13% revisien rate in the partial repair greup. H
E
'U
3E. Betser IE, Martin DE, Stunt CE, Demb EU: Tears ef the tn
3
ligamentum teres: Prevalence in hip arthrescepy using EL
'13
2 classificatien systems. Am } Spur-ts Med 2fl11:39[5up- 1
pl}:11?S-1255.Medline DUI in
El-
The anthers reviewed 5.53 primary hip arthrescepies by
the senier anther between February lflflfl and January
lflll and determined that 51% had partial er cemplete
ligamentum teres tears. Patients with tears were elder
and had werse preeperative functienal sceres. Magnetic
resenance arth regraphy demenstrated lew accuracy and
sensitivity in detectieu ef tears. Level ef evidence: IV.
37. Byrd 1W, Jeues K5: Traumatic rupmre ef the ligamentum
teres as a senrce ef hip pain. Arthrescepy 2004;2fli4}:3 35-
391. Medline DUI
33. 1hl'illar RN: Hip Artbrescepy .Uxferd, Butterwerth Heine-
man, 1992. Medline DUI
35'. Haversath M, Hanke J, Landgraeber S, et al: The distribu-
tien ef neciceptive innervatien in the painful hip: A histe-
legical investigatien. Hesse jer'et} 2013;95-E{6}:??fl-?76.
The anthers perfermed a histelegic investigatien ef the
neciceptive innervatien ef the acteabular labrum, the lig-
amentum teres. and capsule ef the hip in erder te preve
pain— and preprieceptive-asseciated marker expressien.
The labrum demenstrated pain-asseciated free nerve
Urrhepaedic Knewledge Update: Sperrs Medicine 5
 Sectiun 2: Hip- and PHvis
ending expressinn at its base, decreasing in the periphery.
The ligamentum teres was cuncentrated at its center, and
the capsule demunstrated almnst humugenuus marker
expressiun in all investigated areas.
4f]. Kivlan ER, Richard Elemente F, Martin EL, Martin HD:
Functiun cf the ligamentum teres during multi-planar
mnvement cf the hip jnint. Knee Snrg Spurts Tranmatuf
fifths-use: 1fl13;11{?1:1664-1653. Medline DUI
The authnrs dissected the suit tissue uf eight cadaver hips
except fur the liga mentum teres and placed the juints inter
flexiun and abductiun to simulate a deep squat p-usitic-n
until ligamentuus endpuint at the ligamentum teres was
achieved. The erientatinn at the ligamentum teres was
described and fuund tu prevent the femural head from
anterinrl'inferiur subluxaticn because nf its sling-like effect
in suppurt uf the femural head.
41. Phillips AR, Bartlett G, Nurtnn M, Fern D: Hip stability
after ligamentum teres resectinn during surgical dislfl-Ea-
tiun fur cam impingement. Hip Int lflllglljfijtdlfl-334.
Medline DUI
Questiunnaires completed by 161 patients whu had un-
dergune surgical hip dislncatiun with excisinn cf the liga-
mentum teres revealed 39% experience pain with exercise,
35% pepping and lacking, and 24% subjective feelings uf
giving way. Leml of evidence: IV.
42. Yamamute Y, Villar RN, Papavasileiuu A: Supermarket
hip: An unusual cause uf injury tn the hip juint. Affirms-
cupy lflflfl;24{4}:4fffl-49l Medline DUI
.E
43. |[lll"DtIInnell JM, Pritchard M, Salas AP, Singh P]: The lig-
E
a:
u. amentum teres—its increasing impurtance. ,f Hfp Fraser's:
'U Sang 2014:1:3—11.
I:
re
The authurs reviewed the functien, mechanism nf injury,
'9
I clinical assessment, imaging, arthruscupic assessment,
H treatment, untcumes, recnnstrncticn, and unusual cun-
ditiuns cf the ligamentum teres.
|D’Dunnell J, Ecnnnmnpnulus K, Singh P, Bates D,
Pritchard M: The ligamentum teres test: A navel and ef-
fective test in diagnusing tears cf the ligamentum teres.
Am ] Sparse Med 2014:42j1]:133-143. Medline DD]
flrfltupaedie Knnwledge Update: Sparta Medicine 5
The authurs repurted results frum a new test tu detect
ligamentum teres tears. The ligamentum teres test is per-
fur-med by placing the patient supine, flexing the hip to
I'D”, abducting it 30", and rutating it intu maxitnum in-
ternal and external rutatiun. A sensitivity cf 90% and a
specificity pf 35% were repurted.
45. Blankenbalter DG, De Smet AA, Keene J5, Del Rip fiM:
Imaging appearance uf the nnrmal and partially turn liga-
mentum teres e-n hip MR arth mgraphy. FUR Am I Reent-
gene! lflll:199{5}:1093-1fl93. Medline DUI
The authurs reviewed magnetic resunance arthrcgraphy
images uf 116 patients who later underwent hip arthrcrs-
cupy and repurted a high level nf difficulty ef distin—
guishing partially turn versus intact liga mentum teres an
imaging because uf similar findings. Edema and peripheral
irregularity were nut assuciated with partial tears.
46. Devitt EM, Philippnn M], Gnljan P, Peixntu LP, Briggs KK,
Hn CF: Prenperative diagnnsis cf pathulugic cunditinns nf
the ligamentum teres: Is MRI a valuable imaging medali-
ty? Arrhrescupy 2014:30i5}:563-5?4. Medline Bill
The anthers review 3-Tesla MRI in detecting liga mentum
teres tears in 141 patients whu underwent hip arthruscupy.
They repur ted that MRI demunsttated sensitivity and
specificity uf 50% and 34%, respectively, in identifying
any pathnlugic prucess uf the ligamentum teres. MRI was
repurted tu have a 91% sensitivity and ET‘i’i: pnsitive pre-
dictive value at detecting a partial ligamentum teres tear.
Level ef evidence: II.
4?. dc 5A D, Phillips M, Philippun M], Letltcnlann 5, 5i-
munnvic H, nyeni |Gilli: Ligamentum teres injuries uf
the hip: A systematic review examining surgical indi-
catinns, treatment nptiuns, and uutcnmes. Arthrnscupy
2014:3flj12j:1634—IE41. Medline DUI
The authers perfnrmed a systematic review uf all articles
frem 194E tn 2G1}!- pertaining tu surgical treatment {if
the ligamentum teres, identifying nine studies meeting
eligibility criteria with 39 hips undergc-ing arthrnscnpic
débridemcnt er rccensttuctiun uf a turn ligamentum
teres. Déhridement demunstrated gnnd nutcnmes fur
partial tears, whereas recnnstructinn may be indicated
fur full-thickness tears that resulted in instability, fail—
ure uf previuus dEhridement, ur a cumbinatiun uf these
cunditiuns.
El ll] 16 American AcadMy uf Drthnpaedie Surge-nus
Chapter 11
Femoroacetabular Impingement
Ljiljana Bogunovic, MD Shane I. Who. MD, MS
Abstract
Femoroacetabular impingement can lead to pain, limited
motion, and decreased function in active adolescents
and young adults. The condition arises from an osseous
deformity in the proximal femur andior acetabulum that
results in abnormal joint contact force with hip range of
motion. Damage to the labrum and articular cartilage
develops with time, leading to early joint degeneration
and osteoarthritis. In the symptomatic patient, early
recognition and characterization of the deformity is
critical to the success of surgical intervention.
Keywords: femoroatetahular impingement; FAI:
cam deformity; pincer deformity; dysplasia; labral'
tear
I n t rod u cti o n
Femoroacetabular impingement {FAI} is an increasingly -level sports at a young age and the development of
recognized cause of hip pain and dysfunction. FAI has symptomatic disease 9 '3 Studies of young athletes demon-
been described as a condition resulting from a s
mismatch between the osseous anatomy of tr *
femur and that of the acetabulum, leadi
loading of the hip joint and subsequen e to the
underlying labrum and articular cartilage. In the non-
dysplasic hip, increasing evidence suggests that FAI may
lead to the development of early joint degeneration and
osteoarthritis.” Over the past decade, the understanding
of the pathomorphology and pathomechanics of FAI has
Dr. Nho or an immediate famiiy member serves as a paid
consultant to fissur and Stiyken and has received research
or institutionai support from AiioSource, Armrest, Atniet—
ico, DJ Giobai Orthopaedics, ConMed Linva tec Miomed
Orthopedics. Smith Es Nephew: and Stryker; Neither Dr.
Bogunovic nor any immediate famiiy member has received
anything of value from or has stock or stock options held
in a commerciai company or institution reiated directly or
.I'ndirectiyr to the subject of this chapter.
g. 2016 American Academy of Drthopaedic Surgeons
increased significantly, allowing improved recognition,
earlier diagnosis, and the development of effective treat=
ment options.
Etiology
Structural deformity can occur secondary= to the sequelae
of pediatric hip disease such as slipped capital femoral
epiphysis, Legg-Calve-Perthes disease, and hip dyspla-
sia. In most cases of prim ry FAI, no prior history of
disease 15 present, andItfaition is likely caused by a
combination of gen; . vironmental factors. The
prevalence of avity in asymptomatic adults is
estimated at in] ely 14%, with 24% .in males and
5% in fem. * s are three to five times more likely
to have rmities than are females, and the defor-
' " 1e likely to be bilateral in males.“r A 2.8
-. k of cam deformity in the siblings of affected
* Vials suggests additional genetic contributions.a l‘f'
3:.
. - 'eral studies suggest a link between participation in 1:
m
3
D.
'o
'1
strate a lack of cam deformity III skeletally immature 5.
1n
individuals but a presence after physeal closure? Several
studies have reported an increased prevalence of femo-
roacetabular deformities in football, soccer, and hockey
players compared with the general populationfilr‘11““5 Ace
cording to the data from the National Football League
Scouting Combine, 90% of players showed radiographic
evidence of FM, of whom 31% were symptomatic and
69% were asymptomatic. The greater the at angle the more
likely was the athlete to present with symptoms.16 The
repetitive stress that occurs in athletic activities is believed
to influence physeal growth and potentially contribute to
the development of deformity.
Types of Impingement
The deformity of primary FAI can involve the proximal
femur {cam}, the acetabulum {pincer}, or both {combined}.
Isolated cam deformity or combined deformity appears to
be most common, and each occurs with nearly equal fre-
quency {45%). Isolated pincer deformity is less common,
Drrhopaedic Knowledge Update: Sports Medicine 5
 Section 2: Hip and I'Hvis
occurring in fawer than 10% of patients with symptom-
atic PALE” Extra-articular impingement, which includes
trochanteric-pelvic impingement, ischiofemoral impinge-
ment, and anterior inferior iliac spine {A115} impingement,
is another infrequent, but increasingly.r recognized, source
of symptomatic impingement. A thorough understanding
of the pathomorpholog}r and pathomechanics of each
individual deformit}r is critical to the successful surgical
management of FAI.
Cam Impingement
lElam deformity,r is characterized lav decreased offset be-
tween the femoral head and neck, most commonly oc-
curring at the anterolateral head—neck junction. 1|With
attempted hip flexion and internal rotation, the osseous
cam lesion impinges on the acetahulum, limiting motion
and causing damage at the chondrolahral junction with
repetitive impingement. In cam impingement, inclusion of
the deformity.r into the acetahulum results in shear stress
and disruption of the chondrolabral junction, causing de—
lamination of the articular cartilage from the underlving
suhchondral hone.” lL'Ihrer time, intrasuhstance damage to
the lahrum occurs, and the chondral injury,r can progress
to a full-thickness defect. The location and severity.r of
the acetahular injury can he predicted by the sire of the
cam deformity, because a higher E angle is associated
with increased incidence of full—thickness chondral de~
.E
E
fects.lEI In most patients, decreased offset occurs at the
a: anterolateral head—neck junction, resulting in damage to
u.
'U
I:
to
the anterosuperior acetahulum.3 In long-standing cam im—
'9
pingement, degenerative changes can progress to involve
I
oi the weightuhearing spherical portion of the femoral head.
Pinrer Impingement
Pincer impingement is characterized by excessive acetahu
ular coverage. The acetahular overcoverage can he global
[coxa protrusio and coxa profunda] or focal {cephalad
retroversion} or can result from true acetahular retro-
version.“ Pincer impingement leads to intrasubstance
damage of the labrum as it is compressed between the
femoral neck and the abnormal acetahular rim during
extremes of hip range of motion. As in cam impingement,
the anterosuperior acetahulum is most commonlyr af-
fected; less chondral delamination is present with isolated
rim impingement, however. Dver time, repeated levering
of the femoral head against the excessive acetahular rim
can result in contrecoup chondral injurv to the postero-
inferior femoral head and acetahulum.
Extra-articular Impingement
Subspine impingement is a distinct form of pincer impinge—
ment, in which the anterior capsule andfor iliocapsularis
flrdtopaedic Knowledge Update: Sports Medicine 5
muscle becomes pinched between the femoral head-neck
junction and a prominent AIIS.” Pathologic AIIS mor-
phologv can be developmental (types I and II] or can
arise following pelvic csteotomy or secondary.r to prior
rectus femoris injur‘f.r or avulsion {type III}. Affected pa-
tients may report activitv—related groin pain, pain during
prolonged sitting, limitations in motion, and a grinding
sensation during deep flexion and lateral movements. Im—
pingement between the lesser trochanter and the ischium
[ischiofemoral impingement} and the great trochanter
and the ilium {trochanteric—pelvic impingement} are other
potential, although uncommon, sources of extra'articular
impingement that can cause pain and restricted hip exten-
sion and abduction, respectivelv. lntra—articular steroid
iniection tvpicallv provides no relief or onl].T partial relief
of symptomatic extra-articular impingement.“- Bcth open
and arthroscopic resection have been shown to improve
motion and alleviate painfifla
Femoral Version
Femoral version can affect the severity of cam and pincer
deformities and should he assessed in all patients with
svmptomatic FAI. The normal adult femur has ID“ to
15" of femoral anteversion. In the setting of relative or
absolute femoral retroversion, external rotation of the
hip is increased, and internal rotation is decreased. 1When
femoral retroversion coexists with a focal cam or pincer
lesion, the osseous lesion engages earlier {with less inter-
nal rotation} than would be seen in a hip with normal
femoral anteversion.21 The motion restriction in patients
with combined FA] and femoral retroversion is typically.F
more severe than in those patients with isolated FAI.
Acetohular Dysplasia
Symptomatic FA] must be differentiated from acetahular
dvsplasia. In dysplasia, ahnormal joint loading occurs
seconda rv to a relative undercoverage of the femoral head
by an abnormallv deficient acetahulum. Preoperative ra-
diographs are essential to the diagnosis, and common
radiographic parameters should be measured to ensure
proper diagnosis. Although FAI mav coexist with acetah-
ular dysplasia, the surgical treatment for the combined
condition varies dramaticallv from that of an isolated
PAL“ Correction of dvsplasia tvpicallv requires an open
approach, most commonly performed using the Bernese
periacetahnlar osteotomv.”
Given the overlap in svmptomatologv between the lumbar
spine, hip, and pelvis, it is common for patients to present
El 1016 American Academv of Drthnpaedic Surgeons

in a delayed fashion following previous failed treatment,
or with an incorrect diagnosis. A layered approach should
he applied to assess not only the mechanics of the hip
joint but also the surrounding joints and musculature. A
primary hip disorder may be obscured by compensatory
injury to the pelvic musculature, lumbar spine, pubic
joint, or sacroiliac joint as the patient attempts to main-
tain a high level of activity in the setting of restricted hip
motions“5 Patients may present with chronic gluteal pain,
abductor irritability, trochanteric bursitis, osteitis pubis,
or trochanteric bursitis.
The location, duration, and inciting factors of the pa—
tient‘s pain should be elicited. Although most patients
with symptomatic impingement {30%} present with pain
in the anterior groin or lateral hip, approximately 25%
of patients report pain in the lumbar spine, buttock, or
even referred pain to the knee.” Patients may display the
classic “C” sign {Figure 1} when describing the location
of pain. lviost report an insidious onset of symptoms
without a specific injury; however, athletes may recall a
specific event.“ Pain is often worse with activity (running,
cutting, and pivoting} and is exacerbated in positions of
hip flexion, such as prolonged sitting or squatting.
Physical Examination
Gait should be examined in all patients. A mild, inter-
mittent limp is common but can be extremely subtle,
occurring in up to P5 “iii of patients.” Abductor weakness
on the affected side often is seen with a positive Tren-
delenberg sign. Range of motion should be assessed on
supine examination at full extension and at 90“ of hip
flexion. The contralateral limb should be examined for
comparison. Bilateral disease is seen in approximately
75% of patients but is symptomatic in fewer than 25 Si: .3“
Restricted hip motion is a defining feature of symptomatic
FA], and affected individuals often have less than lflfl"
of straight flexion and less than 10" of internal rotation
with the hip at 5‘0“ of flexion.
Several dynamic tests can be used to assess for the pres—
ence of impingement and to compare with the contralater-
al limb. A positive test should re-creatc the characteristic
pain that the patient experiences. The positive anterior
impingement test {Figure 2} causes pain in the anteri-
or groin with flexion, adduction, and internal rotation,
which is present in most patients (33%] with symptomatic
FA]. Although sensitive for hip pathology, the anterior
impingement test is not specific for impingement and
may be positive in any patient with a labral or chondral
injury. The apprehension test {Figure 3} is performed with
the patient supine at the edge of the examination table.
The hip is extended and externally rotated. Patients with
IE! Elllli American Academy of flrthopaedic Surgeons
Chapter 11: Femoroaoetabular Imphigement
I'-
I
5.:
. - A-‘
Figure 1 Photograph shows the classic "E" sign. Patients
with symptomatic impingement til-ten cup their
hand around the lateral hip when describing
the site of pain.
a dysplastic or unstable hip may report uneasiness or
apprehension during this maneuver. The same maneuver
also may re-create pain in patients with symptomatic
posterior impingement. The subspiue impingement test
is performed with the patient in the supine position (Fig-
ure 4). Maximal anterior groin pain with direct hip flex-
ion beyond 91')“ is consistent with subspiue impingement.
Intra-articular anesthetic injection can be a useful ad-
junct to diagnosis. The injection can he performed in the H
office setting via ultrasound or fluoroscopic guidance. E
'U
Following injection, patients are instructed to perform to
3
EL
activities that would typically elicit pain. Substantial or '13
1
complete relief with injection signifies an intra-articular in
El-
source of pathology. Little to no pain relief following
injection warrants further investigation. Such patients
should be assessed for potential extra-articular sources
of impingement {subspine impingement} or other pelvic
or lumbar pathology.11
Plain Radio-graphs
Preoperative imaging is critical to the diagnosis of Phi
and in planning for potential surgical intervention. A
systematic approach should be implemented and should
include the following standard radiographs: standing AP
pelvis, false profile, Dunn views, and frog—lateral views.”
For an accurate standing AP pelvis view, the pelvis should
be aligned with neutral rotation and tilt such that the
coccyx is centered in the midline, the tip is within 1 to 3
cm of the pubic symphysis, and the obturator foramen is
symmetric.” The joint space should be assessed for evi~
dence of narrowing, sclerosis, or cystic change indicative
Drthopeedic Knowledge Update: Sports Medichie S
 Sectinn 2: Hip and Pelvis
a I _-
Figure 2 ttegraphs depict the anterior impingement test. This test is pertermecl with the patient in the supine pnsitinn.
-E
The affected hip is maximally flexed {A} and then adducted and internally rntated {B}. Reprnductinn nf the
2 patient's anterinr grnin pain during this maneuver indicates clinically significant impingement andfnr intra-
cu
n. articular pathnlngy.
1:
I:
as
E-
I
H nf early nstenarthritis. Acetahular depth and cnverage
shnuid be assessed. Glnbal nvercnverage is easilyr iden-
tified when the medial femnral head lies adjacent tn the
ilinischial line {cnxa prnfunda} nr medial tn it {cnxa prn-
trusin}. Excessive anterinr nvercnverage, alsn referred tn
as cephalad retrnversinn, may be signaled by a crnssnver
sign. In cephalad retrnversinn, relative retrnversinn nf the
anternsuperinr acetabulum cnexists with nnrm al versinn
nf the anternmedial aceca bulum. This must be differenti—
ated frnm true acetahular retrnversinn, in which anterinr
nvercnverage is assnciated with a deficient pnsterinr wall,
a cnnditinn that places the patient at risk fnr iatrngenic
instability with isnlated anterinr wall decnmpressinn. A
crnssnver sign, cnmbined with an ischial spine sign and
a pnsterinr wall sign {the pnsterinr wall lies medial tn the
center nf the femnral head}, is indicative nf true aeetahular
retrnversinnf'” {Figure 5}. The lateral center edge angle
{LCEA} can be used tn assess lateral nvercnverage. 1Values
greater than 44]" indicate pincer mnrphnlngy.“ Additinnal
findings cnncerning fnr rim impingement include rim
fractures, a dnwnslnping snurcil, a Tnnnis angle less than
firthnpaedic Knnwledge Update: Spnrts Medicine 5
1
fl", and impingement: cysts nr a trnugh alnng the femnral
head-neck junctinn.
The false prnfile view prnvides additinnal radingraphic
infnrmatinn regarding acetahular mnrphnlngy. This im-
age is nbtained with the patient rntated at an angle nf 65“
between the pelvis and x-ray snurce and prnfiles the an—
terinr acetahulum. An anterinr center edge angle {ACEA}
greatei- than 4D“ indicates excessive anterinr nvercnver—
age.ail The mnrphnlngy nf the A115 alsn can be assessed
with this view (Figure iii).
The Dunn and frng-lateral views are used for assess-
ment nf the femnral cam mnrphnlngy. The n angle is
drawn tn quantify the severity nf the aspherieity. Val-
ues greater than 50“ indicate cam defnrmity [Figure T}.
The different radingraphic views help identify the lnss nf
head-neck nffset at different lneatinns alnng the prnxitual
femur. Nepple et all? used a clnck face technique, in which
the superinr femnral neck is at 12 n’clnclc, and the ante-
rinr neck is at 3 n’clnck, tn cnrrelate the pnsitinn nf the
head—neck junctinn prnfiled nn plain radingraphs tn radial
nhlique CT refnrmats. The 12 n’clnck pnsitinn is seen
fl lflld American Academy nf Cirrhnpaedic Surge-nus
 Chapter 11: Femoruaeetabular Impingement

"1.
s. _ a
- .- "If"

Figure 3 Photographs show the anterior apprehension test. which is performed with the patient supine and positioned at
the end of the examination table. A, The contralate ral hip is held in tlesio n; E, The affected hip is este nded and
l‘s'
externally rotated. Patients with structural instability may re port a sense of instability or appreh ension with this
maneuver. Pain during this maneuver may signify posterior impingement. E
'U
to
3
EL
'13
1
with the AP pelvis view, the 1 o’clock with the 45" Dunn some patients, including those with ligamentous hyper- us
El-

view, the 2 o’clock with the frog-lateral view, and the 3
o’clock with the cross-table lateral view. Given the typical
location of cam deformities at the anterolateral head-neck
junction {1 o'clock}, deformity is identified most readily
on the Dunn view, where the hip has abducted EU” and
flexed to 45“ {45" Dunn} or 90“ {90“ Dunnlfihm The 45“
Dunn view has been shown to be more sensitive in de-
tecting the presence and severity of cam deformity than
the 911]" Dunn viewfi‘l "When compared with the Dunn
view, the frog-lateral view has improved specificity for
cam morphology.“ It is crucial that all radiographs be
scrutinized for evidence of acetabular dysplasia, which
may coexist with FAI or be the primary pathology in a
patient presenting with hip pain.
Radiographic findings on the AP pelvis that are con-
cerning for aceta bular undercoverage and structural insta—
bility include an LCEA less than ED“ and a Tonnis angle
greater than 10" (Figure 3]. Anterior coverage can be
assessed using the false profile view, on which an ACEA
less than EU“ is indicative of undercoverage {Figure 9}. In
laxity, more subtle signs of dysplasia {such as an LCEA
less than 25°, uprising sourcil, ACEA less than 25"} may
give rise to symptomatic instability.”
Magnetic Resonance Imaging
MRI can be helpful in assessing labral pathology. The
sensitivity is significantly enhanced with intra-articular
contrast dye, making magnetic resonance arthrography
{MBA} with gadolinium the preferred imaging technique.
If possible, all imaging should be performed using high-
resolution 1.5 Tesla {or greater} MRI. True labral tears
must be differentiated from naturally occurring clefts.
Paralabral cysts and sub-chondral edema or cysts are in-
direct signs of labral and chondral injury, respectively.
Labral hypertrophy can indicate underlying dysplasia.
The addition of a long—acting anesthetic to the intra—artic-
ular gadolinium can provide additional diagnostic value.
Temporary relief of symptoms verifies an intra-articular
source of pain. The articular cartilage is poorly visualized
with conventional MRI. Delayed gadolinium-enhanced

IE! lfllfi American Academy of flrthopaedic Surgeons Drthopoedic Knowledge Update: Sports Medicine 5
 Section 2: Hip and Pelvis

Figure 4 A and B, Photographs show the subspine impingement test, which is performed with the patient in the supine
position- Maintaining neutral rotation and abduction. the hip is maximally flexed. In a patient with symptomatic
su hspine impingement. the anterior soft tissues heco me pinch ed between the inferior femoral neclt and a
prominent anterior inferior iliac spine {AI IS}. causing pain.

.5
2
to
o.
'r:
i:
rt:
E-
I
H

Figure 5 A, AP radiogra ph demonstrates true bilateral acetahular retrotre rsion. Apparent are a crossover sign on the
posterior wall (dashed line) and the anterior wall [solid line}, a prominent ischial spine {black arrowl. and a positive
posterior wall sign where the posterior wall line lies medial to the midpoint of the femoral head (black. dot}. I. AP
radiograph shows normal acetahulum.

MRI of cartilage {dGEMRIC} is a newer imaging tech- titre 30 minutes before imaging. This technique can he
nique that can detect earl}.r chondral degeneration by a useful adjunct when there is a concern for underlying
measuring the glycosaminoglycan content of the hyaline osteoarthritis, because preexisting chonclral degeneration
laj,rrrr:1'-"'l {Figure 10). Patients receive intravenous contrast is a known risk factor for poor outcomes following hip

a firthopaedic Knowledge Update: Sports Medichte 5 fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 11: Femoroaoetabular Impillgemetlt

.1. lg.:.- .r

. h. -
n‘ sat-.1“: ' _
Subspine _ "
i impingement If _
.II "E! AIIS I. f
. _. “1“”; r1.

Figure 71' Ninety-degree Dunn view shows a cam

Figure IE False profile radiographic 1u'ievu' depicts a deformity with an 1:: angle of T9“.
prominent anterior inferior iliac spine {Alli}.
type II B {arrow}.

'
-'
-' _.
" v” ' 3*_.1..-a:
‘_,r‘_

' .; I it.
I. TIE: 1|. IE“ |

ACEA 5"
H
E
1:
Eu
3
EL
'13
1
tn-
El-

. i
Figure 3 AP pelvic radiograph shows bilateral acetabular
dysplasia- The Tennis angle measures 15‘". with
an up sloping sourcil. The lateral center edge
angle {LEEAII measures 9". Figure 9 False profile view shows acetabular dysplasia
with anterior undercoverage. The anterior
renter edge angle measures 5‘.
arthroscopy and open hip preservation surgery.“

Three-Dimensional CT can be especially helpful in identifying focal rim lesions,

Three-dimensional computed tomography (313! CT},
which provides detailed information about the bony ar—
chitecture, can be a helpful adjunct in planning bony
resection. Although a crossover sign or ischial spine may
alert the surgeon to pincer impingement, CT allows the
direct assessment of acetabular version and depth. This
such as cephalad retroversion, and in differentiating them
from true acecabular retroversion. CT is also invaluable
to the assessment of AIIS morphology, which is poorly
visualized on plain radiographs. Software programs can
be applied to 313 CT images to model areas of impingeu
ment and plan sites of resection.

IE! lfllfi American Academy of flrthopaeclic Surgeons Drtbopoedic Knowledge Update: Sports Medicbie 5
 Section 2: Hip and Pelvis
Figure 1!] Saqittal slice of a delayed gadolinium-enhanced
MRI of the hip shows increased signal {arrow},
which signifies chondral degeneration at the
superior acetahulum.
Nonsurgical Management
-E
2
The nonsurgical treatment of PM is limited to symptom.-
to atic management and includes activity modification,
a.
1:
I:
re
anti-inflammatory medications, and physical therapy.“
E- Because impingement can result in compensatory injury
I
H to the surrounding musculature, physical therapy direct-
ed toward improving muscular mobility and strength
can provide some symptomatic relief. Common areas
of involvement include the rectus femoris, psoas muscle
tendon complex, hip adductors, and hip abt:luctors.3“"3‘5
The therapy program should be customized to address
the individual needs of the patient, including mobility
restriction, athletic demands, and areas of weakness.
Although therapy may be helpful in the symptomatic
management of FAI, no evidence suggests that it will
affect the natural history of the disease andior alter the
progression of degenerative changes.
Surgical Management
The decision to proceed to surgery is based on a combi-
nation of factors including the patient history, physical
examination, imaging studies, failure of nonsurgical man-
agement, and temporary relief with injection. Although
an open approach, such as the surgical hip dislocation
described by Gan, can be used, this chapter focuses on
firthopaedic Knowledge Update: Sports Medicine 5
the arthroscopic management of FAI. Successful treat-
ment requires a comprehensive approach that addresses
the osseous deformity and the resulting intra—articular
damage. Incomplete decompression of the impinging le-
sion is the leading cause of recurrent pain in patients
undergoing hip arthroscopy in the absence of substantial
chondral injury.33~3"
Hip arthroscopy proceeds via the standard technique,
using a minimum of two arthroscopic portals. The pro-
cedure typically begins by addressing pathology in the
central compartment, including the pincer and subspine
deformity and the chondrolahral injury. Afterward,
traction is released, and the arthroscope is advanced to
the peripheral compartment for decompression of the
cam deformity. An extensive capsulotomy [interportal,
H-shaped, or T-shaped} has been described to improve
access to pathology in the central and peripheral com-
partments. When performed, the capsulotomy should
be made hotween the medial and lateral synovial folds
and be extended in line with the femoral neck to prevent
damage to the retinacular vessels. Capsular management
remains an area of controversy. Some surgeons argue that
anatomic closure is required to restore the stability and
kinematics of the hip.
Central Compartment
Pincer Impingement
Acetabuloplasty or rim trimming involves removal of the
pincer impingement. This can be performed with or with-
out labral takedown. The extent of the resection should
be determined preoperatively from the baseline imaging
studies. Fluoroscopy can be used to assess progress intra-
operatively. I[flare must be taken to prevent overresection
and iatrogenic instability.
Lahral Injuries
More than 99% of labral tears occur in conjunction with
impingement deformity. The characteristics of labral in-
jury depend on the type and duration of impingement. In
early cam impingement, minimal intrasu bstance injury to
the labrum is present, because the mechanism of injury
occurs from shear stress between the articular cartilage
from the subchondral bone. Favorable healing rates can
be achieved with labral refixation after rim trimming (Fig-
ure 1]]. In contrast, longestanding cam impingement and
combined impingement typically lead to intrasubstancc
tearing and maceration of the labrum, which may present
with an irreparable labrum. In the setting of an irrepara-
hle labrum, options include selective labral débridetnent
and reconstruction.
fl lflld American Academy of Orthopaedic Surgeons
 Clmpter 11: Fempreaeetahular IatgemflnlI

l‘r'
E
'U
m
:r
Ill
1:
1
E.

II“

Figure 11 Arthrpsccipic VlEWS dempnstrate Iahral repair using a suture passing device. A. A suture anchcsr is placed along the
acetabular rim. B. A suture passing device is then introduced inte the jeint. A single limb at suture is grasped and
passed thrpugh the la hrum. C, An attempt is made tn incerpprate anyI chendral delaminatipn intp the repair. D. A
se cend pass is made with the suture passer rnere peripheral tn the first. E. The limbs are retrieved. and the repair
is secured with an arthrescepic Itnet censisting at a series at alternating half-hitches. F. The repaired Ialsrum and
cartilage have been reapprcntimated tfi the suhd'land ral hpne.

IE! EDIE American .ilasadlstn3,.r pf flnhnpaedic Surgeens Dnhepaedic Knowledge Update: Spur-ts Medichse 5 ®
 Secfien 2: Hip and Pelvis
Figure 12 Arthrescepic 1.I'iew shews the peripheral
compartment ef the cam lesien fellewing
T—ca psuletemy.
-E
E
e:
e.
1:
i:
re
E-
I
H with neutral retatien. The auther’s preference is te use a
Figure 111 A, Preeperatiye AP radiegraph depicts a typical
cam defermity iarrew]. B, Pesteperatiye AP
radlegraph shews the restered fe rneral head-
neck e'ifset fellewing decempressien.
Chendral Injuries
The chendral injuries asseciated with PM can range frem
delaminatien te full-thickness less. In the setting ef an
intact ehendrelabral junctien, labral repair can serve re
reappreximate the delaminated cartilage back tn the sub
ehendral bene. Detached and unstable flaps pese a clin-
ical challenge. Debridemeut, refixatieu with fibrin glue,
remeyal, and micrefracture all have been described, but
ne geld standard treatment exists. In general, significant
cheudral injury is a peer pregnestic faeter fer euteeme
and is ene ef the primary predicters ef centinued pain
and reduced functieu pesteperatiyely.
flrdtepaedic Knewledge Update: Sperts Medicine 5
Arth rescepic View shews the fe me ral head-
neclt junctien fellewing cempletien ef the
esteechendreplasty.
Peripheral Cempartrnent
Failure te reee—gnize and address esseeus patheiegy is a
prime faeter centributing tn treatment failure.” Cempre-
hensiye treatment ef the cam defermity depends en the
understanding ef the deferrnity, adequate yisualiaatien,
the ability te access the CAM defermity in its entirety,
and capsular management. After the central cempart-
ment has been addressed, the hip tractien is released, and
the hip is placed in appreximately lfl" te 30° ef flexien
T-eapsuleteruy perpendicular frem the interpertal capsu-
letemy and extended re the intertrechanteric line between
the iliecapsularis and the glutens minimus {Figure 12}.
The cam defermity is reseeted using a high-speed burr
while using intraeperatiye fluerescepy te cenfirm a cem—
prehensiye femeral esteechendreplasty {Figure 13]. The
hip must be pesitiened frem cemplete hip extensien and
internal retatien te full flexien and external retatien
te permit access re the entire cam defermity. After the
dynamic examinatien and fluerescepie eyaluatien cen-
firm resteratien ef the head-neck effset, the capsule is
cempletely clesed by shuttling numereus high-strength
sutures {Figure 14}.
Dutcemes
Preper patient selectien is critical re the successful surgical
treatment ef PAL Reduced pain and impreyed functien
are reperted in 63% te 96% ef patients.” Appreximately
15% ef athletes are able te return te cempetitien at the
fl lflld American Academy ef Cirrhepaedie Surge-ens

same level or better.“ The long-term effect of hip arthros-
copy and its potential to alter the natural history of FA]
and prevent early degenerative joint disease remain to be
determined. The current literature does not support pro-
phylactic cam or pincer decompression in asymptomatic
patients.”
The presence of preoperative osteoarthritis {Tonnis
grade greater than or equal to E or Outerhridge grade
greater than or equal to fl} is the strongest predictor of
poor outcome following hip arthroscopy. Either factors
associated with a poorer outcome include older age, a
longer duration of symptoms, more severe preoperative
pain, and poorer functional scored-“d” In the absence
of preexisting chondral disease, residual impingement
is the leading cause of continued postoperative pain and
revision surgery.3135
‘5 um mary
Active adolescents and young adults who report hip
andIor groin pain should be assessed for FAI. The pres-
ence of a cam andr‘or pincer deformity not only restricts
motion, but also leads to joint degeneration over time.
Patient history, physical examination, and radiographs
are critical tn the diagnosis of FAI and tn the planning
of surgical intervention. Hip arthroscopy is an effective
treatment modality. Failure to address all the components
of osseous impingement is a prime reason for continued
pain and dysfunction following hip arthroscopy.
Hey Study Points
1* FAI results from a structural mismatch between the
proximal femur {cam} and the acetabulum {pincer}.
1* Extra—articular impingement is a less common but
increasingly recognized source of symptomatic
impingement.
I Most patients with symptomatic impingement pres-
ent with activity-related groin pain.
I Limited range of motion of the hip is one of the
defining characteristics of FAI.
it FAI must be differentiated from dysplasia when
evaluating a patient with hip pain. The two condi-
tions may coexist.
it Both arthroscopic and open techniques are effective
in the surgical management of FAI.
1* Residual deformity is a leading cause of continued
pain after the surgical management of FAI.
1* fllder age, preexisting osteoarthritis, and a longer
duration of symptoms are risk factors for poor out-
comes following surgical intervention.
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 11: Femoroaoembulsr Intpingemerlt
Annotated References
1. Gen: EL, Parvisi J, Beck M, Leunig M, Hotxli H, Sie-
benrock PEA: Femoroacetabular impingement: A cause
for osteoarthritis of the hip. Clix! firth-op Refer Res
Zflfl3;41?:112-120. Medline
Beck M, Kalhor M, Leunig M, Gan: R: Hip morphol-
ogy influences the pattern of damage to the acetabular
cartilage: Femoroacetabular impingement as a cause
of early osteoarthritis of the hip. J Bone joint Sarrg Br
2fl05;3?{?}:1fl12-1013.Mcdlinc DUI
Tannast M, lIGoriclti D, Beck M, Murphy SE, Siebenrock
KA: Hip damage occurs at the zone of femoroacetabular
impingement. Clin Orthop Relat Res 2903;466(2]:2?3-
230. Medline DDI
Hack E, Di Primio G, Rakhta K, Beaule PE: Prevalence
of cam-type femoroacetabular impingement morpholo-
in asymptomatic volunteers. ,l' Horse Joint Surg Am
2010;92i14}:2436-1444.Medline not
Two hundred asymptomatic volunteers underwent MRI of
both hips. The images were examined for evidence of cam
deformity in angle greater than 5115“]. Cam deformity was
found in 14% of asymptomatic volunteers [1 [1.5“ii: bilateral
deformity and 3.5% unilateral deformity].
Kang AC, flooding A], floates MH, Goh TD, Armour P,
Rietveld J: Computed tomography assessment of hip joints
in asymptomatic individuals in relation to femoroacetabu-
lar impingement. Am '1' Sports Med 2D10;33[6}:1 1-50-1165. l‘r'
Medline DID] E
'U
One hundred hips in 51'] patients with no history of hip to
3
dysfunction underwent CT for abdominal pain or trauma. EL
'13
The images were assessed for evidence of impingement 1
pathology. At least one radiographic finding consistent to
El-
with PA] was identified in 39% of hips.
Ili'iosvig EH, Jacobsen S, Sonne-Holm 5, Palm H, Tro-
elsen A: Prevalence of malformations of the hip joint and
their relationship to sex, groin pain, and risk of osteo-
arthritis: A population-based survey. } Bone Joint Saar-g
Am lfllflt92lfiltllfil-1 169'. Medlitte DUI
This is a cross-sectional study of 4,151 individuals in the
Copenhagen IElsteoarthritis Study. Patient radiographs
were assessed for evidence of osteoarthritis and hip de-
formity [impingement and dysplasial. The prevalence of
osteoarthritis was 9.5% in men and 12.5% in women.
Combined deformity and arthritis were found in THE
of men and 36% of women. A pistol-grip deformity was
associated with an increased risk of osteoarthritis {risk
ratio 2.2], as was a deep acetabular socket {risk ratio 1.4}.
Laborie LE, Lehma nn TG, Engesseter IE}, Eastwood DIM,
Engesseter LB, Rosendahl K: Prevalence of radiographic
findings thought to be associated with femoroacetahu-
lar impingement in a population-based cohort of EDS]
healthy young adults. Radiology 2011;26fli2}:494-5l}1.
Medline D01
Drthopaedic Knowledge Update: Sports Medicine 5
 Seetien 2: Hip and Pelvie
This is a prospective study ef 2,031 yeung adults {mean
age, 13 years}. Radiegraphs were reviewed fm evidence
ef impingement pathelegy. A pistel-grip defermity was
feund in 21% cf males and 3% cf females. Piucer defer-
mity was seen equally ameng the sexes [14% in men and
5% in wemen, p e: llflfll}.
Pella rd TC, Villar RN, Nerten MR, et al: Genetic influ-
ences in the aetielegy ef femereacetabular itnpiugcment:
A sibling study. I Beesjefut Saar-g Er 2i] 10:92l2}:2flfl-216.
Medline DID]
Ninety-sis siblings cf 64 patients treated fer primary
FA] were clinically and radiegraphically assessed fer ev-
idence ef hip impingement. The siblings ef patients with
cam defermity had a 2.3 relative risk ef having the same
defermity. Cempared with centrel patients, the siblings
ef affected individuals had a 2.5 relative risk ef having
impingement merphelegy.
Agricela ll, Heiibeer MP, llflinai AZ, et al: A cam defer-
mity is gradually acquired during skeletal maturatien in
adelescent and yeung male seccer players: A prespective
study with minimum 2-year fellew-up. Am j' Sperts MerfI
2fl14;42{4}:293—3{}6.Medline DUI
This is a prespective cehert study bf 63 preprefessienal
seccer players whe were radiegraphically assessed befere
skeletal maturity and then reassessed ever a 2.5-year pe-
ried. The prevalence ef a cam defermity increased frem
2.1% te 12.2% during the time ef physeal clesure, with ne
additienal increase in severity fellewing physeal clnsure.
The anthers hypethesiae that cam defermities develep
slewly areund the time ef physeal clesure and may be
-E prevented by limiting athletic activity during this peried
2 ef skeletal grewth.
cu
e.
1:
I:
an 10. Carsen S, Mere: P], Rakhra K, et al: The |[titre Au-
E- franc Award. Du the et'ielegy ef the cam defermity: A
I
cress-sectienal pediatric MRI study. Cffn D-rtfrep Refer
H
Res 2014;422fllfl3fl-436. Medliue DUI
This is a cress-sectienal cehert study ef pediatric patients.
MRI was used tn evaluate 44 healthy velu nteers {33 hips}
befere and after physeal clnsure. The images were assessed
fer evidence ef a cam defermity in angle greater than er
equal te 50.5“], and velunteer activity level was cellected.
The mean at angles were 33" and 42“ in the patients with
epen and clesed physes, respectively. Altheugh ne patients
with epen physes had cam merphelegy, 3 cf 21 {14%} ef
these with clesed physes had at least ene hip with cam
merphelegy. These patients were all male and had a higher
daily activity level.
11. Kapreu AL, Andersen AE, Aeki 6K, et al: Radiegraphic
prevalence ef femereaceta bular impingement in cellegiate
feetball players: AADS Exhibit Selectien. I Herve jefnt
Snrg Am 2011;93{19}:e111, 1—10. Medline DUI
This is a prespective study ef 62 male cellegiate feetball
players {134 hips}. Plain radiegraphs were ebtained and
assessed fer evidence ef FAI {cam a angle greater than er
equal tn 5!)" er head-neck effset less than 3 mm, pincer
LCEA greater than 46", Tennis angle less than D“, audl'er
pesitivc cmssever sign]. At least ene sign ef cam er pincer
impingement was present in 95% ef hips. An abnermal n
firthepaedic Knewledge Update: Sperts Medicine 5
angle was feund in 22% cf hips, decreased femeral head-
neck effect in 64%, a cressever sign in 61%, a reduced
Tennis angle in 16%, and an increased LCEA in 2%.
12. Siebenreck HA, Eehning A, Mamisch TC, Schwah
JI'vI: IGrewth plate alteratien precedes cam-type defer-
mity in elite basketball players. Elie flrrbep Refer Res
2013:42ll4lflflfl4-1fl91.Medline [ll-DI
A case-centrel cemparative analysis was perfermed eu
yeung {age 9 te 22 years] elite male basketball players.
The presimal femeral physeal cstensien was measured
using radial sequence MRI cuts and cempared with an
age-matched centrel greup ef nenathletes. In athletes
with clesed physes, epiphyseal entensien eccurred enly
at the 3.- e'cIe-ck pesitien and cerrelated with an e angle
greater than 55°. The anthers cencluded that cam defer-
mity develeps in athletes as a censequencc ef alteratiens
re the grewth plate.
13. Siebenreck HA, Kascbka I, Frauchiger L, Werlen S,
Schwab Jl'vf: Prevalence ef cam—type defermity and hip
pain in elite ice heckey players befere and after the end
ef grewth. Am ] Sperts Med 2DlB;41{1fl}:2303-2313.
Medline DUI
Te assess fer evidence ef FAI, 22 elite male ice heckey
players underwent physical examinatien and MRI. flf
the athletes, 20% reperted a histery ef hip pain and had
a pesitivc impingement test finding. Alpha angles were
higher in athletes with clesed physes than in these with
epen physes {53" versus 49"}. The e. angle was higher, and
internal retatien was reduced in symptematic patients
versus asymptem atic patients.
14. Silvia ML, Mesher T], Smetana BS, et al: High prevalence
ef pelvic and hip magnetic resenancc imaging findings in
asymptematic cellegiate and prefessienal heckey players.
Am ] Sperts Med 2011;39l4}:215-221. Medline DUI
This is a cress-sectienal study ef 21 prefessienal and 13
cellegiate asymptematic ice heckey players. Athletes cem—
pleted the medified flswestry Disability Questiennaire
and underwent MRI. Pathelegic hip changes were seen
in 64% ef athletes, and MRI findings ef cemmen adduc-
ter—abdeminal rectus dysfunctien were seen in 36% cf
athletes.
15. Gerhardt MB, Remere AA, Silvers H], Harris DJ, Tata-
uabe D, Mandelbaum ER: The prevalence ef radiegraphic
hip abnermalities in elite seccer players. Am }' Sperts Med
2012;4{l{3]:534-533. Mcdline DUI
The authers retrespectively reviewed the pelvic radiu-
graphs ef 95 elite male and female seccer players te as-
sess fer evidence ef FAI. Symptematic and asymptematic
athletes were included. Radiegraphic evidence ef FAI was
found in 22% cf males and 5{1% ef females. A cam lesien
was feund in 63% ef males {22% bilateral} and 5D% ef
females {90% bilateral}. Pincer lesiens were feund in 22%
ef males and 16% ef females.
16. Larsen CM, Sikka ES, Sardelli MC, et al: Increasing alpha
angle is predictive ef athletic'related “hip” and "grein‘
pain in cellegiate Natienal Feetball League prespects.
Artbrescepy 2U13;29{3}:4f}5-41fl. Medline DUI
fl 2616 American Academy ef Urthepaedic Surge-ens

This is a cohort study involving 125 male collegiate foot;
hall players {139 hips] undergoing physical and radio-
graphic evaluation of the hip during the National Football
League Scouting Combine. Symptomatic and asymp-
tomatic athletes were included. Ninety percent of athletes
had at lea st one radiographic finding consistent with FAI
{pincer or cam deformity]. An increased prevalence of cam
deformity was found in the symptomatic group, and an
increasing a angle was the only independent predictor of
activity-related groin pain.
1?. Elohisy JC, Baca G, Beaule PE, et al; ANEHDR Study
IGroup: Descriptive epidemiology of femoroacetabular
impingement: A North American cohort of patients un-
dergoing surgery. Am] Sports Med 2013;41[El:1343—1356.
Medline DUI
This a cross-sectional multicenter study assessing the
epidemiology of FAI. A total of LETS consecutive pa-
tients {1,13ll hips} undergoing surgical treatment of FAI
were included. A primary cam deformity was the main
pathology in 43% of hips; 4.5% had combined pincer:Ir
cam pathology; and 19% had isolated pincer pathology.
Surgical intervention included a hip arthroscopy in Sfl'i'v’n
of patients, surgical dislocation in 34%, a reverse periac-
etabular osteotomy in 9.4%, a combined hip arthroscopy
and limited open osteochondroplasty in 5.3%, and an
isolated limited open osteochondroplasty in 1.5%. At the
time of surgery, labral and chondral lesions were found in
more than RUSS of hips. A labral repair was performed in
43% of hips, a labral débridement in 16%, a rim trim in
SEE, and a femoral osteochondroplasty in 92%.
IS. Larson CM, IL'iiveans MK: Arthroscopic management of
femoroacetabular impingement: Early outcomes measures.
Arthroscopy lflflR;24[S}:54fl-S45. Medline III-DI
15‘. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Gan:
R: Anterior femoroacetabular impingement: Part II. Mid-
term results of surgical treatment. Ellis Drthop Relet Res
2Dfl4;413:6?—?3.Medline DUI
2f}. Johnston TL, Schenlrer ML, Briggs KK, Philippon M]:
Relationship between offset angle alpha and hip chondral
injury in femoroacetabular impingement. Arthroscopy
EDGE;E4{S}:ESH-6?5.Mcdline DUI
21. Eedi A, Kelly ET, Khanduja V: Arthroscopic hip preser-
vation surgery: Current concepts and perspective. Bose
Ins-rt] 2D13;95-E[1]:lfl-19. Medline [ll-DI
The study is a review of the epidemiology, etiology, diag-
nosis, and treatment of femoroacetabular impingement.
22. Larson CM, Kelly ET, Stone RM: Making a case for
anterior inferior iliac spinefsubspine hip impingement:
Three representative case reports and proposed concept.
Arthroscopy 2G1];2T{12J:1?32-l?31 Medline not
The study is a case report of three patients with symptom-
atic subspine impingement who were treated with arthro-
scopic decompression.
23. Hetsroni I, Larson CM, Dela Torre K, Zbeda KM, Ma-
gennis E, Kelly ET: Anterior inferior iliac spine deformity
as an extra-articular source for hip impingement: A series
IR! EDIE American Academy of flrthopaedic Surgeons
Chapter 11: Femoroaeetabular Impirlgement
of Ill patients treated with arthroscopic decompression.
Arthroscopy lflllglflll oases—less. Medline DUI
The study is a retrospective review of 10 patients with
symptomatic subspine impingement. (if all patients, Hfl'is’:
had a coexisting cam lesion that also was addressed at the
time of hip arthroscopy. The technique for arthroscopic
subspine decompression is presented. Postoperatively, the
mean patient hip range of motion improved from 99" e
T” to 11?“ = 3". The modified Harris Hip Score improved
from 64 to .93 at an average follow-up of 14.? months.
14. Clohisy JC, Nunley RM, Curry ME, Schoeneclter PL:
Periaceta hular osteotomy for the treatment of acetahular
dysplasia associated with major aspherical femoral head
deformities. I Hone joint Sterg Arr: lfiflTflflfflfl‘lfl-HES.
Mcdline DUI
15. Siebenroclt KA, Schiill E, Lottenbach M, Gan: R: Eer-
nese periacetabular osteotomy. Cilia Urtlrop Relat Res
1999;363:9-29. Medline
26. Hammond S, Eedi A, 1idoes JE, Mauro CS, Kelly ET: The
recognition and evaluation of patterns of compensatory
injury in patients with mechanical hip pain. Sports l-l'erll'tl'sI
2014;5{2lflflfl—113. Medlinc DUI
The study is a literature review of the compensatory injury
patterns associated with intra-articular hip pathology,
including osteitis pubis and dysfunction of the sacroiliac
joint andtor lumhosacral spine.
2?. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Har-
rieayes M, Prather H: Clinical presentation of patients
with symptomatic anterior hip impingement. Clio Grthop l‘r'
Relnt Res 2Gfl9:46?{31:633-S44. Medline DUI E
'U
This is a prospective cohort study that evaluated the clin- to
ical presentation of patients with symptomatic FAI. Most
3
EL
patients reported an insidious onset of symptoms with a
'13
1
time of onset to definitive diagnosis beginning at 3.1 years. In
El-
Eighty-eight patients reported pain in the anterior groin.
Hip motion was limited to an average flexion of 9?” and
9" of internal rotation at .913" of hip flexion.
2.3. Allen D, Beaule PE, Ramadan fl, Doucette 5: Prevalence
of associated deformities and hip pain in patients with
cam—type femoroacetabular impingement. I Horse joint
Resp Br lflfl9;91{5J:539—594. Medlinc DUI
This is a cohort study of 113 patients with symptomatic
FAI of at least one hip without evidence of concomitant
dysplasia or osteoarthritis. Bilateral cam deformity was
present in FREE of patients, but only 26% had bilateral
hip pain. A higher a angle was found in symptomatic
hips compared with asymptomatic hips {17W versus 53",
p e flflfll}. The odds ratio of a painful hip was 2.59 in
hips with an a angle greater than fill“.
29. Nepple J], Martel jM, Kim Y— , Zalta I, Clohisy JG; AN—
CHDK Study Group: Do plain radiographs correlate with
CT for imaging of cam-type femoroacetabular impinge-
ment? Clio Drtlvop Relst Res 1012;4TDE12}:3313-332fl.
Medline D0]
This is a retrospective review of 41 surgical patients. Radial
oblique reformats of preoperative CT scans were compared
Drthopaedic Knowledge Update: Sports Medicine 5
 Seefinn 2: Hip and Pelvis
with plain radingraphs. A standard radingraphic hip series
{AP pelvis, 4.5” Dunn, and frng-lateral views} has an 36%
tn 33% sensitivity in detecting an ahnnrmal a angle as seen
nu ET. The Dunn view was mnst sensitive in detecting a
cam defermity {21% tn 33%} but the frng-lateral view was
the must specific {91% tn 103%}. The crnss-table lateral
view did nnt imprnve sensitivity.
3‘3. IElnhisy JC, Carlisle JC, Eeaulé PE, et al: A systematic
apprnaeh tn the plain radiographie evaluatinn cf the ynung
adult hip. j Hesse Inset Surg Am 2flflfltfiflifiuppl 4}:4?— 66.
Medline DUI
31. Meyer DC, Beck M, Ellis T, Gans FL, Leunig M: Cem-
parisnn nf six radingraphic prnjectinns tn assess fem-
nral headfneelr asphericity. Che firshnp Reins Res
2336;445i445]:131~l35. Medline
32. Zilltens (I, Miese F, Kim ‘r'— , et al: Three—dimensinnal de—
layed gadnliniu m-enhanced magnetic resnnance imaging
nf hip jnint cartilage at ST: A prnspective cnntrnlled study.
Eur} Rndr'ni stuns1n 1}:3426-3415. Medline m:
This is a ease—enntrnl study cf 46 patients with symptnm—
atic FAI, dysplasia, nr Legg-Calve-Perthes disease whn
underwent high-resnlutinn dGEMRIC MRI fnr evaluatinn
nf the hip articular cartilage. The patient imaging results
were enmpared with these nf a grnup nf asymptnmatic
cnntrnls. The glycnsaminnglycan cnntent was significantly
higher in the cnntrnl grnup than in the patient grnup,
enrrespnnding tn underlying ehnndral damage in the pa—
tients with FAI.
-E 33. Bngunnvie L, Gnttlieh M, Pashns G, Eaea G, Clnhisyjfl:
E
a: Why dn hip arthrnscnpy prncedures faili' Clive Urshnp
n. Reins Res 2313;421i3}:2523-2529. Medline DUI
1:
I:
rt: This is a prnspective cnhnrt study nf 1,224 cnnsecutive
E-
I
patients whn underwent revisinn hip preservatinn surgery
H
fnllnwing prinr hip arth rnsenpy. Residual FAI was the rea-
snn fnr failure in 63% nf patients, and underlying scetabu-
lar dysplasia was the reasnn fnr failure in 24% nf patients.
Revisinn prncedures included revisinn hip arth rnsenpy
{42%}. Periacetahular nstentnmy {24%}, and surgical hip
dislncatinn {32%}.
34. 1iiiiall PD, Fernandez M, Griffin DR, Fnster NE: Nnnnp-
erative treatment fnr femnrnacetahular impingement: A
systematic review cf the literature. PM P. 2613:5i5JHl3-
426. Medline DUI
This is a systematic review including five studies evaluating
the nnnsurgical treatment nf FAI. Despite limited data
in the included studies, the authnrs suggest that physical
therapy and activity mndificatinn may cnnfer snme henefit
tn patients. Further research evaluating the nutcnme nf
nnnsurgical management, especially physical therapy, is
needed, hnwever.
35. Yashelt PM, Uvanessian h", Martin RL, Fukuda TY:
Hensu rgical treatment nf aeetahular lahrum tea rs: A case
series. I Drthnp Spnrts Phys TIE-er 2311;4“5 1:346-353.
Medline DUI
This is a case series nf fnur patients with a symptnm-
atic lahral tear treated with nnnsurgical management.
firthnpaedic Knnwledge Update: Spnrts Medicine 6
All patients underwent a three-phase physical therapy
prngram prngressing frnm pain cnntrnl and trunk stabi-
lisatinn tn muscular strengthening, sensnry mntnr train-
ing, and spnrt specific prngressinu. All patients repnrted
reduced pain and imprnved functinn.
36. Eieeiardi BF, Fields K, Kelly ET, Ranawat 6.5, Cnleman
3H, Sink EL: Causes and risk factnrs for revisinn hip pres-
ervatinn surgery. Am ] Spnrts Med 2314;42f11]:262?-
1633. Medline DUI
This is a crnss-seetinnal study nf 147‘r patients in whnm
prinr hip arthrnscnpy had failed. Eeasnns fnr print failure
included residual femnrnacetahular impingement [25%]
and residual extra-articular impingement [3.6%]. Ap-
prnt-timately 33% cf revisinn prncedures were perfnrmed
arthrnscnpically. Patients repnrted imprnved functinn
fnllnwing revisinn at an average nf 15 mnnths.
3?. Clnhisy JC, 3t Jnhn LC, Schuta AL: Surgical treatment nf
femnrnacetabular impingement: PL systematic review nf the
literature. Ciit: Orthnp Reins Res 2010;463i2}:555~564.
Medline DD]
This is a systematic review nf 11 studies evaluating the sur-
gical treatment nf F31. The mean fnllnw-up was 3.2 years.
All studies repnrted reduced pain and imprnved funetinn
in patients fnllnwing surgery. Majnr cnmplicatinns ne-
curred in tern tn 13% nf prncedures.
33. Nhn 3], Magennis EM, Singh CK, Kelly ET: l[I'lutcnmes
after the arthrnscnpic treatment nf femnrnacetahular im-
pingement in a mixed grnup nf high—level athletes. An:
I Spurts Med 2311;39i3upplltl43-193. Medline DUI
This is a case series cf 4? high-level athletes whn under-
went arthrnscnpic treatment nf symptnmatic FAI. Fnl-
lnw-up was nbtained in 23% nf patients at 1 year. The
average mndified Harris Hip Senre imprnved frnm 63 tn
33, and the mean u angle imprnved frnm 26° tn .51”. [if
all patients, 29% were able tn return tn play at an average
cf 9 mnnths pnstnperatively. Pit 2—year fnllnw—up, 23% cf
patients cnntinued tn cnmpete.
39. lEnllins Jr's, Ward JP, Ynum T: Is prnphylactic surgery
fnr femnrnacetahular impingement indicated? A system-
atic review. Am ,i Spnrts Med 2614;42i12}:3669-3i}15.
Medline DUI
This is a systematic review perfnrmed tn determine the
efficacy nf prnphylactic surgery fc-r FA]. Ne studies were
identified tn suppnrt treatment nf an asymptnmatic hip.
43. Saad at E, Martin 5D, Thnrnhill T3, Ernwnlee SA, Lnsina
E, Kat: JN: Factnrs assnciated with the failure nf surgical
treatment fnr femnrnaeetahular impingement: Review nf
the literature. Am ] Sperrs Med 2013;42i6}:143?-1495.
Medline Dfll
This is a systematic review nf 13 studies evaluating the
faetnrs assnciated with failure ef hip arthresenpy. Factnrs
assnciated with peer pnstnperative nutcnme and cnnver-
sinn tn hip arthrnplasty included prenperative chnndral
damage, nlder age, a pnnr prenperative mndified Harris
Hip Senre, and a lnnger du ratinn nf symptnms {mere than
1.5 years}. Prenperative nstenarthritis was the strengest
predictnr nf pnstnperative cnnversinn tn hip arthrnplasty.
IE 2616 American Academy nf Cirrhnpaedic Surge-ens
Chapter 12
Extra-articular Hip Disorders
LWC Thomas Byrd, l'l Guillaume D. Dumont, MD
Abstract
Extra-articular etiologies of pain represent an import“
ant subset of hip disorders. Physical examination and
imaging modalities including radiographs, ultrasonog—
raphy, and MRI are helpful in accurately identifying
the pathology. Most hip pathologies can be treated ini-
tially with nonsurgical measures including rest, activity
modification, NSAIDs, and physical therapy. Directed
injections are helpful in the diagnosis and treatment of
extra-articular pain. The surgical treatment of these
disors can be successful in cases that persist despite
nonsurgical measures.
Keywords: greater trochanteric pain syndrome;
trochanteric bursitis: hip abductor tears: piriformis
syndrome: snapping hip
Introduction
Extra-articular hip disorders are common and can present
a diagnostic and therapeutic dilemma. Treatment algo-
rithms have evolved with the advent of modern arthro-
scopic and endoscopic techniques. Thorough directed
history and physical examination techniques as well as
br. Byrd or an immediate famiiy member serves as an on-
paid consultant to A3 Surgical; has stuck or stock options
heici in A3 Surgicai; serves as a paid consuitant to or is an
empioyee of Smith b Nephew; has received research or
institutionai support from Smith a Nephew: and serves as
a board member. owner; officer; or committee member
of the American Drthopaedic Society for Sports Medicine.
the Arthroscopy Association of North America, and the
internationai Society for Hip Arthroscopy. Neither Dr.
Damont nor any immediate famiiy member has received
anything of value from or has stock or stock options heid
in a commercial company or institution reiated directly or
indirectiy to the subject of this chapter.
fl lflld American Academy of Drrhopaedic Surgeons
patient selection for various nonsurgical and surgical
treatment options remain paramount for the successful
treatment of these disorders. This chapter discusses the
scientific advances relating to greater trochanteric pain
syndrome [GTPSL piriformis syndrome, external snap-
ping hip, and internal snapping hip.
Greater Trochanterit Pain Syndrome
GTPS is a term that encompasses various possible eti-
ologies of pain to the lateral hip, including trochanteric
bursitis, tears or enthesopathy of the gluteus medius and
minimus, and occasionally, friction of the iliotihial band
over the greater trochanter. GTPS typically presents with
pain or reproducible tenderness over the greater trochan-
ter, buttock, or lateral thigh and is relatively common,
affecting 113% to 25% of the general population.I The use
of the term “trochanteric bursitis” has declined in recent Pr'
years, after the realization that inflammation of the bursa 3.
'U
typically is not identified in patients with lateral hip pain. to
3
EL
More often, pathology involving the tendinous insertions '13
1
to the greater trochanter appears to be culpable. m
El-
A retrospective study of the ultrasonograms of 3?? pa-
tients with GTPS revealed that only 20.2% (1?? patients]|
had sonographic evidence of bursitis. Elf the remainder,
49.9% (433 patients) had gluteal tendinosis, [1.5% {4 pa-
tients} had gluteal tendon tears, and 23.5 '34: {250 patients}
had thickening of the iliotihial band.1
Although evidence is increasing for the importance of
tendon injury versus bursal abnormality in patients with
GTPS, the importance of the bursa in GTPS should not
yet be discounted completely. h 2fl14 histologic study
found that the presence of substance P was increased,
or found more frequently, in the trochanteric bursa of
patients with GTPS and control subjects, but no increase
was noted within the glutens medius tendon. The study
group and control group showed little evidence of positive
staining for inflammatory cells in the tendon or bursa,
reinforcing the hypothesis that inflammation likely is
not the main cause of GTPS. The increased presence of
substance P also has been identified previously in the
subacromial space of patients with rotator tendinopathy.3
Drthnpaedic Knowledge Update: Sports Medicine 5
 Section 2: Hip and Pelvis
Increasing evidence has shown an association between
abnormal biomechanics and the development of GTPS.
A 2fl15 study of 203 hip MRIs found a significant as—
sociation between increased acetabular anteversion and
the presence of gluteal tendinosis. The mean acetabnlar
version in patients with gluteal tendinosis was 13.4“ com—
pared with 15.?“ in those without gluteal pathology.‘
Several muscles insert at or near the greater trocha nter
of the femur, including the gluteus medius and minimus,
obturator internus, and obturator externus. The gluteus
maximns has a broad origin from the ilium and sacrum
and inserts on the iliotibial band and gluteal tuberosity
of the lateral femur. The gluteus medius and minimus
lie deep to the gluteus maximus, originating from the
ilium and inserting at the greater trochanter. The tensor
fascia latae originates from the iliac crest and inserts on
the iliotibial tract. Figure 1 shows the close relationship
of these structures. Several bursae surround the greater
trochanter to protect it from the surrounding tendons.
The subgluteus medius bursa lies superior to the greater
trochanter, deep to the gluteus medius. The subgluteus
maximns bursa lies between the gluteus maximus and
the gluteus medius and lateral to the greater trochanter.
A division of this bursa commonly is referred to as the
trochanteric bursa.”
Patients typically present with hip pain. A careful his—
tory can help differentiate GTPS from pain originating
-E
2
from the lumbar spine or groin pain originating from
cu intra—articular hip pathologies. Patients often report diffip
o.
1:
I:
an
culty sleeping on the affected side and pain with increased
E- periods of standing on the limb or with walking. Pain
I
H can radiate down the lateral thigh to the knee. A der-
matomal distribution of pain or pain radiation distal to
the knee should trigger the evaluation of lumbar spine
radiculopathy.
The presence of GTPS was evaluated in members of
the military, and its prevalence was found to be higher
in individuals older than 4!} years. Female sex had the
largest association with the presence of GTPS, with a
fivefold increase compared with males? Another prospec—
tive cohort study of women treated for GTPS compared
with an asymptomatic control group found that a lower
femoral neck-shaft angle and adiposityr were associated
with GTPS.fl
Pain from GTPS can cause substantial disability and,
when chronic, can affect mental health, employment,
and quality of life. fine study found that patients with
GTPS were the least likely to be working full time com—
pared with patients with end-stage hip osteoarthritis and
asymptomatic control patients. Dtherwise, GTPS ap-
peared to confer levels of disability and affect the quality
of life similarly to end-stage hip osteoarthritis?
flrdiopaedic Knowledge Update: Sports Medicine 5
Gluteus
ITIEIdLI-E _
Gluteus
mirirrus ——
lliotihial
hand
Troohanterie
bursa
\
Greater
trochanter
Drawing shows the anatomic insertion of the
gluteus medlus and the gluteus minimus on
the greater trocha nter in close proximity to the
iliotihial hand. The truth anteric bu rsa lies deep
to the iliotihial hand. All of these structures
have been implicated in the development
of symptoms of greater trochanteric pain
syndrome.
Physical examination often shows tenderness with
palpation of the greater trochanter. Patients may present
with an antalgic gait or the classic Trendelenburg gait if
weakness of the gluteus medius is pronounced. Manual
muscle testing of the gluteus medius often demonstrates
weakness and reproduces pain at the greater trochanter.
A new physical examination finding, the hip lag sign,
has been described, in which the examiner places the
hip in 10" of extension, maximal abduction, and internal
rotation. The patient’s inability to actively maintain the
position, with a noted drop of 10 cm at the foot, is con-
sidered a positive finding associated with hip abductor
damage substantiated by MRI!“
Radiographs of the hip may show surface irregularities
at the greater trochanter consistent with enthesopathy or
calcific tendinosis. Radiographs are also useful in identi-
fying possible coexisting disorders such as osteoarthritis
of the hip and fractures. MRI has the ability to depict
osseous and soft~tissue abnormalities, including peritro~
chanteric edema and tendinosis or tearing of the gluteus
medius and gluteus minimu s. The use of ultrasonography
to aid in the diagnosis and management of gluteal tendon
tears has evolved because of its low cost, availability, and
ability to guide treatments such as anesthetic and cortico—
steroid injections.ll A systematic review that compared
fl lfllfi American Academy of Orthopaedic Surgeons

the accuracy of ultrasonngraphy and MRI in diagnosing
gluteal tendon pathology with surgical findings of the
same pathology found that MRI had a sensitivity of 33%
to lflD%, a specificity of 91% to lflfl‘ifi, and a positive
predictive value of T'il'i'e to 100%, with a high rate of
false—positive results. Ultrasonngraphy had a sensitivity
of ?9% to lflfl% and a positive predictive value of 95%
to 100%.” Although ultrasonography is dependent on
technician proficiency, it may be a less costly and more
effective imaging modality for gluteal tendon pathology.
Nonsurgical treatment is the mainstay of care and
should begin with activity modification, NSAIDs, stretch—
ing, and physical therapy. Anesthetic and corticosteroid
injections to the trnchanteric bursa can be beneficial and
can be performed with or without image guidance. Ultra-
sonographic guidance offers the advantage of providing
visual evidence of damage to the gluteus medius tendon
and can help accurately position the injectate adjacent to
the damaged tissue tn maximize efficacy.
Fluoroscopic guidance also has been used tn direct
injections in patients with GTPS. A multicenter double-
hlind, randomized controlled study showed no improve-
ment in outcomes at 1—month or 3—month follow—up in
patients who had received flunroscnpically guided in-
jections compared with those who were administered
injections withnut image guidance. The cost associated
with flunrnscnpically guided injectinns was significantly
higher.13 Given the lack of evidence supporting the use
of flunrnscnpically guided iniectinns for the treatment of
GTPS, ultrasonographic guidance can he considered in-
stead, because it offers the ability tn concomitantly assess
the abductor tendnns for structural damage.
A randomized controlled trial of patients with GTPS
assigned tn a group that received corticosteroid injec-
tions or a group that received nonsurgical care withnut
injections showed clinically significant improvement at
3 months in the study group compared with the control
group. The difference in outcomes was no longer present
at 11 months, however.”
The authors of a 21314 study considered some pain relief
from the first injection tn he a positive indicator of com-
plete remission, although pain reduction was maximal
after the third injection tn the region of the trnchanteric
bursa. The radinlngic presence of isolated trnchanteric
bursitis, versus the presence of associated gluteus medius
tendinnpathy, was associated with greater pain reduction
in the immediate postinjection phase and over the long
term.”
A study comparing the efficacy of ultrasound-guided
injections directed toward the trnchanteric bursa with
those administered in the su bgluteus medius bursa found
that those administered in the trnchanteric bursa were
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 12: Extra-articular Hip Disorders
most effective, eliciting a visual analog scale {VAS} score
reduction of 3, compared with D in those given in the
subgluteus medius bursa. No association was seen be-
tween demographic variables or ultrasound findings and
pain relief."5
Extracorporeal shock wave therapy {ESWTJ has been
used tn treat varinus tendinopathies, including GTPS. A
systematic review examining the effectiveness of ESWT
found moderate evidence that it was more effective than
home physical therapy and corticosteroid injections at
short-term {less than 12 months] and long-term {greater
than 12 months} follow—up.” Its use in conjunction with
other nonsurgical treatment methods is supported.
Surgical treatment typically is not required; however,
in cases of recalcitrant pain with tearing of the abduc-
tor tendons, repair of the abductor tendons can be per-
formed.” Various techniques can be used to repair the
tendons to their insertion, including open transnssenus nr
hone-anchored suture techniques, endoscopic techniques,
and tendon augmentation for repair reinforcement.19
Double-row fixation analogous to the repair of the rotator
cuff has been described.” Either authors advocate the
importance of ilintibial band release to reduce excessive
tension between the ilintibial band and the greater tro-
chanter and report a technique for endoscopic bursectomy
and cruciate release of the ilintibial band.“
A study examining outcomes in 12 patients treated
with open repair of the gluteus medius tendon through H
bone tunnels showed improvement in the mean Har- E
'U
ris Hip Score from 53 prenperatively to 3? at 1-year to
3
EL
follow-up and 33 at 5—year follow-up. No correlation '13
1
was found between tear size or pattern and outcomes, us
El-
but the three patients with poor results were in the group
with larger tears. Most patients were satisfied and would
undergo the procedure again if necessary}1
In a series of 13 patients with GTPS who underwent
endoscopic cruciate release of the ilintibial band, substan-
tial improvements were noted in the visual analog scale
pain score, the modified Harris Hip Score, the Western
fintario and McMaster Universities Arthritis Index, and
the Hip IClutcnme Score, at 3, E, and 12 months, compared
with preoperative scores. The mean VAS improved from
3.1 prenperatively to 0.43 at 12 months, whereas the
modified Harris Hip score improved from 40.2 preop-
eratively to 36.29 at 12 months. No patients underwent
additional surgical procedures to the hip within the fol-
low-up period.23L
A systematic review of treatment options for GTPS
found that traditional nonsurgical methods, including
physical therapy with stretching, low-energy shock wave
therapy, and corticosteroid injectinns, help most patients.
The efficacy of all surgical treatments studied, including
Drthnpaedic Knowledge Update: Sports lvledichie .‘i
 Sectinn 2: Hip and Pelvis
bursectnmy, lnngitudinal release nf the ilintibial band,
Z-plasty lengthening cf the ilintibial band, nstentnmy,
and gluteal tendnn repair, was superinr tn nnnsurgical
management; thus, these surgical treatments are wnrthy
nf cnnsideratinn in refractnry cases.M
F'irifnrmis Syndrnrne
Pirifnrmis synd rnme is characterized by extrapelvic cnm-
pressinn nf the sciatic nerve by the pirifnrmis muscle in
the area nf the greater sciatic nntch. Symptnms include
pain and dysthesthesias tn the buttnck, hip, nr pnsterinr
thigh and pain distally as a result nf radicnlar pain. Hy-
perttnphy nf the bands nf the pirifnrmis can cnmpress the
sciatic nerve nr its branches. The sciatic nerve typically
exits the greater sciatic feta men, passing deep tn the belly
nf the pirifnrmis and superficial tn the superinr and in—
ferinr gemelli and nbturatnr internus {Figure 2}. Several
anatnmic variants nf this relatinnship have been nnted
and can cnntribute tn undue cnmprcssinn nf the sciatic
nerve; hnwever, the nnrmal anatnmic relatinnship is fnu nd
in mnst cases. Cine cadaver study identified SETS nf 294
specimens (93.6%} that had the typical anatnmic pattern,
with variatinns nf the anatnmy in the nther 19 specimens
(6.4%).” Dther lesinns such as snft-tissue masses, abscess-
cs, aneurysms nr aberrant veins, and mynsitis nssificans
can cnntribute tn cnmprcssinn nf the sciatic nerve.
-E
2
Diagnnsis relies en a detailed histnry and clinical es:-
tn aminatinn. Pirifnrmis syndrnme shnuld be cnnsidered
:1.
1:
I:
re
in cases nf sciatica nr pnsterinr gluteal nr thigh pain
E- assnciated with nnndiagnnstic clinical evaluatinn and
I
H MRI nf the spine. Palpatinn usually reveals tenderness
cf the pirifnrmis muscle, where a sausage-shaped mass
may be nnted. Palpatinn may rcprnduce radicnlar pain.
Passive straight leg raise {the Lasegue sign} and l'lettinn,
adductinn, and internal rntatinu [FADIR] cf the hip EI-
accrbate the symptnms. Passive internal rntatinu nf the
hip in neutral extensinn and resisted flexinn and external
rntatinn place tensinn cm the pirifnrmis muscle and can
rcprnduce symptnms. Neurnlngic enaminatinn findings
such as abnnrmal reflexes, mntnr weakness, and sensnry
changes are pnssible but rare.
Diagnnstic imaging is used tn exclude nther snurces
nf symptnms, including the lumbar spine and hip jnint.
CT and MRI are useful fnt detecting spaceunccupying
lesinns that cnuld prnduce symptnms nf sciatic nerve
cnmprcssinn. MRI alsn can identify the presence nf a
hypertrnphied nr damaged pirifnrmis and can identify
annmalnus pirifnrmis muscle anatnmy nr variatinns in
the sciatic nerve.
Electrndiagnnstic testing can be useful tn lncalize an
impingement nf the sciatic nerve by the pirifnrmis. The
firthnpaedic Knnwledge Update: Spnrts Medicine 5
Gluteus
metius
Gluteus
ninimue
Piriinnnis
Eiluteus
medius
Gemeilue
superinr
Eemeilus
inierinr
Quadreius
iemnris
Sciatic nerve I i Dbturatnr
intern us
Figure '2 Drawing depicts the cnurse cf the sciatic nerve.
which is typically deep tn the pirifnrmis muscle
and superficial tn the su peni er and inierinr
gemelli, the nhturatnr internus. and the
quad ratus fernnris. In patients with pirifnrmis
syndrnme, the nerve is compressed by one er
mere at these structures.
H-reflex nf the pernneal divisinn nf the sciatic nerve is
substantially prnlnnged in affected patients when the litnb
is placed in the prnvncative FADIR pnsitinn.“ Injectinns
nf lncal anesthetic and sternid intn the pirifnrmis muscle
can be useful tn cnnfirm the diagnnsis.
Cine repnrt suggested a diagnnstic criteria fer the di-
agnnsis nf pirifnrmis syndrnme that included (1} buttnck
nr leg pain made wnrse by sitting, stair climbing, andInr
leg crnssing; {1} pain with palpatinn cf the sciatic nntch;
{3} an evidence nf artnnal lnss nf the sciatic nerve nn elec—
trnphysinlngic testing; {4} nn nther imaging findings that
cnuld explain the presence nf sciatica; and i5} reductinn
nf symptnms by mnre than Efl% with diagnnstic injectinn
under image guidance.”
The treatment algnrithm nf pirifnrmis syndrnme shnuld
begin with rest, anti-inflanunatnry medicatinns, muscle
relaxatinn, and physical therapy directed at stretching
the pirifnrmis muscle. Stretching pnsitinns shnuld include
the FADIR pnsitinn. Therapeutic injectinns tn the piri~
fnrmis muscle using sternids, bntulinum tnsin, nr pain-
blnclting agents have been used with success. Imaging
guidance using CT nr ultrasnnngraphy is acceptable. Sev-
eral studies have verified the placement nf ultrasnund-
guided injectinns using MRI nr CT and fnund the
technique reliable.13~35' Caudal epidural sternid injectinns
fl lflld American Academy nf Urthnpaedic Surge-ens

lliopsoas
Femur internm
A rotated
Fig u re 3 Drawings show the iliopsoas tendon, which produces a loud and sometimes painful snapping when It moves over
the anterior hip capsule and femoral head as the hip is extended, internally rotated, and odducted (ill from an
externally rotated, flexed, and abducted position {3}.
also have been reported for the treatment of piriformis
syndrome. Anesthetic and corticosteroid injections de-
posited into the caudal epidural space can be expected to
course along the nerve root to the sciatic nerve and can
provide substantial relief.
Surgical release of the piriformis tendon and neurolysis
of the sciatic nerve can be performed using an open or
endoscopic surgical approach. lEinly minimal functional
loss occurs after release of the piriformis because of the
contribution of the other external rotators of the hip. In
properly selected patients in whom the piriformis is ac-
tually the impinging structure, immediate relief usually
can he anticipated. In a series of patients treated with
endoscopic decompression of the sciatic nerve, VHS scores
for pain improved from a mean of 6.9 preoperatively to
2.4 at 12-month follow-up. Df all patients, 33% had no
pain after sitting for more than 30 minutes at follow-up.“
In summary, emphasis should be placed on thorough
evaluation of patients presenting with symptoms consis-
tent with piriformis syndrome and on the importance
of exhaustive nonsurgical management, including rest,
activity modification, stretching, and physical therapy.
Diagnostic and therapeutic injections can help confirm the
diagnosis and provide substantial relief. Recalcitrant cases
can be considered for surgical release of the piriformis
and any other structures impinging on the sciatic nerve.
Coxa Saltans Interns
lL'Zoxa saltans interna, or internal snapping hip, is a syn-
drome caused by the snapping of the iliopsoas tendon over
the structures lying deep to it. The iliacus and psoas com—
bine to form one tendon as they pass between the anterior
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 12: Extra-articular Hip Disorders
lliopaoaa
Femur externally
B rotated
inferior iliac spine and the iliopectineal eminence. The
tendon passes over the anterior hip capsule and courses
posterior-1y in its bursa to insert at the lesser trochanter.
Patients typically report an audible, loud clunk, which
they often can reproduce. With the hip in a flexed, abduct-
ed, and externally rotated position, the tendon assumes a
lateral position on the iliopectineal eminence and moves
from lateral to medial as the hip is moved to extension,
adduction, and internal rotation. The snapping results i‘t'
from the movement of the tendon over the anterior hip E
'U
to
capsule and femoral head {Figure 3}. Bony variants or :s
Ill
abnormalities of the anterior acetabulum, femoral head, 1:
1
or lesser trocha nter also can contribute to the pathology. E.
In“
Inflammation of the large iliopsoas tendon bursa also has
been implicated.“
Patients may present for evaluation of medial groin
pain and with history of a hyperextension injury or groin
strain. They may have noted clicking or popping of the
hip that has worsened over time. The popping sound
typically is audible to anyone near the patient, in contrast
to the external snapping hip, which clearly is visible but
not usually audible. Activities of daily living may not be
painful; however, sports requiring hip flexion can aggra-
vate the symptoms.
Physical examination of the hip must be thorough to
rule outother pathologies than can present with medi-
al groin pain, such as adductor strains, osteitis pubis,
and intra-articular disorders such as femoroacetabular
impingement. In the supine position, the patient often
can reproduce the snapping by extending and adducting
the flexed and abducted hip. The examiner can suppress
the snapping by applying pressure over the anterior hip,
thereby restricting the motion of the tendon.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 2: Hip and Pelt-fie
Plain radiographs of the hip typically are normal but
may show bony morphologic variants such as hip dyspla-
sia or femoroacetabular impingement. MRI may show
thickening of the tendon and fluid in its bursa.
a certain portion of the population has a painless snap-
ping iliopsoas tendon. Without the presence of associated
pain, the patient can be reassured, and no treatment is
required. Initial treatment of the painful internal snapping
hip should focus on rest, activity modification, stretching
of the iliopsoas, and HSAIDs. Image-guided anesthetic
injections can help to confirm the diagnosis but also can
be therapeutic with the addition of a corticosteroid.
Surgical treatment involves the release or fractional
lengthening of the tendon and can be performed through
an open, endoscopic, or arthroscopic approach. The ten-
don can be released at its insertion at the lesser trochanter,
from the peripheral compartment, or more proximally
from an intra-articular approach.
Release both from the central compartment and at the
lesser trochanter produced good results in a study com-
paring the two techniques in 2D patients with a minimum
follow-up of 24 months}2 A series of 55 patients undergo-
ing fractional lengthening of the tendon from the central
compartment reported 31.8% {45 patients} excellent or
good outcomes and 31.3% resolution of the snapping.
Resolution of the snapping was highly predictive of im—
proved outcomes. The rate of persistent snapping at 2-year
-E
2
follow-up may be higher than previously thoughtfi'3
cu A 2fl14 case series described the release of the iliopsoas
o.
1:
I:
re
tendon from the central compartment for patients with
E- symptomatic impingement of the anterior lahrum by the
I
H iliopsoas tendon. Two of the patients underwent a second
procedure to release the iliopsoas at the lesser trochanter
for iliopsoas snapping. 0f the remaining 23 patients, 23
had good or excellent results.“
A systematic review of reported outcomes for open
versus arthroscopic techniques for the treatment of in—
ternal snapping hip reported a reduced failure rate, few
complication s, and reduced postoperative pain in patients
undergoing arthroscopic treatment.”
A cadaver study found substantial variability in the
number of distinct tendons of the iliopsoas at the level
of the hip joint. The psoas major tendon consistently
was found to be the most medial tendon, whereas the
primary iliacus tendon was found immediately lateral to
it. An accessory iliacus tendon sometimes was present
adjacent and lateral to the primary iliacus. The presence
of a single—banded, double-banded, and triple—banded
iliopsoas tendon was found in 23.3%, 54.2%, and 2.5%
of specimens, respectively. The study suggests that sur-
geons should be mindful of this anatomic variability when
performing iliopsoas tendon releases.”
firthopaedic Knowledge Update: Sports Medicine 5
Patients with increased femoral anteversion may be at
risk for poorer clinical outcomes after a release of the ilio-
psoas tendon. The iliopsoas may be an important passive
and dynamic stabilizer of the anterior hip in this patient
population, leading to alterations in kinematics, especially
with the hip in terminal extension and external rotation,
when the iliopsoas is most taut.“ Serious complications,
including anterior hip instability or dislocation, have been
reported after iliopsoas release in the setting of increased
femoral anteversion; therefore, caution is advised when
considering the procedure in this patient population.
Coxa Saltans Extorna
Coxa saltans externa, or external snapping hip, is a snap-
ping of the iliotibial band over the greater trochanter of
the femur. Most cases of external snapping hip are not
associated with pain and can be treated with reassurance.
Uccasionally, when the snapping is painful, further in-
vestigation and treatment are warranted.
Proximally, the iliotibial band attaches to the gluteus
maximus posteriorly, and the tensor fascia lata anteriorly.
It courses down the lateral aspect of the thigh and has
insertions on the lines asp-era of the femur and on the
Gerdy tubercle on the anterolateral tibia. The iliotibial
band lies posterior to the greater trochanter when the hip
is extended and translates anteriorly with flexion. In cases
of external coxa saltans, snapping often is noted during
internal or external rotation of the hip, with the hip in
the extended position while standing.
Patients often report the ability to “dislocate” their
hips with certain movements and have pain localized
to the lateral hip at the greater trochanter. The pain is
aggravated by the frequency of snapping episodes and
may improve if activities are modified to avoid snapping.
Repetitive snapping of the hip likely causes thickening
and inflammation of the iliotibial band at the region of
the greater trochanter.
The initial treatment should focus on physical therapy
to stretch the iliotibial band and gluteus maximus, activity
modification, and a course of NSAIDs. Pain refractory
to these measures can be treated with selected anesthetic
and corticosteroid injections to the trochanteric bursa.
Nonsurgical treatment is the mainstay of care, and most
patients will improve.
Surgical treatment occasionally is offered to patients
who have exhausted nonsurgical options. An array of
surgical procedures have been described to lengthen the il-
iotibial band or decompress it over the greater trochanter.
One retrospective study evaluated outcomes in 15
patients with external snapping hip at a mean of 33.3
months after endoscopic transverse iliotibial band release
fl lfllfi American Academy of Orthopaedic Surgeons

just distal to the greater trochanter. Gf all patients, nine
{69%} were pain free. Preoperative 1lli'itS pain scores im-
proved from a mean of 5.5 to 0.53 postoperatively, and
snapping symptoms were resolved in all patients postop-
eratively.“ Another technique involving distal Z-plasty
lenghening of the iliotibial band was presented in a series
of five patients. Although the total number of patients
was small, snapping resolved in all of them.39 Techniques
that involve release or Z-plasty lengthening of the glute-
us maximus tendon also have been reported with good
results.“'“~“ Each of these techniques would benefit from
longer term evaluation within a larger number of study
patients.
Summary
Extra-a rticular hip disorders can present a diagnostic and
therapeutic dilemma. Understanding of these disorders,
including the anatomy involved, diagnostic algorithms,
and treatment options, allows the physician to recommend
effective treatment strategies. Directed anesthetic injec-
tions are useful in narrowing the differential diagnosis in
many cases. Endoscopic surgical techniques continue to
evolve in the treatment of extra-articular hip pathology.
Hey Study Points
' Greater trochanteric pain syndrome encompasses
various etiologies of pain at the greater trochan-
ter of the femur, including trochanteric bursitis,
gluteus medius or gluteus minimus tendon tears,
and friction of the iliotibial band over the greater
trochanter.
1* Plriforrnis syndrome involves the extrapelvic com-
pression of the sciatic nerve by the pitiformis muscle
or other adjacent structures.
I Internal snapping hip is the result of the iliopsoas
tendon moving back and forth over the internally
and externally rotated femoral head.
In External snapping hip is the result of the iliotibial
band snapping over the greater trochanter of the
femur.
Annotated References
1. Strauss E], Nho 5], Kelly ET: Greater trochanteric pain
syndrome. Sports Med Arthrosc lfllfl;13ll}:llS—1 19.
Medline DUI
This article reviews the concepts of GTPS, including its
etiologies, diagnosis, and treatment.
IE! lfllli American Academy of flrthopaecllc Surgeons
Cillapter 12: Extra-articular Hip Disorders
. Long SS, Surrey DE, Nasarian LN: Sonography of greater
trochanteric pain syndrome and the rarity of primary
bursitis. AIR Am I Roentgenol 2013;1fl1l51fllir33-1flflti.
Medline DUI
This article is a retrospective study examining the preva-
lence of gluteus tendon pathology, bursitis, and iliotibial
band pathology on ultrasonograpby in patients with
GTPS.
. Fearon AM, Twin J, Dahlstrom JE, et al: Increased sub-
stance P expression in the trochanteric bursa of patients
with greater trochanteric pain syndrome. Rheumerol Iat
2fl14;34{1{l}:144I-144E.Medline DUI
This study examines the presence of substance P in the
bursa and the abductor tendons in patients with GTPS.
. Moulton KM, Aly AR, Rajasel-taran S, Shepel M, fl-baid
H: Acetabular anteversion is associated with glutesl ten-
dinopathy at MRI. Skeletal Radiol 2DlS;44(1}:4?—54.
Medline DGI
This MEI study evaluates the possible association between
increased acetabnlar anteversion and gluteal tendiuopathy,
trochanteric bursitis, and subgluteal bursitis.
. Mallow M, Hasarian LN: Greater trochanteric pain syn-
drome diagnosis and treatment. Phys Med Rehehll Clin
N Am 2G14;ESI2}:2?9-239. Medline DDI
This review article describes the epidemiology, anatomy,
diagnosis, and treatment of GTPS.
. Flack NA, Nicholson HD, Woodley S]: The anatomy of
the hip abductor muscles. Clix Ariel 1fl14,2?{1}:241-253. l‘r'
E
Mcdline DD]
'U
to
This cadaver study examines the anatomy of the hip ab- 3
EL
'13
ductors in 12. specimens.
1
to
El-
Blank E, Owens ED, Burks 11., Belmont P] Jr: Incidence of
greater trochanteric pain syndrome in active dutyUS military
servicemembers. D-rtboped'r'cs 2011;35{?}:e1011*e101?.
Mcdline DUI
This study examines the epidemiology of GTPS in United
States military service members.
. Fearon A, Stephens S, Book J, et al: The relationship
of femoral neclc shaft angle and adiposity to greater
trochanteric pain syndrome in women. A case control
morphology and anthropometric study. Br I Sports Merl
2fl12;46l12}:333-392.Medliue DUI
This case-controlled study found an association between
increased femoral neck shaft angle and increased adiposity
and the diagnosis of GTPS.
. Fearon AM, lCook jL, Scarvell Jl'vl, Neeman T, Gormick
W, Smith PH: Greater trochanteric pain syndrome nega-
tively affects work, physical activity and quality of life: A
case control study. I Arthroplusty 2fl14;29{1}:333-33IS.
Medline DUI
Drtbopaedic Knowledge Update: Sports Medicine S
 Seetinn 2: Hip and Pelt-Pia
This study fnund that GTPS affects quality nf life scares
and disability levels similarly tn hip nstenat'thritis.
1-3. Kaltenbern A, Enurg CM, Gutaeit A, Kalberer F: The
Hip Lag Sign—prnspective blinded trial nf a new clin-
ical sign tn predict hip abductnr damage. PLnS Utter
2fl14;5[3}:e9156l}. Medline DUI
This study intreduces and validates a new physical exam-
inatinn finding, the Hip Lag Sign, which can be used tn
predict hip abductnr damage.
11. Chnwdhu ry R, Naaseri S, Lee], Rajeswaran G: Imaging
and management nf greater trnehanteric pain syndrome.
Pnstgred Med] 2U14;90{1fl63}:5?fi-§31. Medline DUI
This review article reviews the etinlngies and diagnnstic
imaging nptinns fnr GTPS.
12. 1iiii'estacntt D], l'inns JI, auet P: The diagnnstic accu-
racy nf magnetic rcsnnance imaging and ultrasnnngra-
phy in gluteal tendnn tears—a systematic review. Hip Int
2fl11;21[6]:63?-645. Medliue DUI
This systematic review cnmpa res MRI and ultrasnnngra-
phy as diagnnstic imaging studies fnr GTPS, using surgical
findings as the reference standard.
13. |Cnhen 5P, Strassels 5A, Fnster L, et a]: Cnmparisnn nf
flunrnscnpically guided and blind cnrticnsternid injec-
tinns far greater trnehanteric pain syndrnme: l'vlulticentre
randnmised cnntrnlled trial. BM] 2fl09;333:b1fl33.
Medline DUI
This multicenter randnmiaed cnntrnllecl trial evaluates
-E
E patient nutcnmes after injectinns fer the treatment cf
a:
n. GTPS with and witheut flunrnscepic guidance. It fnund
1: nn benefit tn flunrnsenpic guidance.
l:
rt:
E-
I 14. Brinks A, van Rijn RM, Willemsen SP, et al: Cnrticnste-
H
rnid injectinns fnr greater trnehanteric pain syndrnme: A
randomised cnntrnlled trial in primary care. Ann Fem
Med 2011;9{3}:225-234. Medline DUI
This randnmiaecl cnntrnlled trial cnmpares nutcnmes in
patients receiving injectinns fur GTPS with thnse in pa-
tients nut receiving injectinns. Patients receiving injectinns
had imprnved nutcnmes at 3 mnnths, but the imprnved
nutcnmes were nn lnnger present after 12 mnnths.
15. 1ilii'ilsnn 5A, Shanahan EM, Smith MD: Greater trnehan-
teric pain syndrnme: Dnes imaging-identified pathnlngy
influence the nutcnme nf interventinns? Int] Rheum Dis
2fl14;l?[6}:621—62?.Medlinc DUI
This retrnspective study investigated the assnciatic-n be-
tween imaging-identified pathnlngy {gluteal tendinnpathy
andl'nr trnehanteric bursitis} and nutcnmes after anesthetic
and certicnsternid injectiens tn the area cf the trnehan-
teric bursa.
Iii. McEvny JR, Lee K5, Blankenbalter DU, del Ric AM,
Keene J5: Ultrasnund-guided cnt'ticnsternid injectinns fnr
treatment nf greater trnehanteric pain syndrnme: Greater
Urthnpaeclic Knnwledge Update: Spnrts Iviedich'le 5
trnchanter bursa versus subgluteus medius bursa. AJR Am
I Rnetstgenni' 1013;2fllil}:W313-T. Medline DUI
This study investigates the effectiveness nf cnrticnsternid
injectinns tn the subgluteal bursa versus thnse adminis-
tered tn the trncha uteric bursa. Injectinns tn the trnehan—
teric bursa resulted in greater pain relief.
17'". ivlani—Eahu 5, Mnrrissey D, Waugh {3, Screen H, Eartnn
C: The effectiveness nf extracnrpnreal shnclt wave thera-
py in lnwer limb tendinnpathy: fl systematic review. Am
I Sparts Mad 2fl15;43{31:?52-?61. Medliue DUI
This article is a systematic review cf the use and effective-
ness of ESWT fer lewer-limb tendinnpathies, including
GTP'E. The study fnund ESWT tn be mnre effective than
hnrue training and enrtieusternid injectinns in the treat—
ment cf UTPS.
13. Byrd J‘W: Peritrnchauteric access and gluteus medius re—
pair. Ail-thrust: Tech 2h13;2i3}:e243-e246. Medline DUI
This study describes a technique fer gaining endescepic
access tn the peritrnchanteric space and gluteus medius
tendnn repair.
15". Ebert JR, Eucher TA, Ball 5V, Janes UC: A review nf
surgical repair methnds and patient nutcnmes fnr gluteal
tendnn tears. Hip Int lfllfiflfi {11:15 413. Medline DUI
This article reviews variens surgical repair techniques fer
gluteal tendnn tears and their nutcnmes.
20. Dnmb EG, Carreira D5: Endnscnpic repair nf full-thickness
gluteus medius tears. Artbrnsc Tech 1fl13;1{1}:eTT-e31.
Medline DUI
This article describes an endnscnpic dnuble-rew technique
for the repair nf gluteus medius tendnn tears.
21. Unvaert LH, van Dijlt CH, Zeegers AV, Albers UH: Ende-
scnpic bursectnmy and ilintibial tract release as a treatment
fur refractnry greater trnehanteric pain syndrnme: A new
endnscnpic apprnach with early results. Arthrnsc Tech
2012;1[2he161-e1ii4.Medline DUI
This article describes a surgical technique fer endnscnpic
bursectnmy and crnss incisinn nf the ilintibial band fur
the treatment nf UTPS.
22. Davies JP, Stiehl JE, Davies JA, Geiger PB: Surgical treat-
ment nf hip abductnr tendnn tears. 1 Rune joint Snag Ant
2313;95l15'lfl42fl-1425. Medline DUI
This article reports the clinical enrcnmes nf a series nf
patients with hip abductnr tears whn were treated with
npen surgical repair. The repair at higher-grade tears was
augmented with acellular human dermal allngraft.
2.3. Dnminguea a, Seijas E, Area U, Salient A, lI.'.'.Iusct’:l III, Cugat
R: Clinical nutcnmes nf trecha uteric syndrnme endnscnp-
ically treated. Arch Urthnp Trauma Surg 2fl15;135[1}:39-
94. Medline DUI
This article presents the nutcnmes cf a series nf patients
with GTPS treated with endnscnpic ilintibial band release.
U lfllfi American Academy nf Urthnpaedic Surge-ens

24. Lustenberger DP, Hg VT, Best TM, Ellis T]: Efficacy of
treatment of trochanteric bursitis: A systematic review.
Clix J Sport Med 3011:3115 }:44?-453. Medline DUI
This article is a systematic review of treatment options for
trochanteric bursitis. It found that nonsurgical modalities
helped most patients and that surgery was effective in
refractoryr eases. Surgical treatment resulted in greater
improvements in VAS scores and Harris Hip Scores than
did corticosteroid injections and physical therapy.
25. Natsis K, Totlis T, Konstantinidis GK, Paraslcevas G,
Piagltou M, KeeblteJ: Anatomical variations between the
sciatic nerve and the piriformis muscle: A contribution to
surgical anatomy in piriformis syndrome. Snrg Radiof
Assert 1D14;SE{3}:2?3-13fl. Medline DUI
In this cadaver study, 294 limbs were dissected to evaluate
the relationship between the piriformis muscle and the
sciatic nerve. Anatomic variations were present in 19 of
the limbs examined {6.4%1.
26. Jawish RM, Assoum HA, Khamis CF: Anatomical, clin-
ical and electrical observations in piriformis syndrome.
I Utthop Surg Res 1D1fl;5:3. Mcdline DUI
This article presents a series of patients treated for piri—
formis syndrome, including their outcomes from nonsur-
gical and surgical treatment. The authors identifyr new
anatomic patterns of compression of the sciatic nerve and
ascertain the diagnostic utility of the H—reflex of the pe-
roneal nerve.
2?. Miller TA, White KP, Ross DC: The diagnosis and man-
agement of Piriformis Syndrome: Myths and facts. Can
} Nee-ref Sci 2fl11:39[53:5??-533. Medline DUI
This article discusses various diagnostic and treatment op—
tions for piriformis syndrome and proposes sta ndardiaed
criteria for its diagnosis, which include presenting signs
and symptoms, imaging, and the response to injections.
2-3. Fabregat U, Rosellii M, Asensio- Sampet JM, et al: Com-
puter-tomographic verification of ultrasound-guided piti-
formis muscle injection: A feasibility study. Pair: Physician
2fl14:1?[ti}:5fl?-513. Medline
This study examines the accuracy of ultrasound-guided
injections to the piriformis muscle by adding iodinated
contrast to the botulinum toxin injection and then perv
forming CT to assess intramuscular distribution.
25". Elu nl: JA, Nowotny M, Scharf J, Benrath ]: MKI verifica-
tion of ultrasound-guided infiltrations of local anesthetics
into the piriformis muscle. Pair: Med 2013;14i1fi}:1593v
155' 9. Medline DUI
This study uses MRI to confirm the intramuscular in-
jection of local anesthetic to the piriformis muscle using
ultrasound guidance.
3f]. Martin HD, Shears SA,Johnson JC, Smathers AM, Palmer
I]: The endoscopic treatment of sciatic nerve entrapmenti
deep gluteal syndrome. Arthroscopy lflllglflllflfl-IBI.
Medline DUI
IE! lfllfi American Academy of Urthopaedic Surgeons
Chapter 12: Extra-articular Hip Disorders
This article describes the presentation and evaluation of
deep gluteal space syndrome and presents the surgical
outcomes of endoscopic decompression of the sciatic nerve.
31. Iliaaliturri ‘v’M Jr, Camacho-Galindo J: Endoscopic
treatment of snapping hips, iliotibial band, and ilio-
psoas tendon. Sports Med Artist-use Ifllflfl S{2}:1 2f] -1 1?.
Medliue DUI
This review article discusses internal and external snap-
ping hip syndromes and their surgical treatment options.
32. Ilisaliturri UM Jr, Eugansa-Tepole M, Ulivos-Meaa A,
Acuna M, Acosta-Rodriguez E: Central compartment
release versus lesser trochanter release of the iliopsoas
tendon for the treatment of internal snapping hip: A
comparative study. Arthroscopy 2fl14:3fl{?]:?9fl-?95.
Medline DUI
This retrospective study examines outcomes in a series
of patients with snapping iliopsoas tendon treated with
endoscopic release of the tendon at its insertion at the lesser
trochanter or release through the central compartment of
the hip. Patients in both groups had favorable outcomes.
33. El Bitar YF, Stake CE, Dunne HF, Botser IE, Domb BU:
Arthroscopic Iliopsoas Fractional Lengthening for Internal
Snapping of the Hip: Clinical Outcomes 1i'il'i'ith a Minimum
2-Year Follow-up. Ant: j Sports Med Efll4;4E{T}:lfiE-'fi-
ITUS. Medline DUI
This is a retrospective review of prospectively collected
outcomes data in patients undergoing fractional lengthen-
ing of the iliopsoas tendon for painful internal snapping
hip. Most patients experienced resolution of the painful
snapping. Those with persistent snapping had poorer i‘:'
outcomes. E
'U
to
3
34. Nelson IR, Keene 15: Results of labral-level arthroscopic EL
'13
iliopsoas tenotomies for the treatment of lahral impinge- 1
ment. Arifvroscopy 1fl14t3fl{6}:ESS-694. Medline DUI us
El-
This case series reports the outcomes of patients treated
with arthroscopic iliopsoas tendon release from the central
compartment for the treatment of labral impingement
from the iliopsoas.
35. Khan M, Adamich J, Simunovic N, Philippon M],
Ehandari M, fiyeni UR: Surgical management of inter-
nal snapping hip syndrome: A systematic review evalu-
ating open and arthroscopic approaches. Aviiiitoscom.r
2fl13;29{S}:942-943.Medlirte DUI
This systematic review compares the outcomes of open
techniques and arthroscopic techniques in the manage-
ment of internal snapping hips. A reduced failure rate,
fewer complications, and less postoperative pain with
arthroscopic management were noted.
36. Philippon M], Devitt BM, Campbell K], et al: Anatom-
ic variance of the iliopsoas tendon. Am ] Sports Med
2014;42{4}:Sfl?-311. Medline DUI
This cadaver study explores the anatomic variants of
the iliopsoas tendon at the level of the hip joint. It was
Urthopaedic Knowledge Update: Sports Medicine 5
 Seeders 2: Hip and Pelvis

determined that presence nf mere than twe distinct ten-
dnns is mere cnmmnn than preyiuusly thnught.
3?. Fahricant PD, Eedi A, De La Terre K. Kelly ET: Clinical
nutcumes after arthrnscnpic psnas lengthening: The ef-
fect nf Femnral yersicrn. Arthrnsrnpy 1fl12;23{?l:965-971.
Medlinc DUI
This study reperts inierinr nutcc-mes in patients with in-
creased femnral anteversinn underguing ilinpsnas leng-
thening fur internal snapping hip.
33. Zini R, Munegatn D, De Benedettn M, Carrarn A, Bignni
M: Endnscepic ilintihial band release in snapping hip. Hip
fer 2013;23i2}:125—232. Mcdlinc DUI
This retrespectiye case series reperts the eutcemes after
enduscnpic transverse release [if the ilintihial band fur
sympt-nrnatic external snapping hip.
39. Sayed-Nnnr A5, Pedersen E, Sjijdien GD: A new surgical
methnd for treating patients with refract-a-ryr external snap-
ping hip: Pedersen—Nec-r nperatinn. 1 Surg Dreiser;- Adv
Zfllltllfllrfll-ISS.Medline DUI
This article presents a technique fer lengthening nf the
ilintihial band by E—plasty under lucal anesthesia an an
nutpatient basis. Snapping was resnlyed in the five patients
in this series.
4D. Pnleselln GE, lQueircus MC, Dumb BIG, Cline NE, Hun-
da EH: Surgical technique: Endescnpic gluteus maximus
tendnn release for external snapping hip syndrnme. Bliss
Drrbnp Reins Res 2fl13;4?1{31:24?1-24TE. Medline DUI
This article describes a technique fur the endnscnpic re-
lease ef the gluteus maximus tenden fer external snapping
hip and reperts the results en a small series at patients.
41. Nani KW. "Tee J], Ken EH, Tenn K5, Kim H]: A medi-
lied Z-plasty technique for severe tighmess nf the glute-
us maximus. Scene! I Med Sci Sports 2fl11;21[1}:35-89.
Medline DUI
This article describes a technique fer and presents the
nutcemes fellewiug lengthening ef the ilietihial hand by
Z-plasty for treatment nf external snapping hip caused by
a tight gluteus maximus.

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a:
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an
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H

firthnpaedic Knnwledge Update: Sperrs Medicine 5 fl lfllfi American Academy at Urthnpaedic Surge-ens
Chapter 13
Muscle Injuries of the
Proximal Thigh
James T. Beckmanu. MD. MS Marc E. Safran. MD
Abstract
Muscle cont usions, strains, and lacerations account for
lfl‘l’b to 55% of all sports-related injuries, with many
occurring around the hip. Injuries to hip muscles often
result in a substantial amount of time missed Jfrom
competition. Muscle strains and contusions can usually
be managed nonsurgically, but some tendon avulsions
may require surgical reattachment. The hamstrings
and quadriceps are susceptible to strain injury in spurts
requiring explosive movements andior rapid changes in
direction such as soccer, track, hockey, and football.
Return-to-sport protocols are based on the range of
motion of the joint spanned by the affected muscle,
pain-free use of the injured muscle in basic movements,
strength testing, and the willingness of the athlete to
risk reinjury. Supervised rehabilitation comprising trunk
stabilization, agility exercises, and eccentric strength-
ening is important in preventing reinjury.
Dr: Safran or an immediate family member has received
royalties from EU Orthopaedics and Strylren is a member ofa
speakers' bureau or has made paid presentations on behalf
ofSmith 5 Nephew; serves as a paid consultant to Coaed
Linvatec and Cool Systems; serves as an unpaid consultant
to Cool Systems, Cradle Medical, Ferring Pharmaceuticals,
Biomimedica, and Eleven Blade Solutions; has stocir or stock
options held in Cool Systems, Cradle Medical, Biomimedica,
and Eleven Blade Solutions; has received research or insti-
tutional support from Ferrinp Pharmaceuticals and Smith
a Nephew,- and serves as a hoard member, owner: officer,
or committee member of the American firthopaedic Soci-
ety for Sports Medicine, the international Society for Hip
Arthroscopy; and the international Society ofArthroscopg
Knee Surgery; and Orthopaedic Sports Medicine. Neither Dr.
Becirmann nor any immediate family member has received
anything of value from or has stock or stock options held
in a commercial company or institution related directly or
indirectly to the subject of this chapter.
fl lflln American Academy of Drrhopaedic Surgeons
Keywords: hip: tendon: injury: hamstring: rectus:
quadriceps: contusion: strain: avulsion: treatment
Introduction
Muscle injuries most often occur during athletic par-
ticipation. Muscle contusions, strains, and lacerations
account for lfl‘lt. to 55% of all sports-related injuries,
with many occurring around the hip.” Up to 35% of
all collegiate football injuries‘l and 1fl% to 23% of all
professional soccer injuriesii involve hip muscle injuries,
which can result in a substantial amount of time missed
from competition.
Muscle strains and contusions are far more com-
mon than are lacerations. lE'Jontusions result from direct l‘:'
muscular trauma, which produces damage at the site E
'U
of impact, and are frequently seen in contact sports. In to
3
contrast, muscle strains occur indirectly when tensile
EL
'13
1
forces shear individual muscle fibers during eccentric ul-
El-
loading. Strains around the hip most commonly affect the
hamstrings and quadriceps in sports requiring explosive
movements andlor rapid changes in direction such as
soccer, track, hockey, and football. Muscle contusions
and low—grade strains share similar treatment principles
despite differing mechanistically. Most can be managed
nonsurgically, but some tendon avulsions may require
surgical reattachment.
Return-to-sport protocols are based on the range of
motion of the joint spanned by the affected muscle, pain-
free use of the injured muscle in basic movements, strength
testing, and the willingness of the athlete to risk reinjury.
In some situations, MRI can help to predict the degree of
injury and the recovery time but has the same predictive
value as clinical examination in terms of return to com-
petitive sports]; Patients with a previous musculotendinous
junction injury have a twofold increased risk [or greater}
for recurrent strainf Supervised rehabilitation that in-
cludes trunk stabilisation, agility exercises, and eccentric
strengthening has been shown to reduce the likelihood of
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 2: Hip and Pelt-do

subsequent events.” The focus of this chapter is on injuries

to the quadriceps and hamstrings muscles.

Evaluation of Athletic Hip Injuries

Muscle injuries of the hip can occur in isolation but also
may present with other sources of hip pathology. Up
to 90% of patients with groin pain have been demon-
strated to have more than one injury; therefore, consid—
eration of less obvious sources of hip pain should not be
overlooked simply because contusions and strains are
common.” l[Jonsiderable overlap exists among clinical
signs and symptoms about the hip and pelvis region, ne-
cessitating a formulaic differential diagnosis addressing
both intra-articular and extra-articular sources of hip
pathology.
|Common patterns of concomitant hip pathology Mild Moderate Severe
include the “sports hip triad” of adductor, rectus ab-
dominis, and labral tears; the “symphysis syndrome" of
illustrations show the grading of
abdominal, groin, and adductor pain; and associations musculotendinous strains. Grade 1. stretch.
of muscle strains with labral tears and intra-a tticular hip increased signal on MRI, less than 5% disrupted:
grade 2, less than SUE-ii disrupted; grade 3,
pathology.”13 In addition, femoroacetabular impingement completely disrupted macroscopically.
{PHI}, hip dysplasia, and hip capsular microinsta bility in—
creasingly have been recognised as sources of hip pain in
athletes in whom only recurrent groin pulls and hip flexor the accumulated hematoma.
strains have been diagnosed. The duration of symptomatic Initial treatment is aimed at reducing the size of the
athletic participation with untreated FAI is associated hematoma and producing a conductive environment for
-E
E
with worsening, irreversible joint damage and should an optimal healing response. Hematoma formation is
a: therefore be considered in the differential diagnosis of reduced through rest, ice, compression, and elevation
o.
'o
I:
an
athletes in combination with muscular injuries."l {RICE}. Compression and cryotherapy are associated with
E- smaller hematoma formation. Elevation reduces hydro‘
I
static pressure in the affected extremity and lessens the
Treatment Principles of Muscle Strain Injuries
H

amount of interstitial fluid accumulation. Rest of the

Strains are the most common injuries to the musculoten—
dinous units of the proximal thigh. Muscles most at risk
are fast-twitch muscles that span two or more joints.”
including the quadriceps {particularly the rectus femo—
ris} and hamstring muscles, which cross the hip and the
knee. The most common mechanism of injury is eccentric
contractionfi'fi The location of injury tends to be at the
musculotendinous junction. Clinically, the location of
injury can range from mid-muscle belly to an eccentric
position because some muscles have an elongated mus-
culotendinous junction.
Muscle strains and contusions cause myofiber damage
within the basal lamina, mysial sheaths, and associat—
ed blood vessels.” Avulsion injuries are associated with
different outcomes, a different prognosis, and a differ—
ent surgical recommendation and should be considered
separately.” Symptoms and the clinical course following
grade 1 or 2 muscle strains [Figure 1) or muscle contusion
depend on the amount of muscle damage and the sise of
affected muscle is recommended to allow opposition of
the muscle during early scar formation, which is allowed
to mature until it can withstand the forces applied during
rehabilitation without rerupture but should not exceed 1
week.” Prolonged immobilization has been associated
with an increased risk of rerupture and large permanent
scar formation.”l After the acute phase, range of motion
is initiated within the limits of pain. This phase is impor-
tant to accelerate the regeneration process and properly
orient the regenerating muscle tissue.“*“
The use of NSAIDs during the acute healing phase
is controversial. NSAIDs can provide analgesia, reduce
inflammation, and help prevent ectopic ossification, but
concerns of delayed or weakened healing have been ex-
pressed.:"-2 Some studies have reported no adverse effects
of short-term NSAID use on the healing process; evidence
of later decreased growth and healing exists, however.
Rarely is NSAID use needed for longer than 3 to 7’ days
following injury.

firthopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons

Muscle Contusions
l[:ontusions causing significant muscle damage nearly
always occur in one of four muscles: the quadriceps,
hamstrings, adductors, or calf muscles. Contracted and
stronger muscles will absorb force better and incur less
severe injuries.” Quadriceps contusions should be braced
in 120" of flexion for 24 hours to limit hematoma forma-
tion. Return to play from quadriceps contusions averaged
13 days for mild, 19 days for moderate, and 21 days for
severe contusions in West Point cadets}3 Myositis ossi-
ficans occurs in 9% to 1TH: of contusions.1| lClinically,
myositis ossificans should be considered if improvement
is not seen in 1 week or if symptoms worsen in 2 to 3
weeks postinjury. Radiographic evidence can be present
as early as 3 weeks post injury but may take as long as
several months to become evident. NSAIDs can be used
at the time of acute injury to reduce the possibility of
myositis ossificans development. Rehabilitation for con-
tusions should follow that of low—grade muscle strains,
and should include trunk stabilisation, agilityr exercises,
and eccentric strengthening.
Hamstring Strains and Avulsions
Anatomy
The hamstrings are composed of three muscles: the semi-
membranosus, semitendinosus, and biceps femoris. The
biceps is formed by a short head and a long head, which
are innervated by the peroneal and tibial branches of the
sciatic nerve, respectively. The long head of the biceps
and semitendinosus join proximally to form a single con-
joined tendon that inserts on the medial portion of the
ischial tuberosity, but they separate into distinct tendons
approximately 5 centimeters distally; the semimembra-
nosus inserts on the lateral portion of the tuberosity. The
hamstrings course medially to the sciatic nerve as they
enter the thigh. This anatomic relationship is clinically
significant, because it is common to have sciatic nerve
irritation in chronic avulsions from traction injury or
scarring.”l Distally, the hamstring tendons cross the knee
joint, where they serve as knee flexors. The hamstrings are
maximally stretched with combined knee extension and
hip flexion because they pass posteriorly to both the hip
and the knee. Athletic maneuvers that require this simul-
taneous knee extension and hip flexion such as hurdling
and water-skiing are common causes of hamstring strain.
History
In patients with hamstrings injuries, the history reveals
posterior hip pain located deep in the buttocks. Patients
will typically report that a pop, tearing, or pulling
IE! lfllii American Academy of flrthopaedic Surgeons
|L'ihapter 13: Muscle Injuries of the Proximal Thigh
Shin Expected weakness fl
and! 15““ its"- are
1 it
2 I I
a I it I
Figure .1. Ch art shows the grading of prone hamstring
strength testing. Weakness is expected at
increasing amounts of flexion proportional to
the severity of the muscle strain.
occurred at the time of injury. 1Ii‘il'ith avulsion injuries,
patients occasionally describe feeling a “gunshot” to the
area of the ischial tuberosity. Sitting can be particularly
painful.
Physical Examination
Inspection can show mild to severe ecchymosis over the l‘:'
posterior buttocks. An examination finding of ecchy- E
'U
mosis is associated with a prolonged return to competi- to
3
EL
tion {more than 4 weeks}. Palpation over the ischium or '13
1
musculotendinous junction will reveal tenderness and a in
El-
possible tendinous defect in avulsion injuries. Patients
with hamstring strains will feel tenderness more in the
mid-thigh, at the elongated musculotendinous junction
of the biceps femoris. Patients with more severe injuries
ambulate with a stiff-legged gait to avoid hip flexion.
Range-of—motion and strength testing not only confirm
the diagnosis, but also help determine when return to
sporting activities is appropriate. Strength testing at 15“,
45“, and Hi)“ can help determine the severity of the tear25
(Figure 2}. Knee extension is often limited compared with
the opposite extremity. The sciatic nerve, particularly the
peroneal division, should be examined by testing ankle
dorsiflexion strength and performing a straight-leg raise
for radicular pain.
Imaging
Plain radiography need not be routinely performed, but
can be used to identify bony avulsion injuries. Bony ham-
string avulsions from the ischial tuberosity {Figure 3} are
common before the ischial apophysis closes during early
Drrhopaedic Knowledge Update: Sports Medicine 5
 Sectiun 2: Hip and Pelfie

adulthuod [ages 2D tn 25 years}, but can :3c as a beny l[Ilassii‘icatinn

ayulsiun after skeletal maturity.
MRI is useful in characterizing hamstring strains.
Hamstring tears have intermediate signal intensity cm
Til-weighted imaging, and high signal intensity en T2
imaging. MRI can reliably determine the number uf turn
tendons and the amcunt nf tendun retracticm but was not
shewn in a systematic review ef grade 1 and 1 injuries te
predict reinjury'“ er the return tn spertfi"r Chrunic injuries
can be delineated with MRI based cm the presence ef fatty
infiltratinn, scarring, and reduced hamstring unlurne.
4s "3"“
. '1}.-
. _ III
Prmrimal hamstring injuries can be divided hreadly intu
musculc-tendinnus junctiun {MTJ} er ayulsicn injuries.
MT] strains ccmprise must {up re 90%} of these injuries,
and at the three hamstrings tend-ans, the lung head at
the biceps femuris is must cunununly injured. Ayulsiun
injuries from the ischial tuberusity cumprise 12% cf such
injuries and are less cc-mmnn but are assuciatetl with a
wurse prugnusis and different surgical reccmmendatiuns
than are MT] injuries.” A treatment algurithm fur ham-
string injuries is shuwn in Figure 4.
Ayulsiun injuries can be strictly tendinclus cr ccntain
an auulsed bcmy pnrticm. Subclassificatiun cf pruximal
arulsiens” is presented in Table I. 1illi'ith single—tenden

ayulsitms, retracticm is unlikely because the turn ten-

-' .I‘ i,- .
dun scars tn the intact tendcns, preducing a functic-nal
mu sculutendinuus unit; therefure, single—tendun a‘rulsiuns
rarely require surgery.15 The putential fer tendcm retrac-
tinn and impaired functiunal healing increases pruper-
tic-nally tn the number at ayulsed tenduns. Retractiun
greater than 2 cm requires twn fit more cempletely turn
tendcns, and retracticm greater than 5 cm is indicative
crf a three—tendtm atrulsienn25 {Figure 5}. Strength deficits
with ncmsurgical treatment are clinically detectable when
all three tendens are ayulsed.

Treatment
-E
2
MT] injuries and single-tendun ayulsicns cf the ham-
tn strings can be treated successfully withuut surgical in-
1:. Figure 3 AP radiugreph demnnstrates an apuphyseal
1:
I:
an
erulsien injury at the ischial tuhe resity. terventiun. The initial 3 re 5 days fulluwing injury are
(Cuurtesy crf Marc E. Sefren, MD, Pale Alto. CA.} devoted tn rest, ice, relative immubilisatiun, cempressiun,
E-
I
H

l'Jr'IJJILllT'I-E'tl I'IELr'r'I.E.’[t rig

In i .1 ry

eyulsien M L] scul nten{J i n en :3. ju n-:::ti c-n If M T. .| ]

Rehabilitatien
1. tr Ter'itinns inuclued
:-_. Arne-unt uf r'etrnctiun
1. Strength :- sure
' . Hamstnngtfluad ratie =_= sue-i:
' Tends-n E Tendon '. Full knee estensinn
- .Ml'nimal pain
Fiet rsctinn T
Hehabiiitaticn
cflcm

Fieturn tn spurt 4-6 weeks Eu r-g-e r y Fietu rn tu- spe rt e :5: ts Ie reted

Algerithrn shews the teatment prutucul fur a pruximal hamstring injury. {Cuurtesy uf Mart Ft. Safran, MD, Pale
Alta, EA.)

firthupaedic Knuwledge Update: Sperts Medicine 5 fl lfllei American Academy cit Orthupaedic Surge-ens

and analgesics. 1illii'eight hearing as tolerated with crutches
is permitted until pain-free ambulation without a limp is
achieved. The ability to ambulate unassisted without pain
1 day after injury is associated with a shorter recovery
time than is an inability to do so. lClinical findings such
as bruisingl'hcmatoma, tenderness to palpation, a lack of
complete range of motion, and pain with isometric limb
lengthening 3 to 5 days following injury are predictors
of a prolonged recovery (more than 4 weeks}? Rehabil-
itation following the acute phase should focus on agility
training and eccentric exercises, which have been shown
in randomized trials to return athletes to competitive
sport more quickly than traditional hamstring strength-
ening protocolsdd"
-—
Wood Classification of Hamstring Injuries
Type Characteristic
Bone avulsion
MhWH-l
Musculotendinous junction avulsion
Incomplete avulsion
Complete avulsion {no retraction}
Complete avulsion {retraction}
A
Figure 5 coronal {A} and axial {Ell Mill views depict the appearance of a hamstrlng avulslon injury wlth retraction. {courtesy
of Marc E. Safran, MD, Palo Alto, CA.)
El lfllfi American Academy of flrthopaedic Surgeons
|Ellapter 13: Muscle Injuries of the Proximal Thigh
Corticosteroid and platelet-rich plasma {PEP} injec-
tions have been reported to expedite a return to play
following hamstring injuries of the musculotcndinous
junction. Corticosteroid injections were reported to be
safe in 53 National Football League {NFL} players with
focal hamstring musculotendinous injuries. These players
all had a significant hamstring injury evidenced by a pal-
pable defect on physical examination, but over Slidi- were
ablc to return to play within a week of injury.“ Despite
the beneficial effects found in this case series, concerns
raised by experimental studies question the practice of
corticosteroid injection for acute hamstring injuries. De-
layed hematoma evacuation, skeletal muscle necrosis, and
reduced biomechanical strength all have been found as a
result of glucocorticoid injection. PRP injection for grade
2 MT] injuries was compared with isolated rehabilitation
in a recent nonblindcd randomised trial. Patients receiving
the PRP injection were able to return to sport an average
of 6 days faster.32 Additional studies have found better
pain relief with PEP injection measured by visual analog
scale. This contrasts with the findings of a EDI-4 study
of El} recreational athletes that showed no difference in
return to play or reinjury in a double— blinded study com—
paring PRP with normal saline.”
Strength, range of motion, and pain are the typical
criteria used to determine the timing of a return to sport.
l‘t'
E
'U
to
:i
Ill
1:
1
E.
II“
Drthopaedic Knowledge Update: Sports lvledichie .‘i
 Section 2: Hip and Pubic
Hamstring strength should be at least 30% of the contra-
lateral side, and the hamstringfquadriceps ratio should
exceed 5fl% but can vary significantly by sport and po—
sition played.“ Clinical parameters including full knee
extension, symmetric leg-extension strength at 15° of
flexion, and minimal tenderness over the proximal ham—
strings have been shown to be important predictors in
preventing reinjury when returning to sport. The pres-
ence of pain at the time of the return to sport has been
found to portend a fourfold increased risk of reinjury
on return.”
Reinjury is common following proximal hamstring
musculotendinous strains. Rates of reinjury have been
reported in up to 43% of patients. Prior injury, reduced
hamstring flexibility, strength asymmetry, and age have
been reported as independent predictors of reinjuryfi“
Reduced eccentric hamstring strength was found to
increase the relative risk of hamstring injury FLT-fold
in a prospective study of Australian football players.“
Athletes with prior hamstring injury have been shown
to have smaller improvements with eccentric hamstring
exercises in both the affected and unaffected limb“ and
may require more intense training to reduce the risk of
reinjury. Inadequate warm-up or stretching also could
predispose to re-strain. Previous studies have demon-
strated that warmer muscles have muscle length to failure
ratios.” Trunk stability and agility exercises have been
-E
2
shown to prevent reinjury compared with stretching and
to strengthening for grade 1 and 2 hamstring strains and
o.
1:
I:
an
should be included in rehabilitation protocols.”
E-
I
H Surgical Indications
Complete hamstring avulsions involving all three tendons
or two tendons with significant retraction may benefit
from early surgical repair.” Ischial apophyseal avulsions
are treated with surgical repair only if they are displaced
more than 1 to 31 centimeters. A systematic review of
proximal hamstring avulsions found superior results in
patients treated with acute repair compared with those
treated with chronic repair or nonsurgical management.
Acute surgical repair performed within 4 weeks of injury
was found to have a higher return to preinjury levels
of sport {96%} than chronic repair {T5941} or nonsurgi-
cal management {14%}. Acute surgery was associated
with better patient satisfaction, subjective outcomes,
pain relief, and strength and less chance of rerupture.3E|
Selection bias inherent in the retrospective series design
was present in all studies included in this review. Poor
description of the number of avulsed tendons between
groups also could bias these results and explain the dif-
ferences found.
firthopaedic Knowledge Update: Sports Medicine 5
Postoperative Care
Preventing simultaneous hip flexion and knee extension
protects the repair. Hip or knee braces can be used to
prevent stress on the repair.“ A knee brace locked in
flexion may suffice to limit active knee flexion and is gen-
erally better tolerated. The brace is discontinued IS weeks
postoperatively. At 6 weeks, stretching and range-of-mo-
tion exercises are initiated. Strengthening is introduced
3 months postoperatively, with the goal of returning to
sport at S to 9 months postoperatively.
Quadriceps Strains and Avulsions
Anatomy
The four quadriceps muscles are the rectus femoris, vastus
medialis, vastus lateralis, and vastus intermedius. The
bipennate rectus femoris is the most susceptible to strain
or avulsion, because it is the only quadriceps muscle that
crosses the hip joint and serves as a hip flexor, in addi-
tion to being a knee extensor.” As with the hamstrings,
this anatomic relationship places the rectus femoris at
increased risk for strain compared with the vastus mus-
cles, which are purely knee extensors. In fact, only two
cases of vastus lateralis avulsions have ever been reported.
The direct head of the rectus femoris originates from the
anterior inferior iliac spine {A115}, whereas the indirect
head originates more laterally from the supra-acetabular
ridge adjacent to the acetabular labrum [Figure 6}. The
indirect head is more commonly injured. Distally, the
indirect head extends nearly two-thirds the length of the
entire muscle as a central intramuscular tendon, whereas
fibers from the direct head blend anteriorly on the pe-
riphery of the muscle belly. This anatomy is important to
appreciate because central tendon injuries of the indirect
head are associated with a longer return to play than are
peripheral injuries.”
Patient Evaluation
Quadriceps injuries occur during kicking or sudden
deceleration from a sprint. Soccer players and football
kickers typically are affected. Injury mechanisms include
a sudden forcible block to a kicking motion, or kicking
the air instead of the intended object. Risk factors in-
clude insufficient warm-up, poor muscle conditioning,
and previous tears.
Physical examination demonstrates tenderness to pal-
pation around the A115. Ecchymosis and palpable defects
can be seen in more severe injuries. Rarely, in chronic cas-
es, the avulsed proximal tendon can be palpated distally
as a mass that can sometimes mimic a tumor, but a history
of trauma helps to differentiate the two pathologies.“
Radiographs are not obtained routinely for isolated
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 13: Muscle Injuries {if the Prnitima] Thigh

Anterinr
inierinr
iliac spine

Grnnve
supannr
tn anatahulum

l-ig u m 6 Drawing depicts the anatnmy nf direct and

indirect rectus femnris insertinn.

injuries that fnllnw the expected clinical cnurse. A ra-

dingraphic wnrk—up shnuld he cnnsidered fnr palpable
defects near the A115, recurrent injuries, and ynung pa-
tients with risk Enr avulsinns. MRI helps tn characterize Figure 3' Axial Til-weighted MRI shnvvs a bulls-eye lesinn
asantiated with injury tn the indirect head cf
MT] injuries and prnzcimal avulsinns. Increased signal nn the rectus femnris muscle. {Cnurtesy nf Mart Fl.
fluid-sensitive imaging within the indirect head is the mnst Safran. MD, Pain Ann, CA.)
cnmmnn MRI finding. Injuries nf the indirect head can
invnlve a lnng segment nf the rectus muscle centrally that
can result in a bulls-eye sign nn axial imaging (Figure 7'},
lnngitudinal scarring, nr pseudncystihematnma. l‘r'
E
15
|I‘Elassificatinn Eli
3
EL
PI'flIlIflfll rectus femnris injuries are classified as either '13
1
MT] nr avulsinn injuries, similarly tn prnstimal ham— in
El-

string injuries. Musculntendinnus injuries can invnlve the

indirect head, the direct head, nr the cnnjnined pnrtinn
nf the tendnn. Avulsinns nccur with nr withnut a hnny
pnrtinn nf the A113. In slteletallj.r immature patients, ALIS
avulsinns accnu nt fnr 2U% tn 25% nf all avulsinn injuries
and nearly 50% nf all pelvic apnphyseal avulsinns.“ PUSH-i-
imal avulsinn alsn can nccur less cnmmnnly in skeletally
mature individuals {Figure 3}.
Figure 3 AP radingraph shnvvs an avulsinn injury nf the
right anterinr inferinr ilisc spine in a skeletally
Treatment mature patient. [Cnurtesy nf Marc E. Safran.
MD, Fain Altn, EA.)
Musculntendinnus injuries are treated nnnsurgically with
a graduated rehabilitatinn prngram aimed at returning
athletes tn cnmpetitinn 6 tn 1E! weeks after injury {Ta- AIIS avulsinns with less than 2 centimeters nf ten-
ble 2}. Return tn participatinn was shnvvn tn he prnpnrw dnn retractinn can he treated nnnsurgically. Retractinns
tinnal tn the length nf the central apnneurnsis tear in nf mnre than 2 centimeters are mere likely tn develnp
Spanish snccer players. Every 1-cm increase in tear length nnnuninns nr cause subspinnus impingement and shnuld
greater than 4 cm resulted in an average 5-day increase undergn internal finatinn. Subspinnus impingement can
in return tn spnrt. Prnnimal injuries nf the rectus femnris cause pain and reduced hip range nf mntinn, because the
require a lnnger recnvery perind than dn distal tears by femnral neck nr greater trnchanter impinges cm a lnw—ly-
an average nf apprmtitnately 1 1|.veelit.‘u ing A115.“ Suhspinnus impingement is mnst cnmmnn

IE! Eillii American Academy ni' flrthnpaedic Surgenns Drthnpaedic Knnwledge Update: Spnrts Medicine 5
 Section 2: Hip and Pelvis
-—
Suggested Nonsnrgical Rehabilitation
for Rectus Femoris Injuries
Week 1: Protected weight bearing with crutches
Ice
Anti-inflammatory medications
Modalities
Passive range of motion
Weeks 2-4: Gait training
Active range of motion
lsometrics
Weeks 4-6: Resisted strength training
Running
Functional drills
Weeks
s-m: Return to play
when the AIIS extends to the level of the acetabular rim
-E
2
[type 2] or past the rim, which is seen most frequently as
cu a sequelae of healed avulsion injuries [type 3}. Surgical in—
o.
1:
i:
m
dications for chronic AIIS avulsions include reduction and
E- internal fixation of symptomatic nonunited fragments,
I 1- Hip muscle strains are commonly encountered in
resection of exostoses that cause functional impairment,
H
and painful subspinous impingement.“
Acute surgical reattachment of purely tendinous avul-
sions has been reported in several case series with good
results; other studies have shown good results with non-
surgical management alone, however, even in high-level
kicking athletes.“ In a series of four soccer players and
one hurdler treated with acute repair {at less than 102
days], all were able to return to their previous activity
level between 5 and 1i] months after surgical repair.“
Authors of a 2012 study reported on If) professional
soccer players who underwent repair of an av ulsed rectus
injury with direct suture repair or bone anchors.” At a
mean followup of 35 months, they found fewer reinjuries
in the surgical repair group. In contrast, another study
reported on 11 HF L players, including two punters who
were treated nonsurgically.“ The NFL players were able
to return to professional football at a mean of W) days.
Studies between surgical repair and nonsurgical manage-
ment are needed to compare the two treatment options.
firthopaedic Knowledge Update: Sports Medicine 5
Chronic injuries that fail to improve may require
surgical management. A pain-free remrn to sport has
been reported in a soccer player treated with surgical
repair of a chronic musculotendinous junction injury.”
Surgical debridement of the symptomatic tendon stump
also can enable a return to high—level sport. Authors of
a 2011 study reported on five collegiate athletes who
underwent debridement of chronically painful retracted
indirect heads.” Although all five improved, only one pa~
tient returned to sport without recurrent pain or reduced
athletic ability. Symptomatic pseudoeyst formation, which
can occur around the central tendon of the indirect head,
can be surgically excised with good results.5L1
Sum m ary
Muscle injuries are common in sports and frequently
involve areas around the hip. MT] injuries can be treated
nonsurgically, initially with RICE followed by rehabil-
itation focusing on agility training, trunk stabilization,
and eccentric strengthening. The return to sport should
be determined by physical examination criteria including
minimal pain, full range of motion, and near—symmet—
ric strength to prevent reinjury; full recovery may take
several weeks in some cases. Avulsion injuries should be
recognised and treated differently than low—grade strains
or contusions according to specific guidelines for the af-
fecred muscle.
key Study Points
sports, treatment is largely nonsurgical with RICE
acutely followed by rehabilitation focusing on
agility training, trunk stabilization, and eccentric
strengthening.
'- Complete hamstring avulsions involving all three
tendons or two tendons with significant retraction
may benefit from early surgical repair.
I Rectus femoris strains and avulsions can both be
managed successfully even in high-level kicking
athletes with 6 to 10 weeks of rehabilitation. The
length of the central aponeurosis tear in MT] strains
predicts return to play.
Annotated References
1. Eeiner JM, Joltl P: Muscle contusion injuries: Current
treatment options. I Am Acad Drtbop Sing lflfl1;9{4}:227-
13?. Medline
fl Ellie. American Academy of Orthopaedic Surgeons

. Eltstrand J, Higglund M, Walden M: Epidemialagy
at muscle injuries in praEessianal Faatball {sacccr't Am
,1 Sparta Med 2fl11;39{6}:1226-1232. Medline DUI
Fifty-ane saccer teams, camprising 2,299 players, were
fallawed praspectively far 3 years, registering 2,9133 mus-
cle injuries. Un average, a player sustained [1.6 muscle
injuries per aeaaan. DI the injuries, 92% were sustained
by the majar muscles af the lawer leg. Level af evidence: II.
Uarrert WE Jr, Rich FR, Niltalaau PK, Vaglet JB III:
Camputed tamagraphy af hamstring muscle strains. Med
Sci Sparta Exerc 1939;21i5}:5fl6-514. Medline DUI
. Wands C, Hawkins RD, Malthy S, Hulse M, Thamaa
A, Hadsnn A; Fnatball Assaciatian Medical Research
Pragramme: The Faerball Assaciatian Medical Research
Pragramme: An audit af injuries in prafessianal fact-
ball—analysis af hamstring injuries. Br I Sparta Med
20M:33{I}:35~41.Medline DUI
. Fauseltis K, Tscpis E, Paulmedis P, Atbanasapaulas 5,
Vagenas G: Intrinsic risk factars cf nan-cantact quadriceps
and hamstring strains in saccer: A praspective study af
IUD prafessianal players. Br ,1 Sparta Med 2fl11545[9}l:?fl9-
T14. Mcdlitlc DUI
This cahart study c-f Iflfl prafessianal saccer players fauud
that players with eccentric hamstring-strength asymme-
tries and functianal legalength asymmetries were at greater
risl: far hamstring strain. Quadriceps strains were seen in
players with eccentric strength and flexibility asymmetries.
. Malliarapaulas N, Isinkaye T, Tsitas K, Ma ffulli N: Rein-
jury after acute pasteriar thigh muscle injuries in elite traclt
and field athletes. Arr: jl Sparta Med 2fl11;39{2j:3i}4-31D.
Mcdline DUI
Return ta apart in track and field athletes was lawer far
law-grade injuries: 14 days far grade I, 12.9 days far
grade 2, 29.5 days far grade 3, and Sill days for grade 4
injuries. Uhjective clinical findings accurately predicted
the risk cf reinjury.
. Warren P, Gabbc E], Schneider-Kalslry M, Benncll KL:
Clinical predictcrs cf time ta return ta campetitian and
af recurrence fallawing hamstring strain in elite Austra-
lian faatballers. Br ,1 Sparta Med 201D;44{E}:415—419.
Medline DUI
Australian factballers were 4 times mare likely ta have a
pralanged recavery if they were unable ta wallc pain-free
the day after injury. A lflafald increased risk far recurrence
was seen if the previaus hamstring injury had accurred in
the last 12 manths.
. Arnasan A, Andersen TE, Halme I, Engebretsen L, Baht
Ii: Preventian af hamstring strains in elite saccer: An inter-
ventian study. Scared I Med Sci Sparta 2Gflfl;13{1j:4fl-43.
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. Askiing CM, Tengvar M, Tharatenasan A: Acute ham-
string injuries in Swedish elite Iaatball: A praspective
randamiaed cantralled clinical trial camparing twa
IE! Eillfi American Academy ai' Urthapaedic Surgeans
|l:.'.l1:.:lj:ite1' 13: Muscle Injuries at the Prairimal Thigh
rehabilitatian pratacala. IlrJI Sparta Med 1fl13:4'?{15j:953-
955'. Mcdlinc DUI
Prafessianal saccer players were randamited ta twa re-
habilitatian pratacala. Canventianal rehabilitatian was
faund ta have a langer return ta play {mean af 51 days}
campared with a pratacal emphasising lengthening at the
muscle graup {mean at 2.3 days}.
19. Marelli V, Weaver V: Grain injuries and grain pain
in athletes: Part 1. Print Cars 2005;32{1):163-133.
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11. Feeley ET, Pawell jW, Muller M5, Barnes RP, Warren
RF, Kelly ET: Hip injuries and labral tears in the natianal
Iaatball league. Am ,1 Sparta Med 2UD3;36{11}:213?-2195.
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12. Galla RA, Silvis ML, Smetana B, et a1: Asymptomatic hiplf
grain pathalagy identified an magnetic resanance imaging
af prafessianal hackey players: Uutcames and playing sta-
tus at 4 yes rs‘ Iallaw—up. Arthrascapy 2014;30{1fll:1222-
1233. Medline DUI
Twenty-cue asymptamatic hackey players underwent MRI
and were fallawed far 4 years. Despite a high prevalence
c-I muscle strains {11“.} cf 21} and labral tests {15 at 11},
anly ane player missed campetitian because cf a hipy’pelvis
injury. Level af evidence: IV.
13. Faete E], Maislin EV, Shrauder J, lI'Srrant MM, Eedi A,
Ayeni UR: The assaciatian between avulsians af the re-
flected head at the rectus femaris and labral tears: A ret-
raspective study. } Pedistr Urtirap 2013:33i3}:22?—231.
Medline DUI re
3.
Seven af nine pediatric patients with sparts-related rectus 'U
femaris avulsians alsa were faund ta have labral tears an tu
3
magnetic resanance arthragraphy. The ages ranged ftam EL
'13
ii ta 1? years, with twa patients requiring surgery. Level 1
af evidence: IV. in
El-
14. Philippan M], Weiss DR, Kuppersmith DA, Briggs KK,
Hay CI: Arthraacapic labral repair and treatment af fema-
raacetabular impingement in prefessianal hackey players.
Arr: J Sparta Med lfl'lil;33j1l:99-Ifl4. Medline DUI
Treatment cf femaraacetabular impingement and labral
lesians in prafessianal hncltey players resulted in successful
autccmcs, with high patient satisfactian and a prampt
return ta apart within a mean cf 3.4 manths. Level cf
evidence: IV.
15. Safran MR, Garrett WE Jr, Seaber AV, lIErlissan RR,
Ribbeclc EM: The tale af warmup in muscular injury
preventian. Am } Sparts Med 1933:16j2}:123-119.
Mcdline DUI
16. Hughes C IV, Hasselman CT, Best TM, Martinez 5, Ear-
rett 1i‘iFEJr: Incamplete, intrasubatance strain injuries cf the
rectus femaris muscle. Am I Sparta Med 1995;13j4ltiflil-
5116. Medline DUI
Urthapaedic Knawledge Update: Sparta Medicine 5
 Section 2: Hip and Pelvic
1?. Jiirvinen TA, Jiirvinen M, Kalimo H: Regeneration of in-
jured skeletal muscle after the injury. Mnscles Ligcments
Tendons I1013;3[4j:33?-34S. Medline
This review focused on fire basic biologic principles of filial-
eta] muscle regeneration and healing pmcesses. Clinical
and animal studies were discussed, with recommendations
provided to promote healing and return athletes safely to
competition.
13. Wood DE, Packham I, Trikha SP, Linklater J: Avulsion
of the proximal hamstring origin. j Bonejoini Surg Am
2UflS:90l11j:2365-23?4.Medline DUI
19. Jiirvincn M: immobilization effect on the tensile properties
of striated muscle: An experimental study in the rat. Arcl:
Phys Merl Reliabil 19?7;SS{3j:113-12?. Medline
ll]. Afirimaa V, Rantanen ], Best T, Schultz E, Corr D, Ka-
Iirno H: Mild eccentric stretch injury in skeletal muscle
causes transient effects on tensile load and cell prolif-
eration. Sccerl ] Merl Sci Sports lflfl4:14{6}:36?-3?2.
Medline DUI
21. Kannus P, Parkltari J, Jiirvinen TL, JS rvinen TA, Jiirvin-
en M: Basic science and clinical studies coincide: Active
treatment approach is needed after a sports injury. Scared
I Med Sci Sports lflflS;lS[3}:15fl-154. Medline DUI
22. Almekinders LC, ISilhert JA: Healing of experimental mus-
cle strains and the effects of nonsteroidal antiinflammatory
medication. Am J Sports Med 1935;14l4jr3 [13 -3-flfl.
Medline DID]
-E
E of hamstring injuries: A randomised controlled trial. Am
a: 13. Ryan JB, WheelerJH, Hopkinson W], Arciero ILA, Ko-
o.
1: la kowslci KR: Quadriceps contusions. West Point update.
l:
rt: Am J Sports Med 1991;19l3}:299-304. Medline DUI
E-
I with and without a single platelet—rich plasma {PR P} injec-
H
2.4. li'iross M], Vandersluis R, 1|Wood D, Banff M: Surgical
repair of chronic complete hamstring tendon rupture in
the adult patient. Am I Sports Merl 1993;26ffij:TSS-TSS.
Medline
25. Cohen 5, Bradley]: Acute proximal hamstring rupture.
I Am Acerl Urilrop Siirg 2G0?;15{E}:330-355. Mcdlinc
16-. De 1|li'os R], Reurinl: G, Goudswaard G], Moen Mi-I, Weir
A, To] JL: Clinical findings just after return to play predict
hamstring re-injury, but baseline MRI findings do not. Br
I Sports Med lfll4:4fl{1flj:13??—13il4. Modline DUI
This cohort study found no association bepeecn baseline
MRI findings and hamstrings reinjury within iii months;
previous hamstring injuries and clinical signs {knee ex-
tension or isometric-force deficits and tenderness with
palpation] were significant independent predictors of re-
injury, however.
2?. Moen MH, Reurink G, 1|Illicit A, Tol JL, Mass ivi,
|lii'roudswaard G]: Predicting return to play after ham-
string injuries. Br 1 Sports Merl lfll4;4S{1fi}:lSSS-1363.
Medline DUI
firthopaedic Knowledge Update: Sports Medicirie S
In 3’4 nonprofessional athletes, MRI findings were unable
to predict return to play. |[illnly a self-predicted time to re-
mrn to play by the athlete and a passive straight leg raise
deficit remained significantly associated with the time to
return to sport.
ES. Koulouris ('3, Council D: Evaluation of the hamstring
muscle complex following acute injury. Skeletal Radiol
lflfl3;31{1flj:SSE-SSS. Medline DUI
19'. Guillodo ‘1", Bouttier R, Sarat A: Value of sonography
combined with clinical assessment to evaluate muscle in-
jury severity in athletes. } Arlil Train .101 1:4Sl3}:.'ifl D-SEH.
Medline
Ninety-three consecutive sports-related muscle injuries
were analyzed. Physical examination findings (bruising,
tcnderuess to palpation, limited range of motion, and
pain with isometric contraction} and ultrasound findings
including hematoma volume were found to predict the
return to play following muscle strain.
3f]. Sherry MA, Best TM: A comparison of 2 rehabilita-
tion programs in the treatment of acute hamstring
strains. J Grrhop Sports Phys Ther lflfl4;34{3}:i 16-125.
Medline DD]
31. Lewne WN, Bergfeld jA, Tessendorf W, Moorman CT
LII: Intramuscular corticosteroid injection for hamstring
injuries. A 13—year experience in the National Football
League. An: _l Sports Med EDDG;ES{3}I:29?FSDG. Medline
32.. A Hamid MS, Mohamed Ali MR, Yusof A, George J,
Lee LP: Platelet-rich plasma injections for the treatment
y Sports Med 1014:41llfljfl4lfl-1413.Medline not
This randomised trial compared rehabilitation programs
tion on return to play following hamstring strain. Return
to play was, on average, 15 days longer in the rehabilita-
tion-only group. The study was not placebo controlled.
Leml of evidence: II.
33. Rcurink G, lGoudswaard G], Moen MH, er a]: Dutch
Hamstring Injection Therapy {HIT} Study Investigators:
Platelet-rich plasma injections in acute muscle injury. N
Eirgljr Merl lfli4;3?fl{26j:2546-254?. Medline DDI
In a three—center randomized, placebo—controlled trial
comparing PEP to isomnic saline, the investigators found
an equal return-to-play time {mean of 42 days} for both
groups. Two injections were given: one S days after injury,
and the second at it! to 12 days after injury.
34. Clanron TC}, Coupe K]: Hamstring strains in athletes:
Diagnosis and treatment. _.l Arr: Acarl Drtlrop Sarg
1993;5l4}:23?-24S. Medline
35. Engehretsen AH, Mylrlehusr G, Holme I, Engebrersen
L, Bahr Ii: Intrinsic risk factors for hamstring injuries
among male soccer players: A prospective cohort study.
Am I Sports Merl lfllflfifllfijtll‘lT-IISS. Medlitle DUI
Q lfllfi American Academy of Orthopaedic Surgeons

In a cahart af SHE prafessianal saccer players, TE ham;
string injuries were identified. In multivariate analysis,
previaus hamstring injury was the mast predictive factar
far reinjury, mare than daubling the risk af a new injury.
Level af evidence: II.
36. Upar DA, Williams MD, Timmins RG, Hickey J, Duhig
5], Shield A]: Eccentric hamstring strength and hamstring
injury risk in Australian faatballers. Med Sci Sparta Exarc
2D15;4?{4}:SS?—SES.Medline DCiI
Australian faathallers with reduced preseasan eccentric
hamstring strength belaw a threshald value had a l.?—fald
increased risk af hamstring injury that seasan. Canversely,
increased eccentric strength mitigated ather risk factars,
including increased age at previnus injury.
3?. Clpar DA, Williams MD, Timmins RG, Hickey J, Duhig
5], Shield AJ: The effect af previaus hamstring strain
injuries an the change in eccentric hamstring strength
during preseasan training in elite Australian faatbaIlers.
Ant J Sparta Mad 1fl15;43{2}:3??-334. Medliue DUI
Athletes with previaus hamstring iniuries shawed a rela-
tively reduced capacity far eccentric strengthening with
exercise campared with these withaut previaus injury.
This finding was true far the affected and the nnnaffected
limb. Level af evidence: II.
33. Harris JD, Griesser MJ, Best TM, Ellis TJ: Treatment af
prairimal hamstring ruptures - A systematic review. Int
J Sparta Mad 2fl11;32{?]:49fl-495. Medline DUI
This systematic review campared surgical treatment with
nansnrgical treatment and acute repair timing af prmtimal
hamstring avulsians with that af chranic repair. Han-
surgical and chranic repairs were faund ta have inferiar
autcames in terms af patient satisfactian and return tn the
previaus level af campetitian.
35'. Crass TM, Gibbs N, Hauaug MT, Gameran M: Acute
quadriceps muscle strains: Magnetic resanance imaging
features and pragnasis. Am I Sparta Med lflil4;32{3}:?lil-
7’19. Medline DCII
413'. Hasselman CT, Best TM, Hughes C IV, Martinez S,
Garrett WE Jr: Au explanatian for varinns rectus fem-
aris strain injuries using previnusly undescribed muscle
architecture. Am I Sparta Med 1995;23{4}:433—499.
Medline DCiI
41. Schuett D], Eamar JD, Pennack AT: Pelvic apaphyseal
avulsian fractures: A retraspective review af 113 cases.
J Pediatr Drthap 2fl14. Medline DUI
The authars identified 123 apaphyseal avulsians. The
mean age was 14, and TESS af injuries accurred in males.
Mast injuries accurred during sprinting at kicking. AIIS
avulsians were mast camman {49%}, fallawed by avulsians
at the anteriar superiar iliac spine {30%}, ischial tuberasity
[11%], and iliac crest {'lfl‘i'al. Level af evidence: IV.
42. Balius R, Maestra A, Pcdret C, et al: Central apaneurasis
tears cf the rectus femaris: Practical sanagraphic pregna-
sis. Br J Sparta Med 2Ufl9;43[11}:313-324. Medline DDI
IE! Eillii American Academy af Clrthnpaedic Surgeans
Chapter 13: Muscle Injuries cf the Praarimal Thigh
43. Hetsrani I, Paultsides L, Bedi A, Larsau CM, Kelly ET:
Anteriar inferiar iliac spine marphalagy carrelates with
hip range af matian: A classificatian system and dynamic
madel. Ciir: Drtbap Raint Rea 2fl13;4?1{3}:149?-25fl3.
Medline DUI
The authars reparted a carrelatian between AIIS marphal-
agy and hip range af matian. A lawer-hanging AIIS {at
at belnw the level af the acetabular rim] carrelated with
decreased hip flexian and internal ratatian an clinical
eaaminatian. Level af evidence: III.
Hetsrani I, Larsau CM, Dela Tarre K, Zbeda RM, Ma-
gennis E, Kelly BT: Anteriar inferiar iliac spine defarmity
as an extra-articular saurce far hip impingement: A series
nf lfl patients treated with arthrascnpic decampressinn.
Arthraarapy lflllglfljl 1}:lfi44-ISSS. Medline DCII
The authars describe the arth rascapic technique and aut-
camll af AIIS decampressian. At a mean cf 14 manths
pastaperatively, hip range af matian and madified Harris
Hip scares impraved significantly. Level af evidence: IV.
45. Gamradt SC, Ernphy RH, Barnes R, Warren RF, Thnmas
Byrd JW, Kelly ET: Hanaperative treatment far prairi-
mal avulsian cf the rectus femaris in prafessianal Amer-
ican fantball. Arr: J Sparta Meal lDflS’;3T{TJ:13Tfl-1374.
Medliue DUI
46. Irmala T, Heikkilii JT, Drava S, Sarimn J: Tatal praatimal
tendan avulsian at the rectus femaris muscle. Stand} Med
Sci Sparta EGUTHTHJfiTS-SSE. Medline
4?. Garcia VV, Duh rkap IJC, Seiias FL, Area 0, Cugat R: Sur-
gical treatment af pranimal ruptures af the rectus femaris F‘:'
in prafessianal saccer players. Arch Grthap Trauma Satrg E
1012:132E3}:329—333.Medline an: 'U
tn
This study included ten praaimal rectus avulsians in
3
EL
'13
high-level athletes wha underwent surgical repair. Sis: 1
were repaired directly, whereas suture anchnrs were used In
El-
in faur cases. Na recurrences accurred, and all athletes
returned ta the same level af campetitian.
4E. Straw It, Calclaugh III, Geutjens G: Surgical repair af :1
chranic rupture cf the rectus femaris muscle at the PIC!!-
imal musculatendinnus junctian in a saccer player. Br
J Sparta Med 1003,3?[2}:131—1fl4. Medline DDI
49. Wittstein J, Klein S, Garrett WE: Chranic tears nf the
reflected head cf the rectus femaris: Results af apera—
tive treatment. Ant I Sparta Mad 2011:39t9}:1942-194?.
Medline DUI
Five patients with chranic tears af the rectus femaris that
failed nansnrgical therapy were treated with encisiau af
the reflected head. All reparted a reductian in pain se-
verity, but four af five had mild residual symptams with
athletic participatinn. Level af evidence: IV.
Si}. Gicvarid T, Lucin K, Rath S, Ivancii‘.‘ A, Marinavifi M,
Santic V: Giant pseudacyst af the rectus femaris muscle—
repetitive strain injury in recreatianal saccer player. Call
Antrapai lfllfl;34{Suppl 21:53-55. Medline
Drthapaedic Knawledge Update: Sparta Medicine S
Chapter 14
Athletic Pubalgia/Core Muscle
Injury and Groin Pathology
Ch ristophcr M. Larson. MD David M. Rowley. MD
Hip and groin-related symptoms and disorders are in-
creasingly recognised as a cause of significant disability
in athletes. Hip and groin symptoms can be the result
of extra-a rticular disorders [sports herniaiathlctic pub-
algiaicore muscle injury, proximal adductor pathology,
osteitis pubis} and or intra-articular disorders (labral
tears, chondral pathology, femoroacctabular impinge-
ment}. It is now recognized that there is a compensatory
relationship between intra-articular and extra-articular
hip and groin disorders, and a high index of suspicion
is required to accurately diagnose these conditions. A
thorough history and physical examination combined
with appropriate imaging studies can lead to an accurate
diagnosis and effective treatment recommendations.
Ultimately, this can help to minimize disability duration
and maximize return to athletic participation in this
potentially challenging patient population.
Keywords: athletic puhalgia: groin injuries: hip
Injuries
Introduction
Hip and groin injuries are common problems that can
lead to disability in athletes. The clinical and diagnostic
presentations of the various potential entities can over-
lap, making diagnosis and treatment difficult. These
Di: Larson or an immediate family member serves as a paid
consultant to A3 Surgicai and Smith S- Nephew: has stock or
stock options held in A3 Suryicai; and has received research
or institutionaisupport from Smith 5 Nephew Neither fir.
Rowiey nor any immediate family member has received
anything of vaiue from or has stock or stock options heid
in a commerciai company or institution reiated direci‘iyr or
indirectly to the subject of this chapter:
fl lflld American Academy of Drrhopaedic Surgeons
challenges can lead to time lost from athletic participa-
tion and subsequent frustration for athletes with these
conditions.1 The differential diagnosis for activity-related
groin pain has been described in broad categories as core
muscle injury {athletic pubalgia or sports hernia}, hiplf
joint pathology {intra-articular pathology), and other
etiologies.2 This chapter discusses extra-articular hip
pathology with a focus on athletic pubalgia, proximal
adductor injuries, and osteitis pubis.
The anatomic structures of the hip and pelvis have
been described based on layers. Layer 1 consists of the
osseous morphology, including the pelvic bones, acetab-
ulum, and proximal fcmu r. Layer 2. consists of soft tissue
in and around the hip including the labrum, capsule,
and ligaments, which add substantial stability to the hip.
Layer 3 consists of the contractile layer around the hip l‘:'
including the adductors, abductors, flexorsiextensors, and E
'U
internal and external rotators of the hip. Layer 4 consists to
3
of the neurovascular structures that surround the hip.
EL
'13
1
The main components of this layer are the lateral femoral in
El-
cutaneous nerve, obturator nerve, inguinal nerve, sciatic
nerve, and genitofemoral nerve.J It should be noted that
all of these structures can be sources of pain when eval-
uating patients with lower abdominalihipigroin pain. In
addition, patients with extra—articular hip pathology can
have concomitant femoroacetabular impingement {Frill}
or intro-articular hip pathology.
Athletic F'ubalgia
Pathoanatomy
The anterior bony pelvis, with its many muscle attach-
ments and the pubic symphysis, forms the center of core
injuries and sports hernia.1 The abdominal wall mus-
culature also has been described in layers. The layers,
from superficial to deep, are the fascia, external oblique
fascia and muscle, internal oblique fascia and muscle,
transversus abdominis muscle, and transversalis fascia.‘
The rectus abdominis muscle, conjoint tendon (internal
oblique and transversus abdominis fascia}, and external
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 2: Hip and Pelvis

Images show the abdominal wall musculature. A, Illustration depicts the opposing forces of the rectus
abdominis {HA} and the adductor longus muscles {AL} at the pubic tubercle. The rectus abdominis muscle creates
su peroposterior tension. whereas the add uctor long us muscle creates jnferoa nterior tension. Disruption of either
muscle leads to altered biomechanics. The blaclt circle represents the superficial inguinal ring. B, Gross specimen
demonstrates the rectus ahdominis tstraig ht arrow}. the add uctor lo ng as {curved arrow}, and the pubic tubercle
attachment of the rectus ahdominisradductor aponeurosis {arrowhead}. (Reproduced with permission from Palisch
A, Eoga A, Meyers W: Imaging of athletic pubalgia and core muscle injuries: Clinical and therapeutic correlations.
flirt Sports Med 2m 3;32[3]:42?-441}

-E
2
oblique muscle merge to form the pubic aponeurosis,
to which inserts onto the pubic tubercle. The medial thigh
a.
1:
I:
rt:
compartment consists of the pectineus, the gracilis, and
E- the adductor brevis, longus, and magnus muscles {Fig-
I
H ure 1). The ligamentous complex at the pubic symphysis
consists of the anterior, superior, posterior, and arcuate
ligaments. The superior and arcuate ligaments are the
main stabilizers of the pubic symphysis.‘
The pubic symphysis is the center of the various forces
generated at the anterior pelvis. Athletic pubalgia is de—
fined as an injury to one of the previously described struc-
tures, as it inserts into the pubis, without the presence
of a clinically recognizable hernia, so the term spurts
hernia is a misnomer.5 Injury to or deconditioning of one
of the anterior pelvic structures can result in increased
stress and strain on the adjacent structures. This can lead
to complete disruption of one of the musculotendinous
originsfinsertions or ligaments about the pelvis.
Clinical Presentation
Rapid lateral motion, acceleration, deceleration, hyperezc—
tension, or hyperabduction can lead to increased tension
in the pubic region.‘ Athletic pubalgia is seen primarily
in athletes who are involved in cutting and pivoting ac—
tivities. In one study, 31% of patients who presented with
athletic pubalgia were athletes.‘5 Patients typically present
with exertional pain during activity without a specific in-
jury or event causing the pain. They report anterior groin
or lower abdominal pain that is brought on by physical
activity and is usually relieved with rest.‘r The lower ab-
dominal or groin pain often resumes with activity after a
period of rest from vigorous activity. Coughing, sit-ups,
and kicking can reproduce the symptoms. l[itccasionallyg
pain can radiate proximally into the abdominal muscula-
ture or distally into the thigh, groin region, or scrotum.1
Physical Examination
The physical examination should begin with palpation
of the pubic symphysis, the rectus ahdominis muscle, the
internali'eaternal oblique muscles, the origin of the adduc-
tor muscles, the pectineus and gracilis muscles, and the
inguinal ring for areas of tenderness. Lower abdominal
pain or groin pain, pain that is worse with sport-specific
activities including kicking, cutting, sit—ups, and sprinting
and that is relieved with rest, tenderness to palpation over
the pubic ramus, pain with resisted hip adduction, and
pain with resisted abdominal sit-ups are the five most
common complaints or findings in patients with athletic
pubalgia.E Evaluation of potential intra—articular hip pa—
thology using the FADIR {fleecion, adduction, internal

firthopaedic Knowledge Update: Sports Medicine 5 fl lfllfi American Academy of Orthopaedic Surgeons
 lli'lllapter 14: Athletic Pubalgiail'Core Muscle Injury and |l'3toin Pathology
rotation] test should be performed, because concomitant
hip-joint pathology is not uncommon, and intra-articular
and extra—articular hip and pelvis disorders often are
related and compensatory in nature.
Imaging
Initial imaging begins with a well-centered AP pelvis and
lateral hip radiograph.9 These images are usually negative
in patients with isolated athletic pubalgia but are used to
rule out avulsion injuries about the pelvis, radiographic
signs of bony impingement, stress fractures, osteitis pubis,
sacralised lumbar vertebrae, and other potential sources
of pain.
MRI is the current standard for evaluation of activity—
related pelvic pain.” A dedicated athletic pubalgia MRI
protocol, including large field-of-view and small field-o f-
view images focusing on the pubic symphysis, is useful for
accurate diagnosis and location of the pathology.1 MRI
is 68% sensitive and lflfl'ii: specific for rectus abdomi-
nis pathology compared with findings at surgery and is
36% sensitive and 39% specific for adductor pathology.
It also is lflfl% sensitive for osteitis pubis.” MRI should
be reviewed closely for osteitis pubis, rectus abdominis
strain, adductor tendon injury, rectus abdominis or ad-
ductor apoueurotic injury or plate disruption, inguinal
hernias, femoral stress fractures, and hip—joint—related
pathology.” The most frequent finding on MRI is fluid
signal extending from the anterior-inferior insertion of
the rectus abdominis into the adductor origin, with cor
responding fluid signal in the pubis"!11 {Figure 2.].
Diagnostic Injections
As described previously, sewral potential pain genera-
tors are present about the pelvis and groin. Diagnostic
injections can help determine the etiology of pain when
conflicting results appear on clinical examination. Ad-
ministering an intra—articular injection of local anes—
thetic into the hip joint can be useful before having the
athlete perform activities that typically provoke pain or
re—examining the patient in the office. Persistent pain
in the groin or lower abdominal regions after intra-ar-
ticular injection can be consistent with concomitant or
isolated athletic pubalgia. Anesthetic injection into the
pubic symphysis, adductor cleft, or psoas bursa also can
aid in diagnosis.
Treatment
Nonsurgical Treatment
Relative rest and avoidance of activities that provoke pain
comprise the initial treatment. Physical therapy should
focus on core strengthening as well as identifying areas
of weakness or reduced range of motion. Therapy should
IE! lflli‘i American Academy of flrthopaedic Surgeons
Figure 1 MRI of the hip and pelvis of a 22-year-old
football player with left-side lower abdominal
and proximal adductor—related pain reveals
a disruption of the distal rectus ahdominislr
atltl uctor aponeurosis on the left (arrow).
{Reproduced with permission from Larson EM.
Sports hernial'athletic pubalgia: Evaluation and
management. Sports Health 2D14;E[2]:135-1d4.]
focus on resolving imbalances between the pelvic and hip
stabilizers.Gr NSAIDs and ice can he used to minimise H
swelling and pain during the rehabilitation period. E
15
Patients generally are treated for at least 3 months with Eu
3
EL
activity modification and physical therapy. If substantial '13
1
improvement is achieved, nonsurgical treatment is con- in
El-
tinued with a gradual sport-specific activity progression.
If no improvement is seen by 3'.- months, surgery might
be considered? Ultimately, the duration of nonsurgical
treatment and the timing of potential surgery are variable,
depending on the level of the athlete and the schedule of
the sport season.
Surgical Treatment
Various surgical procedures have been described for the
treatment of athletic pubalgia. Plication of the transver-
salis fascia, reapproximation of the conjoint tendon to
the inguinal ligament, and approximation of the exter-
nal oblique apoueurosis has been described.” Patients
had a return—to—sport rate of 95% at 12 weeks. An open
approach for the treatment of athletic pubalgia has been
described, with reattachment of the anterior—inferior
rectus abdominis with an adductor releasef' 152 of 15'?
patients with athletic pubalgia who underwent primary
pelvic floor repair were able to return to their preinjury
level of competition. In a study examining results over
Drthopaedic Knowledge Update: Sports Medicine .‘i
 Sectiun 2: Hip and Pub-fie
20 years, 95% nf athletes were able tn return tn spurts
participatiun at 3 mnnths pnstnperatively.” An npen re-
pair technique using mesh has been studied; all patients
underwent bilateral mesh repairs with the mesh bridging
frnm the pubis tn the anterinr superinr iliac spine.15 The
perituneum was clused uvcr the mesh, and it was rcpurted
that all patients were able tn return tn full spurts pa rtic-
ipatinn pnstnperatively. Multiple authnrs have published
their experience with laparuscupic repain'fid'" A. recent
randnmized cuntrnlled trial cumpared patients with ath-
letic pubalgia treated with a laparnscnpic mesh technique
with thuse whn underwent nunsurgical treatment. At
3.- munths, Elfl'ii: nf the laparnscupic gruup retunted tn
spurt cumpared with 2?"?4: nf the nuusurgical gruup. At
12 munths, STEP—ii uf the surgical gruup had returned tn
spurt cnmpared with sex. nf the nunsurgical gruup.”
It is recummended that patients with suspected athletic
pubalgia be referred tn an experienced general surgeun
with an interest in grain pathnlngy. There is little evidence
tn suggest that une repair technique is superiur tu anuther,
based nn the current published literature.
Enmplicatinns
The must cummun pnstnperative cnmplicatiun is edema
in the abdnmeu, thighs, genitals, and perineum. Wnuud
infectiun is rcpurted at {1.4%, and hematuma requiring
renperatiun has a rate nf fl.3%. Herve dysesthesia has
-E
2
a less than 1% nccurreuce rate and usually affects the
cu anteriurirlateral femnral cutaneuus nerve distributinn, the
n.
1:
I:
an
ilininguinal nerve, nr the genitufemnral nerve.” Penile
E- vein thrnmbusis is rcpurted in the literature but all cases
I
H resnlved. The must cummun reasnn fur renperatiun is
the develnpment nf athletic pubalgia nu the cuntralateral
side. The sncund must cummun reasnn fur renperatiun
is inadequate adductur release nr repair at the time nf
the athletic pubalgia repair.” Failure tn address intra-
articular pathulugy {Phil is anuther reasnn fur cuntinued
disability after repair.”
Rehabilitatinn
Must recent studies have repurtecl a return tn full activity
1 tn 6 mnnths after surgery, depending nu the type nf
repair."=“' Patients may bear weight as tulerated pustup-
cratively, with physical therapy starting at 1 tn 14 days
pustuperatively. Physical therapy initially fucuses un ab”
duminal and adductur flexibility and targeted abduminal
strengthening. A stepwise running prngram begins at 4
weeks after surgery, with spurt—specific exercises starting
at week 533'" Activity as tulerated is alluwed aruund 6
weeks pnstnperatively.“
firthupaedic Knnwledge Update: Spurts Medichie 5
Figure 3 AF pelvis {A} and Dunn lateral {B} radiugraphs
frurn a 23-year-uld man shuw cumbined
iernnrnacetabular impingement (FM) and
athletic pubalgia.
|IZabined Athletic Pubalgia and Fill
llEil'verlap between intra-articular and extra-articular pa-
thulugy uften uccurs in patients presenting with luwer
abduminal grnin nr hip pain. Recently, using a cadaver
made], it has been shnwn that patients with FAI have
increased stress placed un the pubic symphysis, which
may predispuse tn cumbined FA] and athletic pubalgia.“
It is imperative tn determine the snurce nf the pain an that
pmper expectatiuns and treatment nptiuns can be present-
ed. A subset nf patients will present with cumbined FAI
and athletic pubalgia. Clinical examinatinu and detailed
imaging can help tn determine the cumbined diagnusis
{Figure 3}. ten, it is difficult tu determine huw much
pain nr disability results frnm each entity. In these cases,
anesthetic intra—articular and extrararticular injectiuns
can aid in the diagnusis. When it is determined thrnugh
a detailed examinatinu, imaging, and pussibly diagnustic
injectiuns that a cumbined prucess is uccurring, treatment
can he tailnred fur bnth entities. Treatment nf nnly nne nf
the pathulugies can lead tn a subuptimal result. In a study
nf patients with cumbined FA] and athletic pubalgia, pa-
tients whn had athletic pubalgia surgery alnne returned
tn their previuus level uf spurt participatiun 25% uf the
time. Df patients whn underwent arthrnscnpy for PA]
unly, 50% returned tn their previuus level. Di patients
whn had bnth athletic pubalgia surgery and hip arthrus—
cnpy, 35% tn 91% returned tn spurt. Nu difference was
seen, whether surgery was perfnrmed in a staged fashinn
ur if huth treatments were perfurmed at the same time.”
adductur Strain
Pathnanatnmy
Myutendinuus injuries and strains are mure cummun
when the muscle crnsses twu juints, and they usually
result frnm eccentric cuntractinn.11 The injury usually
uccurs at the myntendinuus junctiun. Adductnr injures
nften nccur at the urigin nntn the pelvis, hnwever, and
fl lflld American Academy nf Cirrhnpaedic Surge-nus

may be caused by a different mechanism than typical mus-
cle strainll {Figure 4}. Adductnr attains are cnmmnn in
athletes whn participate in pivnting and cutting activities
and in kicking in snccer. The adductnr grnup wnrlcs in
cnnjunctinn with the abdnminal musculature tn stabilise
the pelvis during walking and running.” The adductnr
lnngus nrigin en the pelvis may be predispnsed tn injury
because nf its small crnss-sectinnal area cnmpared with
the size cf the muscle belly.21 Annther etinlngy fnr adduc-
tnr strain is a muscle imbalance between the abductnrs
and the adductnrs. It has been reperted that prnfessinnal
hnclcey players are 1? times mnre likely tn incur an ad—
ductnr strain if their adductnr strength was less than
Efl'lfi nf their abductnr strength?-1 In a fnllnw—up study,
the authnrs shnwed a significant reductinn in adductnr
strains in a similar pnpulatinn when a preventive adductnr
strengthening prngram was institu 3“?”
Clinical Presentatinn
Adductnr strains are cnmmnu in athletes participating
in fnntball, snccer, hnckey, and dance.“ These athletes
nften present with acute medial grnin nr prnximal thigh
pain. Adductnr strains are usually self—limiting, requir—
ing minimal treatment with very high rates nf return tn
play. Chrnnic prnximal adductnr pain related tn spnrts
participatinn can be assnciated with athletic pubalgia nr
hip impingement, such as FAI. Cine study nf athletes with
prnximal adductnr pain repnrted underlying FAI in 94%
nf athletes, based nn radingraphs.” Du examinatinn, ten—
derness tc- palpatinn is present ever the adductnr lnngus
tendnn.“ Patients experience pain with passive abductinn,
and a palpable defect snmetimes will be present. Patients
alsn have pain with resisted adductinn. When evaluating
patients with adductnr injury, it is impnrtaut tn assess fnr
athletic pubalgia and PAL
Imaging
Imaging fnr adductnr strains is usually nnt indicated,
because many at these injuries are self-limiting. Fnr
patients experiencing chrnnic disability secnndary tn a
grnin injury nr in patients with a palpable defect, imaging
may be warranted. A well-centered AP pelvis radingtaph
shnuld be nbtained, with initial evaluatinn fnr apnphyseal
avulsinns, nsteitis pubis, pelvic stress fractures, nr intra-
articular findings that may explain cnntinued disability.
MRI is the next study fnr evaluatinn nf musculntendinnus
injury, injury at the insertinn site, and intra-articular hip
pathnlngy. MRI sequences that have been described fer
the evaluatinn nf athletic pubalgia are indicated? Muscle
strains with a cress-sectinnal area invnlvement greater
than Sfl‘li- nu MRI, fluid cnllectinns, and muscle tears are
assnciated with lnnger recnvery times. Adductnr lnngus
IE! lfllti American Academy nf flrthnpaeclic Surgenns
cluster 14: Athletic Pubalgial'Cc-re Muscle Injury and Grain Patbelngy
Hentus
abduminls
Inguinal
ligament
Superficid ring
Ilinpsnas
Sent-nus
FEGllI'IEUE
Adductnr
Inngue
Figure 4 Illustration shnws Injury tn the ahdnminal wall
at the fascial attachments cf the rectus and
add uctnrs nntn the pubis, which is implicated
in athletic pubalgia. The two arrews shnw the
nppnsing fnrces that are placed an the pubis
secnndary tn the rectus and adductnrs.
tears with a palpable defect usually shnw a 3—cm nr great—
er retractinn nf the tendnn nn MRI“? {Figure 5}.
Treatment
Activity mndificatinn, ice, cnmpressinn, NSAIDs, and
gentle range-nf-mntinn exercises are the mainstay nf ini- H
tial treatment after adductnr injury. When pain decreas- E
'U
es, formal physical therapy can begin using a variety of tn
3
EL
mndalities, including static stretching, massage, tissue '13
1
mnbiliaatinns, and prnprinceptive neurnmuscular facili- tn
El-
tatinn. Cryntherapy may be helpful fer the reductinn nf
swelling and pain relief.15 Electrical stimulatinn may be
used tn prevent muscle atrnphy. External wraps can litnit
the amnunt nf active and passive hip abductinn and can
prnvide cnmfnrt in the acute setting.
1'Ii'lil'hen pain is manageable, gentle range-nf-mntinn
exercises can begin, including exercise-bike riding and
pen] exercises. After full range nf mntinn is achieved,
a strengthening prngram is instituted fncusing nn cnre
strengthening, plynrnetrics, and gentle running straight
ahead.21 The patients‘ activities are gradually advanced
with spnrt-specific drills. Patients are able tn return tn
play after full strength and painufree mntinn are achieved,
with a mean return tn play nf 6 weeks.“
Fnr patients in whnm nnnsurgical treatment has failed,
injectinns may be warranted. Platelet—rich plasma {PEP},
cnrticnsternid, and simple anesthetic injectinns have been
described fnr adductnr strains. Injectinns intn the adduc-
tnr enthesis have shnwn snme success in cnmpetitive and
recreatinnal athletelI
Drthnpaedic Knnwledge Update: Spnrts Medichie 5
 Section 2: Hip and Pelvis

Figure 5 MRI depicts an anterior adductor avulsion in a professional football defensive back presenting with severe left-
side groin pain. Flight-side defensive backs often injure their left rectus abdominisradductor aponeurosis when
transitioning during pass coverage. A, Large field-of—view coronal short tau inve rsion —recovery {STIR} image of the
bony pelvis shows detachment of the left adductor origin from the aponeurosis {arrow} with the retracted tendon
fibers {arrowhead}. The distance of retraction often is measured best on the coronal STIR images. B. Small field-
of-view coronal oblique Tit-weighted fat—saturated fast spin—echo image using a pubalgia protocol demonstrates
the detachment of the left anterior adductor origin from the aponeurotic plate {a now). te n, the pectineus
and adductor longus muscles detach together. This condition is referred to as an anterior adductor avulsion
because these muscles are the two most anterior muscles at the pubic attachment. [He produced with permission
from Pallsch A, logo A, lvleyers w: Imaging of athletic puhalgia and tore muscle injuries: Clinical and therapeutic
correlations. Clio Sports Med 2D13:32[3]:42?-44?.}
-E
E
o:
o.
1:
I:
in
If nonsurgical treatment of 3 to 6 months has failed, Complications
E- surgical treatment may be considered. In a case series of Injury to the spermatic cord can occur during surgical
I
H 16 competitive athletes with chronic isolated addnctor lengthening of the addnctor longus if dissection is carried
pathology, nonsurgical measures including rest, physical medial to the gracilis origin on the pubisfii’d”
therapy, NSfiIDs, and corticosteroid injections failed in
all patients.23 Surgical treatment consisted of open tenot- Rehabilitation
orny 1 cm from the adductor longns origin. All patients Postoperatively, patients can bear weight as tolerated with
improved and were able to return to sports activities. crutches until a nonantalgic gait is achieved. Gentle range—
At final follow-up, ll] of It? patients were pain free. Ad- of-motion exercises may begin as tolerated. Strengthening
duction strength was weaker after full recovery. One of exercises may begin at 6 to 3 weeks, with a mean return
the authors of this chapter {CML} prefers a fractional to play of 12 weeks.
lengthening 3 cm distal to the origin to minimize post-
operative weakness. Caution should be exercised when
considering a release in soccer strikers, because this pro-
cedure might lead to detrimental adductor weakness.2T Pathoanatomy
In a 2013? study of 19 National Football League {NFL} |liii'steitis pubis is thought to be a stress injury of the para“
players who sustained a rupture of the addnctor longns, symphyseal pubic bones secondary to increased strain on
14 were treated nonsurgically, and 9 underwent surgical the anterior pelvis.“ It is described secondary to chronic
repair.2T The nonsurgical group returned to play at 6 overuse, resulting in a stress reaction adjacent to the pubic
weeks, compared with 12 weeks in the surgical group. symphysis and later leads to symphyseal pathology.“ This
No strength deficits were present in either group. {if the was demonstratcd in a study of pubic rami hone biopsies
surgical group, 2fl% experienced wound complications, a of athletes in whom osteitis pubis had been diagnosed.”
fact that favors nonsurgical treatment in these instances. The specimens showed formation of new woven bone,

firthopaedic Knowledge Update: Sports Medicine 5 fl lfllfi American Academy of Orthopaedic Surgeons
 |ililtapter 14: Athletic Pubalgiai'flore Muscle Injury and Gram Pathology

Figure E AP hip radiographs from a collegiate soccer player show bilateral FAI and athletic pubalgia. The preoperative
radiograph {A} shows a crossover sign {dotted line} indicative of pincer-type impingement, cam impingement
(solid arrow}, and lytic changes at the pubic symphysis {da shed arrow} consistent with osteitis pubis. After rim
resection and femoral resection osteoplasty (B). an improved relation can be seen between the anterior and
posterior acetabular walls, and removal of the crossover sign {dotted lines) is seen. (Reproduced with permission
from Larson EM, Pierce Bit, Gives ns l'v'l: Treatment of athletes with symptomatic intra-articular hip pathology and
athletic puhaigiarsports hernia: A case series. Ardrroscopy 2D11; 2?[E]:?EE-T?5.]

osteoblasts, and neovasculariaation, with an absence of of motion. Patients with reduced hip range of motion are
inflammatory cells and no signs of osteonecrosis. Osteitis also more likely to have osteitis pubis, because it is thought
pubis is seen most commonly in athletes participating to cause compensatory stress at the pubic symphysis.“
in soccer, Australian—rules football, rugby, ice hockey,
American football, and distance running.“ Imaging
The initial imaging study for the evaluation of osteitis le‘
Clinical Presentation pubis is plain radiography. A wellrcentered AP pelvis 3.
'U
Patients often present with lower abdominal pain, radiograph will be normal in acute cases. |Chronic cases to
3
EL
bilateral or unilateral groin pain, andfor pain over the {those lasting more than 5 months} of osteitis pubis can '13
1
anterior pelvis. Initial symptoms are similar to those in present with cystic changes, sclerosis, or widening of in
El-

patients who present with athletic pubalgia or adductor
strains. Patients also have tenderness to palpation over the
pubic symphysis and adjacent rami.Em Pain also can be es:-
perienced in the perineal, inguinal, and scrotal regions.“
Patients may report a clicking sensation over the anterior
pelvis with activity. Pain is usually aggravated by running
or cutting activities, loading of the rectus abdominis,
and resisted hip flexion and adduction. Dsteitis pubis is
often a chronic condition that can result in an inability to
compete in athletics secondary to pain and discomfort.33
This presentation is distinctly different from the osteitis
pubis presenting with disability during daily activities and
a waddling gait, which is seen more typically in females.
Physical Examination
Examination findings commonly overlap with athletic
pubalgia and adductor strains and include tenderness to
palpation over the pubic symphysis and pubic tubercle, ad-
ductor origin tenderness, and pain during resisted adduc—
don.“ Patients may have apprehension during hip range
the symphysis. A single-leg stance AP flamingo view of
the pelvis can be used to evaluate for pubic instability.
Widening greater than 7' mm or vertical shift greater
than 2 mm indicates instability at the pubic symphysis.Jij
Radiographs also should be evaluated for the presence of
FAI, stress fractures, and avulsion injuries” {Figure 6}.
MRI will show subchondral bone marrow edema simi-
lar to that seen in osteoarthritis of other joints. The edema
is usually bilateral but often will be asymmetric, with
increased signal intensity on the more symptomatic side
[Figure '5’}. The bone marrow edema will encompass the
entire subchondral region of the symphysis from anterior
to posterior, thus differentiating it from isolated edema
related to an avulsion injury. Subchondral cysts and re-
sorption of the subchondral bone also can be present on
l'irIRI.1“I A severe episode of osteitis pubis can show artic-
ular erosion in addition to subchondral edema similar
to that seen in patients with osteolysis at the acromio-
clavicular joint. Healing can be protracted in these more
advanced cases.“

IE! lfllfi American Academy of flrthopaedic Surgeons Drthopoedic Knowledge Update: Sports Medichie 5
 Section 2: Hip and Pelvis
Treatment
Nonsurgical Treatment
Nonsurgical management consists of rest, ice, NSAIDs,
activity modification, corticosteroid or PEP injections,
and physical therapy focusing on core strengthening. Cur-
rently, the evidence for nonsurgical treatment of osteitis
pubis is level IV. In a prospective cohort study, osteitits
pubis was diagnosed by physical examination and MRI
in 2? professional Australian-rules football players. Treat-
ment consisted of swimming and upper-body activities as
tolerated. Core strengthening and cycling were started at
3 weeks in patients who were relatively pain free. Stair
-E
E
stepping was started at 6 weeks, with a graduated running
a: program instituted at 12 weeks. Using this protocol, 39%
o.
1:
I:
rt:
of the athletes returned to their sport at 1 year, and 100%
E- returned at 2. years.“ It is not uncommon in the chapter
I
H authors’ practice for osteitis symptoms subside after 1 to
2 years regardless of treatment.
Surgical Treatment
The surgical treatment of osteitis pubis is indicated pri-
marily for demonstrable instability on radiographs or
failure of prolonged nonsurgical management. Techniques
that are described in the literature for the treatment of
osteitis pubis include curettage of the symphysis, wedge
resection, mesh reinforcement of the symphysis, arthrode-
sis of the symphysis using compression plating, and broad
pelvic—floor core-muscle proceduresfi‘biii‘”
Complications
Complications after surgical treatment of osteitis pubis
include hemospermia, scrotal swelling, continued symph-
yseal instability, and chronic anteflor groin pain?1
Rehabilitation
Postoperatively, patients are initially kept nonweight hear—
ing. Gentle range-of-motion exercises and stretching are
firthnpaedic Knowledge Update: Sports Medicine 5
instituted once pain allows. Patients progress through a
graduated strengthening program with return to activity
as tolerated at 45 weeks.
The understanding of athletic pubalgia and groin pathol-
ogy is constantly expanding. Previously, they were seen as
several isolated pathologies, but substantial evidence now
supports the overlap of intra-articular and extra-articular
hip and pelvis disorders as well as other compensatory
disorders up and down the kinetic chain in patients pre-
senting with groin pain. As the ability to diagnose specific
groin—related pathology improves, precise treatment of
these disorders will help to optimise results and minimise
disability times in this challenging and demanding patient
population. Based on the evidence supporting an overlap
between athletic pubalgia and PM, athletes presenting
with groin or pelvic pain should be evaluated for both en—
tities. A critical aspect of treating patients with combined
intra-articular hip pathology and athletic pubalgia, adduc-
tor strain, or osteitis pubis is deciding whether patients
require treatment for both entities. This is a challenging
scenario, because a point likely exists at which treating
FA] alone is inadequate secondary to advanced injury to
the anterior pelvic musculature andi'or structures.
Key Study Points
it The key anatomic structures involved in extra”
articular hip pain should be identified.
1' An understanding of the diagnosis and treatment
of the various causes of extra-articular hip pain is
imperative.
i Key physical examination findings differentiate in-
tra-articular and extra-articular hip pain.
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 14: Athletic Pubalgiat'flure Muscle Injury and |Grain Pathulugy
Annatated References
1. Palisch A, Zuga AC, Meyers WC: Imaging uf athletic
puhalgia and cure muscle injuries: Clinical and therapeu-
tic carrelatians. Elia Sparta Med 2013;32{3J:41?—44?.
Medline DUI
This article highlights several camman causes af grain
pain in the athlete. The article describes the clinical pre-
sentatiun and MRI findings uf these cummun causes uf
grain pain. It alsa highlights the averlap af symptams and
presentations that these cunditiuns share.
Meyers W, Zuga A,]useph T, et al: lCurrent understanding
af care muscle injuries {athletic puhalgia, “spurts hernia”),
in Thamas Byrd JW, ed: Dperetiee Hip drthraseapy. New
Turk, Springer, 2013, pp EFT-T71 DUI
This chapter aims tu clarify suft-tissue injuries in the
pelvis. It explains why spurts hernia is a misnumer and
describes the camplea anatamy af the pelvis. The chapter
alsu stresses the impurtance uf currectly identifying the
injured area as intra—articular ur extra—articular.
Draavitch P, Edelstein J, Kelly ET: The layer cancept:
Utilizatiun in determining the pain generaturs, pathulugy
and huw structure determines treatment. Cu rr Rea Mats-
eulaaltelet Med 1011;5{1}:1-S. Medline DUI
This article discusses the cumpletr anatamy uf the pelvis
in layers. Layer 1 is the asseaus layer, layer 2 is the tissue
layer, layer 3 is the cuntractile layer, and layer 4 is the
neurumechanical layer. Level uf evidence: V.
Birmingham PM, La rsun CM: Medial saft tissue injuries
uf the hip: Adductur strains and athletic puhalgia, in Kelly
ET, Larsun CM, Eedi A, eds: Sparta Hfp Injuries: Diag-
naar'a and Managemertt. New Jersey. SLAEK Inc. 2013.
This review highlights camman extra-attic ular causes af
grain pain, facusing an athletic puhalgia and adductar
injuries.
Farher A], 1iu'.'i£"ilcltens JH: Sparta hernia: Diagnasis and ther—
apeutic appraach. J Am Aeed Grtbap Snrg 20D?:15{S]:50T—
.514. Medliue
Taylur DC, Meyers WC, Muylau JA, Luhues J, Bassett FH,
Garrett WE Jr: Ahdamina] musculature ahnannalities as a
cause uf gruin pain in athletes. Inguinal hernias and puhal-
gia. Arr: ,I Sparta Med 1991:19{3}:139-241. Medline DUI
Meyers WE, Fuley DP, Garrett WE, Lahnes JH, Ma ndle—
haum ER: PAIN {Perfarming Athletes with Ahdaminal
ur Inguinal Neurumuscular Pain Study Gruup}: Manage-
ment at severe luwer ahdaminal ur inguinal pain in high-
perfarmance athletes. Am 1 Sparta Med lflflfl:28{1l:2—S.
Medline
Litwin DE, Sneider EE, McEnaney PM, Euscuni ED:
Athletic puhalgia {spurts hernia}. Clint Sparta Med
ZflllafiflilltdrIT-drddr.Medline DUI
This article pravides an appraach far the diagnusis and
treatment uf athletic pubalgia. It alsu instructs clinicians
haw re use the current infurmatiun and understanding
af grain pathalagy ta accurately diagnase the cause at
lawer ahduminal pain syndrame in the athlete. Level af
evidence: V.
IE! lfllfi American Academy af flrrhapaedic Surgeans
Nufsinger C, Kelly ET: Methudical appruach tn the his-
tury and physical exam af athletic grain pain. Uper Teal:I
Sparta Med 2Ufl?;15{4l:152~156. DUI
10. Mullens FE, Zaga AC, Marrisan WE, Meyers 1WC: Review
uf MRI technique and imaging findings in athletic puhalgia
and the “spurts hernia“. Eur J Radfuf 1011;S1{121:37’39-
31'92. Mcdliue DUI
This article presents a cumpreheusive, current review uf
cummuu and uncummun MRI findings in patients with
athletic puhalgia. It alsu evplains an MRI pratacul spe-
cifically devised fur the diagnusis af athletic puhalgia.
Level af evidence: V.
11. Zaga AC, Kavanagh EC, |[l'mar IM, et a1: Athletic puh-
algia and the “spurts hernia“: MR. imaging findings.
Rudialugy lflfifl;24?{3}:?9?—Sfl?. Medline DUI
12. Larsun CM: Sparta herniatathletic puhalgia: Evaluatiun
and management. Sparta Health aa14,a{a}:139—144.
Medline D01
This article pravides up-ta-date infarmatian an the averlap
af athletic puhalgia and PM. It highlights that patients
with cumhined intra-articular and extra-articular pathul-
ugy have impruved uutcumes when buth are addressed.
Level uf evidence: 1.".
13. Gilmure UJA: Gilmure‘s grain: Ten years experience uf
grain disruptiun—a previuusly unsulved prublem in spurts-
men. Sparta Med Saft Tissue Treasure 1991;1{3}:12-14.
Medline
14. Meyers WC, McKechnie A, Philippun M], Hurner MA,
Zuga AC, Devun UN: Experience with “spurts hernia”
spanning twu decades. Ann Surg 1Dfifl;143{4J:BSS-SSS.
l‘:'
15. Genitsaris M, Guulimaris l, Silcas N: Laparascapic E
'U
repair uf gruin pain in athletes. Arr: j Sparta Med tn
3
2Ufl4:32{5}:1233-1242. Medline DUI EL
'13
1
16. Kluin J, den Hued PT, van Linschuten R, IJaerman JC, van tn
El-
Steensel C]: Enduscupic evaluatiun and treatment uf gruin
pain in the athlete. Am I Sparta Med lfifl4;31{4}:944-949.
Medliue DUI
1?. Inguldhy C]: Laparascapic and cunventiunal repair af
grain disruptian in spartsmen. Br] Starg 199?:34{2}:213-
215. Medline [ll-DI
13. Paajanen H, Erinclt T, Hermunen H, Airu I: Laparu-
seupic surgery fur chruuic gruin pain in athletes is mure
effective than nuuaperative treatment: A randumiaed
clinical trial with magnetic resanance imaging at {it} pa-
tients with apartsman’s hernia {athletic puhalgia]. Surgery
2fl11:15fl{1}:99-1D1Medline DUI
This praspective randamiaed trial campared nansurgi-
cal treatment with surgical treatment uf athletic puhal-
gia. Thirty patients were randumizecl intu each gruup
after nunsurgical treatment at at least 3 munths duratiun
failed. Uf surgical patients, Slfl‘lrh returned tu spurts at 3
munths, cumpared with 2?% uf the nunsurgical patients
at 3 munths. Level af evidence: II.
15'. Larsun CM, Pierce ER, Giveans MR: Treatment uf ath-
letes with symptamatic intra-artieular hip parhalagy and
Drthapaedic Knuwledge Update: Sparta Medichte S
 Seeders 3.: Hip and Pelvic
athletic pubalgiaisparts hernia: A case series. Artbrascapy
2fl11:2?{6}:?63-??5.Medline DUI
This case series presents 37'" patients wha had camhined
femaraacetabnlar impingement {FAI} and athletic pubala
gia. {If patients wha underwent hip arthrascapy far FAI
and athletic pubalgia surgery, 39% were able ta return
ta apart, campared with 2.5% wha had isalated athletic
pubalgia surgery and 513% wha had isalated hip arthras-
capy. Level af evidence: IV.
ll]. Birmingham PM, Kelly ET, Jacabs R, McGrady L, Wang
M: The effect af dynamic femaraacetabular impinge-
ment an pubic sy mpbysis matian: A cadaveric study. Am
] Sparta Med 1312;40'115 1:1113-1113. Medline DUI
This cadaveric study leaked at pubic symphysis matian in
specimens with FAI. Cam lesians led ta increased matian
at the pubic symphysis and were prepased ta cantribute
ta athletic pubalgia in patients with FAI. Centralled lab-
aratary study.
21. Andersan K, Strickland SM, Warren E: Hip and grain
injuries in athletes. Am I Sparta Med 2001;29l4}:521v533.
Medline
Larsan GM, Birmingham PM, Uliver SM: Athletic pub-
algia, in Deiee tit Drea's Drtirapcedic Sparta Medicine:
Principles and Practice, dtb Editian. Philadelphia, PA,
Elsevier, 1315, pp SSS-STA.
This baalc chapter is dedicated tn the anatamy, diagna-
sis and treatment af athletic pubalgia. It discusses key
imaging findings af athletic pubalgia. It alsa discusses
nansurgical and surgical treatment af athletic pubalgia.
-E
2 13. Mann RA, Maran GT, Daugherty SE: |Camparative elec-
cu tramyagraphy af the lawer extremity in jagging, running,
a.
'a
I:
and sprinting. An: I Sparta Med 1936:14i6}:5fl1-51fl.
rt: Medline DUI
E-
I tiJap Reict Res 1936;203:261—Efl. Medline
H 14. Tyler TF, Nichalas S], Campbell R], McHugh MP: The
assaciatian af hip strength and flexibility with the inci-
dence af adductar muscle strains in prafessianal ice hacltey
players. Am ] Sparta Med lflfl1;39{2}:124-123. Medline
35. Strauss E], Campbell K, Easca JA: Analysis at the crass—
sectianal area cf the adductar langus tendan: A descriptive
anatamic study. Am I Sparta Med lflfl?;3S[SJ:SSS-999.
Medline DUI
25. Weir A, de Vas R], Maen M, Hiilmich P, Tal: Prevalence
af radialagical signs af femaraacetabular impingement in
patients presenting with lung-standing adductar-related
grain pain. Br 1 Sparta Med 201 l:45[l}:6-5. Medline DUI
This case series leaked at 34 patients with Iang-standing
adductar-related grain pain. Pelvisihip radiagraphs were
talren af each patient. Uf all patients, 94% had radia-
graphic signs af FAI. Level af evidence: IV.
2'3". Schlegel TP, Bushnell BD, Gadfrey J, Eaublilt M: Success
af nanaperative management af adductar langus tendan
ruptures in Hatianal Faetball League athletes. Am ] Sparta
Med 2D09;3?{7}:1394-1399. Medline DUI
Urthnpaedic Knawledge Update: Sparta Medicine 3
This case series presents 19 Natianal Faatball League
[NFL] players with dacnmented praacimal adductar langus
teadan ruptures. Nansu tgical treatment led ta a faster
return ta play with fewer camplicatians than did surgical
repair. All players were able ta return ta play in the NFL.
Level af evidence: IV.
13. Alrermarlr C, Jahanssan C: Tenatarny cf the adductar
langus tendan in the treatment af chranic grain pain
in athletes. Am I Sparta Med I??2;20{fi}:64fl-S43.
Medline DUI
29. Riaia L III, Salva jP, Schiirhaff MR, Uribe JW: Addue-
tar langus rupture in prafessianal faatball players: Acute
repair with suture anchars: A repart af twa cases. Arr:
i Sparta Med assassinate—145. Medline ear
3'3. Rabertsan I], Curran C, McCaffrey N, Shields C], McEn-
tee GP: Adductar tenatamy in the management af grain
pain in athletes. fat I Sparta Med lflll;32{1]:45a43.
Medline DUI
In this case series, IIEIiEI male athletes underwent unilateral
tenatamy far the treatment af chranic adductar pain. {If
all patients, 91% repartcd impravement after tenatamy.
The pracedure was mast successful far patients wha pre—
sented with severe preaperative pain and disability. Level
af evidence: IV.
31. Hiti G], Stevens K], Jamati MK, Garza D, llvlathesan GU:
Athletic asteitis pubis. Sparta Med 3011;41i5}:361v3?e.
Medline DUI
This article presents the current understanding af and
variaus treatment aptians far asteitis pubis. The authars
emphasise the need far future research ta determine the
apu'mal treatment af this pathalagy. Invel af evidence: IV.
32. Gamble JG, Simmans SC, Freedman M: The symphysis
pubis. Anatamic and pathalagic cansideratians. Ciir: Ur—
33. Verrall GM, Henry L, Faaaalari NL, Slavatinek jP,
Ualteshatt RD: Bane biapsy af the parasymphyseal
pubic bane regian in athletes with chrnnic grain injury
demanstrates new waven bane farmatian cansistent with
a diagnasis af pubic bane stress injury. Am I Sparta Med
lDflS;35{IE}:2415-2431.Medline DUI
34. Eadie R, Annear P: Use af pubic symphysis curettage far
treatment-resistant asteitis pubis in athletes. Am I Sparta
Med lflflS;3S{1j:121—IZS. Medline DUI
35. Williams PR, Tbamas DP, Dawnes EM: |EII'steitis pubis
and instability cf the pubic symphysis. When nanapera-
tive measures fail. Arr: ] Sparta Med lflflfl;13{3j:35[ll-35.5.
Medline
36. Cunningham PM, Brennan D, |D’Eannell M, MacMaban
P, U’Neill P, Eustace S: Patterns af bane and saft-tissue in-
jury at the symphysis pubis in saccer players: Ubservatians
at MRI. AjH An: I Raeritgeitaf 200?;133i3}:W291-256.
Medline DUI
3?. Grace JN, Sim FH, Shives TC, Gaventry ME: Wedge re-
sectian cf the symphysis pubis far the treatment af asteitis
pubis. ] Banejaint Snrg Am 1939;?1l3}:33 3-364. Medline
D 21315 American Academy af Cirrhapaedic Surge-ans
 ctio '

Knee and Leg

Chapter 15
Cruciate Ligament Injuries
Lucas 5. McDonald. MD, MPHStTM Nathan Coleman, MD
Abstract
Anterior cruciate ligament iACL} injuries and their
treatment continue to bc intensively studied. Isolated
injury to the posterior cruciate liagcment {PCL} is rare.
A low-grade injury can be successfully managed non-
surgically. The discussion includes the anatomy and
function of the ACL and PCL, the evaluation of injuries,
surgical techniques for ACL reconstruction and revision
including tunnel placement and graft choice, surgical
management of the PCL including surgical techniques,
and the association of the PCL with multiligamentous
knee injury.
Keywords: anterior cruciate ligament
reconstruction: posterior cruciate ligament
reconstruction; revision anterior cruciate ligament
reconstruction
Introduction
lCruciate ligament injuries of the knee are common, and
their incidence continues to increase. Current research
focuses on anatomic evaluation, the biomechanics of in-
jury, and reconstruction techniques. Clutcome studies can
guide treatment, but ideal graft locations and surgical
techniques have not yet been identified.
Dr. Pearle or an immediate family member has received
royalties from Biomet; serves as a paid consultant to Biomet
and Makofiurgical: has stoclr or stock options held in Blue-
belt Technologies; and serves as a board member, owner,
officer; or committee member of Bluebelt Technologies.
Neither of the following authors nor any immediate family
member has received anything of value from or has steel: or
stock options held in a commercial company or institution
related directiy or indirectly to the subject of this chapter:
Dc McDonald and Di: Coleman.
@ lflld American Academy of Drthopaedic Surgeons
Andrew [1 Pearle. MD
Anterior Eruciate Ligament Injury
The rate of anterior cruciate ligament [ACL] reconstruc-
tions in the United States increased from 32.9 to 43.5
per lflflflflfl' person—years from 1994 to lflflfi because of
an increased number of reconstructions in patients who
were women, were younger than 10 years, or were older
than 443 years.1 High rates of radiographic osteoarthritis
have been reported after ACL reconstruction, with recent
long-term outcomes data demonstrating a threefold in-
crease in prevalence} Predictors for the development of
radiographic knee osteoarthritis after ACL reconstruction
include a prior medial or lateral meniscectomy, medial
meniscectomy at the time of reconstruction, elevated body
mass index, and a relatively long time from injury to sur-
gery}!3 Nonsurgical management of ACL—deficient knees
in active patients does not lead to a satisfactory result,
and a delay of more than 12 months before reconstruction
is associated with meniscal and chondral injuries."1 The
cost-effectiveness of early ACL reconstruction is an addi-
tional argument for surgical treatment. The cost to society
is $1,5{li} lower, and there is an increase in the patient’s
qualityuadjusted lifeuyears when surgical stabilization was
performed within 1 year rather than 2 years after injury.5
Anatomy and Biomechanics
The anatomy of the ACL footprint and the ideal surgical
graft position remain areas of active research. Macroscop-
ically, the ACL consists of anteromedial and posterolateral
functional bundles (Figure 1}. The anteromedial bundle
is tighter in knee flexion, but the posterolateral bundle is
tighter in extension. Both bundles are under tension during to
loading with anterior translation or combined anterior F.
:5
translation and internal rotation, with the anteromedial re
re
tn
bundle maintaining tension throughout knee flexion. 3
El.
The native ACL inserts on the tibia just anterior to the
posterior part of the anterior horn of the lateral meniscus. s
Tibial tunnel placement should include a portion of the
anteromedial bundle footprint to provide optimal graft
obliquity. lGraft placement anterior to the footprint notch
can cause impingement in extension or posteriorly can
cause impingement on the posterior cruciate ligament
(PCLJI.
Orthopaedic Knowledge Update: Sports Medicine 5
 Sectibn 3:1iinee andLeg

AM buncla

F'L bundle

Figure 1 Schematic drawings shbwing the anterbmedial

{AM} and pesterblateral {PL} macrbscbpic
bundles bf the anteribr cruciate ligament (AELIr.
A. The pesterblateral bundle {in blue) is tighter
than the anterbmedial bundle in extensibn.
althbugh it is less isbmetric than in flexibn. I.
The anterbmedial bundle {in red} is tighter than
the pbsterblaterai bundle in flexibn.

A systematic review based bn all studies published since

2030 repbrted radibgraphic findings and arthrbscbpic
landmarks related tb ACL fembral anatbmy.I5 The center
bf the ACL fernbral fbbtprint is 43% bf the distance frbm
the presimal tb distal articular cartilage margin. The cen-
ter bf the anterbmedial bundle is 29.5% bf the prbrcimal tb
distal distance bf the lateral fembral intercbndylar nbtch,
and the center bf the pbsterblateral bundle is 50% bf the Figure 2 Schematic drawings representing the anteribr
same distance. The pbsteribr edge bf the ACL is 2.5 mm cruciate ligament {AEL} fern bral fbbtprint.
The pbsteribr edge bf the ACL is 2.5 mm frbm
frbm the pbsteribr articular cartilage bbrder‘5 {Figure 2}. the pesteribr articular cartilage ipu rple lines].
Histblbgic evaluatibu bf ACL fembral fbbtprint anat- A. The center bf the AEL fem bral fbbtprint
bmy is defined by direct and indirect insertibn fibers. iblaclt dbt albng the red line). is 43% bf the
distance frbni the presimal tn the distal
Direct insertibn fibers are rubre critical than indirect articular cartilage margin. B, The center bf the
insertibn fibers in the prbcess bf linking ligaments tb anterb medial {AM} bundle {bla cit dbt albng
the blue line] is 29-5% bf the distance hen:
bbne, and the placement bf recbustructibn tunnels may the prbirimal tb the distal articular margin. The
prbduce a mbre anatbmic ACL recbustructibn. A we center bf the pesterblateral {PL} bundle {blade
relatibn bf histblbgic and macrbscbpic findings bf ACL dbt along the red line) is sess bf the distance
frbm the prbnimal tb the distal articular margin.
DI
fembral insertibn anatbmy fbund that the ACL inserts
cu
._I rubre anteribrly bu a macrbscbpic than bu a histblbgic
T:
l:
n:
level.T The direct insertibn is in a narrbvv area extending Diagnbsis
cu
Iii-1 frbm the intercbndylar ridge tb a secbnd bssebus ridge 4 The diagnbsis bf an ACL rupture is made frbrn patient
I:
a: mm pbsteribr. The direct fibers db nbt cbntinue tb the histbry, physical examinatibn findings, and imaging
pbsteribr articular cartilage. Pbsteribr fibers that extend studies. The Laehman test remains the mbst clinically
H

re the articular cartilage are indirect fibers with a fanlike
attachment? {Figure 3}. Further research is necessary tb
determine the best lbcatibn fbr graft placement based bn
macrbscbpically visible bundles br histblbgic principles.
sensitive in-bffice examinatibn fbr diagnbsing an acute.
cbrnplete ACL rupture. The sensitivity bf the in-bffice
pivbt shift test is nbt as high. During an examinatibn
under anesthesia. the Laehman test remains mbre sen-
sitive but the sensitivity bf the pivbt shift test imprbves,
and it is the mbst specific physical examinatibn finding

flrrhbpaedie Knbwledge Update: Sperm Medicine 5 El ll] 16 American Acadeimr bf Cirrhbpaedie Surge-ems

AEL direct fiber
insertion
AGL indirect fiber
insertion
Schematic drawing depicting the narrow oval-
shaped direct fibers {hash marksl in the anterior
aspect of the anterior cruciate ligament MEL}
insertion and the fa n-shaped indirect fibers
{dots} in the posterior aspect.
for ACL tears.El MRI can be useful for the diagnosis of
ACL disruption or associated meniscal, osteochondral,
or collateral ligament injury.
A delay in AC1. reconstruction is correlated with an
increased likelihood of meniscal injury or chondral dam-
ageiMedial collateral ligament {MEL} injuries are com-
monly associated with ACL disruptions. Grade I and II
{MEL} injuries are treated nonsurgically, but distal grade
III injuries may be best treated with surgical repair or
reconstruction. Missed or untreated fibular collateral
ligament or posterolateral corner knee injuries, which
increase the stress on the ACL graft, are common reasons
AC1. reconstruction is unsuccessful.m
Surgical Treatment
IIllutcomes
(July 65% of patients return to their preinjury level of
sports after ACL reconstruction, and only 55% return
to a competitive level.“ Factors having a positive asso-
ciation with return to a preiujury level of participation
include relatively young age, symmetric hopping ability,
male sex, and sports participation at an elite level.11 The
desire to return to sports soon after ACL reconstruction
is not always realistic. A 33% rate of successful return
to competitive sports was reported 12 months after ACL
reconstruction with hamstring autograft.ll
Although women are at a greater risk than men for
primary ACL disruption, a recent systematic review found
no greater risk among women than men for graft failure,
contralateral ACL rupture, or postoperative knee laxity
El Ifllii American Academy of Urthopaedic Surgeons
Chapter ’15: lEruciate Ligament Injuries
as determined on physical examination or by patient-re-
ported outcomes.”
Cigarette smoking negatively affects the outcome of
ACL reconstruction. Patients who smoked had an in-
creased risk of postoperative anterior translation and knee
instability after ACL reconstruction with bone-patellar
tendon-bone {EPTB} autograft.“ Patients who stopped
smoking at least 1 month before ACL reconstruction had
no difference in outcome from patients who had never
smoked. Surgeons should consider delaying reconstruc-
tion until patients have stopped smoking tobacco.
Tunnel Placement
Multiple techniques exist for drilling ACL tunnels. 1'Iilii'ith
the traditional transtibial endoscopic single-bundle tech-
nique from the early 199fls, in some knees the tibial bone
tunnel was placed in the posterior portion of the native
ACL footprint at the posterolateral bundle insertion. This
placement can result in a malpositioned femoral tunnel,
with vertical graft placement and femoral insertion su-
perior to and outside of the native footprint. A cadav-
er comparison of transtibial and independent femoral
drilling techniques found that a smaller portion of the
tunnel aperture was contained within the anatomic tibial
footprint during transtibial drilling.”
Evaluations of femoral tunnel placement with tran-
stibial and anteromedial drilling techniques found that
anteromedial techniques created a more anatomic femoral
tunnel position and improved postreconstruction stability
on the anterior drawer, Lachman, and pivot shift tcsts.1'5*1"'
A systematic review found mixed results; in some cadaver
and clinical studies rotational stability was superior when
the anteromedial technique was used, but in other studies
there was no difference based on the use of a transtibial
or anteromedial technique.” flue registryubased study
demonstrated slightly higher failure rates 4 years followr
ing ACL reconstruction with transtibial techniques than
with anteromedial techniques, hypothesizing a greater
force placed on this anatomically placed graft.” Although
debate exists as to the ideal method for creation of the
femoral tunnel, the goal is to be in the correct position. 1.4,:
The use of flexible guide pins and reamers can be ad- FT.
:5
vantageous because they permit transtibial drilling of re
re
tn
femoral tunnels to the anatomic ACL femoral footprint.” 3
El.
Although anatomic tunnel placement is possible using
anteromedial techniques with rigid instruments, the use E
of flexible instruments results in longer femoral tunnels
that exit further from the posterior femoral cortex.”
Biomechanical evidence supports the importance of
an anatomic ACL reconstruction. ACL reconstruction
in the center-center position {anatomic} was compared
with reconstruction in the posterolateral-to-anteromedial
Drthopaedic Knowledge Update: Sports Medicine .5
 Section 3:1l'inee andLeg
[nonanatomicl position}1 With an instrumented Lach-
man examination, the use of the center-center position
reduced anterior tibial translation from 4.? mm to 2.0
mm following ACL reconstruction.
Q. Video 15.1: Arthroscopic Double-Bundle
ACL Reconstruction Using Quadriceps
Tendon Autograft. Sung-Jae Kim, IVID;
Sui-Gee Rim. MD; Sung-Hwan Kim. MD;
nae-Young Lee. lD; ln-Ree Jo. MD; and
Yong-Min Chun, MB {10 min]
Double-Bundle Reconstruction
A meta—analysis of randomized controlled studies com—
paring clinical outcomes of ACL reconstruction using
single-bundle or double-bundle techniques found that
double—bundle techniques may improve rotational sta—
bility without adding a substantial clinical benefit.12 Any
benefit of an anatomic double-bundle ACL reconstruction
is limited to biomechanical findings rather than clinical
outcomes, and it is not known which patients will benefit
from this reconstruction technique.
Q. Video 15.2: Revision Single Bundle ACL
Reconstruction Using BPTB Autograf't
part 1. Bernard R. Bach. Jr. MD (21 min-
utes}
Q. Video 15.3: Revision Single Bundle ACL
Reconstruction Using BPTB Autograft
part 2. Bernard R. Bach. Jr. MD {13 min)
Revision Surgery
Causes of failure following ACL reconstruction include
recurrent instability, postoperative complications includ
ing infection, or loss of motion and comorbidity from
concomitant pathology such as a meniscus deficiency. A
graft rupture rate of 4.5% and a contralateral ACL injury
rate of 15% were reported at 3—year follow-up?-3 There
was an increased risk for injury to either knee in patients
UI
who were younger than 20 years or who had returned
to
._I to sports requiring cutting and pivoting. A longer term
T:
I:
m srucly reported a 23% rate of graft rupture or contralat-
to
III-1 eral ACL rupture at a minimum 15-year follow-up?1 The
I:
S: 93% rate of expected graft survival at 5 years decreased
to 39% at 15 years.
H
The reasons an ACL reconstruction was unsuccessful
must be determined before a revision reconstruction is
attempted. Early recurrent instability results from poor
surgical technique, failure of graft incorporation, or pre-
mature return to high—demand activities. Late recurrent
instability usually is the result of trauma, poor graft
flrrhopaedic Knowledge Update: Sports Medicine 5
placement, or failure to treat concomitant pathology.m
Technical challenges during revision ACL reconstruc-
tion include the management of tunnel expansion, need
for bone grafting, graft choice, and hardware remov-
al. Weight—bearing plain radiographs, alignment radio-
graphs, MRI, and CT are useful in decision making.
Tunnel dimensions that absolutely necessitate bone graft-
ing and staged procedures have not been determined,
although a tunnel diameter exceeding 16 mm typically
requires bone grafting."J Removal of the initial implant is
not always required during tunnel drilling; it is possible to
avoid a metallic implant located outside the new footprint
or to drill through a biocomposite implant. The use of
autograft for revision ACL reconstruction leads to better
outcome and activity scores than the use of allograft, and
the rate of subsequent graft rupture is almost three times
lower when autograft is used?-5
Video 15.4: Pitfalls in AEL Reconstruction.
@' Darren L. Johnson, MD [12 minutes}
Video 15.5: Anatomic AEL Reconstruc-
@' tion-All Corners. Marl: D. Miller, MD; Jo-
seph Hart, PhD, ATE; and Gregory Hurltis.
Medical Student {20 min}
@ Video 15.6: Anatomical Rectangular Tun-
nel AEL Reconstruction Using BTB Graft.
. Ronsei Shino, MD, PhD {1? min}
Video 15.1: ACL Reconstruction Using a
@' Free-Tendon Quadriceps Autograft. John
P. Fulkerson, ll (21 min}
Video 15.5: Technique for Harvesting
@' Hamstring Tendons for ACL Reconstruc-
tion. Stephen M. Howell, lv'lD {B min]
Video 15.9: Tips for Harvesting BTB Auto-
@' graft. K. Donald Shelbourne. ll {13 min)
Graft Selection
Several studies have compared hamstring to BPTB auto-
grafts and compared the use of autografts or allografts.
The graft choice should be individual to the patient,
with consideration of the research literature. At 15-year
follow-up of ACL reconstruction, hamstring autografts
had an overall survival rate of 33%, and BPTB autografts
El 1016 American AcadMy of Urrhopaedic Surgeons

had a similar survival rate?“ The size of the hamstring
graft may play a role in the outcome; grafts smaller than
3 mm in diameter have a relatively high risk of failure.“
Large Scandinavian and Danish studies found that the
overall risk of revision after ACL surgery was less than
.5“ but was significantly higher after hamstring autograft
reconstruction than after BPTB autograft reconstruc-
tionsmdg A comparison of outcomes after BPTB or ham—
string autograft reconstruction in young athletes found
no difference in return to preinjury activity levels at 2- to
10—year follow-up, although hamstring autografts were
associated with more complete restoration of knee exten-
sion, less radiographic osteoarthritis, and better patient
outcomes scores}D Hamstring autograft reconstruction
is more likely to lead to deep surgical site infection than
BPTE autograft or allograft reconstruction.3|
@' Video 15.10: ACL Reconstruction Us-
ing Achilles Allograft and Interference
Screws. IZolin G. Looney, MD, and William
I. Ste-rett, MD [1' min)
a' Video 15.11: Anatomic Single Bundle ACL
Fteconstruction without Roof and PCL
Impingement - Tibialis Allograft. Stephen
M. Howell, MD, and fiscar Andres, MD
{20 min}
Randomized controlled studies comparing hamstring
autograft and soft—tissue allograft reported no differences
for any outcome measures, although one study found
increased laxity with irradiated allograft than with an-
tograft.32 These results were in patients with an average
age older than 31] years and may not he applicable in
younger patients. In skeletally mature patients younger
than 13 years, EPTB allogra fts failed 15 times more often
than BPTB autografts; all failures occurred within the
first year after ACL reconstruction.33 EPTB autograft
reconstruction led to less anterior knee pain and better
overall International Knee Documentation |Eommittee
scores, pivot shift test results, and return to preinjury
activityr levels than BPTB allograft?I The rates of graft
rupture and knee laxity were higher and overall patient
satisfaction was lower with BPTB allograft, however.
Systematic reviews comparing the outcomes of ACL re—
construction with autograft, nonirradiated allograft tis-
sue, and nonirradiated, nonchemically treated allograft
tissue found no difference on any outcome measurefi'lm5
Finally, a comparison of Achilles tendon with anterior
tibial tendon allograft found no differences in clinical or
laxity testing after ACL reconstruction.”
Eb Ifllti American Academy of Urthopaedic Surgeons
Chapter ’15: lEruciate Ligament Injuries
Rehabilitation and Return to Sport
A wide variety of criteria are used to determine readiness
for return to unrestricted sports activities after ACL re-
construction, and no consensus criteria exist. However,
many surgeons require full motion and normal Lach-
man, pivot shift, anterior drawer, and proprioception tests
without using specific clinical scores as retum-to-play
criteria.” flbjective data on testing and return—to—play
criteria are not yet available, although most researchers
recommend at least 6 months of rehabilitation, an absence
of knee effusion, full knee motion, symmetry greater than
90% with single-leg hop, and quadriceps strength of 35%
compared with the contralateral side.”
Posterior |Eruciate Ligament Injury
No recent studies have defined the incidence of isolat-
ed PCL injury, but it is less common than ACL injury.
Emergency department studies report PCL injury in 3Tb”:-
to 44% of knees affected by trauma and in 1% to 3%
of all injured kneesfimr41 PCL injury is often associated
with other pathology, with concomitant ligament inju-
ry in up to 95% of high-energy PCL injuries. The most
common causes of FCL injury are motor vehicle crashes
involving a motorcycle or dashboard impact, followed
by sports—related injuries such as falls onto a flexed knee
with a plantar flexed foot.” Prospective data collected an
average 3 years after injury indicated that 40% of patients
had an excellent result with nonsurgical management of
an isolated PCL—deficient kneeflar‘” Functional knee scores
had not deteriorated at an average 14-year follow-up,
but 11% of patients had moderate to severe radiographic
osteoarthritis.
Anatomy and Biomechanics
The PCL is stronger than the ACL, has a broader femoral
attachment, and because of its extrasynovial location, it
has better healing potential. The primary function of the
PCL is to resist posterior displacement of the tibia in all
knee flexion angles. The PCL is also a secondary varus,
valgus, and rotational stabilizer, and it facilitates inter- to
nal rotation of the tibia at higher flexion anglesfii‘Hi The FT.
:5
FCL has two functional components, the anterolateral m
at
tn
and posteromedial bundles l[Figure 4}. The anterolateral 3
El.
bundle carries more load in flexion, and the posteromedial
bundle carries more load in extension {Figure 5}. The S
PCL is associated with the meniscofemoral ligaments of
Humphrey {anterior} and Wrisberg {posterior}.
The femoral insertion of the PCL extends more than
20 mm from anterior to posterior. The antemlateral bun-
dle is more vertical than the posteromedial bundle and
inserts on the anterior roof of the intercondylar notch.
Drthopaedic Knowledge Update: Sports Medicine .5
 Sectien 3:1Cnee andLeg

AL
fibers
leeee

PM
fibers
light

A
Figure 5 Schematic drawings depicting tensiening
patterns ef the anterelateral {AL} and
peste remedial {PM} bundles ef the pesterier
cruciate Iiga ment th re ugh a range of metien.
A, The PM bundle with a greater lead than the
AL bundle with knee estensien is shewn. B.
The AL bundle with a greater lead than the PM
bundle with lrnee flexien is shewn.

Figure 4 Schematic drawings depict the insertien sites

ef the antereiateral {AL} and pesteremedial
{PM} bundles ef the pesterier cruciate ligament
iFCLi. A. The PEL insertien en the antereiateral
aspect ef the medial femeral cendyle in the
intercendyiar netch is shewn. I. The PEL
insertien en the pesterier tibia. 1 cm distal tn
the jeint line, is shewn.

The pesteremedial bundle is mere ebliqne, inserting pes-

terierl'f en the lateral wall ef the medial femeral cendjrle.
The PCL and meniscefemeral ligaments cever almest all
ef the medial aspect ef the intercendylar netch anterier re
DI
the medial intercendylar ridge. The anterier margin ei the Figure 5 Schematic drawing shewing an arth rescepic
a:
._I PCL is 2 mm frem the articular cartilage.| and the bundle view at the temeral attachment ef the
T: pesterier cruciate ligament {MEL} in a right
r:
in
centers are an average ef 11 mm apart”*‘” [Figure 15}. knee. ALE = the antereiateral bundle. aMFL
re
Iii-1 The tibial insertien ef the PCL is narrewer than the = the anterier menisce'iemeral ligament.
i: PM E = the pesteremedial bundle. pMFL = the
s: femeral insertien and is in the pesterier intercendylar pesterier meniscefemerai ligament. The PCL
fessa ef the prestimal tibia. The PCL feetprinr extends
H

and meniscefemeral ligaments ceuer must ef

anterierl}F and prea'imall}.r frem the medial meniscus met
and the edge ef the lateral plateau articular cartilage re
a peint 1 re 1.5 cm belew the jeint line and distal re the
pesterier esseeus ridge ef the tibial plateau?“ The meat
pesterier distal fibers censist ef the thicker pesteremedial
bundle, and the}.F blend with the periestenm and pesterier
the inte rce ndylar netch anterier tn the medial
interce ndyiar ridge.
capsule te insert distal re the esseeus ridge cradling the
anterier prescimal fibers ef the antereiateral bundle. The
centers ef these bundles en average are 9 mm apart."3

flrdtepaedie Knewledge Update: Sperts Medicine 5 El ll] 16 American Academe ef Cirthepaedie Surge-ens

Diagnnsis
A I’CL injury can be diagnnsed frnm the patient histnry
and physical examinatinn. Examinatinn maneuvers spe-
cific tn the PCL include the pnsterinr drawer and quad-
riceps active tests. The pnsterinr sag sign indicates a PCL
injury. The accuracy, sensitivity, and specificity nf the
clinical examinatinn findings fnr PCL injury are greater
than 90% .5“ Assessment nf tibial statinn is useful fnr de—
termining the severity nf a PCL injury. In the intact state,
the medial tibial plateau is apprnximately 1 cm anterinr
tn the medial femnral cnndyle. In a grade I injury there
is {1.5 cm nf pnsterinr tibial translatinn, a grade II injury
is flush with the femnra] cnndyles, and a grade III injuryr
causes tibial translatinn pnsterinr tn the femnral cnn—
dyles. Determining the amnunt nf pnsterinr translatinn
is challenging, hnwever, and a simplified grading system
has been develnped fnr PCL injuries?1 With the knee in
9D“ nf flexinn, a pnsterinr fnrce is applied tn the tibia.
The result is nn tibial nffset in a nnrmal knee, a slight
lnss nf anterinr tibial nffset in a grade A injury, a tibia
flush with the femnral cnndyles in a grade Ii- injury, and
tibial displacement pnsterinr tn the femnral cnndyles in a
grade C injury. Grades A, B, and C injuries cnrrelate with
grades I, II and III injuries when cnnsidering treatment
nptinns and nutcnmes.
A cnmplete series nf plain radingraphs shnuld be nb-
tained if knee ligament injury is suspected. Radingraphs
can reveal PCL tibial avulsinn injury, capsular avulsinn,
nr assnciated fracture as well as resting pnsitinn and any
pnsterinr subluxatinn nf the tibia. Stress radingraphs alsn
can be used tn assess PCL disruptinnfil-SJ MRI is used tn
determine the ln-catinn and severity nf PCL disruptinn and
shnws cnncnmitant meniscal, nstenchnndral, chnndral,
and ligament injuries. If grade III pnsterinr tibial laxity
is present and radingraphs shnw mnre than II] mm nf
pnsterinr subluxatinn, a cnmbined PCL and pnsternlateral
cnrner injury shnuld be suspectedfi‘bfi
Treatment and nutcnmes
Nnns urgical treatment is recnmmended for a patient with
an isnlated grade I nr II injury. The prngram includes
extensinn bracing, prntected weight bearing, and quad
riceps strengthening rehabilitatinn. Return tn sp-nrt can
be cnnsidered as early as 2 tn 4 weeks after injury. Twn
natural histnry studies nf nnnsurgically treated isnlated
grade I nr II PCL injuries fn und gnu-d subjective and nbjec-
tive nutcnmes with nn functinnal deterintatinn and 9Tb“:
quadriceps and 93% hamstring strength.“3="“l A T—year
fnllnw—up study repnrted that based nn Tegner Activity
Level Scale and Lyshnlrn-II Knee Questinnnaire scnres,
92% nf patients with grade I nr II injuries had a gnnd tn
excellent result after nnnsurgieal management.”
Eb Ifllti American Academy nf Urthnpaedjc Surgenns
Chapter ’15: lEruciate Ligament Injuries
The treatment nf isnlated grade III PCL injuries is cnn-
trnversial. Snme experts recnmmend acute recnnstructinn
nf grade III injuries in ynung athletes nr if nnrmal tibial
statinn cannnt be maintained in the presence nf a sn-
called peel—nff lesinn. Surgical treatment is recnmmended
fnr a chrnnic grade III lesinn if the patient is symptnmat-
ic.‘9!“~54 There is nn cnnsensus nn graft chnice nr technique
fnr repair nr recnnstructinn nf the PCL.“
Avulsinn nf the PCL usually nccurs at the femnral
attachment and can be repaired using suture anchnrs nr
femnral bnne tunnels. Large nssenus avulsinn fragments
frnm the tibial attachment can be repaired with np-en
reductinn and screw-and-washer fixatinn.
1|y'arinus surgical techniques permit recnnstructinn nf
the PCL. The tibial inlay technique is usually perfnrmed
thrnugh an npen pnsterinr apprnach. The bnne blnclt
is recessed and fixed with an interference screw at the
pnsterinr tibia, ensuring tn avnid graft prntrusinn. The
advantages cf the tibial inlay technique include nssenus
graft healing, avnidance nf sn—called killer turn stresses,
decreased graft wear, and imprnved graft binmechanics.
An arthrnscnpie inlay technique using suture buttnn fix-
atinn nver the tibial-side bnne blnck has been described
as cnmbining the advantages nf arthrnscnpie and inlay
techniquesfifl In the transtibial technique, the tibial tun-
nel is reamed frnm anterinr tn pnsterinr th rnugh the tibia
under direct arthrnscnpic and flunrnscnpic visualizatinn.
The tibial fnntprint is apprnxitnately 7' mm anterinr tn
the pnsterinr tibial cnrtex as seen cm a perfect lateral
imagefif Cadaver binmechanical data revealed nn differ—
ence between transtibial and tibial inlay techniques when
grafts were apprnpriately pretensinned befnre insertinn.“
Multiple studies repnrt nn difference in functinnal, radin-
graphic, nr clinical nutcnmes between transtibial and
tibial inlay techniques nr between arthrnscnpie and npen
techniqucsfg'fl'm'fi“
Binmechanical cnmparisnn studies nf dnuble-bundle
and single-bundle PCL recnnstructinn techniques cnn-
cluded that clnuble—bundle recnnstructinn is preferable
fnr decreasing pnsterinr tibial translatinn and imprnving
rntatinnal restraint?“ Binmechanical advantages were 1-9
nnt cnrrelated with superinr clinical nutcnmes, hnwever, FT.
:5
and isnlated single-bundle recnnstructinn yields gnnd re
re
tn
lnng-terrn results withnut functinnal differences in cnm- 3
El.
parisnn with dnuble—bundle recnnstructinn."“‘~""i
E
Summary
Althnugh ACL injury is amnng the must cnmmnnly
studied nrthnpaedic injuries, many questinns remain
unanswered. Irrespective nf technique, the gnals nf ACL
recnnstructinn include an anatnmic tunnel pnsitinn fnr
Drthnpaedic Knnwledge Update: Spurts Medicine 5
 Sectinn 3:1Cnee andLeg
nptimal binmechanical and clinical nutcnmcs. Return-tn-
play prnfiles are similar after ACL recnnstructinn with
hamstring nr BPTB autngraft, althnugh lnwer rates nf
revisinn surgery and Inwer infecticn rates were nbserved
with the use nf BPTB autngraft. Allngraft use is an np—
tic-n but requires cautinn in ynung athletes. Further study
cf [nag-term entcnmes is needed tn determine the anti-
mal patient age ranges and activity levels fnr each graft
chnice. Mnst PCL injuries can be managed nnnsu rgically,
altbnugh surgical recnnstructinn is preferable fer snme
higher grade injuries. Differences exist between the bin-
mechanical advantages and patient nutcnmes nf specific
surgical techniques.
Key Study Pnints
1* ACL anatnm].r has bnth macrnscnpic and micrnscnp-
ic definiticns, and the chnice cf the best lecaticn
fnr recnnstructinn after injury shnuld cnnsider the
native anatnmy.
I: The specifics nf ACL recnnstructinn, including the
methnd nf tunnel drilling and the graft chnice, re-
main debatable. It is impnrtant that the tunnels
be placed cnrrectly. The use nf autngraft may be
preferable tn allngraft in ynung athletes.
1' Mnst isnlated PCL injuries can be nnnsurgically
managed, thnugh sntne higher grade injuries ben-
efit from surgical recnnstructicn. Optimal graft
chnice and methncls nf tibial graft attachment re-
main debatable.
Annntated References
1. Mall NA, Chalmers PH, Mnric M, et al: Incidence and
treflds nf anterinr cruciate ligament recnnstrnctinn in the
United States. Am ] Spnrts Med 2U]4;42I[lfl}:2363 -23?0.
Medline DUI
An epideminlcgic study described an increase in the num-
ber nf ACL recnnstructinns in the United States between
DI 1994 and lC-‘flfi, particularly in wnmen and in patients
a:
._I ynunger than 2i] years nr nlder than 43 years.
T:
I:
as
a:
III-1
2. Barenius E, Pnnaer 5, Shalabi A, Eujalt R, Nerlén L,
I:
a:
Erikssnn K: Increased risk nf netenarthritis after anterinr
H
cruciate ligament recnnstructinn: A 14-year fnllnw-up
study nf a re ndnmiaed cnntrnlled trial. Am ,i' Spurts Med
2fl14;42{5 1:1049-1051 Medline DDI
A threefnld increased incidence cf nstenarthritis was fnund
after ACL reccnstructinn ccmpared with the cnntralateral
ltnee. Level nf evidence: I.
Drdtnpaedic Knnwledge Update: Spnrts Medicine 5
3. Li RT, Lnrens 5, Eu Y, Harner CD, Fu FH, Irrgang J]:
Predictnrs nf radingraphic ltnee nstenarthritis after ante-
rinr cruciate ligament recnnstructinn. Am I Sparta Med
2fl11:39(12}:1595-26l}3.Medline DUI
Despite decreased instability and imprnved activity levels,
patients undergning ACL recnnstructinn were at increased
risk fnr ltnee nstenarthritis. Level nf evidence: III.
. Fnlc AW, Tau 1WP: Delay in ACL recnnstrnctinn is assnci-
ated with mere severe and painful meniscal and chnn—
dral injuries. Katee Snag Spcrts Ttaametci Artbrnsc
2013:21i4}:928-933.Medline DUI
Delay befnre flCL recnnstructinn was assnciated with an
increased incidence nf articular cartilage and meniscus
pathnlngy. Level cf evidence: III.
. Mather RC III, Hettrich CM, Dunn WE, et a1: Cnst-ef-
fectiveness analysis nf earlyr recnnstructinn versus reha—
bilitaticn and delayed recnnstructinn fnr anterinr cruciate
ligament tears. Art: I Spnrts Med 2fl14;42{?]:1533-1591.
Medline DUI
in ecnnnmic and decisinn analysis studyr fnund that early
MIL recnnstructinn imprnved quality-adjusted life—years
at a lnwer ccst than delayed ACL recnnstructinn after
rehabilitatinn and frnm a health system perspective was
the preferred treatment. Level nf evidence: II.
. Piefer JW, Pflugner TR, Hwang MD, Lubnwitz JH: An-
teflnr cruciate ligament fcmnral fn-ntprint anatnmy: Sys—
tematic review cf the 21st century literature. Aflbrcsccpy
2012:23i6}:3?2-831.Medline DUI
A systematic review nf basic science studies cnncluded
that the center nf the ACL fnntprint is 43% nf the prmt-
imal—tn—distal length cf the mmnral intercnndylar nnteh
wall and the radius cf the femnral sncltet is 2.5 mm ante-
rinr tn the pnsterinr articular margin.
. Sasaki N, Ishibashi Y, Tsnda E, et al: The femnral insertinn
nf the anterinr cruciate ligament: Discrepancy between
macrnscnpic and histnlngical nbservatinns. Artbrnscnpy
lflllglflifllfllSS-IHE. Medline DCII
a basic science study defined the direct and indirect fem.
nral insertinns nf the ACL as they cnrt'esp-nnd tn macrn-
scnpic appearance.
. van Eclt CF, van den Bel-:ernm MP, Fu PH, Pnnlman
11W, Kerkhnffs GM: Methn-ds tn diagnnse acute ante-
rinr cruciate ligament rupture: A. meta—analysis nf phys—
ical eaaminatinns with and withnut anaesthesia. Katee
3mg Spnrts Tranmetnf Artbrnsc 2013;21i8]:1395-19i}3.
Medline DUI
A meta-analysis nf diagnnstic test accuracy cnncluded
that the Lachman test is mnst sensitive fnr diagnnsing
acute aCL disruptinn in an nffice setting. With the patient
under anesthesia, the Lachman test remained the mnst
sensitive, but the pivnt—shift test was mnst specific. Level
nf evidence: II.
Sri—Ram K, Salmnn L], Pincaewski LA, Fine JP:
The incidence cf secnndary pathnlngy after anterinr
ID ll] 16 American Academy nf Drtbnpaedic Surge-ens

cruciate ligament rupture in .5036 patients requiring lig-
ament recanstructian. Barre jafnt I 2D13;95-E{1]:59-64.
Medline DUI
A retraspective review ta determine the incidence af sec-
andary patltalagy with respect ta time between injury and
recanstructian faund an increased incidence af medial me-
niscal tears and chandral damage. Level af evidence: III.
ID. Kamath CV, Redfern JC, Creis PE, Eurlts ET: Revisian
auteriar cruciate ligament recanstructian. Am I Sparta
Med 1fl11;39{1}:199—21?. Medline DUI
A clinical update an revisian ACL recanstructian reviewed
diagnastic and surgical challenges as well as causes af
failure ta pravide decisian-malting guidance.
11. Ardern CL, Taylar NF, Feller 13:, Webster HE: Fifty-five
per cent return ta campetitive spurt fallawing auteriar
cruciate ligament recanstructian surgery: An updated
systematic review and meta—analysis including aspects af
physical functianing and cantextual factars. Br J Sparta
Med 2014;4S{21}:1543-1552. Medline DUI
A systematic review reparted varied return-ta-sparts rates
after ACL recanstructian; 31% af patients returned tn
same apart, but anly 55% returned ta a campetitive-level
apart.
12. Ardern CL, 1Webster BEE, Taylar HF, Feller JA: Return
tn the preinjnry level af camp-etitive apart after anteriar
cruciate ligament recanstructian surgery: Twa-thirds af
patients have nat returned by 12 manths after surgery.
Ant ] Sparta Med 2011:39f3]:333-543. Medline DUI
A case study faund that patients may require [anger than
the typically reparted ill-manth return ta spurts after
ACL recanstructian. Level af evidence: IV.
13. Ryan J, Magnussen RA, Cax CL, Hurbanelt JG, Plani-
gan DC, Kaeding CC: ACL recanstructian: Da autcames
differ by sex? A systematic review. 1 Base faint Surg Am
2fl14t95{fi}:5fl?-512.Medline DUI
A systematic review and meta-analysis faund na difference
in graft failure risk, cantralateral ACL rupture rislt, ar
pastaperative ltnee laxity based an the sex af the patient.
Level af evidence: II.
14. Him 5-], Lee 5-K, Kim 5-H, Kim 5-H, Ryu S-W, Jung M:
Effect cf cigarette smelting an the clinical autcames af ACL
recanstructian. 1 Hana faint Sarg rim 2fl14:96{12}:iflfl?-
1fl13. Medline DUI
A pragnastic study faund that cigarette smalting had a
negative effect an the autcame af ACL recanstructian.
Level af evidence: III.
1.5. Keller TC, Tampltins M, Ecanamapaulas K, et al: Tibial
tunnel placement accuracy during anteriar cruciate liga-
ment recanstructian: Independent femaral versus trans-
tihial femaral tunnel drilling techniques. Artbraacapy
satasutsinna—nss. Medline DUI
A cadaver study suggested that transtibial drilling had
deleterians effects an tibial tunnel pasitian and aperture.
Independent femaral drilling was assaciated with a higher
4D Ifllii American Academy af Urtltapaedic Surgenns
Chapter 15: Cruciate Ligament Injuries
percentage af placements cf the tibial tunnel in an ana-
tamic pasitian.
16. Hedi a, Musahl V, Steuber V, et al: Transtibial versus
anteramedial partal reaming in auteriar cruciate ligament
recanstructian: An anatamic and biamechanical evalua-
tian af surgical technique. Artbraacapy lfl]1:2?l3}:33fl-
390. Medline DUI
a cadaver study faund that, campared with transtibial
techniques, anteramedial partaI drilling allawed place-
ment af the femaral sachet central in the native faatprint,
thus impraving time-aera tibial translatian and pivat shift
testing.
1?. Tampkins M, Milewski MD, Brackmeier SF, Gaskin CM,
Hart jM, Miller MD: Anatamic femaral tunnel drilling in
auteriar cruciate ligament recanstructian: Use af an acces-
sary medial partal versus traditianal transtibial drilling.
Am ] Sparta Med 2012:4flifii:1313~1321. Medline DUI
A cadaver study faund that anteramedial drilling placed
the femaral tunnel in the native femaral faatprint mare
aften than transtibial drilling.
13. Chalmers PN, Mall NA, Cale E], Verma NH, Bush-Jaseph
CA, Each ER Jr: Anteramedial versus transtibial tunnel
drilling in anteriar cruciate ligament recanatructians: A
systematic review. Arrhraacapy 2fl13t29{?}:1235-1242.
Medline DUI
A systematic review with a review af cadaver studies cam-
pared anteramedial and transtibial drilling techniques far
ACL recanstructian. Same studies faund superiarity af
anteramedial techniques, and athers faund na differences.
Level af evidence: III.
19. Baht-Wagner L, Thillemann TM, Pedersen AB, Lind MC:
Increased risk af revisian after anteramedial campared
with transtibial drilling cf the femaral tunnel during pri-
mary auteriar cruciate ligament recanstructian: Results
fram the Danish Knee Ligament Recanstructian Register.
Arthrascap'y 2fl13;29{1}:93-1fl5. Medline DUI
A registry—based study camparing revisian rates fallawing
ACL recanstructian with femaral tunnels drilled thraugh
transtibial and anteramedial appraaches that demanstrat-
ed higher revisian rates with the anteramedial appraach.
2.0. Steiner ME, Smart LR: Flexible instruments antperfarm
rigid instruments ta place anatamic auteriar cruciate liga-
ment femaral tunnels withaut hyperflexian. Arthraacapy
2013;23i6}:335-S43.Medline DUI 1-9
FT.
A cadaver study faund that the ability ta abtain an an-
:5
rs
atamic femaral tunnel with transtibial drilling was im-
rs
tn
praved by the use af flexible instruments and langer tunnel
3
CI.
length when campated with use cf the same instruments
in an anteramedial drilling technique.
E
31. Hedi a, Maalt T, Musa hl V, et al: Effect af tunnel pasitian
and graft site in single-bundle auteriar cruciate ligament
recanstructian: An evaluatian af tirne-aera l-tnee stability.
AflflfflScflpj} lil]1:2?(11}:1543-1551. Medline DUI
Unhapaedic Knawledge Update: Sparta Medicine 5
 Section 3:1Cnee andLeg
A cadaver study found that increased graft size does not
compensate for nonanatomic tunnel position or improve
time-zero stability of the knee after ACIL reconstruction.
Li 'f—L, Hing G—Z, Wu Q, et al: Single-bundle or doua
Isle-bundle for anterior cruciate ligament reconstruction:
A meta-analysis. Knee 2fl14;11{1}:lS-3?. Medline DD]
A meta-analysis comparing single- and double-handle
ACL reconstruction techniques found better outcomes
for rotational laxity with double-bundle techniques, but
there were no functional between-group differences. Level
of evidence: II.
23. 1|I'ili'ehster RE, Feller JA, Leigh ”WE, Richmond AK:
Tfounger patients are at increased risk for graft rupture
and contralateral injury after anterior cruciate ligament
reconstruction. An: }' Sports Menr 20145433,}:641—641
Medliue DDI
A case-control study determined that patients younger
than 2‘3 years are at higher risk for graft rupture and
contralateral ACL injury than older patients after ACL
reconstruction. Level of evidence: III.
14. Bourke HE, Salmon L], Waller A, Patterson V, Pincaewski
LA: Survival of the anterior cruciate ligament graft and the
connalateral AEL at a minimum of 1.5 years. Arr: J Sports
Med 1012;4fl{9}:1935-1992. Medliue DflI
A case study reported an 39% survival rate of ACL grafts
15 years after surgery. The expected survival rate for the
contralateral ACL was S?%. Level of evidence: IV.
MARS Group: Effect of graft choice on the outcome of
revision anterior cruciate ligament reconstruction in the
Multicenter ACL Revision Study {MARS} Cohort. Am
] Sports Med 2014;4lllfl}:1301-131l}. Medline DUI
A cohort study reported improved sports function and
patient—reported outcomes with decreased graft rerupture
rates when autograft rather than allograft was used for
revision ACL reconstruction. Level of evidence: II.
26. Bourke HE, Gordon D], Salmon L], Waller A, Linklater
], Pinczewski LA: The outcome at 15 years of endoscop-
ic anterior cruciate ligament reconstruction using ham-
string tendon autograft for ‘isolated' anterior cruciate
ligament rupture. ] Bone Joint Sarg Br 2011;94l5]:630-
63?. Medline D-Dl
At 15 -year follow-up after ACL reconstruction using
DI
e:
._I
hamstring tendon autograft, graft survival was 33%,
T: and Fit of patients had osteoarthritic changes. Level of
I:
n: evidence: IV.
w
III-1
I:
S: 2?. Conte E], Hyatt AE, Gatt E] Jr, Dhawan A: Hamstring
H
autograft size can he predicted and is a potential risk fac-
tor for anterior cruciate ligament reconstruction failure.
Arthroscopy 1014;30{?J:SSE-SSD. Medline DUI
A systematic review found decreased failure rates in qua-
drupled hamstring autogra ft with a diameter of more than
3 mm. Level of evidence: IV.
Drrhopaedie Knowledge Update: Sports Medicine 5
ES. Gifstad T, Foss CIA, Engehretsen L, et al: Lower risk of
revision with patellar tendon autografts compared with
hamstring autografts: A registry study based on 45,593
primary ACL reconstructions in Scandinavia. Am. I Sports
Med 1U14;42{1l}}:1319-2313. Medline DUI
In a cohort study of Scandinavian patients, ACL recon-
struction with patellar tendon autograft led to a lower
rate of revision than ACL reconstruction with hamstring
autogra ft. Level of evidence: II.
29. Rahr—Wagner L, Thillemann TM, Pedersen AB, Lind M:
Comparison of hamstring tendon and patellar tendon
grafts in anterior cruciate ligament reconstruction in a
nationwide population-based cohort study: Results from
the Danish registry of knee ligament reconstruction. An:
I Sports Med 2014;41{2}:2?S-234. Medline DUI
A population-based cohort study reported an increased
percentage of ACL reconstruction using hamstring auto-
graft and overall good outcomes with both patellar tendon
and hamstring autogra ft. There was an increased relative
risk of revision ACL reconstruction surgery with ham-
string autograft. Level of evidence: II.
Si}. Mascarenhas R, Tranovich M], Kropf E], Fu FH, Harner
CD: Bone-patellar tendon-hone autograft versus ham—
string autograft anterior cruciate ligament reconstruction
in the young athlete: A retrospective matched analysis
with I-lfl year follow-up. Knee Burg Sports Tronmator'
Arthrose 1012;Zfl{3_]:1520—152?. Medline DE}!
A casemontrolled therapeutic study comparing hamstring
and BPTS autograft AC1. reconstruction techniques fou ad
that TUSS of patients returned to sports. Duly SUSS re-
turned to their preinjury activity level. Hamstring graft
reconstruction yielded better motion and outcomes scores,
and it led to less radiographic osteoarthritis than EPTE
graft reconstruction. Level of evidence: III.
31. Maletis GB, Inacio MC, Reynolds S, Desmond JL, Maletis
MM, Funahashi TT: Incidence of postoperative anterior
cruciate ligament reconstruction infections: Graft choice
makes a difference. An: I Sports Med 2fl13;41{Sl:1?Sfl-
ITSS. Medline DUI
A cohort study reported a DASSS rate of surgical site in-
fection after ACL reconstruction. The risk was 3.1 times
higher after hamstring tendon autograft than after EPTB
autograft reconstruction. Level of evidence: II.
32. Cvetanovich GL, Mascarenhas R, Saccomanno MF, et al:
Hamstring autograft versus soft-tissue allografr in anterior
cruciate ligament reconstruction: A systematic review and
meta—analysis of randomised controlled trials. Arthrosco-
py lflldgdflflfiirldlS—ldld. Medline no:
A systematic review and meta-an alysis reported no signif—
icant difference between ACL reconstruction with ham-
string autograft or soft-tissue allograft in patients with
an average age older than 342} years. Level of evidence: II.
33. Ellis HE, I'vIatheny LI'vI, Briggs KK, Pennock AT, Stead-
man JR: Outcomes and revision rate after hone—patellar
tendon-hone allograft versus autograft anterior cruciate
El 1016 American AeadMy of Drrhopaedie Surgeons

ligament reconstruction in patients aged 13 years or young-
er with closed physes. Arthroscopy 2013;33j12]:1319-
1325. Medline DUI
A retrospective comparative study found no differences
in function, activity, or satisfaction between EPTE al-
lograft and autograft for AEL reconstruction in young
patients, although allograft reconstruction had a 15 times
higher failure rate than autograft reconstruction. Level
of evidence: III.
34. Kraeutler M], Bravman IT, McCarty EC: Bone-patellar
wndon-hone autograft versus allograft in outcomes of an-
terior cruciate ligament reconstruction: A meta-a nalysis of
.5132 patients. Am I Sports Med 2fl13:41{1flj:2439-244S.
Medline DUI
A meta—analysis concluded that patients who underwent
ACL reconstruction with BPTB autografts had lower rates
of graft rupture or knee laxity and better satisfaction than
those who underwent ACL reconstruction with BPTE
allograft.
3.5. Mariscalco MW, Magnussen RA, Mehta D, Hewett
TE, Flanigan DC, Kaeding EC: Autograft versus non-
irradiated allograft tissue for anterior cruciate ligament
reconstruction: A systematic review. Am I Sports Med
lfll4,42{1j:491-499.Medline DUI
A systematic review compared autografts with nonirradi—
ated allografts for AUL reconstruction in patients in their
late 20s to early 30s. No differences were reported in graft
failure rate, postoperative knee laxity, or outcome scores.
Level of evidence: III.
35. Lamblin CI, Waterman ER, Lubowitz IH: Anterior cru-
ciate ligament reconstruction with autografts compared
with nonwirradiated, nonmchemically treated allografts.
Arthroscop'y 2fl13;19{6]:1113-1122. Medline DUI
A systematic review compared outcomes after autograft or
non—chemically treated, nonirradiated allograft tissue was
used for ACL reconstruction. No statistically significant
differences were found. Level of evidence: III.
37. Kim 5—], Eae J-H, Lim H-fl: Comparison of Achilles and
tibialis anterior tendon allografts after anterior cruciate
ligament reconstruction. Knee Snrg Sports Tranmutol
Arthrosc ll] 14:11j1}:135 -141. Medline DUI
An outcome study found no significant differences be—
tween outcomes of ACL reconstruction using Achilles
tendon or anterior tibial allograft. Level of evidence: III.
SS. Petersen W, Zantop T: Return to play following ACL
reconstruction: Survey among experienced arthroscopic
surgeons [AUA instructors}. Arch Urthop Trauma Surg
2013;133l?):969-9T1Medline DUI
Surgeons were surveyed on the outcome measures they
used to determine readiness for return tn play after ACL
reconstruction. Most surgeons relied primarily on physical
examination and motion while considering other factors
to a lesser degree.
D 11116 American Academy of Urthopaedic Surgeons
Chapter IS: lEruciate Ligament Injuries
39. Mueller LM, Bloomer EA, Durall C]: Which outcome
measures should be utilized to determine readiness to play
after ACL reconstruction? I Sport Refrain? 2014;23l2}:153-
154. Modline DUI
Uutcome measures to determine readiness for return to
play after ACL reconstruction were discussed.
40. Fanelli GEE: Posterior cruciate ligament injuries in trauma
patients. Arthroscopy 1993;9{3):291-294. Medline DUI
41. Fanclli (3C, Edson C]: Posterior cruciate ligament injuries
in trauma patients: Part II. Arthroscopy 1995:11j5 1:526-
529. Medline DUI
4E. Schulz MS, Russe K, Weiler A, Eichhorn H], Strobe] M]:
Epidemiology of posterior cruciate ligament injuries. .IlirctilI
Urtbop Trunnm Snrg 2003:123l4jflf16-1 91. Medline
43. Shelbourne KD, Muthulcaruppan Y: Subjective results of
nonoperatively treated, acute, isolated posterior cruci-
ate ligament injuries. Arthroscopy lflflS:21{4}:4S?—461.
Medline DUI
44. Shelbourne K1), Clark M, Gray T: Minimum lfl-year
follow-up of patients after an acute, isolated posterior cru-
ciate ligament injury treated nonoperatively. Am I Sports
Med 2G13:41{?j:1SES-1533. Medline DUI
Sixty—eight patients treated nonsurgically for isolated PCL
injury were followed prospectively with subjective and
objective outcome measures. At an average 14-year fol-
low-up, 44 patients had good strength, remained active,
and had full knee motion. The rate of osteoarthritis was
11%. Lewl of evidence: W.
45. Li G, Papa nnagari R, Li M, et al: Effect of posterior cruci-
ate ligament deficiency on in vivo translation and rotation
of the lcnee during weighthearing flexion. Am I Sports
Med 19H3;36{3}:4T4-4?S'. Medline DUI
4S. Kennedy HI, Wijdiclcs CA, Goldsmith MT, et al: Kine-
matic analysis of the posterior cruciate ligament: Part
1. The individual and collective function of the antero-
lateral and posteromedial bundles. Am I Sports Med
1D13j41j11]:1323—1f133.Medline DUI
A controlled cadaver biomechanics laboratory study eval-
uated knees at different flexion angles in the intact, PUL-
deficient, and PCL-reconstructed state after a single-hun-
dle graft fitted in the anterolateral position. A single-hun-
dle graft was found to reduce ltnee laxity at all angles but P!
not to the intact state. FT.
:15
re
re
4?. Amis AA, Gupta: CM, Bull AM, Edwards A: Anatomy tn
3
of the posterior cruciate ligament and the meniscofem- 1:1.
oral ligaments. Knee Sterg Sports Tranrnntof Arthrosc S
1Dfl6;14{3}:25?d263.Medline DUI
4S. Anderson C], Ziegler CG, Wijdiclcs CA, Engebretsen L,
LaPrade RF: Arthroscopically pertinent anatomy of the
anterolateral and posteromedial bundles of the posterior
cruciate ligament. I Bone Joint Surg Am 2012;94{21}:1936-
1945. Modline DUI
Urthopaedic Knowledge Update: Sports Medicine S
 Sectian 3:1I'inee andLeg
A cadaver dissectian study described the anatamy af the
PCL in relatian ta relevant anatamic landmarks.
45". MacGillivray JD. Stein BE. Park M. Allen AA. Wickiewicr.
TL. Warren RF: lCamparisan af tibial inlay versus trans-
tibial techniques far isalated pasteriar cruciate ligament
recanstructian: Minimum 3-year fallaw-up. Arrhraacapy
2Dfl6;22l3}:32fl-323.Medline DUI
5G. Rubinstein RA Jr. Shelbaurne RD. McCarrallJR. 1ivl'anMe-
ter CD. Rettig AC: The accuracy af the clinical examina-
tian in the setting af pasteriar cruciate ligament injuries.
Am J Sparta Med 1994:22{4}:550-551 Medline DDI
51. Marx RC}. Shindle MR. Warren RF: Management af pas-
teriar cruciate ligament injuries. |Dper Tech Sparta Med
20 09;l?:1t52-1ti ti. DDI
Institutianal preferences far treatment af PCL injury ta
include patient selectian. surgical timing. preferred surgi-
cal technique. graft selectian. rehabilitatian and return ta
apart were reviewed. Additianally. previaualy published
literature an autcames was reviewed.
52. Jackrnan T. La Prade RF. Panrinen T. Lender PA: Intraab-
server and interabserver reliability af the kneeling tech-
nique af stress radiagraphy far the evaluatian af pasteriar
knee laxity. Am I Sparta Med 2Ufl3;36{3l:15?1—15?6.
Medline DDI
53. Schulz M5. Steenlage ES. Russe K. Strabel MJ: Distri-
butian af pasteriar tibial displacement in knees with
pasteriar cruciate ligament tears. I Barre faint Snrg Arr:
EDDTfifi'tljfifl—flfl.Medline DDI
.54. Harner CD. Hfiher J: Evaluatian and treatment af
pasteriar cruciate ligament injuries. Am J Sparta Med
1993;26{3J:4?1-432. Medline
55. ‘v’aas JE. Maura C5. Wente T. Warren RF. Wickiewics
TL: Pasteriar cruciate ligament: Anatamy. biamechanics.
and au'tcames. Am J Sparta Med 2fl12;4fl{1}:212-131.
Medline DUI
The literature an the anatarny and biamecbanics af the
PEL as well as its diagnasis and treatment was reviewed.
.56. Patel D‘v". Allen AA. Warren RF. Wickiewica TL. Simu—
nian PT: The nanaperative treatment af acute. isalated
DI
{partial ar camplete} pasteriar cruciate ligament-defi-
cient knees: An intermediate-term fallaw—up study. H33
cu
._I
T:
__I meanness—14a Medline aai
I:
as
a:
Iii-1 5?. Hammaud S. Reinhardt KR. Marat RE: Uutcames af
I:
a: pasteriar cruciate ligament treatment: A review af the
H
evidence. Sparta Med Artbraae 2D1Il;13{4l:23{i-291.
Medline DUI
A systematic review af databases evaluating treatment
autcames af isalated PCL injury and multiligament injury
knee injury faund na cansensua an treatment af isalated
PCL injury ar recanatructian technique. The results af
nunsurgical and surgical treatment generally are gaad.
Drrhapaedie Knawledge Update: Sparta Medicine 5
.53. Jardan 55. Campbell RE. Seltiya JK: Pasteriar cruciate
ligament recanstructian using a new arthrascapic tibi-
al inlay dauble-bundle technique. Sparta Med Arthraae
200?;15H]:1?6-133.Medline DD]
59. Campbell RB. Jardan 55. Schiya JR: Arthrascapic tibial
inlay far pasteriar cruciate ligament recanstructian. Ar-
thraacapy 2i]U?;23[12]e1356.e1-1356.e4. Medline DDI
5D. McAlliater DR. Markalf KL. |Dishes DA. ‘r'aang CR.
McWilliams J: A biamechanical camparisc-n af tibial inlay
and tibial tunnel pasteriar cruciate ligament recanstruc-
tian techniques: Graft pretensian and knee laxity. Am
J Sparta Med lflfllflfllfljflll-Lill Medline
61. Zehms CT. Wbiddan DR. Miller MD. et al: Campar-
isan af a dauble bundle arthrascapic inlay and apEn
inlay pasteriar cruciate ligament recanstructian using
clinically relevant ta-als: A cadaveric study. Arthraacapy
Eflflfigl4i4}:4T2-43fl.Medline Dfll
61. Sang E-K. Park H—W. Ahn Y—S. Sean J—R: Transtibial ver—
sus tibial inlay techniques far pasteriar cruciate ligament
recanstructian: Lang-term fallaw-up study. Am I Sparta
Med amassnsjasaassvi. Medline am
A cahart study faund that the autcames af the tranatibial
and tibial inlay techniques far PCL recanatructian were
camparable. Level af evidence: III.
63. May JH. Gillette EP. Margan JA. Krycb AJ. Stuart M].
Levy BA: Tra natibial versus inlay pasteriar cruciate liga-
ment recanstructian: An evidence-based systematic review.
J Knee Sarg lfl]fl;23{2}:?3-?9. Medline DDI
Studies camparing tibial inlay ta tranatibial PCL recan-
structian were reviewed. Ha differences were faund in
clinical results.
64. Panchal HE. Seltiya JR: Dpen tibial inlay versus arthra-
acapic tranatibial pasteriar cruciate ligament recanstruc-
tians. A-rthraacapy 1011;2T{9]:1239—1195. Medline DUI
A systematic review af biamechanical and clinical studies
camp-ared apen tibial inlay and arthrascapic tranatibial
techniques far PCL recanstructian. Level af evidence: IV.
65. Markalf KL. Feeley ET. Jacksan 5R. McAlliater DR:
Biamechanical studies af dauble-bundle pasteriar cru-
ciate ligament recanstructians. ] Bane faint Surg Am
2Uflfi;33{3l:1?33-1?94.Medline nai
66. l'vlarkalf KL. Jacksan 5R. McAlliater DR: Single- versus
dauble—bundle pasteriar cruciate ligament recanstructian:
Effects af femaral tunnel separatian. Am J” Sparta Med
2010;33tfilfll41-1146.Medline DDI
A cantralled labaratary cadaver study evaluated the bin-
mechanics af dauble-bundle femaral recanstructian af
the PCL. The pasteramedial bundle carries a high laad
in full eatensian.
6?. Markalf KL. Feeley BT. Jacksan 5R. McAlliater DR:
Where shauld the femaral tunnel af a pasteriar cruciate
El 1016 American Aeadenty af Drrhapaedie Surge-ans

ligament recnnstrnctinn he placed tn hest restate antern-
pnsterinr laxity and ligament fnrcesiI Am I Spnrts Med
lflfl6;34{4]:fifl4-511.Medline nnl
I53. Hermans S, Cnrten K, Bellemans J: Lung-term results nf
isnlated anternlateral hnndle recnnstrnctinns nF the pee-
terinr cruciate ligament: A 5- tn 12-year fellnw-up studs.
Ant I Spnrts Merl lflfl9;5?{3]:1499-15{11 Medline DUI
The medium- tn lnng-tetm nutcnmes nf 25 patients with
isnlated single-bundle PCL recnnstructinn were evaluated.
Level nf evidence: IV.
59'. Knhen RE, Selciva JK: Single-bundle versus dnnhle-hnndle
pnstericu' cruciate ligament recnnstruetinn. ArilerevsttcijzijI
2009;25lllltl4TD-14TT.Medline DUI
A systematic review nf studies cnmparing single- and
dnnhle-hnndle PCL recnnstructinn did nnt find either tn
be superinr. Level nf evidence: IV.
tilden References
15.1: Kim S], Kim 5G, Kim SH, Lee DY, Jn Iii: Artlrrnscnp-
is Daniele-Handle AEL Recnnstrnctinn Using Quadriceps
Tencic-n Antngraft [viden excerpt]. Easement, IL, American
Academy nf Drthnpaedic Snrgenns, 20111}.
15.2: Bach Jc ER: Reeisinn Single Handle ACL Recnnstrnctinn
Using HPTE Antngraft, part 1 [viden excerpt]. River Fncest,
IL, lfllfl.
15.3: Each Jr ER: Renisinn Single Bundle ACL Reennstrnetinn
Using EPTB Aatngrnft. part 2 [viden excerpt]. River Fncest,
IL, Ifllfl.
4D Ifllii American Academy nf flctlinpaedie Snrgenns
Chapter 15: lErueiate Ligament Injuries
15.4: Jnhnsnn DH: Pitfalls in ACL Recenstrnctinn [viden
excerpt]. Rnsetnnnt, IL, American l'tcademlir nf lCirthnpaedic
Snrgenns, 213111}.
15.5: Miller MD, Hart J, Knrlcis G: Anatnntic ACL Recen-
strnctinn—-All Centers [viden excerpt]. ll'_."harlnttes'r.rille, VA,
2013.
15.6: Shine K: Anatomical Rectangnlar Tunnel ACL Recen-
strnctinn Using BTB Graft [viden excerpt]. |Lil'salta, Japan, 11] ll].
15.5“: Fulltersnn JP: AUL Recenstra ctinn Using a Free-Tension
Qnaciricsps Antngrafl [viden excerpt]. Farmingtnn, CT, 5101!].
15.5: Harwell 5M: Technique fer Harvesting Hamstring Ten-
:inns fer ACL Resnnstrnctinn [viden excerpt]. Sacramentn,
CA, Hill].
15.9: Shelhnurne KD: Tips for Harvesting BTB Antngraft [vid-
en excerpt]. hdianapnlis, IN, Zillll.
15.10: Lianne}: CG, Sterett WI: ACL Reennstrnctinn Using
.Aelrilles Allngraft and interference Screws [viden excerpt].
Franklin, TN, lfllfl.
15.11: avell SM, Andres O: Anatnrnic Single Bundle ACL
Reconstructinn witnnat Rnnfanci PCL l-nipingentent — Tibialis
Allegraft [viden excerpt]. Sacramentn, CA, lfllfl.
1.4.}
5'":
:5
cu
m
a:
3
1:1.
.5
Drthnpaedic Knnwledge Update: Spnrts Medicine 5
Chapter 15
Collateral Ligament Injuries
Eduard Alentorn-Geli. MD. MSc. PhD. FEEDT Joseph I. Stuart. MD
Abstract
The most important research related to the medial
collateral ligament, posteromedial corner, lateral col-
lateral ligament, and posterolateral corner during the
past 5 years includes more than 5'] studies related to
the basic science, anatomy, biomechanics, diagnosis,
and treatment of these structures. Most of the studies
involved anatomy or biomechanics {25 studies} or injury
treatment {19 studies}. The most important advances
in research into collateral ligament injuries of the knee
have involved anatomic identification, biomechanical
testing, and clinical outcomes of anatomic reconstruc-
tion of ligament injuries.
Keywords: lateral collateral llgament; mecllal
collateral ligament: posterolateral corner:
posteromeclial corner
Introduction
Collateral ligament injuries of the knee are common and
challenging to treat. Medial collateral ligament {MEL}
and lateral collateral ligament (LCL) injuries often occur
with cruciate ligament injury, and the combined injury
Dr. Moorman serves as a paid consultant to or is an em—
ployee of HeadTrainer; has stoclr or stock options held in
HeadTrainec Privii: and Hegado; has received research
or institutional support from Torniec Moxlmed. Eetroz.
HeadTrainei; and Histogenics; and serves as a board mem-
hec ownec offices or committee member of the Atlantic
Coast Conference Team Physicians Society and the Amer—
ican Orthopaedic Society for Sports Medicine. None of
the following authors or any immediate family member
has received anything of value from or has stocir or stoclr
options held in a commercial company or institution re
lated directly or indirectly to the subject of this article: Dr.
Alentorn-Geii. Dr. Stuart and Dr Choi.
@ lfllfi American Academy of Drthnpaedic Surgeons
].H. Iames Choi. MD Claude T. Moorman III. MD
is even more complex to treat. The number of original
investigations related to collateral ligament injuries has
increased in recent years. This chapter reviews the most
important recent research related to the MCL, postero-
medial corner (PMC), LCL, and posterolateral corner
{PLC} and provides clinical recommendations for treat-
ment of these injuries.
The Medial Collateral Ligament
Basic Science
The healing potential of the MCL is greater than that of
the anterior cruciate ligament {ACL}. An in vitro inves-
tigation found differences in the stem cell characteristics
of the MCL and ACL} Specifically, the size and number
of ACL—derived stem cell colonies were smaller, and they
grew at a slower rate than MEL—derived stem cell colo-
nies. The MEL-derived stem cells expressed lower levels
of stem cell marker genes than the MCL—derived stem
cells. MIL-derived cells had less potential for adipogen—
esis, chondrogenesis, and osteogenesis. Another recent
investigation found that gene expression of lysyl oxidases
was higher in MEL fibroblasts than in ACL fibroblasts.2
These enzymes are important for cross-linking between
collagen and elastin during injury healing. In response to
transforming growth factor—I31, which is an important
mediator of ligament healing, MCL fibroblasts had a
higher expression of lysyl oxidases; ACL fibroblasts had
a higher expression of matrix metalloproteinases, which
increase the degradation of extracellular matrix?| The
same results were observed when the expression of lysyl 1-‘r'
oxidases and matrix metalloproteinases was compared in FT.
:5
response to interleukin-1H, which is an important chem- re
re
ical mediator of acute inflammatory response in injured tn
3
El.
ligaments.4 Together, these results show that the MCL
has good healing potential because of the growth rate and :5
functioning of its stem cells and the expression of impor-
tant enzymes for ligament healing. These results may
explain why isolated MCL injuries have a better response
to nonsurgical treatment than isolated ACL injuries.
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 3:1Inee andLeg
Anatomy and Biomechanics
Three studies recently were published on MEL anatomy.”
The perpendicular mean distance from the saphenous
nerve to the adductor tubercle or the medial epicondyle
was found to be 5 cm or 6.1 cm, respectively.j The per—
pendicular mean distance of the sartorial branch of the
saphenous nerve to the anterior aspect of the superficial
MEL was 4.3 cm at a point 2 cm distal to the joint line,
4.1 cm at 4 cm distal to the joint line, and 3.3 cm at 6 cm
distal to the joint line. A comparison of displacement of
the meniscus in a healthy MEL and an MEL detached
from the femoral insertion found that only a few fibers
of the ligament radiated to the medial meniscus and that
the displacement did not significantly differ between the
healthy and the detached MEL.‘ The femoral insertion
site of the superficial MEL was found to be a mean 1.6
mm posterior and 4.9 mm proximal to the intersection
between a line paralleling the posterior femoral cortex
and a line drawn perpendicular to the posterior femoral
cortex, where it intersects the Blumensaat line? Thus,
intraoperative fluoroscopy can be valuable in treating
a chronic tear with an absence of ligament footprint or
bony attrition.
Several MEL biomechanical studies have investigat~
ed aspects of MEL injury diagnosis, tensile properties,
length patterns during gait, structural properties of the
individual components of the medial complex, and bio~
mechanical characteristics of several surgical procedures
in cadavers?” Isolated grade III superficial MEL injury
in a cadaver model resulted in a mean increase of 3.2
mm in medial joint line opening; in the intact state, the
opening increased to 3.3 mm when the deep MEL and
posterior oblique ligament {PEI'L} were injured and to 13.3
mm when AEL injury was added.'5 A cutoff distance of
3.2. mm of medial joint line opening was established as
the basis for suspecting an isolated grade III superficial
MEL injury. In another biomechanical study, the MEL
and LEL showed no significant difference in stiffness, but
the ultimate tensile strength of the MEL was twice that
of the LELf' The MEL was most commonly torn at the
DI
femoral insertion site, and the LEL failed at the fibular at-
as
._I tachment {60%} or midsubstance {41] ‘ifsl. In a healthy knee
T:
I:
ro
the anterior bundles of both the superficial and deep MEL
ru
III-1 were elongated in flexion during gait, and the posterior
I:
a: bundles were distended with knee flexion angles.m The
elongation of the posterior bundles peaked at midstance
H
and the terminal extension-preswing stance phase.
The structural properties of the individual compo—
nents of the medial knee ligaments (superficial MEL,
deep MEL, and POL} were investigated in a controlled
laboratory study.“ The superficial MEL with intact fem—
oral and distal tibial attachments had the highest load to
Erdtopaerlic Knowledge Update: Sports Medicine 5
failure and stiffness, followed by the PDL and the deep
MEL. A significant increase in displacement was observed
after all medial knee structures were sectioned for valgus
angulation, external rotation, internal rotation (from O“
to 60" only], anterior tibial translation {from EC!" to 90"
only), and posterior tibial translation {from I)“ to 30“
only).11 The optimal position for MEL reconstruction
to reproduce native knee kinematics was found at the
center of the femoral attachment and the center of the
superficial MEL attachment {the most isometric point1.”
Minor variations of the insertion sites were found to sig-
nificantly modify the graft excursion. The anatomic MEL
reconstruction {superficial MEL and PEIL, Figure 1] com-
pletely restored stability for valgus angulation as well as
external and internal rotation but did not restore anterior
and posterior tibial translation” [Figure 1}. A subsequent
cadaver study compared superficial MEL anatomic repair
augmented using ipsilateral semitendinosus graft with
anatomic reconstruction using bovine digital extensor
tendon gra ft.” Both techniques significantly reduced me—
dial joint space gapping and valgus rotation compared
with the sectioned state of the MEL, with no significant
differences based on surgical technique. Neither technique
was able to reproduce the behavior of the native intact
MEL. Nonanatomic MEL reconstruction using a shorter
graft technique produced greater tibial external rotation
during active knee extension and passive stability testing
conditions, in comparison with anatomic superficial MEL
reconstruction, which restored normal knee kinematics
and stability.15
Treatment of Injuries
A recent large epidemiologic study of 346 MEL injuries
in soccer players found that the mean return-to-play time
was 23 days."5 This time did not significantly differ be-
tween players with an index injury {13 days} or a reinjury
{13 days}. Whether patients underwent nonsurgical or
surgical treatment was not specified, but it can be assumed
that almost all patients received nonsurgical treatment.
The outcomes of nonsurgical treatment of recalcitrant
MEL injuries recently were published.” The therapy
consisted of an image—guided injection of anesthetic and
hydrocortisone beneath the periosteal attachment of the
MEL. A significant improvement in pain and function
was observed at a mean 9—month follow—up, and 66% of
athletes returned to the previous level of sports competi-
tion, including professional sports.
Recent studies related to the surgical treatment of iso-
lated MEL injuries were based on modifications of the
surgical techniquem‘i-1 {Table 1}. In the MEL recession
technique for treating symptomatic chronic MEL lax-
ity, a bone block of the medial epicondyle containing
El ll] 16 American AcadMy of Eirrbopaedic Surgeons

Schematic drawing showing an anatomic
medial knee reconstruction. PDL = postetior
ohliq ue ligament. sMEL - superficlal medial
collateral ligament
the ligament insertion was obtained.“I The bone was
removed from the bone window to a depth that would
create sufficient tension on the MCL. The bone block
was fixed with a cancellous screw and spiked washer.1E|
The results of using this technique were not reported.
Another nonanatomic MCL reconstruction procedure
used a triangular double—bundle allograft. The anterior
bundle was placed 4.5 cm distal to the joint line, and the
posterior bundle was placed 2 cm below the joint line with
the same femoral fixation site in anatomic position“ [Fig-
ure 2}. The medial joint line opening and anteromedial
rotatory stability improved after the reconstruction. The
International Knee Documentation Committee {IKDC}
Subjective Knee Evaluation Form scores {grade A in 59%
and grade B in 36%} represented a significant improve-
ment over scores from the preoperative period. These
parameters did not significantly differ between patients
who underwent isolated MCL reconstruction and those
who underwent MEL plus ACL reconstruction.11 Another
study reported the outcomes of the surgical treatment of
MCL injuries.HI Anatomic medial knee reconstruction led
to a significant increase in subjective IKDC scores and a
significant decrease in medial compartment gapping on
valgus stress radiographs."*‘-~'m The natural history and out-
comes of surgical repair of proximal deep MEL injuries
have been described.” This subgroup of injuries did not
respond well to nonsurgical treatment. Most injuries were
caused by a combined valgus stress and external tibial
rotation during sports participation. MRI revealed edema
Eb Ifllti American Academy of flrdmpaedic Surgeons
Chapter 15: Collateral Ligament Injuries
in the proximal insertion of the deep MCL. None of the
patients had improvement with nonsurgical treatment.
Surgery revealed lack of healing as well as retraction. The
surgical repair elicited good results; all patients returned
to spurts and remained asymptomatic at a mean 43—week
follow-up.”
Pasteremedial Corner and Either Combined Injuries
Anatomic and Biomechanical Studies
An MRI-based retrospective study found that 31% of
patients with a confirmed knee dislocation or a knee
dislocatable under anesthesia had an injury to the PMC,
and 63% had a superficial MCL tear alone.“ All patients
with injury to the posterior horn of the medial meniscus
had concomitant meniscotibial ligament injury, and sass
had a tear of the PCIL. All patients with grade III [unity of
the MCL had a complete tear of the POL and meniscotib-
ial ligament. The researchers concluded that high-grade
medial instability or an MCL tear with an associated
tear of the posterior horn of the medial meniscus should
raise suspicion for I’MC instability.11 A biomechanical
study compared injured and intact knees for PCL or
PflL injury alone or in combination, before and after
reconstruction.“ Reconstruction of the PUL was found
to significantly contribute to a decrease in the posterior
tibial translation of knees with associated PCL injury
and applied valgus and internal rotation moments. The
addition of MCL reconstruction did not improve knee
kinematics. A nonanatomic reconstruction of the PMC
was done using a double—strand semitendinosus graft.”
Surgical Treatment
Although most MEL injuries do not require surgical treat-
ment because of the great healing potential of the MCL,
some injuries need to be surgically fixed, particularly if
other ligaments also are injured. The outcomes of surgical
treatment of the PMC, with or without injury to the MCL
and cruciate ligaments, generally are good {Table 1}. In
a study of a minimally invasive reconstruction of medial
structures with ACL reconstruction, MEL and POL re-
pair was done through advancement and retensioning pg
of both ligaments proximal to the medial epicondylefM FT.
:5
Improvement in subjective and functional outcomes as m
rs
in
well as stability in valgus stress and external rotation was 3
El.
reported in the postoperative period compared with the
preoperative period. A similar surgical technique was used E
in patients with acute or chronic grade III ACL or medial
knee injury}:T Medial knee injuries were treated with prox-
imal advancement of the superficial and deep MC L, PDL,
and joint capsule {Figure 3). 0f the 13 patients, I” needed
double semitendinosus tendon augmentation to achieve
adequate medial-side knee stability.15 The researchers
Drrhopaedic Knowledge Update: Sports Medicine .5
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Dnhnpaedie Knnwledge Update: Sparta Medicine .5

Chapter 16: Culleternl ligament Injuries

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 Sectien 3:1Cnec andLeg

Interference screw

Ailegraft 4.5 e

I tibial
Phaterier
tunnel ' _Anterier
tibial tunnel - II "
.5 an em

Peeterier
Anterier tibial tunnel
lihial tunnel

A B

Schematic drawings shewing frental {A} and lateral [B] 1irie'ilirs ef the ltnee after a tria ngular. deuhle-bundle
recenstructlen ef the medial cellateral ligament.

Veetue
madialis

Adducter
matinee

F'CI'L

Superficial MEL
EemirneIriJraneaus

Deep MEL

Gracilia

Eerritendinesus
Sarierius

DI B
cu
._I
T:
I:
Figure 3 Schematic medial-view drawings showing the preximal advancement precedure fer peemremedial cerner repair
in alene {A} and with deuhle semltentlinesus tenden augmentatien {I}. MEL - medlal cellateral Ilga ment, PDL -
ca
Iii-1 pesterier ehligue ligament.
I:
a:
H

repetted significant imprevenient in radiegraphically as-
scssed valgus larcitjr as well as adequate functien, sperts
perferrnance, and satisfactien with surgery. Beth studies
fennel geecl results after surgical treatment ef medial knee
ininry in patients with a cencemitant ACL tear.
Twe studies reperted the eutcernes ef surgical
treatment ef MCL injnr].r nsing Achilles tenden allegraft
in the cement ef cemhined ligament iniuryz'i'” {Table 1}.
The MC L was recenstrncted by fixing the hene hleck ef
the Achilles tenden allegraft inte anaternic pesitien in
the femur and fixing the tenden part inte the tibia with a
certical screw and spiked washer.16 The MEL was fixed

flrdiepaedic Knewledge Update: Sparta Medicine 5 El ll] 16 American Academe ef Cirthepaedic Serge-ens

at 10“ nf fleainn and slight varus after recnnstructinn nf
the ACL. The 14 patients had gned functienality, sta-
bility, and return tn preinjnry activity level. A similar
technique was used tn cnrrect subacute and chrenic valgus
instability in multiliga ment—injured knees thrnugh super—
ficial MEL recnnstructinn.“ 1'llalgus lat-city and functinnal
nutcnmes significantlyr impreved after surgeryr en the su-
perficial MEL with the ether injured ligaments. Because
nf cnncerns related tn the difficulty nf the surgical tech-
nique, the risk nf infectinn, and the less nf mntinn, seme
surgenns prefer tn use Achilles tendnn allngraft nnly if
multiple ligaments are invnlved and net fnr isnlated MEL
injury. The surgical nutcnmes ef MEL recnnstructinn
were repnrted when a nnvel hybrid technique was used
in multiligament-injured knees.IE The MEL was recnn-
structed using bnth semitendinnsus tendnn autngraft and
a pnlyester tape (Henligamentsl. The tibial tape pnrtien
nf the graft was reflected tn the anternmedial tibia under
the subcutaneeus tissue after being passed theugh the
tibial tunnel {Figure 4]. This recnnstructinn has binme-
chanical prnperties cnmparable tn thnse nf a hens-patel-
lar tendnn-bnne graft fixed with an interference screw,
allnws anatnmic tunnel placement, and has gnnd length
and thickness adaptability. Functinn and stability were
satisfactnry at an average 1-year fellnw-up.
A study nf the surgical treatment nf PME injuries in—
cluded a cnmparisnn nf repair and recnnstructinn nf beth
the MEL and PUL.” The repair was dnne with suture
Viden 15.1: Medial Enllateral Ligament
@I {MEL} Acute Meniscntibial Repair. David
Gnrden, MB, EhE, MD; Len Pincaewski,
FRACS [9.fl4 min}
anchnrs in injuries less than 4 weeks nld. Repairs ef PME
injury had a higher failure rate than recnnstructinn with
autngraft nr allngraft. Therefere, recnnstructinn may be
preferable tn repair ef PME injury.
The rccnmmended surgical technique for PME injuries
is the medified Eeswnrth technique, with plicature nf the
pnsterinr capsule tn treat injury tn the FEIL.
The Lateral Enllateral Ligament
.lllinatnmyr and Binmechanics
In an anatnmic study, the LEL femnral insertinn site was
identified after anatnmic dissectien and cnrrelated with
the radingraphic lncatinn.“ The LEL was feund tn be
lncated at 53% nf the width nf the cnndyle frem the an-
terinr aspect and at 2.3 mm distal tn the file mensaat line,
and there was less than 5 mm variance frem mean values.
Annther study determined the relatinnship between the
El Ifllti American Academy nf flrflmpaedic Surgeens
Ehapter 15: Enllateral Ligament Injuries
Schematic drawing shewlng an anatnmic
medial cnllateral ligament recnnstructinn using
a hybrid technique with semitendinnsus tenden
autngraft and a pnlyester tape. The arrnws
de me nstrate the directinn ef the cnnstruct,
which is anchnred in the lateral aspect ef the
distal humerus (dashed lines].
LEL femnral insertinn site and the physis nf skeletally
immature cadaver knees.31 The midpeint nf the femnral
nrigin ef the LEL in infants and children was 6.3 mm nr
5.9 mm distal tn the physis. respectively. LEL recnnstruc—
tinn is uncnmmnn in patients with npen physes, but this
study allnws preventinn nf iatrngenic injury by imprnving
the understanding nf the spatial relatinnship between the
LEL femnral nrigin and the distal femnral physis.
A binmechanical study using a finite element analysis
determined the stress changes ef the LEL at several knee
flexinn angles (0“, 3D“, 60“, 90", and 120“} and translatinn
fnrces {anterier-pnsterinr, varus rntatinn, and internal-
esternal rntatinn]? The LEL was fnund tn shnrten with
increasing knee flexinn and tn be mest vulnerable with
varus mntinn in almnst all evaluated knee flexinn angles. pg
The stress en the LEL increased with anterinr-pnsterinr FT.
:5
translatinn and internal-external rntatinn at 3C!“ nf knee re
re
tn
flexien. A binmechanical cadaver study cnmpared the 3
El.
varus stability nf isnlated LEL tears after figure—nf—fl re-
cnnstructinn er biceps femeris tenndesis}3 Nine knees s
were leaded at 10 him {0" and 30" nf knee fleainn] in
three states: with an intact LEL, with a sectinned LEL,
and after recnnstructinn. Beth techniques restnred varus
stability at least tn baseline values. The nnrmaliaed varus
displacement was significantly lewer after tenndesis than
after figure-ef-E recnnstructinn. The advantage nf this
Eirrhnpaedic Knnwledge Update: Spnrts Medicine 5

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Dnhnpaedie Knnwledge Update: Sparta Medicine .5

Chapter 16: Cellaternl ligament Injuries

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 Sectinn 3:1Cnee andLeg
nnnanatnmic recnnstructinn technique is that it is simple
and dnes nnt require allngraft nr autngraft.
Treatment cf Injuries
The nnly recent study nf the treatment nf isnlated LCL
injuries evaluated return tn play in prnfessinnal American
fnntball players after nnusurgical nr surgical treatment
nf an isnlated grade III LCL injuryM {Table l}. The fnur
surgically treated patients missed an average 14.5 weeks
nf play and did net return tn play until the next seasnn.
In cnntrast, the five nnnsurgically treated patients missed
nnly an average 2 weeks nf play. Fnur patients returned tn
play at an average nf 11'] days, and the remaining patient
returned tn play the next seasnn. Althnugh the study’s
sample size was limited, the data warrant further research.
Posters-lateral Corner and Either Ccmhinecl Injuries
Anatnmic and Binmechanical Studies
Anatnmic studies have been based en identificatinn nf lig-
aments invnlved in the PLC and the intertunnel relatinn—
ships in multiligament-injnred knees.35'” A recent study
detailed the anatnmy nf all structures cf the PLC.“ The
LCL was fnund tn be mnre prnximal tn the lateral femnral
epicnndyle (mean, 3.5 mm) than the pnplitens tendnn {PT}
insertinn, which was mnre anterinr tn the LCL fnntprint
(mean, 5.? mm] than previnu sly repnrted. The study alsn
specified the length and diameter nf the fabellnfibular,
arcuate, nblique pnpliteal, pnsterinr meniscnfemnral, and
pnplitenmeniscal ligaments. The intertunnel relatinnship
in multiligament knee surgery was investigated in three
studies. The mnst adequate tunnel angles fnr anatnmic
PLC recnnstructinn were determined in CTuassessed, muln
tiligament—injured cadaver kneesfi‘5 Tn avnid cnllisinn with
ACL and PCL tunnels, the safest femnral tunnel drilling
angles fnr anatnmic PLC recnnstructinn were fnu nd tn he
PT drilling at 3i)“ nf angulatinn in bnth axial and cnrnnal
planes and LCL drilling at 3D“ angulatinn in the axial
plane and fl" angulatinn in the cnrnnal plane. A study
nf the vinlatinn nf the intercnndylar nntch and pntential
tunnel cnllisinn in single-bundle nr dnuble-bundle ACL
DI
recnnstructinn fnund that the safest angles fnr the LCL
as
._I and PT tunnels were 2U“ anterinr and 1C!” prnximal tn the
T:
I:
[I'll
transepicnndylar axis}T Detailed data were prnvided cm
cu
Iii-1 distances and angulatinns in ACL recnnstructinn based
I:
a: nn single—bundle nr dnuble-bundle recnnstructinn and
anternmedial nr transtihial femnral tunnel drilling. In a
H
similar study, the safest angulatinns tn prevent intersec-
tinn nf LCL and ACL tunnels were 4-3“ anterinr angu—
latinn in the axial plane and CI” prnximal angulatinn in
the cnrnnal planefi'fl Hnwever, at these angles twn nf six
specimens fnr the axial plane and twn nf five specimens
fnr the cnrnnal plane had a trnchlea vinlatinn withnut a
flrdmpaedic Knnwledge Update: Spnrts Medicine 5
tunnel cnllisinn. It is likely that small variatinns in the
LCL femnral nrigin may explain differences in angles
related tn tunnel cnllisinn. This study determined that the
LCL femnral insertinu site was 1.4 mm prnximal and 3.1
mm pnsterinr tn the lateral epicnndyle.“
Several recent binmechanical studies were related tn
PLC recnnstructinn.39"'3 The LCL and pnplitenfibular
ligament {PFL} were fnund tn equally limit tibial external
rntatinn at lnw flexinn angles {13“ and 30"), and the PFL
was mnre impnrtant than the LCL fnr limiting external
rntatinn at fill“ and 90" nf knee flexinn.“I These results
suggest that PLC knee injuries nccurring at a high knee
flexinn angle may have mnre invnlvement nf the PFL
{and prnbably the PT} than the LCL. Fnur binmechan‘
ical studies cnmpared recnnstructinn techniques. Varus
and external rntatnry laxity were cnmpared in PT and
LCL recnnstructinn using the pnsterinr tibial tendnn, PT
and PFL recnnstructinn using patellar tendnn and hnne,
and PFL and LCL recnnstructinn using the semitendi-
nnsus tendnn.” Nn significant differences were fnund
in varns and tibial external rntatinn at fl”, 3D“, 6D“, and
fill“ nf knee flexinn. Nnne nf the three techniques cnuld
achieve the strength nf the native knee. Tibial external
rntatinn depended nn whether the PT, PFL, nr bnth were
recnnstructed {in an intact LCL mndel}.“3 Sectinning bnth
structures significantly increased external rntatinn. The
PFL recnnstructinn restnred external rntatinn tn that nf
the intact knee at 3!)“ and 90” nf knee flexinn. Hnwever,
the PT and PT plus PFL recnnstructinn techniques nver-
cnnstrained external rntatinn at El“, 311]“, 45”, 60“, 9!)“, and
11!?“ cf knee flexinn. Varus and tibial external rntatinn at
IT, 30", and 60" nf knee flexinn were cnmpared in several
fibularhased recnnstructinn techniques: femnral attach-
ment with a single-tunnel nr dnuble-tunnel technique
and fibular attachment with an anterinrupnsterinr nr
nblique tunnel technique.“ All recnnstructinn techniques
restnred varns and external rntatinn cnmpared with the
ligament-deficient state, but the dnuble femnral tunnel
(nne tunnel fnr the PT and annther fnr the LCL} with an
nblique fibular tunnel was the best technique fnr restnr-
ing native knee kinematics. Nnne nf the recnnstructinn
techniques nvercnnstraincd the knee at the evaluated knee
flexinn angles. Hnwever, drilling mnre than nne tunnel
in the femur may increase the cnmplexity nf a revisinn
surgery, especially if tunnel cnmmunicatinn develnps,
and can increase the risk nf tunnel cnllisinn if there is
assnciated ACL inju ry.“ Varus and tibial external rntatinn
were cnmpared in a fibula—based figure—nf—S technique
alnne and a cnmbined PT and fibula-based figure-nf-S
technique.“ These techniques similarly restnred varus
and tibial external rntatinn stability at 3'3" and 90“ cnm-
pared with the intact state. Varus stability at 31]" in the
El 1016 American AcadMy nf Drthnpaedic Surgenns

fibula-based reconstruction technique was significantly
lower than in the combined procedure, although it was
not significantly different from that of the intact knee.
Diagnostic Studies
An MRI-based study determined the location of bone
bruises in PLC injuries.“ In 23 patients with an isolated
grade III I’LC injury and T4 with a combined ligament
injury, the most common bone bruise location was in
the medial compartment. Specifically, bone bruises were
located in the anteromedial femoral condyle in 60% of
patients with an isolated injury and 52% of patients with
a combined injury. Bone bruise of the posteromedial tib-
ial plateau also was found in 29% of patients with PLC
and ACL injury. Another diagnostic study classified the
peel-off type of acute grade III PLC injury using both
MRI and intraoperative arthroscopy in 43 patients.“ A
peel-off injury was found in 19 patients {413%}, of whom
4 (21%} had a type I isolated PT injury, 3 {41%} had a
type II combined PT and LCL tear, and Ti [3?%] had a
type III complex tear involving intra substance-based antbr
or fibula-based injury. Peel-off injury led to tibial external
rotation of more than ID” in 34% of patients and to pos—
itive varus instability in 93% of patients. These injuries
could be diagnosed with visualization of the lateral gutter
during arthroscopy in 94% of patients.“
Surgical Treatment
Two recent studies evaluated the results of surgical treat—
ment of isolated PLC injuries‘liv‘ii [Table 2]. In a study of
1? patients with this injury who were treated with ana-
tomic reconstruction of the PLC {LCL, PT, and PFL] with
hamstring autogra ft, 26 {95 ‘34:.) achieved adequate rotato-
ry stability, and 19 {91%) had a normal or near-normal
IKDC score.” Five of six pediatric patients {mean age,
13.3 years) were surgically treated with fragment fixation
after an acute avulsion fracture of the femoral attachment
of the LCL and PT.“fl At a mean 5-year follow-up, the
patients had a mean Lysholm Knee Questionnaire score
of 93, a mean Knee Injury and Dsteoarthritis Dutcome
Score {KGB 5} quality of life score of SD, and normal knee
stability and range of motion.
A study of PLC injuries associated with other ligament
injuries compared the surgical outcomes of ACL and PLC
reconstruction with those of ACL reconstruction alone‘lif
{Table 2}. All PLC injuries were treated with the split bi-
ceps tenodesis technique. At a mean 35-month follow-up,
all patients had a negative dial test, and the Lysholrn,
fliDC, and K005 scores had significantly improved com-
pared with preoperative values. Several parameters were
lower after a combination of procedures than after ACL
reconstruction alone, but the patients who underwent a
Eb Ifllii American Academy of Urthopaedic Surgeons
Chapter 15: Collateral Ligament Injuries
Schematic lateral-view drawing showing the
modified biceps femoris rerouting technique
fer posterolate ral corner insufficiency. After
confirming the isometric point, a 3.2-mm hole
was created proximally from the isometric point
as long as the radius of a so'ew and washer {9
mm] used for fixation.
combined procedure had excellent return to work and
sporting activity outcomes. Three studies reported the
outcomes of surgical treatment of PLC injuries associ-
ated with PULP“fl The outcomes of patients who under-
went PCL reconstruction in combination with anatomic
PLC reconstruction {LCL and PT} were compared with
those of patients who underwent posterior tibial tendon
allograft or the split biceps tenodesis technique51 [Fig-
ure 3}. The anatomic PLC reconstruction technique led
to significantly better results in terms of rotatory stability,
varus stability, Lysholm score, IKDC score, and range of
motion than the biceps tenodesis technique. A study of 19
patients with PLC and PCL injuries surgically treated with 9."
a single-bundle reconstruction of the PCL and a modified 5'":
:5
Larsson technique for LCL and PFL reconstruction found re
re
or
excellent results in terms of absence of complications, 3
El.
dial test and varus stress stability, range of motion, and
function.5”A comparison of the results of single-bundle s
PCL reconstruction with Achilles tendon allograft com-
bined with a miniopen PFL reconstruction using anterior
tibial tendon allograft found significant improvement in
posterior tibial translation, tibial external rotation, and
function (as measured using IKDC scores] at a minimum
1-year follow-up?“1
Drthopaedio Knowledge Update: Sports Medicine .5
 Sectinn 3:1I'inee andLeg
The recnmmended Surgical technique fnr treating PLE
injuries is the fibula—based, single-bundle, figure-nf-S sem-
itendinnsus autngraft recnnstructinn.
@I Video 15.2: Pnsternlateral Enrner Primary
Repair and Recnnstructinn. Ease Based.
Marl: D. Miller, MD; Brian E. Werner,
MD; Sean Higgins [17345 mini
Surnrrlaryr
The mnst recent findings nn injury tn the cnllateral liga'
ments cf the knee are related tn the basic science, anat-
nmy, and binmechanics nf the MEL and LEL. Many nf
the studies cnrrespnnd tn studies cm the PME nr PLE.
These injuries clearly impair knee stability and may
warrant surgical treatment. In general, auatnmic recnn—
structinn is recnmmended tn achieve knee stability and
functinn. Hnwever, clinical studies are needed tn cnmpare
anatnmic and unnanatnmic PME nr PLE recnnstructinn
befnre definitive cnnclusinns can be drawn.
Hey Study Pnints
1* The MEL has gnnd healing pntential thanks tn
greater grnwth and functinn nf stem cells and ex-
pressinn nf impnrta nt enzymes fnr ligament healing,
as cnmpared with the AEL.
1' Mnst MEL injuries can be treated nnnsurgically,
especially if they are incnmplete nr isnlated jnnt
assnciated with PME nr multiligament knee injury}.
* Mnre than 3.2 mm nf medial jnint line npem'ng
shnuld raise suspicinn fnr a grade III cnmplete tear
in a superficial MEL injury.
1! The MEL and LEL have similar stiffness, but the
ultimate tensile strength nf the MEL is twice that
nf the LEL.
1' lsnlated anatnmic MEL recnnstructinn, PME re-
cnnstructinn, and MEL recnnstructinn assnciated
with cruciate ligament recnnstructinn have gnnd
DI
results in terms nf knee stability I[valgus angulatinn
as
._I and external and internal rntatinnj and functinn.
T:
I:
as 1' The drilling angles in an anatnmic PLE recnnstruc-
as
III-1 tinn tn avnid tunnel cnllisinn with cruciate ligament
I:
M recnnstructinn are the PT drilled at 311]“ nf angula-
H
tinn in bnth axial and cnrnnal planes and the LEI.
drilled at 30“ angulatinn in the axial plane and fl”
angulatinn in the cnrnnal plane.
*I The fibularbased and cnmbined fibular and tibial
PLE recnnstructinn techniques allnw adequate res-
tnratinn nf ltnee varus and tibial external rntatinn.
Elrdtnpaedie Knnwledge Update: Spurts Medicine 5
@ ,
Its-y Study Pnints t’rnntr'rmedj
* lsnlated PLE recnnstructinn and PLE recnnstruc-
tinn assnciated with cruciate ligament recnnstruc—
tinn lead tn gnnd nutcnmes in terms nf stability
and functinn at shnrt-term and midterm fnllnw-up.
Annotated References
1. Ehaug J, Pan T, Im HJ, Fu Fl-I, Wang JH: Differential
prnperties nf human AEL and MEL stem cells may be
respnnsible fnr their differential healing capacity. BME
Med Efl11;9:63. Medliue DUI
flu in vittn study fnund differences in the stem cell char-
acteristics nf the human AEL and MEL, which are related
tn differences in healing pntential.
. Iie J, Huang W, Jiang J. ct al: Differential expressinus
nf lysyl nxidase family in AEL and MEL fibrnblasts
after mechanical injury. Injury 2013;44{?j:393-9flfl.
Medliue DUI
in in vitrn study fnund higher expressinn nf lysyl nxidase
in the human MEL than in the REL, which is related tn
greater healing pntential in the MEL.
. Hie J, Wa ng E, Huang DY, et a1: TGF—betal induces the
different expressinns nf lysyl nxidases and matrix metal-
lnprnteinases in anterinr cruciate ligament and medial
cnllateral ligament fibrnblasts after mechanical injury.
J Bins-tech 2fl13;45[5}:390—393. Medline DEII
An in vitrn study fnund that transfnrming grnwth fac-
tnr—Bl induces higher expressinn nf lysyl nxidase in the
human MEL than in the PLEL. There is higher expressinn
nf matrix metallnptnteinases in the human AEL than in
the MEL. These findings are related tn a lnwer healing
pntential in the AEL than in the MEL.
. Elie J, Wang E, Yin L, En E, Zhang Y, Sung KL: Interleu-
ltiu-l beta influences nn lysyl nxidases and matrix metal-
lnprnteinases prnfile nf injured anterinr cruciate ligament
and medial cnllatetal ligament fibrnblasts. Int Drrhnp
Efl13;3?[3]:495-505. Medline DUI
em in vitrn study fnu ad that interleukin-1 induces higher
expressinn nf lysyl nxidase in the human MEL and higher
expressinn nf matrix metallnprnteinases in the human
nEL, which are related tn a lnwer healing pntential in the
AEL than in the MEL.
. 1i'lii'ijdiclts EA, Westerhaus ED, Brand EJ,Jnhansen 5, En-
gebretsen L, Laf'rade RF: Sartnrial branch cf the saphe-
nnus nerve in relatinn tn a medial knee ligament repair
nr recnnstructinn. Knee Snrg .Epnrts Tmametnl Artbrnsc
Efllflflfljflhllflfi-llfliMedline DID]
a human cadaver study repnrted the anatnmic relatinn-
ships between the surgical apprnach fnr MEL injuries and
the saphennus nerve with its sartnrial branch.
El 1016 American AcadMy nf Drthnpaedie Surge-ens

Stein G, Keebke J, Faymenville U, Dargel J, Miiller LP,
Schiffer U: The relatienship between the medial cellateral
ligament and the medial meniscus: A tepegraphical and
biemechanical study. Surg Eadie! Ana: 1011:33l9]:?63-
166. Medline DUI
A human cadaver study feund that the deep MUL had ne
relevant influence en the stability ef the medial meniscus.
Hartshern T, Utaredifard K, 1|White EA, Hatch GP III:
Radiegraphic landmarks fer lc-cating the femeral erigin
ef the superficial medial cellateral ligament. Am } Sperts
Med sels,41{11}:sssv—ssss. Medline DUI
A human cadaver anatemic and radiegraphic study re-
perted the exact le-catien ef the femeral attachment ef the
superficial MEL using true lateral radiegraphs.
LaPrade RF, Bernhardsen A5, Griffith C], Macalena JA,
Wijdicks CA: Cerrelatien ef valgus stress radiugraphs
with medial knee ligament injuries: An in vitre bieme—
chanical study. Am I Sperts Med lfllfl:33{2}:33fl-333.
Medline DUI
A human cadaver anatemic and radiegraphic study quan-
tified medial cempartment gapping with valgus stress tests
based en types ef medial knee injuries.
Wilsen ”WT, Deakin AH, Payne AP, Picard F, Wearing 5C:
Cemparative analysis ef the structural preperties ef the
cellateral ligaments ef the human knee. } Urrbep Spears
Phys Ther 2611;42j43:345-351. Medline DUI
A human cadaver study cempared the structural preperties
ef the LEL and MEL. Differences were feund in geemetry
and strength but net stiffness.
ll]. Liu F, lUadiketa HR, Keadnek M, et al: In vive length
patterns ef the medial cellateral ligament during the
stance phase ef gait. Knee Surg Sperts Traumetei Arch-resc-
2Il11;1 91:5 }:?1 951?. Medline DUI
A human biemecha nical study feund differences in the
elengatien ef anterier and pesterier bundles ef the super—
ficial and deep MCL du ring gait.
11. Wijdicks CA, Ewart DT, Huckley D], Jehansen 5, En-
gebretsen L, LaPrade RF: Structural preperties ef the
primary medial knee ligaments. Am I Sperts Med
2D1fl;33jflj:1633—1646.Medline DUI
A human biemechanical cadaver study investigated lead
te failure and stiffness ef the superficial and deep MEL
and the PUL.
12. Ueebs ER, Wijdicks {3A, Armitage BM, et al: An in vitre
analysis ef an anatemical medial knee recenstrucn'en. Am
I Spur-ts Med lfllfl;33{2]:339-34T. Medline DUI
A human biemechanical cadaver study feund that anarem-
ic medial knee recenstructien cempletely restered valgus
and internal-external retatien instability.
13. Feeley ET, Muller M5, Allen AA, Graechi CC, Pearle AD:
Isemetry ef medial cellateral ligament recenstructien.
4D 1616 American Academy ef Urthepaedie Surgeens
Chapter 16: Uellateral Ligament Injuries
Knee Surg Sperts Traumarei Arthresc Eflflfiflflfljflfli’fl-
1032. Medline DUI
A human cadaver biemechanical study investigated the
isemetry ef anatemic MCL recenstructien. The lewest
graft excursien was feund when the graft was fixed in the
center ef the MCL femeral attachment and the center ef
the superficial MCL attachment.
14. Wijdicks CA, Michalski MP, Rasmussen MT, et al: Su-
perficial medial cellateral ligament anatc-mic augmented
repair versus anatemic recenstructien: An in vitre bieme-
chanical analysis. Am ] Sperrs Med lfl]3;41[12}:2353-
2366. Medline DUI
A human cadaver study cempared superficial MCL ana-
ternic repair and anatumic recenstructie-n. Beth tech-
niques significantly reduced medial jeint space gapping
and valgus retatien cempared with intact knees.
15. 1iIi'an den Begaerde JM, Shin E, Neu GP, Marder RA: The
superficial medial cellateral ligament recenstructien ef
the knee: Effect ef altering graft length en knee kinemat-
ics and stability. Knee 3mg Sperts Traumatel' Arthresc
lfl11;19{5uppl 11:560-563. Medline DUI
A human biemechanical cadaver study feund that nenana-
temic superficial MEL recenstructien led re higher values
ef tibial external retatien than anatemic recenstructien.
16. Lundhlad M, 1iLil'aldIE-n M, Magnussen H, Earlssen J, Ek-
strand]: The LlEFA injury study: 11-year data cencerning
346 MEL injuries and time tn return te play. Br} Sperts
Med 2fl13;4?{12}:?59-T62. Medline DUI
A prespective cehert study ef 346 MCL injuries in Eure-
p-ean seccer players feund that the mean time te return
tn play was 23 days. Level ef evidence: II.
Drumm U, Chan U, Malliaras P, Merrissey D, Maffulli
N: High-velume image-guided injectien fer recalcitrant
medial cellateral ligament injuries ef the knee. Elie Rediei
2fl14;69j5}:e211-e215.Medline DUI
A retrespective case study reperted geed results after im-
age-guided anesthetic and hydrecertisene injectien fer
recalcitrant MEL injuries. Level ef evidence: IV.
13. Backes JR, Wiltfeng RE, fiteensen RN: Medial cellateral
ligament recessien fer chrenic medial knee laxity. Jlr Knee
Surg 2313:26f3}:1?3—133. Medline
A surgical technique fer chrenic iselated MEL laxity pg
censisted ef MEL recessien. Eerie black was ebtained FT.
frem the femeral erigin ef the superficial MCL, bene was :5
m
remeved frem the depth ef the windew, and bene bleck m
a:
fixatien was clene in a mere lateral pesitien te increase 3
El.
tensien.
s
15'. Narvani A, Mahmud T, Lavelle J, Williams A: Injury te the
preximal deep medial cellateral ligament: A preblematical
subgreup ef injuries. ] Harte jeint Sarg Br lfllfl;92{?j:94fi-
953. Medline DUI
In a retrespective case study, injury te the preximal deep
MCL was identified as having a peer pregnesis. This
Urrhepaedie Knewledge Update: Sperrs Medicine 5
 Sectien 3:1Cnee andLeg
injury may nnt heal easily and may be best treated surgi-
cally. Level nf evidence: IV.
213'. LaPrade RF, Wijdicks EA: Surgical technique: Develnp-
ment nf an anatnmic medial knee recnnstructinu. EH1:
Urrliep Eels: Res 2fl12;4?fl{3j:3fl6-314. Medline DO]
A prnspective case study ef patients with anatnmic MEL
recenstructien {superficial MEL and PDL} fennd geed
nutcnmes related tn stability and functinn. Level nf
evidence: IV.
21. Dnng JT, |Ehen BC, Men HQ, et al: Applicatinn nf trian-
gular vecter tn functienally recenstruct the medial cnl-
lateral ligament with deuhle~bundle allegraft technique.
Artbrnsenpy 2012;23l10]:1445-1453. Medline DUI
A retrespective case study cempared patients with isnlated
MEL injury tn these with MEL and ACL injury. Triangu-
lar vectnr recenstructien ef the MEL led tn geed stability
and functien. Level ef evidence: IV.
22. Ehahal J, AI—Taki M, Pearce D, Leibenberg A, 1i'i'ihelan DB:
Injury patterns re the pesteremedial cerner ef the knee
in high-grade multiligament knee injuries: A MRI study.
Knee 3mg Spnrts Trenmetnl Artbrnsc 2GID:13{3}:1093-
IIIH. Medline DUI
A retrespective diagnestic study cerrelated MRI—assessed
injury patterns in the PME in multiligament knee injuries
with examinatinn under anesthesia. Level nf evidence: IV.
23. Weimann A, Schatka I, Herbert M, et al: Recnnstruc-
tinn nf the pnsterinr nhlique ligament and lite pnsterinr
cruciate ligament in knees with pnsternmedial instability.
Arthrnscepy 2312;2fllflj:1233-I239. Medline DUI
A human biemechanical cadaver study reperted gned
stability after recenstructien nf the PUL in knees with
injury tn the PME and PEL.
24. lCanata GL, Ehiey A, Lenni T: Surgical technique: Dnes
mini—invasive medial cnllateral ligament and pnsterinr
ehlique ligament repair restnre knee stability in cnmbined
chrenic medial and AEL injuries? Elie Urrhep Eels: Res
2fl12;4?fl{3}:?91-292.Medline DUI
A pruspective case study fnund that a nnvel technique
cnnsisting nf minimally invasive MEL and PUL repair in
patients with chrenic medial laxity led tn geed stability
and functinn. Level nf evidence: IV.
DI
tu
._I 25. Kega H. Munera T. Yagishita Ii"... Ju Y]. Sekiya 1: Surgical
T: management nf grade 3 media] knee injuries cnmhined
I:
re wid1 cruciate ligament injuries. Knee Snrg Spnrts Trest-
a:
III-1
I:
metel Arthrese 2012;20i1j:SS—94. Medline DEII
:e
H
A retrespective case study ef presimal advancement ef
heth the superficial MEL and the PEL with the underlying
deep MEL and jnint capsule in patients with cnmhined
cruciate ligament injuries reperted reasnnahle restnratinn
ef medial knee stability. Level ef evidence: IV.
2S. Mars: RE, Hetsreni I: Surgical technique: Medial cellat—
eral ligament recenstructien using Achilles allegraft Int
Elrrltepaedie Knewledge Update: Sperts Medicine 5
cnmhined knee ligament injury. Eli's: Urthnp Field! Res
2012;4?fl{3}:293-SDS.Medline DUI
A retrespective case study in which patients with MEL
and cembined knee ligament injuries were treated with
Achilles tenden allegraft reperted gend medial stability
at 2- tn 5-year fnllnw-up. Level nf evidence: IV.
2?. Liu X, Feng H, Zhang H, et al: Surgical treatment ef
suhacute and chrenic valgus instability in multiligament-
injured knees with superficial medial cnllateral ligament
recenstructien using Achilles allegrafts: A quantitative
analysis with a minimum 2-year fnllnw-up. Am I Spert-s
Med 2fl13;41{5j:1fl44-Ifl50. Medline DUI
A retrespective case study nf patients with a multiligament
knee injury treated with Achilles tenden allngraft recen—
structien ef the superficial MEL reperted gen-d functienal
and valgus stability. Level nf evidence: IV.
2E. Kitamura H, Ugawa M, Kende E. Kitayama S. Tehyama
H, Yasuda K: A nnvel medial cnllateral ligament recnn-
structinn prncedure using semitendinesus tenden aute-
graft in patients with multiligamenteus knee injuries:
Clinical eutcemes. An: I Sperss Med 2013:41lfijfl224-
1231. Medline DUI
A retrespective case study nf patients with a multiligament
knee injury treated with a nevel superficial MEL recen—
structien technique cembining semitendinesus tenden
autngraft and synthetic tape reperted gnnd functinnal
and stability eutcemes. Level nf evidence: IV.
29. Stannard JP, Black ES, Achell E, agas DA: Pnstern-
medial cerner injury in knee dislncatiens. I Knee Snrg
2fl12525{5}:429-434.Medline en:
A retrespective case study nf patients with a knee disln—
catien cempared repair and recenstructien ef the PME.
Recnnstructinn led tn better stability than repair. Level
nf evidence: IV.
Si}. Kamath UV, Redfern JE, Burks RT: Femnral radingraphic
landmarks fer lateral cnllateral ligament recenstructien
and repair: A new methed ef reference. An: I Sperrs Med
2010;33l3}:5?fl-5?4.Medline DUI
A human anatnmic and radingraphic cadaver study identi-
fied the femnral nrigin nf the LEL. Intranperative flunrns-
cepy can be used In determine femeral tunnel placement
during pesterelateral er LEL recenstructien.
31. Shea KG, Peleusky JD, Jacebs JE Jr, Ganley T]: Anatem—
ical dissectien and ET imaging ef the pesterier cruciate
and lateral cnllateral ligaments in skeletally immature
cadaver knees. ] Eerie feint Sang Am 2014.;96(9J:253-?59.
Medline DUI
A human anatnmic and radingraphic cadaver study in
skeletally immature knees described the relatienship ef
the PEL and LEL tn the physeal structures.
S2. 2".heng TL. 1Wang Y. 1ilii'ang HP, Reng K. Xie L: Stress
changes nf lateral cnllateral ligament at different knee flex-
inn with er witheut displaced mevements: A S-dimensienal
El 2016 American AcadMy ef Urthepaedie Surge-ens

finite element analysis. (Shir: I Tremearnl 2011;14i2]:?9-
33. Medline
A binmechanical study investigated stress changes nf the
LCL at different knee flexinn angles, with nr withuut dis-
placement mnvements. The LCL was vulnerable tn varus
fnrce and susceptible tn anterinr-pnsterinr translatinn and
internal-external rutatinn at 313° nf knee flexinn.
33. Eeitn C, Parks 13G. Tsai M, Hintnn RY: Biceps tenndesis
versus allngraft recnnstructinn fnr varus instability. ] Knee
Surg2014:2?{1j:133—13?.Medline but
A human binmechanical cadaver study fnund that buth
biceps tenndesis and allngraft recnnstt uctinn restnted var.
us stability tn baseline values.
34. Bushnell ED. flitting 55. l{Stain JM, Enublik M, Schlegel
TF: Treatment nf magnetic resnnance imaging-dncument-
ed isnlated grade III lateral cnllateral ligament injuries
in Natinnal atball League athletes. Am I Spnrts Med
lfllfl;33{l}:SE-91.Medline DUI
A crnss-sectinnal study nf grade III LEI. injuries fnund
that nunsurgical treatment led tn mnre rapid return tn
play than surgical treatment.I with an equal likelihnud uf
returning tn prnfessinnal-level play. Level nf evidence: III.
35. Usti M, Tschann P, Kiinxel KH, Eenedettu KP: Pusterulat-
eral cnrner nf the knee: Micrnsurgical analysis nf anatnmy
and mnrphnmetry. Urthnpedies 2013:36i91m1114-e112fl.
Medline DUI
A human cadaver study detailed the anatnmy nf structures
cf the PMC. with emphasis en the LCL.
36. Gelb-er PE, Erquicia JI, Susa G, et al: Femnral tunnel drill-
ing angles fur the pnsternlateral cnrner in multiligamentary
knee recnnstructinns: IEnmputed tnmngraphy evaluatinn
in a cadaveric mndel. Arthrnscn‘py 2fl13;29{2}:15?-265.
Medline D'UI
A human anatnmic cadaver study nf intertunnel relatinna
ships in FLC and cruciate ligament recnnstructinn fnund
that the safest angulatinn fnr avniding tunnel cnllisinn was
3D” axial and fl” cnrnnal angulatinn fur the LCL and 3D”
angulatinn fnr buth axial and cnrnnal planes fur the PT.
3?. Kim 5], Chang CB, Chni CH, et al: Intertunnel relatinn-
ships in cnmhined anterinr cruciate ligament and pnstern-
lateral cnrner recnnstructinn: An in vivn 3-dimensinnal
anatnmic study. Am J Spnrts Med lfl13;41[4}:349-351
Medline DUI
A human anatnmic cadaver study repnrted intertunnel
relatinnships in cnmhined PLC and cruciate ligament
recnnstructinn. The safest angulatinns tn avnid tunnel
cnllisinn nf the LCL and PT tunnels were I'll“ anterinr and
Ill“ prnximal tn the transepicnndylar axis.
33. Narvy 5]., Hall MP, Kvitne RS, Tibnne JE: Tunnel intersec-
tiun in cnmhined anatnmic recnnstructinn nf the ACL and
pnsternlateral cnrner. Urrhnpedics lfll3:3fi[?l:529—532.
Medline DUI
A human anatnmic cadaver study nf intertunnel relatinn-
ships in LCL and ACL recnnstructinn found that the safest
Eb Ifllti American Academy nf Urthnpaedie Surgenns
Chapter 16: Unilateral Ligament Injuries
angulatinn tn avnid tunnel cnllisinn fnr the LEL was 40"
anterinr angulatinn in the axial plane and 0" pruximal
angulatinn in the cnrnnal plane.
39. Feeley ET, Muller M5, Sherman 5, Allen AA, Pearle
AD: Cnmparisnn nf pnsternlateral cnrner recnnstruc-
tinns using cnmputer—assisted navigatinn. Arthrnscnpy
Zfllfltlfijfllflflflfltlflfi'fi.Medline DUI
A human binmechanical cadaver study cnmpa red several
fibula-based techniques fur PLC injuries. The dnuhle fem-
ural tunnel with an nblique fibular tunnel was the best
technique fnr restnri ng native knee kinematics.
4D. Kim S], Kim HS, Mnnn HK, l[lbs-mg Iilllli'I-I, Kim 5G, Uhun
1t'l'vi: A binmechanical cnmparisnn nf 3 recnnstructinn
techniques fnr pnsternlateral instability nf the knee in
a cadaveric mndel. Arthrnscnpy ZDID;25{3}:335-341.
Medline DUI
A human binmechanical cadaver study cnmpared varus
and external rntatinn laxity in PT—LCL. PT-PFL, and PFL—
LCL recnnstructinn techniques. There were nu differences
in varus and external rntatinn laxity.
41. Rauh PB, Clancy WU Jr, Jasper LE, lCurl LA, Eelknff
S, Mnnrman CT III: Einmechanical evaluatinn nf twn
recnnstructinn techniques fnr pnsternlateral instability cf
the knee. ,7 Bnne fnirrt Snrg Br 2010:92f1fl}:146{i-1465.
Medline DUI
A human binmecha nical cadaver study cnmpared fibula-
based and cnmhined tibial and fibular tunnel recnnstruc-
tinn techniques. Bnth techniques restnrcd varus and tibial
external rntatinn stability at 3E!" and 9D" nf knee flexinn.
43. Lim HC. Bae JI-l. Bae TS, Mnnn BC, Shyam AK, Wang
JH: Relative rnle changing of lateral cnllateral ligament
en the pnsternlateral rntatnry instability accnrding tn the
knee flexinn angles: A binmechanical cnmparative study
nf rnle nf lateral cnllateral ligament and pnplitenfibular
ligament. Arch Urtfrup Trauma 3mg 2fl12;132{11}:1631-
1635. Medline DUI
A human binmechanical cadaver study fnund that the PFL
and LCL equally restnred tibial external rntatinn at lnw
knee flexinn angles but that the PFL was mnre impnrtant
than the LCL at limiting this mnvement at ED” and 9'0".
43. Ehang H. Zhang J. Liu K. et al: In vitrn cnmparisnn nf
pnpliteus tendnn and pnplitenfibular ligament recnnstruc-
tinn in an external tntatinn injury mndel cf the knee: A
cadaveric study evaluated by a navigatinn system. Arr: pg
FT.
] Spurts Med 2013:41f9}:1135-2142. Medline DUI :5
rs
rs
A human binmechanical cadaver study cnmpared PT, PFL, a:
and PT-PFL surgical recnnstructinn techniques fnr PLC
3
El.
injuries. All techniques restnred external rntatinn, but
PT and PT-PFL techniques nvercnnstrained the external
s
rntatinn.
44. Shuler M5. Jasper LE, Rauh PB. Mulligan ME. Mnnrman
CT III: Tunnel cnnvergence in cnmhined anterinr cruciate
ligament and pnsternlateral cnrner recnnstructinn. Ar-
thrnscnpy lflflfi:21{1}:153-193. Medline DUI
Urthnpaedic Knnwledge Update: Spurrs Medicine .5
 Sectitm 3:1Cnee andLeg
A human cadaver anatnmic study nf tunnel cnliisiun in
cnmbined PLC and flCL recnnstructinn feund that tunnel
cullisinn is cemmun and that the surgeun shnuld keep a
neutral alignment in the cc-rnnal plane, avcid leng tunnels.
and direct the lateral tunnel anterinrly in the axial plane
nn mnre than 4U“.
4.5. |Geeslin AG, LaPrade RF: aatinn nf bunne bruises and
nther nssenus injuries assnciated with acute grade III
isclated and ccmbincd pasteralateral knee injuries. Are
,1 Sparta Med lfllflfifltlllfljfll-ESDE. Medline DD]
A retrnspective case study described the lncatinn nf bnne
bruises in PLC injuries. Must bnne bruises were lncated
in the medial cumpartmcnt in bath isulated and cumbined
PLC cnrner injuries. Lewl cf evidence: IV.
Feng H, Ehang H, Hung L, 1|Wang XS, '3t KB, Zhang
J: Femcral peel-eff lesicns in acute pcsterclateral ccrner
injuries: Incidence, classificatinn, and clinical character-
istics. Arthrnscnpy 2fl11;2?{?}:951-953. Medline DUI
A retrnspective diagnnstic study described the peel-eff
type cf injury, which represents 40% cf PLC injuries.
Level cf evidence: IV.
4?. Jakcbsen B'iV, Lund E, Christianscn 5E, Lind MC: Ana-
temic tecnnstructinn ef the pesterclateral cerner cf the
knee: A case series with isnlated recnnstructinns in 1? pa-
tients. drtbruscepy 201 fl:26{?}:913-925. Medline DUI
A retmspective case study cf patients with an isulatcd
PLC injury treated with anatcmic reccnstructic-n with
hamstring autngraft fuund gend functinn and stability
nutcnmes. Level nf evidence: IV.
43. vnn Heidelten J, Mikkelssnn C, Eustrfim Windhamre H,
Janarv PM: Acute injuries tn the pnsternlateral cnrner
cf the knee in children: A case series cf 6 patients. Am
I Sparta Med 2011;39i1fl}:2199-2105. Medline DUI
A retrespective case study cf acute PLE injuries {acute
Iemnral avulsinns} in children fnund gnnd functic-nal and
Stability nutcnmes after fragment rcattachrnent. Level nf
evidence: IV.
43'. Cartwright—Terry M, Yates J, Tan CH, Pengas IP, Banks
IV, McNichelas M]: Medium—tenn {Svyear} ccmpa risen cf
the functinnal nutcnmes nf cnmbined anterinr cruciate lig-
ament and pesternlateral cnrner recnnstructinn cnmpared
with isulatcd antcric-r cruciate ligament recunstructicn.
DI Arthrnscepy 2014;3{i{?]:311-31?. Medline DUI
tu
._I
T:
I:
II!
a:
III-1
I:
as:
H
flrfltepaedic Knnwledge Update: Sparta Medicine 5
A crnss-sectinnal study uf surgical treatment nf PLC in-
juries fnund that the split biceps tenndcsis technique plus
ACL rcccnstructicn impreved functinnal and stability
c-utcemes. Laval af evidence: III.
50. Zcrei {3, Alan: M, Iac-anc- V, Madenna V, Rcsa D, Maffulli
N: Cnmbined PCL and PLC reccnstructicn in chrcnic
pnsternlateral instability. Knee 3mg Sparta Traumatic!
Arthrnsc 2fl13521{5}:1fl36-1041. Medline DUI
A retruspcctive case study cf patients treated using the
medified Larsscn technique fer PLC reccnstructic-n and
PCL recnnstructinn reperted gnnd results in firms c-f sta-
bility and range of mntinn. Level nf evidence: IV.
51. Kim 5], Kim TW, Kim SIG, Kim HP, Chun TM: Clinical
cnmparisnns cf the anatnmical recnnstructinn and mud-
ified biceps reruuting technique for chrcnic pusterulateral
instability ccmbined with pcsteriar cruciate ligament re-
cnnstructic-n. I Bnae Inimt Strrg Am 2D11;93{9}:3fl9 «313.
Medline DUI
A crnss-sectinnal study cnmpared the results nf anatnmic
and biceps tencdesis techniques fer PLE injuries asscciated
with PCL reccnstrucn'en. Anatcmic reccnstructien had
better functinna] and stability nutcnmes than the biceps
tenndesis technique. Level nf evidence: Ill.
52. Ehang H, Hnng L, Wang KS, et al: Single-bundle pers-
terinr cruciate ligament tecuuatructinn and mini-upen
pc-plitecfibular ligament reccnstructicu in knees with
severe pnsterinr and pnsternlateral rntatinn instability:
Clinical results nf minimum 2-year fnllnw-up. Arthrne-
copy lfllfl:16[4}:503—514. Medline DEII
.6. crass-sectiunal study repc-rtcd the results cf PCL and
minicpen PFL reccnstructic-n. This technique prc-vided
gnnd pnsterinr and p-nsternlateral rntatury stability. Level
nf evidence: III.
Videe References
16.1: Gnrdnn D, Pincaewslti L: Viden. Mediai Unilateral Lig-
ament (MEL) Acute Meeiscutibiai Repair. Sydney, Austalia,
2.012.
16.1: Miller MD, 1Werner ED, Higgins 5: Videc. Pustereiater-
a! Career Primary Repair and Receastrectine. Case Based.
Charlnttesville, VA, 2fl14.
El 1016 American Academy at Drthnpaedic Surge-ans
Chapter 17
Patellofemoral Joint Disorders
iviiho ].Tanalta.I'vID John I. Elias, PhD Andrew I. Cosgarea. MD
Abstract
The evaluation and treatment of patellofemoral disorders
requires a thorough understanding of the multiple fac-
tors that can contribute to these conditions. Treatments
should be individualized to address the specific anatomic
or functional deficits of a patient, while taking care to
avoid the commonly reported complications that can
. occur with these procedures.
Keywords: patellofemoral Instability: medial
patellofemoral ligament; tibial tuberoslty
osteotomy
Introduction
The patellofemoral joint is a complex structure in which
the patella articulates with the femoral trochlea. The
patella serves as a fulcrum for the extensor mechanism,
and as a result, high loads are transmitted across the
patellofemoral joint. Disorders of the patellofemoral joint
typically arise from joint overload or instability. Joint
overload can he caused by overuse or excessive force and
Dr. Eiias or an immediate famiiy member has received
research or institutional support from Meddhape and
has received nonincome support [such as equipment or
services}, commerciaiiy derived honoraria, or other non-
research-reiated funding {such as paid travel) from Miteir
and Synthes. Dr. Cosyarea or an immediate family member
has received research support from Toshiba and serves as
a hoard member. owner: officer: or committee member
of the American Academy of Orthopaedic Surgeons. the
American Orthopaedic Society for Sports Medicine, and
the Pateiiofemorai Foundation. Neither Dr. Tanaira nor any
immediate family member has received anything of value
from or has stock or stock options held in a commercial
company or institution reiated directly or indirectiy to the
subject of this chapter.
@ lfllfi American Academy of Drthopaedic Surgeons
often is exacerbated by mechanical or structural vari-
ations that contribute to kinematic alterations within
the joint. In contrast, patellar instability is a partial or
complete displacement of the patella. from the trochlear
groove. The stability of the patellofemoral joint is influ-
enced. by the interaction of multiple anatomic factors that
generally are categorized as static soft-tissue restraints,
osteochondral constraints, dynamic restraints, and lower
extremity alignment.
Anatomy and Biomechanics
The medial patellofemoral ligament {MFFIJ is the pri-
ma ry static restraint to lateral patellar translation within
the first 30“ of knee flexion. A cadaver dissection study
described the femoral origin of the MPFL as 9.5 mm
distal and 9.5 mm anterior to the adductor tubercle.1
The femoral origin was radiographically described as
a point 1 mm anterior to a line that extends along the
posterior cortex, 2.5 mm distal to the posterior origin of
the medial femoral condyle, and proximal to the posterior
aspect of the Elumensaat line.‘1 On its patellar insertion,
the MPFL typically merges with the attachment of the
vastus medialis obliquus {VMD} and vastus intermedius
tendons and extends to the medial border of the patella.”|
The average width of the MPFL is 1'? mm at its insertion
on the proximal two-thirds of the medial border of the
patella. The MPFL remains relatively isometric between
fl“ and T0“ of knee flexion and tension decreases with
greater knee flexion.‘
At a flexion angle greater than 3d“, the osteochondral pg
constraint of the trochlea provides primary stability to F.
:l
the patellofemoral joint {Figure 1}. Au MRI study of pa- m
m
tients with normal anatomy found that the mean depth in
3
El.
of the trochlea was 4.0 mm. This value differed signifi-
cantly by sex {3.4 mm in women and 4.2 mm in men}.5 E
The media] facet contributed to 314% of the width of
the cartilage covering the trochlea, and the lateral facet
contributed to 52.6%. Decreased trochlear depth can
reduce the cffecrivencss of the osteochondral restraint of
the patella and contribute to patellar instability. A recent
Study using a created cadaver model found that elevating
Orthopaedic Knowledge Update: Sports Medicine 5
 Sectien 3: Knee and Leg
Figure 1 axial three-dimensienal ET recenstructien
at the knee demenstrates the esteeehendral
restraint ef the trechlea previding stability
te the patellefemeral jelnt at flexlen angles
greater than 3D“.
the fleer ef the trechlea simulated trechlear dysplasia.‘
Bic-mechanical studies feund that measurements ef trech—
lear dysplasia are significantly cerrelated with increased
lateral patellar displacement and tilt acress a range ef
knee flexien angles.“3
The Vivifl presides a dynamic restraint te lateral
trauslatieu. In vitre studies feund that increasing the
force applied by the VHS decreases the maximum lat-
eral patellefemeral centact pressure and lateral patellar
shift at multiple flexicm angles?” Ililienversely, a study
using dynamic cine phase—centrast MRI feund that ad—
ministering a meter branch black tn the VMU increased
lateral patellar shift during knee extensien.“ The mer-
phelegy ef the VMD was feund te be cerrelated with its
functien. A senegraphy-based study feund a significant
DI
difference in the characteristics ef the VMU based en
as
._I whether a patient had patellefemeral pain.11 The 'msertien
T:
I:
re
level ef the Vhdfl {measured as distance re the preximal
re
III-1 pele ef the patella}, the medial erientatien ef the VMO
I:
s: muscle fibers, and VIVID muscle velume were lewer in
these with parellefemeral pain. The rele ef the Vhdfl in
H
patellar stability can be assessed in terms ef its relatien-
ship tn the vastus lateralis. A prespective study ef men
undergeing military training feund a significant delay in
activatien ef the VMU with respect re the vastus lateralis
in these whe later experienced patellefemeral pain.” A
hiemechanical study using weight-bearing MRI feund
flrrhepaedic Knewledge Update: Sparta Medicine 5
that measurements ef lateral patellar translatien and tilt
were cerrelated with a delay in the activatien ef the VMU
in patients with pain and that an increase in the activatien
ratie ef the vastus lateralis re the tastes medialis was
asseciated with increased lateral patellar tilt.“
Abnermalities in lewer extremity alignment can in-
fluence the kinematics ef the patellefemeral jeint. An
MRI—based study feund that measurements of femeral
anteversien and gene valgum were greater in knees with
patellar instability than in healthy centre] knees.” In-
creased lateralixatic-n ef the tibial tuberesity relative tn
the trechlear greeve is a cemmen type {if lewer extremity
malalignment. Recent studies have decumented the rela-
tienship ef radiegraphic measurements ef malalignment
with patellar pesitien. A study ef patellar kinematics
based en MRI at multiple knee fiexien angles feund that
a radiegraphic measurement ef malalignmeut was sig‘
nificantly cerrelated with increased lateral shift and tilt
ef the patella in patients with patellar instability]; An in
vitre study feund that reducing tuberesity lateralisatien
with a tibial tuberesity esteetemy {TTDJ decreased the
lateral shift and tilt ef the patella.”
The patellar height type ef malalignment influences
patellefemeral kinematics by increasing the extent ef knee
fiexien befere the patella can engage within the trechlear
greeve. A. study evaluating tepegraphic differences en
MRI between patients with er witheut patellar insta~
bility feund that radiegraphic measurements ef patellar
height were significantly greater in these with patellar
instability.“r An earlier biemechanical study alse found
a relatienship between patellar height and abnermal pa-
tellar tracking, with greater lateral shift and tilt ef the
patella in subjects with an increased patellar height index
{patella alta}.1’-‘
Clinical Evaluatien
History and Physical Examinatien
The primary ebjective in evaluating patellefemeral dys—
functien is te differentiate between pain and instability. A
clear descriptien ef the patient’s symptems can be helpful
when distinguishing patellar subluxatien frem symptems
such as giving way ef the knee because ef pain er weak-r
uess. The mechanism ef injury and the chrenicity, num-
ber, and type ef episedes (dislecatien versus subluxatien]
are impertant elements ef the patient’s histery. Knewledge
ef earlier treatments and surgical precedures can aid in
determining treatment eptiens.
A systematic examinatien that extends beyend the
pateliefemeral jeint can identify multiple facters centrib-
utiug te a patient’s symptems. General ligamenteus laxity
has been asseciated with an increased risk ef patellar
El 1016 American AcadMy ef Unbepaetlic Surge-ens
 Chapter 1?: Patellnfemnral Jnint Disurders

instability” and can be identified using criteria such as

the Beightnn hypermnbility scnre. The assessment nf
alignment begins with the patient in a standing pnsitinn.
Alignment cf the lnwer extremity traditinnally has been
quantified with the Q angle, but this measurement shnuld
be used with cautinn because its reliability and validity
have nnt been established. The lateralizatinn cf the tibial
tubernsity is assessed relative tn the axis nf the femur.
Abnnrmalities in alignment such as external tibial tnrsinn
and a greater than nnrmal valgus angle at the knee, as
well as the presence nf increased femnral anteversinn,
can effectively increase lateraliaing fnrces nn the extensnr
mechanism. Rntatinnal malalignment in particular was
fnund tn be a risk factnr in patellar instability.” Excessive
fcmnral anteversinn nften can be detected in hip range nf
mntinn, and nften sn-called squinting patellae are present
when the patient stands in neutral pnsitinn {Figure 2}.
Dynamic assessment nf the lnwer extremity includes
quadriceps strength. Quadriceps weakness is assnciated
with the presence nf patellnfemnral pain. In unilateral
limb-lnading tests such as single-leg squatting and land-
ing frnm a single-leg hnp, greater dynamic knee valgus
was fnund tn be present in patients with patellnfemnral
pain than in cnntrnl subjects.” Patients with unilateral
symptnms had increased dynamic knee valgus angles in
the symptnmatic knee cnmpa red with the nnrmal cnntra—
lateral knee. Deficits in hip strength, particularly in hip
abductinn and external rntatinn, alsn were assnciated
with the presence nf symptnms.?-1 "aen with patellnfem-
nral pain had less activatinn nf the gluteus medius than
cnntrnl subjects during single-leg squat testing. Lack nf
flexibility nf the hamstring musculature and tightness nf ' gifl' -__' I" .u' -

the ilintibial band {detected using the I.Il'ber test} alsn are Figure 2 Phctn-graph shnwing squinting patellae.
assn-ciated with the presence nf symptnms. Ilintibial band which are assntiated with excessive fern nral
tightness can lead tn excessive lateral retinacular tightness anteversinn and tibial tnrsinn.

and decreased medial patellar mnbility.

Patellar mnbility is assessed using the glide test. A
fnrce is applied in bnth medial and lateral directinns,
and the translatinn is quantified based nn patellar quadr
rants {15% cf the width nf the patella] {Figure 3}. The
presence nf twn quadrants nf patellar mntinn is nnrmal,
with variatinn in snme individuals. Cnmparisnn tn the
cnntralateral side is useful fnr gauging nnrmal patellar
mntinn in patients with unilateral symptnms. The patellar
tilt test is used tn assess lateral retinacular tightness. A
recent study fnund that patients with unilateral patellar
instability had increased lateral patellar translatinn and
tilt in bnth knees, and they had greater lateral patellar
translatinn and tilt than patients with nnrmal knees.“ In
patients with patellar instability, the apprehensinn sign
can be elicited using a manually directed lateral fnrce cm
the patella. Patellar tracking is nbserved as the patient
actively extends the knee frnm a flexed pnsitinn. Increased
lateraliaatinn during terminal extensinn, called the] sign,
may indicate lnss cf the medial snft—tissue checkreins.
A pnsitive apprehensinn test and] sign in the setting nf
increased lateral glide can represent a lnss nf patellar 1.4.}
stability. Nut all patients with these clinical signs have in— FT.
3
stability episndes, hnwever. Findings shnuld be cnrrelated m
m
a:
with the patient‘s descriptinn nf symptnms tn determine 3
El.
whether the patellnfemnral jnint is functinnally unsta blc.
E
Hedingraphy
The radingraphic assessment cf the patellnfemnral jnint
includes AP, lateral, and axial views. Patellar height is
assessed nn lateral radingraphs using several different

Eb Ifllii American Academy nf Urthnpaedie Surgenns Drthnpaedic Knnwledge Update: Spnrts Medicine .5
 Secticm 3:1i'2nee andLeg

radingraphie measurements {Figure 4}. The Insall-Salvati
index describes the ratic cf the length {if the patellar
tendnn tn the length cf the patella; an ahnnrrnal value
is greater than 1.1L The mndiiied Insall-Saivati index
Figure 3 Fhetegraph shewing the glide test, in which
fcirce is applied in bath medial and lateral
directicns tci assess patellar mchility.
adjusts fer differences in patellar muirphulugsr by mea-
suring the length {if the articular surface cf the patella
relative to the length nf the patellar tendcin {frcnn the
inferier articular surface tn the tuberesitvi; an abnermal
value is greater than 2. The Catnu—Deschamps index al—
lews assessment cif patellar height regardless nf patellar
tendnn length and can be helpful if the patient has had
a TTCI. The l|f.‘.atci~n—]3'eschamps index is calculated by
dividing the distance farm the inferinr articular surface
uf the patella tn the anteresuperinr margin nf the tibial
plateau b}? the length of the patellar articular surface.
Nnrmal values are less than 1.3. In a lateral radingraph
used fer determining patellar height, the knee shnuld be
pcsiticmed in 3i)” c-f flexinu tn allnvv apprc-priate tensicm
an the patellar tendnn.
Trnehlear dvsplasia is assessed en lateral radiegraphs
using the Dejc-ur classificatinu {Figure 5 i. The severity,r cf
trcichlear dvsplasia is classified as mild (type A] re severe
ltvpe D}, based en the appearance ef the anterier femnral
cendvles. Tvpe A dvsplasia is described as a crcssing sign
at the superinr margin nf the truchlea, which cnrrespnnds
re the presence ef a shall-aw trnchlea. Type E is described
as a crnssing sign with a supratrcchlear spur, indicating
a flat trcchlea. Type C is characterized by the presence
at a dnuble-centeur sign in additien tn the cressing sign;
the dnuble ccutnur indicates medial cnndvlar hvpcplasia.
Tvpe D dvsplasia has all three cnmpcnents {the crnssing

DI
cu
._I
T:
I:
us
ca
Iii-1
I:
a:
H

Figure 4 Lateral radingraphs shnwing measurements ef patellar height with the ltnee in 3D” nf flesien- A, The Insall-
Salvati index describes the ratin cf the length cf the patellar tendcin tn the length cf the patella {BIA}. A value
greater than 1.2 is abnci rmal. B. The mcdifi ed lnsalI-Salvati indeu adjusts fer differences in patellar mcirphullciggir by
measuring the length cif articular surface nf the patella relative to the length ef the patellar tend en {BIA}. A value
greater than 2 is abncrmal. C, The Catcn -Descha mps index divides the distance frcim the infericr articular surface
at the patella tn the anterusuperier margin ef the tibial plateau by the length cf the patellar articular surface
{BIA}. A value greater than 1.3 is pathelngic.

flrdinpaedic Knnwledge Update: Sparta Medicine 5 El 1016 American Academir cif Cirrhnpaedie Surgenns
 Chapter 1?: Patcllofemoral Joint Disorders

wallow! Dream-Trifle B

Shallow Eupre Flat

, trochlear li'eehlear
{ire-smug :- ma” spin
slgn j

Baseball Tire- I: Drapleah'l'rlfl D

Lateral Double contour

Double onnvauily
contour Glifl

Supra
trochlear
spur

l-ig u re 5 Schematic drawings showlng the Dejour classtflcatlon. which grades the severity of trochlear dysplasla from mlld
{type Al to severe {type D] based on the appearance of the anterior femoral condyles.

sign, supratrocblear spur, and doubleucontour sign} and is
correlated with a sorcalled cliff pattern, which is a promr
inence at the junction of the medial and lateral margins
of the trochlea.
LT and MRI
MRI is comparable to CT in its ability to show patello-
femoral morphology and in particular allows measure
ment of patellar tilt and the patellar height index.” MRI
has two advantages over CT: it allows chondral lesions
and the location of MPFL injury to be identified, and it
carries on radiation risk. After an acute patellar disloca-
tion episode, bony edema on the lateral femoral condyle
and medial patella may be seen on MRI, as is typical
with a relocation event. The presence of a large chondral
fragment may suggest the necessity of an early surgical
repair. MPFL injuryr is identified in most patients who
have had a patellar dislocation event. Skeletally immature
patients are most likely to sustain a patellar-side injury.
Those with femoral—based ruptures of the MPFL have
been found to he older (25.? +l'- 9.1 versus 19.? +!- 6.1
years} than those with patellar-based ruptures after a
patellar dislocation event?”
Axial CT or MRI studies are used to measure the sul-
cus angle and trochlear inclination in trochlear dysplasia
(Figure 6}. The sulcus angle is measured by determining
the angle formed by the two lines that connect the ante-
rionnost points of the medial and lateral femoral condyles
to the deepest point of the trochlear groove. An angle
greater than 144“ is considered pathologic. Trochlear
inclination is determined by measu ring the angle between to
the line through the posterior condylar axis and a second F.
:5
line along the lateral trochlear wall. An angle of less than re
re
a:
11" indicates trochlear dysplasia. Lateral patella: tilt is 3
El.
determined by measuring the angle between the posterior
condylar axis and the midpatellar line. An angle greater s
than Zfl" is pathologic and may indicate lateral retinac-
ular tightness.
The distance between the tibial tuberosity and troch-
lear groove {the TTTG dista ncel is measured as the lateral
distance between the deepest portion of the trochlear
groove and the apes: of the tibial tuberosity, on a line

El Ifllli American Academy of flrflinpaedie Surgeons Drrhopaedic Knowledge Update: Sports Medicine 5
 Sectic-n 3:1Enee and Leg

Atrial view an MRI shciwing measurements at trechlear dysplasia and patellar tilt. A, The sulcus angle is farmed by
twp lines that cunnect the antericirmust paints at the medial and lateral femural cundyles tn the deepest purtiun
pf the trnchlear grnnve. An angle greater than 144“ is cnnsidered pathnlngic. B, Lateral trachlear inclinatien is
determined by the angle between twu red lines, pne parallel tn the line thruugh the pusteripr cundylar aais [blue
Iinei. and a secnnd line aleng the lateral trnchlear wall. An angle at less than 11" is indicative ef trechlear dysplasia.
C, Lateral patellar tilt is a measurement at patellar pcisitien that is determined by the angle {in red} between
the line parallel tn the pusteriur cundylar axis {blue line} and the midpatellar line. An angle greater than 20" is
cansidered abnnrmal.

parallel tn the pusteric-r candylar axis {Figure T}. CT

traditiunally is used far this measurement, but MRI alsn
has been used. Hewever, MRI may underestimate the
TTTG distance by 2.3 mm, and this pussibility shuuld be
cunsidered when determining surgical treatment}5 Vari—
ability in the TTTG distance has been identified based
cm differences in measurement techniques. An MRI study
cif patients withuut patellar instability fuund that the
T'TTG distance decreased as patients flexed the knee.it
Patients-specific facturs alsu have an influence. A currela—
tiun was repurted between TTTG distance and the age
and height pf the patient.“ TTTG distance increased as
a functiun cif height regardless [if whether the patient had
patellar instability. The TTTG distance was fuund tp
decrease with increasing age in patients with instability.
Because c-f the variability in TTTG distances, the distance
from the tibial tuberusity tn the medial border pf the
Figure 7 CT axial image shuwing measurement at the
pustericir cruciate ligament has been prnpused as an alter- tibial tuberusity and truchlear gruuve distance
DI
native measurement fur determining malalignment.“ This tin mm. dencited in red {ill between the deepest
partinn at the trnchlear grnnve {2} tn the apex
cu
._I technique uses nvu landmarks en the tibia and thereby at the tibial tu berusity (3], cm a line parallel tn
T:
I:
m
eliminates the influence {if the knee flexibn angle as well the pestericir cendylar axis {1}.
cu
III-1 as the difficulty uf measuring TTTG distance in patients
I:
a: with severe truchlear dysplasia. Further study is needed tn
validate the applicability cif the tibial tuberusity—pnsterinr these with unilateral patellar instability were fuund tn
H

cruciate liga ment distance in determining indicatinns fer
tuberusity usteutumy {TTU}.
Dynamic CT and MRI recently have been used In
allnw nbjective evaluatinn nf patellnfemnral mntinn and
tracking. Dynamic kinematic MRI was used in a study
uf patients with at withuut patellar instability, in which
have abnnrmal patellar subluicatinn and tilt in bath the
affected and the asymptumatic knee.“- Anuther study used
preeperative and pestciperative dynamic CT tn create a
camputatinnal recnnstructinn at in viva knee functinn
and applied this technique tn the assessment pf patellar ki-
nematics.“5 Surgical patellar stabilizatien with tuberusity

flrdtnpaedic Knnwledge Update: Sparta Medicine 5 El ll] 16 American AcadMy cit Cirtbnpaedie Surge-ens

medialixatinn was fnund tn decrease lateral patellar shift
and tilt, particularly at lnw knee flexinn angles.
Patellnfemnrel Pain Syndrnme
Patellnfemnral pain syndrnmc is a nnnspecific diagnnsis
traditinnally used tn describe anterinr knee pain withnut
nvert instability. Patients nften describe pain with run—
ning, jumping, climbing stairs, nr prnlnngcd sitting with
the knee in a flexed pnsitinn. Althnugh many thenries
have been prnpnsed, the cause nf patellnfemnral pain
mnst nften is multifactnrial.
An assnciatinn between jnint nverlnad and pain in the
patellnfemnral jnint has been suppnrted by finite element
analysis studies that used cnmputatinnal mndeling tn
predict stress distributinns within the jnint. One study
repnrted greater peak and average strain levels within
the jnint during squatting maneuvers in wnmcn with
patellnfemnral pain, cnmpared with cnntrnl subjects.“
Increased jnint stresses and altered cnntact fnrces within
the patellnfemnral jnint alsn may be the result nf patellar
maltracking. A kinematic study using a three-dimensinnal
nptical mntinn capture system cnmpared patellnfemnral
kinematics during squatting maneuvers in patients with
nr withnut patellnfemnral pain.“ The patients with symp-
tnms had mnre lateral rntatinn and lateral translatinn nf
the patella at 9‘3“ nf knee flexinn.
Chnndral damage in the patellnfemnral jnint has been
implicated in the develnpment nf anterinr knee pain, al—
thnugh this finding nften is nnnspecific. A cnmparisnn
nf wnmen with patellnfemnral pain and cnntrnl subjects
identified a negative relatinnship between cartilage thick
ness and cnmputatinnally determined strain magnitude
within the patcllnfemnral jnint. This relatinnship was cnn-
stant in bnth grnups. Thnse in the grnup with symptnms
had significant reductinn in patellar cartilage thickness
in cnmparisnn with thnse in the cnntrnl grnup.”
The mainstay treatment nf patellnfemnral pain is an
exercise prngram emphasising strengthening nf the quad—
riceps, cure, and hip muscles. A multicenter randnmiaed
study fnund that adding hip- and cure-strengthening ex-
ercises tn an exercise prngram fncused cm the knee led
tn an earlier resnlutinn nf pain and increased gains in
strength.31 A systematic review fnund several factnrs that
significantly predicted successful management nf patellar
pain with exercise treatment, including negative patellar
apprehensinn, lack nf patellar chnndral defects, and tibial
tubernsity deviatinn nf less than 14.6 mm; in cnmparisnn
with nther patients, these patients alsn had symptoms
less nften and nf shnrter duratinn, were ynunger, had a
faster VMD respnnse time, and had a larger quadriceps
crnss-sectinnal area nn MRI}2
Eb Ifllti American Academy nf flcthnpaedic Surgenna
Chapter 1?: Pateflnfemnral Jnint Disnrders
Patellar taping was fnund tn alter patellnfemnral hin-
mechanics, specifically by cnrrecting lateralixatinn and
increasing the pnsterndistal pnsitinn nf the patella.“I Ear-
lier and increased muscle activity in the vastus medialis
was repnrted when Mcnnell taping was used during
squatting activities.“ at nrthnses are used as an adjunct
treatment because altered mechanics in the fnnt affect
tibial rntatinn; nrthnses can be used tn cnrrect fnrefnnt
valgus, rearfnnt cversinn, and prnnatinnf'1 In a study nf
fnnt nrthnsis use in patients with patellniemnral pain,
nnly 25% repnrted a marked imprnvement in pain after
12 weeks nf use. In cnmparisnn with all patients in the
study, thnse whn had a favnrable respnnse wnre relatively
unsuppnrtive fnntwear, repnrtecl a lnw initial level nf
pain, had decreased ankle dnrsiflcxinn, and repnrted an
immediate reductinn in pain during single-leg squatting
while wearing fnnt nrthnses.”
Surgical treatment rarely is indicated fnr patellnfem-
nral pain syndrnme. nlthnugh lateral retinacular release
nr lengthening can be used tn treat isnlated lateral pa-
tcllnfcmnral cnmpressinn syndrnmc, the indicatinns are
limited, and it is critical that patellar instability be ruled
nut befnre the prncedure is cnnsidered. Lateral retinacu-
lar release shnuld nnt be used as an isnlated treatment nf
instability because it can lead tn disastrnus medial and
lateral patellar instability.
F'ntellnfemnral Instability
Mnst patients whn have had a first patellar instability
episnde can he successfully treated withnut surgery. Re-
current episndes nf instability nccur in fewer than half nf
these patients.“ Small lnnse bndies are cnmmnnly fnund
but nften are asymptnmatic.
First Dislncatinn
The initial gnals after an acute patellar dislncatinn are
tn cnntrnl pain, manage swelling, and prntect the knee
while the symptnms and functinn gradually imprnve.
Pain and swelling can he treated using a cnmbinatinn nf
cryntherapy, nver-tbe-cnunter analgesic medicatinns, and 1.4,:
cnmpressinn. Must patients benefit frnm using crutches FT.
:5
tn limit weight bearing. Thnse whnse knee is unstable nr m
m
tn
uncnmfnt‘table shnuld use a knee immnbilixer, fnllnwed 3
El.
by a functinnal hinged brace as they gradually return tn
recreatinnal and nccupatinnal activities. Knee aspiratinn :5
helps tn relieve pain in patients with a tense hema rthrnsis.
Heel slide and quadriceps activatinn exercises are initiated
within a few days nf the injury and are fnllnwed by a super-
vised rehabilitatinn prngram. Physical therapy allnws the
patient tn prngress tn light activities withm days tn weeks
and tn athletic activities within weeks tn a few mnnths.
Drrhnpaedic Knnwledge Update: Spnrts Medicine 5
 Sectinn 3:1Cnee andLeg
Radingraph5 5hnuld be nbtained tn a55e55 for the pre5-
ence nf a fracture nr large n5tenchnndral lnn5e bndie5.
MRI can be 5eIective u5ed tn a55e55 the 5tatu5 nf the
exten5nr mechani5m and rule nut cnncnmitant intra-ar—
ticuIar pathnlngy. Lnn5e bndie5 are cnmmnnly fnund
after di5lncatinn but u5ually are 5mall, a5ymptnmatic,
and net amenable tn fixatinn. The primary indicatinn5 fnr
5urgery after a fir5t—time di5lncatinn are the pm5ence nf
repairable n5tenchnndral Inn5e bndie5 nr large chnndral
lnn5e bndie5 that are nr are likely tn becnme 5ymptnm-
atic. Other indicatinn5 include a cnncnmitant injury 5uch
a5 a meni5cal tear, anterinr cruciate ligament tear, nr
per5i5tent 5ublunatinn. I'viany clinician5 cnn5ider primary
repair nf the turn MPFL after a fir5t—time di5lncatinn if
5urgery i5 nece55ary fnr annther rea5nn. In the ab5ence
nf annther indicatinn, MPFL repair ha5 nnt been 5hnwn
tn be beneficial fnr re5tnring functinn nr avniding recur—
rence. I5nlated lateral retinacular relea5e i5 nnt effective
in treating patellar in5tahility.
Recurrent Instability
The repnrted incidence nf recurrent in5tahility after a
fir5t di5lncatinn i5 15% tn 44%_35.35 Surgical 5tabiliaa-
tinn i5 indicated if the patient ha5 recurrent in5tahility
and nnn5urgical treatment ha5 nnt been 5ucce55ful. A
rehabilitatinn prngram nften can be cnn5idered 5ucce55ful
if the patient i5 willing tn mndify athletic activitie5. A
patient with 5ub5tantial malalignment i5 relatively likely
tn have nngning in5tahility epi5nde5. hnwever. I’hy5ical
examinatinn and imaging 5tudie5 are u5ed tn identify the
anatnmic and binmechanical factnr5 that created a pre-
di5pn5itinn tn in5tahility and tn develnp a patientu5pecific
5urgical treatment plan. The three main 5tabiIiaer5 cf the
patellnfemnral jnint are the muscle5 that prnvide dynamic
5tabi1ity {the V1510, hip external rntatnr5, and cure}, the
medial 5nft—ti55ue re5traint5 {MPFL and medial retinacu—
Inm} and the n5tenchnndral cnn5traint5. 1‘-}"'Il"'ealcne55 nf the
dynamic 5tabiliaer5 i5 treated thrnugh rehabilitatinn. If
medial 5nft—ti55ue in5ufficiency i5 identified, a prncedure
such 55 MPFL recnn5tructinn can 5tabiliae the patella by
BI
ree5tabli5hing the deficient medial 5nft-ti55ue checkrein.
55
._I If the primary deficiency invnlve5 the n5tenchnndral re—
T:
I:
m 5traint5, a 5nft-ti55ue prncedure alnne nften i5 in5nfficient
:5
III-1 tn cnrrect the underlying pathnanatnmy, and a TTfl may
I:
:5: be nece55ary.
H
Medial Patellnfemnral Ligament Hernn5tructinn
The MPFL prnvide5 the primary m5traint tn pathnlngic
lateral tran5latinn. Repair cf the IvIPFL i5 5 gnnd np-
tinn after an acute fir5t-time di5lncatinn if the lncatinn
nf the tear can be identified. The re5ult5 are inferinr tn
thn5e nf MPFL recnn5tructinn in a patient with rec nrrent
flrfltnpae-dic Knnwledge Update: Sparta Medicine 5
in5tahility. A ca5e 5tudy nf i5nlated MPFL repair fnr re-
current in5tability fnund that 3 nf 29 kneE5 {23%} had a
later recurrence.3H Numernu5 technique5 fnr IvIPFL recnn.-
5tructinn have been de5cribed, u5ing a variety nf different
graft 5nurce5 and fixatinn methnd5, but nn nne technique
i5 clearly 5uperinr. Althnugh the graft ti55ue i5 much 5trnn-
ger than the native ti55ue, MPFL recnn5tructinn alnne
may nnt be ennugh tn 5tabiliae the patellnfemnral inint
in a patient with 5ub5tantial malalignment. The initial
enthu5ia5m fer MPFL recnn5tructinn ha5 been mnderated
by recngnitinn nf the difficulty nf the 5urgica1 technique
and the frequency nf cnmplicatinn5???”
Studie5 nf MPFL recnn5tructinn repnrted 5ucce55 rate5
nf 313% tn 96%, with few nccurrence5 nf recurrent in-
5tabiIity.“ In general, excellent nutcnme5 were repnrt-
ed, with a high likelihcnd nf re5umptinn nf activitie5 nf
daily living. MPFL recnn5tructinn had a gnnd nutcnme
in 31 knee5 with recurrent patellar in5tahility.“ Range
nf mntinn, Kuiala Anterinr Knee Pain Scale 5cnre5, and
radingraphic indexe5 imprnved after 5urgery, and nnly
nne patient 5hnwed 5ign5 nf apprehen5inn at fnllnw-up.
Studie5 repnrting the re5ult5 nf MPFL recnn5tructinn
generally are limited by 5mall 5ample 5iae5, 5hnrt-term
fnllnw~up, and the u5e nf cnncnmitant prncedure5 55 well
55 limited infnrmatinn nn rehabilitatinn and return tn
5pnrt5. The large5t 5tudy tn date included 240 cnn5ecu-
tive MPFL recnn5tructinn5 at a 5ingle clinic. The mean
Kujala 5cnre imprnved frnm 62.5 tn 30.4 at a minimum
1-year fnllnw—up. A cnncnmitant TTO wa5 dnne in 23%
nf patient5.“I
The mn5t cnmmnn cnmplicatinn5 cf MPFL recnn-
5tructinn are recurrent in5tability, ln55 nf mntinn, pain-
ful hardware, and patellar fracture. The large5t 5tudy
tn date repnrted a 4.6% rate nf recurrent di5Incatinn.”
In additinn, 14% nf patient5 had a pn5itive apprehen-
5inn 5ign, and 12% had a Her-Linn deficit nf 1G“ nr mnre.
A meta-analy5i5 cf 25 5tndie5 repnrting cm a tntal nf
625' knee5 fnund that a cnmplicatinn nccurred in 154
knem (26.1%).“ The mn5t cnmmnn nf the5e cnmplicav
tinn5 were recurrent apprehen5inn {521’164 l-tnee5}, ln55
nf knee fleainn {22], painful hardware {19} and patellar
fracture {4] (Figure 3]. The ri5k nf patellar fracture frnm
vinlatinn nf the anterinr patellar cnrteit nr large-diameter
tran5ver5e patellar tunnel5 ha5 led tn the develnpment nf
numernu5 alternative graft fixatinn technique5. Apprn~
priate pn5itinning cf the bnny turmel5 and ten5innir1g
cf the graft are thnught tn be crucial tn the 5ucce55 nf
MPFL recnn5tructinn. Malpn5itinning nf the femnraI
tunnel and 5ecuring nf the graft with exce55ive ten5inn
are a55nciatecl with medial patellnfemnral articular nver-
lnad. iatrngenic medial 5ublurtatinn, and recurrent lateral
in5tahility.35'~‘5 Prnper pn5itinning cf the femnral tunnel
El 1016 American AcadMy nf Drthnpaedic Surge-um

CT sagittal image showing a patellar fracture
after MPFL reconstruction. Such fractures are
most common with surgical violation of the
anterior cortex or creation of large patellar
tunneh.
can be difficult, even for experienced surgeons. In a study
of MPFL reconstructions, ll] of the 29 femoral tunnels
were malpositioned.” Intraoperative fluoroscopy is useful
for achieving optimal tunnel positioning. Confirmation of
normal patellar translation and full knee range of motion
is recommended before final graft fixation to prevent
overtensioning of the graft.
Tibial Tuherosity Dsteotomy
TTD procedures correct malalignment by permanently
realigning the abnormal bony anatomy. Modification of
the position of the patellar tendon attachment on the tibia
changes the forces applied to the patellofemoral joint.
A variety of T'TIICII| procedures have been described for
use with different types of malalignment. A medialiaing
osteotomy such as the Elmslie-Trillat osteotomy is used
to correct maltracking caused by a lateraliaed tuberosity
{an increased TTTG distance]. A distaliaing osteotomy
is used to treat patella alta. An anterioriaing {Magnet}
or anteromedializing {Pulkerson} osteotomy is used to
unload specific areas of articular cartilage wear. lElomplex
distaliaing osteotomies incorporate medial or anteromedi—
al displacement of the tuberosity shingle. Medialiaing os-
teotomy is indicated if the TTTG distance is greater than
15 to 2G mm. The TTD is modified to the patient’s needs
by adjusting the amount of medialiaation, the amount of
distaliration, and the slope of the osteotomy to achieve
the desired degree of correction. Surgeons often combine
a TTD with soft-tissue release, repair, or reconstruction.
El Ifllii American Academy of Urthopaedic Surgeons
Chapter 1?: Pacellofcmoral Joint Disorders
a study of 34 athletes found that excellent overall results
were achieved by anteromedialiaation combined with
lateral retinacular release. Distalixation also was used
in the patients with patella alta.“'E There is no consensus
as to when distaliaing osteotomies should be included.
IGood to excellent outcomes were reported in 63%
to 95% of patients, with modest deterioration of results
caused by patellofemoral pain and arthritis.” The overall
rate of recurrent patellar instability after TTD ranged
from 0% to 15%. Male sex, predominant instability
symptoms, and low-grade cartilage lesions were generally
positive prognostic factors." The location of chondral
lesions was found to be correlated with clinical results
after anteromedialiaation.“ Patients with distal or lat-
eral lesions had improvement after surgery, but patients
with medial, proximal, or diffuse lesions had little to no
improvement. Postoperative decrease in lateral patellar
shift and tilt was reported in a small group of patients
who underwent successful TTU.”
The most common complications of TTiZ‘.I include
painful screws, loss of motion, proximal tibial fracture,
shingle fracture, delayed union, nonunion, neurovascu-
lar injury, thromboembolic events, and overcorrection.
In one study, 49% of patients required screw removal.“
Painful hardware after TTC} is more common with the
use of 6.5— or 4.5—mm screws than with 3.5—mm screws.
Postoperative fracture of the proximal tibia and tibial
tuberosity shingle can be prevented by optimal screw
fixation and 5 weeks of postoperative protected weight
bearing {Figure 9}. Patients with proximal patellar lesions
may be adversely affected by anterioriaation. flvermedial-
iaation of the tuberosity increases patellofemoral contact
pressures in the medial patellofemoral compartment and
may lead to patellofemoral osteoarthritis.” Anterome-
dialiaation also can cause postoperative changes in the
tibiofemoral compartment loading, with unknown long-
term consequences?
Trochleoplasty
Trochlear dyspiasia is found in 35% of patients with re-
current patellar instability.” The goal of a trochleoplasty 1.4.}
procedure is to correct the shape of the deficient distal FT.
:5
femoral articular constraint. A sulcus-deepening trochleo- m
m
tn
plasty is prefmable to elevation of the lateral condyle to 3
El.
avoid the risk of increasing the lateral patellofemoral joint
forces. Trochleoplasty is contraindicated in patients with :5
patellofemoral arthritis, open physes, or isolated anterior
knee pain without instability. The procedure generally is
performed through an arthrotomy, is technically chal-
lenging, and carries a significant risk of cartilage damage,
osteoarthritis, and arthrofibrosis. Trochleoplasty almost
always is done with a concomitant soft-tissue procedure
Eirthopaedic Knowledge Update: Sports Medicine .5
 Sectien 3: Knee and Leg
A instability. Identifying and treating the anatemic er func-
Figure El AP {A} and lateral {a} radiegraphs sh ewing a
tibial fracture that eccurred as a cemplicatien
cf tibial tu beresity esteetemy. {Re preducecl
with permissien frem Luhmarin Sl, Fuhrhep
5, D'Dennell JE, Gerden JE: Tibial fractures
after tibial tubercle esteetcimies fer patellar
instability: A cum parisen at three esteeten'iy
ce nfiguratiens. J Child Ctrthep 2011;5[1]:19-25.]
{especially lateral release and MPFL recenstructien] and
eften with TTD with anteremedialiaatien er distaliea-
tien. As a result, it is difficult te determine the efficacy ef
trechleeplasty as an iselated precedure. Recemmenda—
tiens fer eptimal surgical treatment are elusive because ef
the variable pathelegy as well as the variety ef precedures
described in the literature. Trechleeplasty usually is net
necessary te achieve patellar stability, even in the presence
ef a dysplastic trechlea.’i1 Because ef the relatively rare
indicatiens and the technical difficulty ef trechleeplasty,
it sheuld be reucineiy perfermed enly by surgeens with
extensive experience in the precedure.
Studies ef trechleeplasty cemhined with MPFL recen—
atrnctien feund excellent results at a minimum 1-year
DI
fellew-up.fl+” The incidence ef pesteperative pain and
cu
._I radiegraphic arthresis was lew, especially in these with
T:
I:
in
minimal degenerative changes at the time ef the index
cu surgery. Patients with substantial preeperative pain,
Ill-1
i:
s: unsuccessful earlier patellar stabilizatien, and chendral
degenerative changes had the peerest results. Very geed
H
results can be ebtained even in patients whe had under-
gene unsuccessful patellar stabilisatien surgeryflM
A systematic review ef studies ef patients with severe
trechlear dysplasia found a cemplicatieu rate ef 13.4% in
these whe underwent trechleeplasty cempared with 19.1%
ef these whe underwent a nentrecheeplasty precedure.”
flrfltepaedic Knewiedge Update: Sparta Medicine 5
Nene ef the analyzed studies directly cempared the twe
precedures, and there was ne streng evidence ef superier
clinical eutcemes after a trechleeplasty precedure. The
patients treated with trechleeplasty had a lewer redisle-
catien rate {0.9% vs 16.2%} but a higher rate ef deficits
in range ef metien than these treated with a nentrech-
leeplasty precedure. The meat cemmen cemplicatiens ef
trechleeplasty were arthrefibresis, persistent pain, and
esteearthritis. Pesteperative centinueus passive metien
eften is recemmended te reduce the risk ef stiffness.
Summary
lvlultiple facters centribute te the stability ef the pa—
tellefemeral jeint, including static restraints, dynamic
restraints, esteechendral censtraints, and lewer extremity
alignment. Patellefemeral diserders appear as pain er
tinnal deficits specific te the individual patient are crucial
fer directing nensu rgical and surgical treatments. Surgery
may be indicated in patients with recurrent instability
after unsuccessful nensurgical treatment. The surgical
precedure sheuld be tailered te the specific dynamic and
anatemic variatiens centributing re the patient’s instabil—
ity. Future directiens in patellefemeral research include
quantificatien and standardizatien ef the measurements
ef centributing facters te determine the apprepriate in~
dicatiens fer surgical cerrectien.
Hey Study Peints
1* The clinician sheuld differentiate between patelle-
femeral pain and instability based en the patient’s
histery and physical examinatien.
i The etielegy ef patellar instability is multifacterial,
and successful surgical management requires iden-
tifying and censidering the centributing facters.
' The cemplicatiens ef patellefemeral instability
surgery eften can be aveided by using apprepriate
surgical techniques.
Annotated References
1. Placella G, Tei MM, Sebastiani E, et a1: Shape and size
ef the medial patellefemeral ligament fer the best surgi-
cal recenstructien: A. human cadaveric study. Knee Sur'g
Sperts Traumatef Arthresc 2fl14;21l10}:231?-2333.
Medline [101
Analysis ef ll} cadaver knees revealed that the MPFL at—
taches en the preximal third ef the patella. (in the femur,
El 1016 American AcadMy ef Drthnpaedic Surge-ens

the attachment was on average 9.5 mm distal and anterior
to the adductor tubercle.
. Schiittle PB, Sch meling A, Rosenstiel H, 1lili'eiler A: Radio-
graphic landmarks for femoral tunnel placement in medial
patellofemoral ligament reconstruction. Arn ] Sports Med
2flfl?;35{5}:301-3fl4. Medline DUI
. Mochiauki T, Nimura A, Tateishi T, Yamaguchi K, Mu-
neta T, Akita K: Anatomic study of the attachment of
the medial patellofemoral ligament and its characteristic
relationships to the vastus intermedius. Knee Snrrg Sports
Trnnrnnioi Arthrosc 2013;21i2}:3l]5-31l]. Medline DUI
Analysis of 16 cadaver knees revealed that the proximal
fibers of the MPPL are attached to the vastus intermedius
tendon and that the distal fibers are interdigitated with
the medial retinaculum attached to the medial margin of
the patellar tendon.
. Smirk C, Morris H: The anatomy and reconstruction of
the medial patellofemoral ligament. Knee 2003;1lli3}:22l-
22?. Medline DDI
. Hasler RM, Gal I, Eiedert RM: Land marks of the normal
adult human trochlea based on axial MRI measurements:
A cross-sectional study. Knee Snrg Sports Tronrnntof Ar-
throse 2614;22i1fl}:23?2-23?6. Medline DUI
In an MRI study of 53 patients without trochlear dys-
plasia, the mean trochlear depth was 4.6 mm {3.4 mm
in women, 4.2 mm in men}. The lateml facet contributed
62.6% of the width of the cartilage, and the medial facet
contributed 32.4%. Level of evidence: II.
. Latt LD, Christopher M, Nicolini A, et al: A validat-
ed cadaveric model of trochlear dysplasia. Knee Snrg
Sports Trnnrnatol Arthrosc 2DI4:22{16}:235?—2363.
Medline DO]
A model of trochlear dysplasia was created in a cadaver
Study by elevating the floor of the trochlear groove and
comparing radiographic markers of dysplasia before and
after modification. Decreased trochlear depth, increased
sulcus angle, and positive cmssing signs were noted.
. Biyani R, Elias J]. Saranathan A, et al: Anatomical fac-
tors influencing patellar tracking in the unstable patel-
lofemoral ioint. Knee Snrg Sports Trnnntntoi Ambrose
2fl14522flflltl334-234I.Medline DUI
Computational models were created using MRI to repre—
sent knees with patellar instability when flexed and loaded
to multiple flexion angles. The patellar bisect offset index
and lateral tilt were significantly correlated with the lateral
trochlear inclination and the distance between the tibial
tuberosity and trochlear groove. Level of evidence: II.
. Teng HL, |Chen ‘1’], Powers CM: Predictors of patellar
alignment during weight bearing: An examination of pa-
tellar height and trochlear geometry. Knee 2fl14;21{1}:142-
146. Medline DUI
MRI of the patellofemoral joint at multiple flexion angles
in 36 participants indicated that lateral trochlear inclina-
tion was the best predictor of lateral patellar displacement
4D 2616 American Academy of Drthopaedic Surgeons
Chapter 1?: Paoellofemoral Joint Disorders
and that patellar height was the best predictor of patellar
tilt at El". Level of evidence: III.
Elias J]. Kilambi S, Goerke DR, Cosgarea A]: Improv-
ing vastus medialis obliquus function reduces pressure
applied to lateral patellofemoral cartilage. I Cirthop Res
2UUS:2?{S]:5?S-533.Medline nor
A blomechanical study assessed changes in patellofemoral
cartilage pressures with VMD loading. Increasing the
VMD force significantly decreased the maximum lateral
pressure and increased the maximum medial pressure at
different knee flexion angles.
ll]. Shaihoub S, Maletsky LP: Variation in patellofemoral
kinematics due to changes in quadriceps loading config-
uration during in vitro testing. ] Biomeeh 2014:4?{1}:13fl-
136. Mediine DUI
In vitro kinematic simulation of 14 knees indicated that
a weak vastus medialis increased patellar lateral shift
and abduction rotation and that a weak vastus lateralis
increased patellar medial shift and adduction rotation.
11. Sheehan FT, Borotikar BS, Eehnam A], Alter KE: Alter-
ations in in vivo knee joint kinematics following a femoral
nerve branch block of the vastus medialis: Implications
for patellofemoral pain syndrome. Elie Biomecb (Bristol,
Avon} 2D12;2?[6}:525-531. Medline DD]
In kinematic analysis of asymptomatic knees of women
using dynamic cine phase-contrast MRI, administering a
motor branch block to the HMO increased patellar lateral
shift, tibiofemoral lateral shift, and tibiofemoral external
rotation.
12. Jan MH, Lin DH, Lin J], Lin CH, Cheng CK, Lin ‘i'F:
Differences in sonographic characteristics of the vastus
medialis obliquus between patients with patellofemoral
pain syndrome and healthy adults. An: 1 Sports Med
2Dfl9;3?l9}:1?43-1T49.Medline DUI
Sonographic analysis of the VMD in 54 patients revealed
that insertion level, fiber angle, and muscle volume were
significantly smaller in those with patellofemoral pain than
in control subiects. Level of evidence: III.
13. Van Tiggelen D, Cowan S, lfloorevits P, Duvigneaud N,
Witvrouw E: Delayed vastus medialis obliquus to vastus
lateralis onsfl timing contributes to the development of
patellofemoral pain in previously healthy men: A pro-
spective study. Am } Sports Med 2609;32i6}:1099-11l}5.
pg
Medline DD]
FT.
Surface electromyographic analysis of the VMD and vas-
:5
to
n:
tus lateralis in '29 healthy men before 6 weeks of military to
basic training found a significant delay in VMD activi-
3
El.
ry in those who later had patellofemoral pain. Level of
evidence: II. 2
14. Pal S, Draper CE, Fredericson M, et al: Patellar mal-
tracking correlates with vastus medialis activation de-
lay in patellofemoral pain patients. An: ] Sports l’vllenlI
1fl11;39{3]:59fl-593.Medline DUI
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectien 3:1I'inee audLeg
Based an weight-bearing MRI, patellar lateral tilt was
cerrelated with an increase in the ratia ef vastus lateralis
ta vastus medialia activatien. Lateral translatian and tilt
were carrelated with vastus medialis delay in patients
with pain arising frem maltrackiug. Level ef evidence: III.
1.5. Diederichs U, Kahlita T, Karnarepaulas E, Heller MU,
1infallnberg E, Scheffler 5: Magnetic reaeuance imaging
analysis af ratatianal alignment in patients with patel-
lar dislecatiens. elm ] Sparta Med 2013:41i1}:51-5?.
Medline DUI
MRI ef 30 patients with patellar instability and 3!] central
subjects revealed that symptamatic knees had apprexi-
mately 1.6 times mere femeral antetarsian and knee reta-
tian than knees af central subjects and almast three times
mare mechanical axis deviatian. Level af evidence: III.
16. Elias J], Carrina JA, Saranathan A, Uuseila LM, Tanaka
M], Cesgarea A]: Variatians in kinematics and functieu
fellawing patellar stabilizatien including tibial tuheras-
ity realignment. Knee Sarg Sparta Traamutai Artbraac
2fl14tllj1lljtl35fl-235fi.Medline DUI
|I'Semputatianal medels af six knees based en dynamic CT
were used ta quantify lateral shift and tilt ef the patella
at varying flexian angles. Cemparisan af CT befere and
after atabilisatian surgery shawed decreased shift and tilt
at law flexien angles. Lavel af evidence: II.
1?. Charles MD, Halaman S, Chen L, Ward 5R, Fithian D,
Afra E: Magnetic resana nce imaging-based tepegraphical
differences between central and recurrent patellafemeral
instability patients. Am J' Sparta Med 2013;41{2}:3?4—3 34.
Medline DUI
A retraspective review af MRI ef 40 patients with recu r-
rent patellar instability and 31 central subjects shawed
that the symptematic knees had mare patellar tilt, patellar
height, and trachlear dysplasia. Level af evidence: III.
13. Ward SR, Terk MR, Pewera CM: Patella alta: Assecia-
tien with patellafen'iaral alignment and changes in can-
tact area during weight-hearing. 1 Hana JItznt'act Sarg Arr:
2Dfl?;39[3]:1?49-1?55.Medline DUI
19. Arubjernasen A, Egund H, Rydling Ct, Stackerup R,
Ryd L: The natural histary ef recurrent dislecatian af
the patella. Lang-term results af canaervative and apera—
tive treatment. I Barre jairit Sarg Br 1992;?4{1}:14D-I42.
Medline
U'I
tu
._I
T: 20. Herringtan L: Knee valgus angle during single leg squat
I:
n: and landing in patellefemaral pain patients and cantrels.
a:
III-1 Knee 2014;EI{2}:514—511 Medline DUI
I:
a:
H Twelve wemen with unilateral patellafemaral pain and 3D
asymptamatic central subjects were assessed far frantal
plane prejectian angle during single-leg squatting and
single-leg happing. Patients in the symptematic graup
had significantly greater frantal plane angles in bath tests.
21. Hakagawa TH, Mariya ET, Maciel CD, Serrae FV: Trunk,
pelvis, hip, and knee kinematics, hip strength, and glu-
teal muscle activatian during a single-leg squat in males
UrrItapae-die Knawledge Update: Sparta Medicine 5
and females with and withaut patellefemaral pain syn-
drame. I Urtbap Sparta Phys Tiber 2012:41j6}:491-501.
Medline DUI
a study ef Si} patients faund that patients with patellar
pain had greater trunk lean and centralateral pelvic drep
and knee ahductian as well as 1'?% less hip adductian and
1?% less hip external retatien strength an single—leg squat
testing than these withaut pain.
21. Regalada G, Lintula H, Eskelinen M, et al: Dynamic
HIRE—MRI in patellafemaral instability in adalescents.
Krtee Strrg Sparta Truflmutaf Artbraac 2914;22i11}:2?95 -
23112. Medliue DUI
Kinematic MRI was used te campare patients with patellar
instability and centre] subjects. A significant difference
was nated in bisect affset, lateral patellar displacement and
patellar tilt angles between the affected knees, unaffected
knees in patients, and healthy knees in central subjects.
Level af evidence: II.
23. Felus ], Kewalcsyk E: Age—related differences in medial
patellafemaral ligament injury patterns in traumatic patel-
lar dislecatian: Case series af 5U surgically treated children
and adaleacenta. Arr: I Sparta Med 2012;4fli10}:235?—
2364. Medline DUI
The lecatiens af MPFL injuries in first-time traumatic
patellar dislecatiens were campared using sanagraphy.
Ferry-six percent ef patients had injury in mere than
ane lacatian. Skeletally immature patients had a greater
incidence af patellar—aide injury than akeletally mature
patients {Wiri- versus 54%}. Level af evidence: IV.
24. Petri M, van Falck C, Eraese M, et al: Influence af rupture
patterns ef the medial patellefemaral ligament [MPFL]
an the autceme after aperative treatment ef traumatic
patellar dialecatian. Knee Surg Sparta Trunruutai Artbraar:
2fl13;11{3]:633-639.Medline DUI
.6. retraspective study af 4!] patients wha underwent MRI
after first-time traumatic patellar dislecatien faund that
patients with patellar-based MPFL rupture were campara-
tively yaung {mean age, 19.5 years} and that elder patients
were mere likely ta sustain femaral-side ruptures {mean
age, 25.4 years}. Lavel af evidence: IV.
2.5. Camp UL, Stuart M], Krych A], et al: UT and MRI mea-
surements ef tibial tubercle-trachlear graeve distances
are net equivalent in patients with patellar instability. Ana
1 Sparta Med 1013:41t3}:1335—1340. Medline ear
a randamised, blinded study used CT and MRI af patients
with patellar instability ta determine TTTU dista nces. The
mean TTTG distance was 15.9 mm an CT and 14.? m an
l'lI. Interrater reliability was excellent far each madality
but anly fair when the eve madalities were campa red.
Level ef evidence: II.
2.6. Dietrich T], Bets M, Pfirrmann CW, Kach PP, Fucentese
5F: End-stage extensien af the knee and its influence en
tibial tuheresity-trachlear graeve distance {TTTG} in
asymptamatic valunteers. Knee Sarg Sparta Traametal'
Arthraac 2fl14;22{1}:214—213. Medline DUI
U ll] 16 American AeadMy af Urrhapaedic Surge-ans

Thirty asymptematic individuals underwent MRI at
‘3'", 15", and 3D“ ef knee flexinn. Mean TTTG distances
were feund te significantly decrease with increasing knee
flexien.
1?. Penneck AT, Alam M, Bastrenl T: Variatien in tibial
tubercle—trechlear greeve measurement as a functien ef
age, sex, size, and patellar instability. Am I Sperts Med
ED14;42{1]:339-393.Medline DUI
'TTTG distance was measured cm MRI, and nermal val-
ues were reperted. TTTG distance increased with everall
height in patients with patellar instability and centre]
subjects, and it decreased with age in these with instability.
Level nf evidence: III.
23. Seitlinger G, Scheurecker G, Hegler E, Labw L, Innecenti
E, amann 5: Tibial tubercle-pesterier cruciate ligament
distance: A new measurement te define the pesitien ef the
tibial tubercle in patients with patellar dislecatien. Am
I Sperts Med 2fl12;4-fl{5}:1119-1125. Medline DUI
A new tibial tubercle-pnsterier cruciate ligament distance
measurement was described as an alternative tn TTTG
distance. Mean values were 13.4 mm in centrel subjects
and 21.9 mm in patients with patellar dislecatien. A value
greater than 24 mm was censidered abnermal. Level ef
evidence: II.
29. He KY, Keyak JH, Pewers CM: Cnmparisen nf patella
bnne strain between females with and with-nut patelle-
femeral pain: A finite element analysis study. J Biemecb
2014:4Ti1jildfl-336.Medline DUI
Finite element analysis ef 1!] patients with symptems and
1f] centre] subjects shnwed that the patients had greater
peak and average principal strain in the patella. Patellar
cartilage thickness was negatively asseciated with peak
minimum and maximum principal patellar strain.
3D. Wilsen NA, Press JM, Keh JL, Hendrix KW, Zhang LQ:
In vive neninvasive evaluatien nf abnnrmal patellar track-
ing during squatting in patients with patellefemeral pain.
j’ Beeejeiet eg Aer 2009:91j3}:553-566. Medline DUI
An epteelectrenic metien capture system was used te
recerd three-dimensienal patellar kinematics in 9 patients
with patellefemeral pain syndreme and ill] centre] sub-
jects. At 91'1“ nf knee flexien, the patients had increased
lateral spin and lateral translatien.
31. Ferher R, Belgla L, Earl-Eeehm JE, Emery I3, Hams-
trar‘iliiright K: Strengthening ef the hip and cere versus
knee muscles fer the treatment ef patellefemeral pain:
A multicenter, randemiaed cnntrnlled trial. I AIM Train
[Published enline ahead ef print bievember 3, 1014].
Medliue Ell-DI
Patients with patellefemeral pain were assigned te a
6-week knee- er hip-exercise pretecnl. 1Visual analeg scale
scnres imprnved in patients in hnth grnups but irnpreved
1 week earlier in these in the hip pretecel, whe else had
greater everall gains in strength.
32. Lack 5, Batten E, Vicenzine B, Merrissey D: But-
ceme predicters fer censervative patellefemeral pain
Eb Ifllfi American Academy ef Urthepaedjc Surgeens
Chapter 1?: Peuellefemeral Jeint Diserders
management: A systematic review and meta—analysis.
Sperts Med 2014;44i12}:1?fl3-1?16. Medliue [II-DI
A systematic review ef eutcnme predicters in nensurgical
management nf patellefemeral pain fennd that several fac-
ters were asseciated with successful exercise interventien:
absence ef chendremalacia patella and TTTG distance ef
less than 14.6 mm, as well as a relatively shnrt symptnm
duratinn, lnw frequency nf pain, ynung age, fast VMG
reflex respense time, and large cress-sectienal area ef the
quadriceps en MRI.
33. Snug CY, Huang HY, Chen 5C, Lin JJ, Chang AH: Effects
ef femeral retatienal taping en pain, lewer extremity
kinematics, and muscle activatien in female patients with
patellefemeral pain. } Sci Med Spent ll] 14. Medline DUI
Electremyelegraphy was perfermed in 16 patients with pa—
tellefemeral pain and S centre] subjects during single—leg
squatting after tandem assignment tn kinesietaping, sham
taping, er ne taping. In the patients with symptems, ki-
nesietaping shifted the patella pesterierly and distally.
34. Lee SE, Che SH: The effect ef Mcnnell taping en vastus
medialis and lateralis activity during squatting in adults
with patellefemeral pain syndreme. j Exerc Hebe-fad
1fl13;9{1}:325-330. Mcdline DUI
Sixteen patients with patellefemeral pain received an tap-
ing, placehn taping, er McCennell taping. Vastus medialis
activity and its ratie te vastus lateralis activity were greater
after McCennell taping than ne taping.
35. Barten I3], Men: HE, IL'Iresslcy KM: Clinical predicters ef
feet ertheses efficacy in individuals with patellefemeral
pain. Med Sci Sperts Exerc 1011:43{9j:1603-151fi.
Medline DC}!
Twenty—five percent ef patients reperted imprevement
in patellefemeral pain after 12 weeks ef wearing feet
nrthnses. The percentage increased te Tfl‘ib if three nf
these criteria were met: use ef relatively unsuppertive
feetwear, visual analeg pain scale scere lewer than 21,
weight-bearing ankle dersiflexien ef less than 41", and
reduced pain during single-leg squatting while wearing
the ertheses.
36. Cefield EH, Bryan RS: Acute dislecatien ef the patella: Re-
sults ef censervative treatment. I Trauma 19T?;1?{?}:525-
.531. Medlinc DUI
3?. Pithian DC, Paxten EW, Stene ML, et a]: Epidemielegy
1.4,:
and natural histery ef acute patellar dislecatien. Am
FT.
I Seer-rs Med 2004:31i511:1 114-1121. Medline DGI :5
re
re
e:
33. lCamp CL, Krych AJ, Da hm DL, Levy BA, Stuart M]: Me- 3
dial patellefemeral ligament repair fer recurrent patellar
1:1.
dislecatien. Am I Sparta Med lfllflflflj‘lljfll-‘I-fl-llfid. E
Medline DUI
Retrespective review a minimum ef 2 years after 2? pa-
tients [29 knees] underwent MPFL repair fer recurrent
dislecatien fnund that 23% nf patients had a recurrent
dislecatien. The nnly significant risk factnr was nnnana-
temic MPFL repair at the medial femeral cendyle. Level
ef evidence: IV.
Drthepaedic Knewledge Update: Sperts Medicine 5
 Sectinn 3:1Inee andLeg
39. Ballier M, Fulkersnn J, Cnsgarea A, Tanaka M: Technical
failure nf medial patellnfemnral ligament recnnstructinn.
Artiste-seep}! 101 1,2?{31fl 153-1 159. Medline DUI
Five patients with malpnsitiuned femural tunnels and
disabling symptnms required revisinn MPFL reconstruc-
tinn. The effects nf a malpnsitinne-d femnral graft were
described, with strategies to identify the femnral insertinn
during surgery. Level at evidence: IV.
40. Servien E, Fritsch B, Lustig S, et al: In vivu pusitinning
analysis at medial patellnfemnral ligament recnnstructinn.
Am J Spares Med 2011:39i1}:134-139. Medline DD]
A prnspective study bf 29 patients undergc-ing MPFL
recnnstructinn faund that that 19 femnral tunnels were
in the pruper lncatinn and 10 were in an anteriur and!
er high pnsitic-n. This study highlighted the difficulty nf
reptnducible anatnmic femnral tunnel p-nsitinning. Level
nf evidence: IV.
41. Buckens CF, Saris DE: Recnnstructinn cf the medial
patellnfemnral ligament fur treattnent cif patellufemnral
instability: A systematic review. Am _I Sports Med
2U]fl:33{1]t131-133. Medline DUI
A systematic review {if 14 studies fnund generally excellent
functinnal nutcnmes after MPFL recnnstrnctinn. Mast
studies were small, had limited fellnw-up, and encum—
passed additinnal prucedu res. As a result, it was difficult
tn distinguish the determining factnrs in the nutcnmes.
Level c-f evidence: IV.
42. Deie M, Uchi M, Adachi N, Shibuya H, Nakamae A:
Medial patellnfemnral ligament recnnstructinn fixed with
a cylindrical bane plug and a grafted semitendiuusus
tendnn at the nriginal femnral site fur recurrent patel-
lar dislncatinn. Am I Sparta Med 2911;39illtl4fi-145.
Medline DUI
Thirty—cine knees in 19 patients with recurrent patellar
dislncatie-n were treated with MPFL recnnstructinn. At
a minimum 2-year fnllnw-up, the mean Kujala Anterinr
Knee Pain Scale scare had imprnved frnm 64 tn 94.5
paints. Une patient had residual apprehensinn, but there
were an redislncatinns. Level nf evidence: IV.
43. Enderlein D, Nielsen T, Christiansen SE, Fauna P, Lind
M: Clinical nutcnme after recnnstructinn at the medial
patellnfemural ligament in patients with recurrent pa-
tella instability. Knee Stetg Spain‘s Treamntal' Artistes-s
2fl14;22{1{l}:2453-2464.Medline DUI
DI
tu
._I
T:
A prospective study ed 114 patients undergning MPFL
I:
as recnnstructinn with a gracilis tende-n autngraft faund
ea
4-1
imprnvement in mean Kujala scare frum 51.5 tn 30.4
I:
as
at 1-year fnllnw—up. The revisinn rate was 2.3%. MPFL
H
tecnnstructinn cnnsistcntly nnrmalixed patella stability
and imprnved knee functinn. Age greater than 30 years,
nbesity, cartilage injury, and female sex were predictnrs nf
a peer subjective nutcnme. Level nf evidence: IV.
44. Shah JN, Hnward JS, Flanigan DC, Brnphy RH, Carey JL,
Lattermann C: A sysmmatic review at cumplicatinns and
failures assnciated with medial patellnfemnral ligament
Urdtnpaedic Knnwledge Update: Spares Medicine 5
recc-nstructinn far recurrent patellar dislncatic-n. Am
] Spar-rs Med 1fl12;4fl{3]:1916-1923. Medline DUI
A systematic review {if 15 articles an MPFL recnnstructinn
fnund a tntal at 164 cnmplicatiuns in 629 knees {26.1%}.
The rate at recurrent subluxatinn was 4.3%, and 13’96 {if
patients had cantinued apprehensinn withnut subluxatinn.
45. Elias J], Cusgarea A]: Technical errnrs during medial
patellnfemnral ligament recnnstructinn ccrnld nverlnad
medial patellufemural cartilage: A cumputatinnal analysis.
rim I Sparse Med 2U flfi;34{9}:14?S—I4SS. Medline DUI
46. Tjuumakaris FP, Fnrsythe B, Bradley JP: Patellnfemu-
ral instability in athletes: Treatment via mndified Fulk-
ersnn nstentnmy and lateral release. Am I Sparts Med
2010;33t5}:992-999.Medline nnI
Fatty—cine knees in 34 athletes underwent Fulkersnn aste-
utnmy and lateral retinacular release fur patellnfemnral
instability. Une patient had recurrent instability at a
minimum 22-mnnth fallnw-up. Seventeen patients had
symptnmatic hardware remnved. Level {if evidence: IV.
4?. Naveed MA, Ackrnyd CE, Partenus A]: Lang-term {ten- tn
15—year} nutcnme nf arthrnscnpically assisted Elmslie-Tril-
lat tibial tubercle usteute-my. Bane fairer I 2013:95-
Bl4]:4TS-435.Medline DUI
In a study nf patients whn underwent an Elmslie-Trillat
TTU, 19 knees {?9.1%} had a guard err excellent nutcnme
at 4-year fullnw-up, and 15 knees (62.5%] had a gund
nr excellent uutcnme at a minimum III-year fulluw-up.
Intranperative chandral damage created a predispnsitinn
tn the develnpment nf patellnfemnral nstenardtritis. Level
of evidence: IV.
4B. Pidnriann A], 1|ill-"Einstein RN, Euuck DA, Fulkersc-n JP:
Currelatinn at patellar articular lesinns with results frnm
anternmedial tibial tubercle transfer. Ans I Spur-ts Med
199T:25{4}:533-53?.Medline LII-DI
49. Eurnda R, Kambic H, Valdevit A, Andrish jT: Articular
cartilage cantact pressure after tibial tubernsity transfer:
A cadaveric study. An: I Spurts Med1001;19(4}:4fl3-4fl9.
Medline
50. Deiuur H, 1|IIIir'alnth G, Heve-Jusserand L, Guier C: Factnrs
at patellar instability: An anatnmic radingraphic study.
Knee Satrg Sparts Traumntnl Artbrnse 1994;2{1}:19-26.
Medline DUI
51. Thaunat M, Bessiere C, Pujnl N, Enisrennult P, Eeaufils P:
Recessinn wedge trnchlenplasty as an additinnal pracedure
in the surgical treatment at patellar instability with majnr
truchlear dysplasia: Early results. Urtbnp Treamatnl Sarg
Res 2011:9?{Sl:333-345. Medline DUI
Seventeen patients {19 knees) with severe truchlear dys-
plasia and patellnfemnral instability underwent recessinn
wedge trnchlenplasty. At a minimum 1—year fullnw—up,
the trnchlear prnminence was reduced frnm a mean 4.8
mm tn 41.3 mm. Twn patients had instability, and three
required further surgery. Level nf evidence: IV.
El 1016 American AcadMy nf Urrhnpaedic Surge-ans

52. Nelitr M. Dreyhaupt J. Lippacher 5: Eumbined truchleu-
plasty and medial patellufemnral ligament recnnstructinn
fur recurrent patellar dislncatinns in severe trnchlear dys-
plasia: A minimum 2-year fulluw-up study. Am } Spurts
Med 2013;4“5 }:lflflfi-IDIE. Medliue DUI
Twenty-three cunsecutive patients (26 knees} with patella-
femnral instability and severe trnchlear dysplasia under-
went cnmhined trnchlenplasty and MPFL recnnstructinn.
At a minimum 2-year fulluw—up. there was significant
impruvement in Kujala. Internatiunal Knee Ducumenta-
tic-n Cnmmittee Subjective Knee Evaluatinn Farm, and
visual analng scale scnres. Nu dislncatinns nccurred, and
22 patients (95.??9] were satisfied ur very satisfied. Level
cf evidence: III.
.53. Ntagiupuulus PG. Byu P. Dejuur D: Midterm results
uf cumprehensive surgical recunstructiun including
sulcus- deepening trnchleuplasty in recurrent patellar dis-
lucatiuus with high-grade truchlear dysplasia. Am I Sperts
Med 2013:41i5}:993-10fl4. Medline DUI
Twenty-seven patients {31 knees] with recurrent patellar
dislncatiun and high-grade truchlear dysplasia withnut
previnus surgery underwent sulcus-deepening trnchlenu
plasty cnmhined with additiunal hnne ur suft-tissue
surgery. There were nu pnstuperative dislncatinns er
radingraphic evidence of patellnfemnral nstenarthritis
Eb Ifllfi American Academy cf flrfltnpaedic fiurgenus
Chapter 1?: Panellufemural Juint Disurders
at a minimum 2-year fulluw-up. The mean Kujala scure
imprnved item .59 tn 3'3". The apprehensinn sign remained
pnsitive in 19.3% cf patients. Level nf evidence: IV.
54. Dejnur D, Eyn P, Ntaginpnulns PG: The Lynn's sul-
cus-deepening truchlenplasty in previnus unsuccessful
patellefemural surgery. int Ortbup 2D13:3?{3]I:433-439.
Medliue [II-DI
Twenty-twp patients {24 knees} whc- had undergnne
unsuccessful patelln-femn-ral surgery underwent sulcus-
deepening trnchlenplasty cnmbined with additinna]
suit—tissue and huuy surgery. At a minimum 2-year ful-
luw-up. Kujala scures had imprmared.r and nu patient had
p-nstnperative instability nr patellnfemnral arthritis. Level
c-f evidence: IV.
.55. Sung GT, Hung L, Zhang H, et a]: Trnchlenplasty versus
neutruchleuplasty precedures in treating patellar insta-
bility caused by severe truchlear dysplasia. Artbruscupy
2fl14;3i}{4}:523-532.Medline DUI
A systematic review {if 1? studies {if patients with pa-
tellar instability and severe trnchlear dysplasia treated
with trnchlenplasty {329 patients} ur a nuntruchleuplasty
prucedure {130 patients] fuund luwer redislucatiuu and
nstenarthritis rates but pnnrer range nf mntinn after
trnchlenplasty. Level nf evidence: IV.
1.4.}
F.
:F
m
n:
e:
3
El.
Drrhupaedic Knewledge Update: fipurrs Medicine 5
Chapter 13
Articular Cartilage of the Knee
Andreas H. IL’Iiomoll. MD Brian I. Chilelli, MD
Abstract
Injuries to articular cartilage of the knee are increas-
ingly common. Chondral lesions may involve only the
superficial layer of articular cartilage or may extend
more deeply to affect the underlying subchondral bone,
leading to an injury to the entire osteochond ral unit.
Symptomatic defects are often associated with injury to
ether structures of the knee and can lead to significant
pain and dysfunction. Management of these conditions
continues to be challenging despite recent advances in
surgical technique and cartilage repair technology. It is
crucial for the surgeon to evaluate the articular cartilage
and subchoudral bone as an intimately related unit. Sev-
eral procedures are available to treat both the chondral
and suhchondral components of the osteochondral unit.
Keywords: articular cartilage: cartilage
repair: cartilage restoration; chondral defect:
osteochondral defect
Introduction
Articular cartilage injuries are common and may be
idiopathic, associated with repetitive microtrauma, or
traumatic in etiology. Defects that extend beyond the
superficial chondral surface have the potential to affect
the underlying subchondral bone. Careful attention to ar—
tic ular cartilage and subchondral bone pathology should
Dr. Gomoll or an immediate family member serves as a
paid consultant to Aesculapifl. E‘raun, CartiheaL Geistlich,
Genzyme, Novartis. and Science for Eioivla teriais and serves
as a hoard memhec owner; offices or committee member
of the American Orthopaedic Society for Sports Medicine
and the international Cartilage Repair Society: Neither Dr.
Chilelli nor any immediate family member has received
anything of value from or has stock or stock options held
in a commercial company or institution related directly or
indirectly to the subject of this chapter.
@ lflld American Academy of Drthopaedic Surgeons
be given and articular cartilage and suhchonclral hone
should be viewed as a closely related osteochondral unit.
Any disturbance of this osteochondral unit can lead to
altered biomechanics and abnormal joint contact pres-
sures, leading to an inflammatory response. This response
may result in pain and dysfunction with the theoretical
risk of widespread joint degeneration. An initial trial
of nonsurgical management is usually warranted in the
form of rest, activity modification, anti-inflammmatory
medications, physical therapy, bracing, or injections. Pa-
tients who do not respond to conservative measures may
benefit from surgical intervention. Surgical management
should focus on removing inflammatory mediators and
restoring the osteochondral unit. Surgical options include
arthroscopic de'bridement, bone marrow stimulation, os-
teochondral autograft transfer, osteochondral allograft
transplantation, autologous choudrocyte implantation, as
well as various newer, emerging techniques. This chapter
will concentrate on the evaluation, diagnosis, and man-
agement of injuries to the interrelated osteochondral unit
of articular cartilage and subchoudral bone in the knee.
Basic Science
Articular cartilage is a complex and highly organized
structure. The primary component of articula r cartilage
is type II hyaline cartilage, which decreases force through
the joint by dissipating stress to the suhchondral hone
and facilitating low-friction motion. Articular cartilage
is aneural, alymphatic, and lacks a blood supply. These
characteristics contribute to the poor healing potential
of articular cartilage and its inability to restore its struc- 1.4.}
ture after injury. Chondral defects have little potential FT.
:5
for self-repair or spontaneous healing.” A full-thickness re
re
defect that penetrates the subchondral bone may release cu
3
bone marrow content, mesenchymal cells, and growth
El.
factors. An intralesional clot may then form, followed :5
by a fibrocartilaginous scar primarily composed of type
I collagen.”I The biomechanical properties and wear char-
acteristics of this fibrocartilage were found to be inferior
to those of hyaline cartilage, which is primarily composed
of type II collagen.5=lj
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 3: Knee and Leg
Epidemiology and Natural Historyr
Chondrai or osteochond ral lesions were found in 61% to
66% of patients undergoing knee arth roscopyf'i’ A recent
systematic review estimated a 36% prevalence of focal
chondral defects of the knee in athletesd" The true inci-
deuce and prevalence are difficult to determine because
many defects are asymptomatic. A cartilage defect can be
idiopathic, traumatic, andfor associated with repetitive
microtrauma. Cartilage damage is often associated with
injury to another anatomic structure of the knee and
sometimes occurs in conjunction with malalignment.
Acute anterior cruciate ligament tears and meniscal de-
rangement are highly correlated with chondral defects.“+12
A chondral or osteochondral lesion was found in more
than 9fl‘ib of patients with a patellar dislocation.” The
natural history of articular cartilage defects is not com—
pletely understand, but any disruption of the osteochon-
dral unit can alter its biomechanics and increase the joint
contact forces to the surrounding chondral surfaces and
subchondral bone. The resulting mechanical wear and
loose body formation can lead to an inflammatory re-
sponse, and subsequent release of cartilage-degrading
enzymes potentially causing joint degeneration. If left
untreated, chondral defects can lead to osteoarthritis.”~”
Clinical Evaluation
Patients with a symptomatic chondral defect typically
have knee pain and swelling. Instability and mechanical
symptoms such as catching and locking may be present.
A traumatic etiology is often associated with a specific
event such as a fall or a twisting injury while playing
sports. The patient may not recall a specific event pre-
ceding the insidious onset of an idiopathic lesion or a
lesion associated with repetitive microtrauma. A detailed
history as to the onset of symptoms should be followed by
a comprehensive physical examination, although neither
the history nor examination is sensitive or specific for
a cartilage defect compared with another type of intra-
articular derangement. The physical examination begins
DI
cu
._I with a gait analysis and continues with an assessment for
T:
I:
m
effusion, deformity, contracture, malalignment, range of
or
III-1 motion, ligament stability, and patella: maltracking, with
I:
at close attention to the possible presence of a mechanical
blockage or crepitus.
H
The routine radiographic studies include the stand-
iug AP, lateral, Merchant, and 45" flexion PA views. The
radiographs are scrutinized for fractures, loose bodies,
osteophytes, and joint space narrowing. Full—limb length
radiographs may be helpful to determine mechanical align—
ment in a patient with a known chondral defect. MRI
flrrltopaodic Knowledge Update: Sports Medicine 5
is effective for evaluating the articular cartilage and de-
tecting subchondral edema. Determining the size of the
lesion on imaging is helpful for prognostic purposes and
can help guide surgical decision making. The size of a le-
sion is often underestimated by more than fifl‘ib on MRI,
however.” Ligamentous and meniscal structures should
be assessed for any evidence of injury. CT can provide line
anatomic detail of subchondral bone if a bone injury is
suspected, as after subchondral drilling, bone grafting, or
osteochondral allograft transplantation, for example. The
addition of intra—articular gadolinium to CT allows excel-
lent visualization of the articular cartilage. The distance
from the tibial tubercle to the trochlear groove or from
the tibial tubercle to the posterior cruciate ligament can be
determined from axial MRI or CT in patients with patel-
lofemoral instability or a patellofemoral chondral defect.
Nonsurgital Treatment
Most articular cartilage lesions are initially managed
with rest, activity modification, anti-inflammatory
medications, and physical therapy. Steroid or viscosup-
plementation {hyaluronic acid} injection may decrease
inflammation and improve symptoms, especially in a
patient who is sedentary or older than 55 years. However,
physiologic age is often more important than chronologic
age when determining treatment options. The use of an
unloader brace can be effective in a patient with unilat-
eral compartment overload, in which a chondral defect
is exposed to excessive forces as a result of malalignment
or meniscal deficiency.
Q. Video 13.1: Combined Cartilage Resto-
ration and Distal Realignment for Patellar
and Trochlear Chondral Lesions. Peter
Chalmers. MD; Adam Yanks. MD; Seth
Sherman, MD; ‘v'asili icaras. ES; Brian J.
Cole, MD, MBA [24 min}
Surgical Treatment
Patients whose symptoms are not relieved by nonsurgical
measures should be considered for surgical intervention.
The patient’s age, activity level, expectations, defect size,
and associated injuries are important factors in deter-
mining whether surgery is appropriate. A patient who is
considered to be a candidate for surgery must understand
that many cartilage-restoring procedures require exten-
sive rehabilitation, a return to activity will not be possible
for an extended period, and high-impact activity such as
running or basketball is discouraged.
El 1016 American AcadMy of Drtbopaedic Surgeons

Fig u re 1 Schematic drawings shnwing steps in micrnfracture. A. The chnndral defect is prepared with a ring curette tn
create stable herders. I. The sub-chnndral plate is penetrated muttiple times 2 tn 3 mm apart tn a depth cf 2 tn It
ITIITI.
Arth rnscnpic Débridement
Arthrnscnpic déhridemeut is cnmmnnly dnne as a first-line
prncedure. The gnal nf the surgery is tn remnve inflam-
matnry mediatnrs, lnnse hndies, and unstable chnndral nr
meniscal flaps. Arthrnscnpic debridemeut can be useful
fnr a patient whn is nnt a gnnd candidate fnr cartilage
restnratinn {nlcler than 55 years, advanced degenerative
changes, high BMI}, nr a patient whn is unwilling tn
adhere tn a strict pnstnperative rehabilitatinn ptntncnl.
Data are lacking tn suppnrt the lnngrterm efficacy nf
arthrnscnpic déhridement, hnwever.
Bnne Marrnw Stimulatinn
Bnne marrnw stimulatinn using micrnfractute, intra-
lesinnal drilling, nr ahrasinn arthrnplasty is cnmmnnly
dnne tn treat a full—thickness chnndral defect. A review
nf mnre than 153,flflfl cartilage prnceclures in the knee
nver a 6-year perind fnund that 93% cnnsisted nf micrn-
fracture nr chnndrnplasty.” Bnne matrnw stimulatinn can
he dnne arthrnscnpically, thtnugh a mininpen apprnach,
nr thtnugh an npen medial nr lateral parapatellar ap-
prnach. The arthrnscnpic and mininpen rnethnds mnsc
frequently are used.
The micrnfracture technique invnlves preparing the
lesinn with an arthrnscnpic shaver nr curette tn remnve
lnnse chnndral flaps and create a cnntained lesinn with
stable hnrders nf healthy cartilage {Figures 1 and 2}. The
suhchnndral plate is penetrated multiple times tn recruit
mesenchymal stem cells frnm the bane marrnw intn the
Eb Ifllti American Academy nf Urthnpaedic Surgenus
lChapter 13: Articular Cartilage cf the Knee
B
defect; penetratinn is dnne 2 tn 3 mm apart and 2 tn 4 mm
deep perpendicular tn the surface.” a micrnfractute awl
is traditinnally used tn penetrate the suhchnndral plate,
but recent investigatinns fnund that drilling prnvides
a superinr result?“ Enne marrnw stimulatinu causes
fnrmatinn nf an intralesinnal clnt with the pntential tn
fnrm fibrncartilage repair tissue {type I cartilage}. Fncal
lesinus smaller than 4 cm‘I in patients ynunger than 3!]
years were fnund tn he must amenable tn this tech nitlueffl
Micrnfracture shnuld he avnided if sub-chnndral h-nne
deficiency is present.
Pnstnp-erative rehabilitatinn generally invnlves a prn-
lnnged perind nf nnn—weight bearing nr partial weight
hearing. The use nf passive mntinn is recnmmended be-
ginning immediately after surgery, generally by using a
cnntinunus passive mntinn (CPM) machine fnr a perind
nf 6 weeks. The gas] is tn return the patient tn spurts
activity 6 tn 9 mnnths after surgery. pg
F.
:i
Dstenchnndral Autograft Transfer re
re
tn
flstenchnnd ta] autngraft transfer {HAT}, alsn called mn- 3
El.
saicplasty, invnlves harvesting nne nr mnre nsten-chnn-
dral cylinders frnm a minimally weight-hearing area E
cf the femur fnr transfer tn a defect in a mnre heavily
weight—bearing area {Figures 3 and 4}. DAT can he dnne
as an arthrnscnpic, npen, nr mininpen prncedute. The
mininpen prncedure is increasingly recngnized as a useful
cnmprnmise nffering minimal mnrbidity and maximal
precisinn.
Drrhnpaedic Knnwledge Update: Spnrts Medicine 5
 Section 3:1Enee and Leg

Figure 2 Arthroscopic views shows steps in microf ractu re. A, The ch ondral defect as prepared for microtractu re, with
loose chondral flaps removed to create a healthy, stable rim of articular cartilage. B. Multiple penetration of the
su hch ondral plate with an awl to release bone marrow contents into the defect is shown.

Figure 3 Schematic drawings showing steps in osteochondral autograft transfer. A, The size and shape of the chond ral
detect are determined, and the defect is prepared using proprietaryr equipment. B. The donor asteachandral
cylinder is obtained from the intercondylar region of the peripheral trod'Ilea. C. The osteochondral cylinder ls
inserted into the prepared recipient tunnel using a press fit.

Most commonly, diagnostic arthroscopv is followed bv to the articular cartilage.” The graft is inserted into the
DI
UAT through a miniopen approach. The size and shape prepared recipient tnn nel using a press-fit technique. Ag-
as
._I of the defect are determined, and the defect is prepared gressive impaction of the chondral surface of the graft
T:
I:
m
with the use of proprietaryr equipment. The femoral do- should he avoided to minimize chondrocyte death.15'“
as
III-1 nor site is selected based on the size and contour of the Contact pressures and forces are normal when grafts
I:
a: recipient defect. The reconunended donor sites include are placed flush with the surrounding articular cartilage.
the intercondylar notch region or the peripheral trochlea Small incongruities, especially if the graft is proud, can
H

{medial or lateral} above the level of the sulcus terminalis.
The lateral trochlea is larger than the medial trochlea,
but the medial trochlea has lower contact pressures.“
The osteochondral cvlinder is obtained using a harvesting
chisel. To obtain an even chondral surface, it is important
to ensure that the harvesting chisel remains perpendicular
increase contact pressures}?
Dne of the main advantages of this procedure is that
it provides hvaline cartilage at the defect site?“ In ad-
dition, OAT can be successfnlhr used in the setting of
subchondral bone loss or abnormality. The drawbacks
of DAT include possible donor site morbidity and the

flrdtopaedic Knowledge Update: Sports Medicine 5 El 1016 American Academv of Cirrhopaedic Surgeons
 Chapter 13: firticular Cartilage cf the Knee

|"' ‘ II.' . '- IL.

' I'I - -|- I*’E'-—1.
:-
" fill-5- _'_I."- 11.1151;t l' I—qjl
1.. I- . u I . ILL |_. " 'llrhtmflli _I
a

[:1- .-|_ I- —.II:- I | _L

I" 4'"- H ‘1'; Ill-L- ? -|.J.|;:':“"" d-rl" fiakilII-H'Lt'l'

Figure 4 Phntngraphs shnwing steps in nstenchnndral autngratt transfer. A. An nstecchnndral cylinder has been harvested
and is ready tn be inserted intn the prepared recipient site. B, The nstenchnndral cylinder is inserted intn the
recipient site using a press fit.

limited amnunt nf graft material that can be harvested. is larger than can he nhtained in an autngraft {Figures
As a result, DAT is ideal fnr chnndral nr nstenchnndral 5 and 6}. A medial nr lateral parapatcllar arthrntnmy is
defects smaller than 2 cm1. perfnrmed, and the lesinn is identified. A guidewire is
Pnstnperative rehabilitatinn includes tnedtnuch weight placed in the center nf the defect fnr sizing. When the
bearing fnr 4 tn 3 weeks, depending cm the size nf the size has been determined, the defect is prepared using
lesinn and the number nf nstenchnndral cylinders used. prnprietary equipment. The defect is reamed tn remcve
Early prngressive mntinn is encnuraged with use nf a the abnnrmal cartilage and apprnzimately E tn lfl mm
(3PM machine. A return tn athletic activity is delayed nf sub-chnndral bnne. The recipient tunnel is created, and
far 4 tn 6 mnnths. the dnnnr nstecchnndral cylinder is taken frnm the fresh
allngraft specimen. An attempt is made tn harvest frnm a
|Illistenchnndral Allngraft Transplantatinn matching area nf the allngraft specimen an that the cnn—
flStEflCl'tDflElI'fll allngraft transplantatinn is an excellent np- tnur will match the recipient area. The dnnnr cylindrical
tinn fnr chnndral nr nstenchnndral defects larger than 2 tn plug is inserted intn the recipient tunnel with a press fit.
4 cm1. This prncedure alsn can he used as a salvage nptinn As in DAT, the use nf a mallet shnuld he avnidcd during
after an unsuccessful cartilage repair surgery. The defects insertinn tn minimize chnndrncyte death.
mnst cnm mnnly treated are in the weight-hearing medial Pnstnpcrative reh abilitatinn includes tne-tnuch weight
nr lateral femnral cnndyle. Tibial and patellnfemnral deF bearing fnr 6 tn 12 weeks. Early prngressive mntinn is
facts can he treated with this prncedure, but tihial access encnuraged with use nf a CPM machine. Snme surgenns
requires extensive surgical dissectinn. The cnmplez pa- recnmmend limiting fleainn tn 45" during the first 4 tn 1.4,:
tellar and trnchlear surface genmetry presents challenges 6 weeks in patients treated fnr a patellnfemnral lesinn. FT.
:5
fnr graft matching and preparatinn. Fresh refrigerated High-lnading activities such as running and jumping re
re
tn
allngrafts are used rather than frnzen nr freeze-dried shnuld he avnidcd fnr 6 tn 12 mnnths after surgery. 3
El.
specimens tn ensure the highest level nf chnndrncyte vi—
ahilityfi'1 The recnmmended time frnm graft harvest tn Autnlngnus Chnndrncyte Implantatinn s
transplantatinn is an mare than 23 days because at that nutclngcus chnndrncyte implantatinn {AC1} is an ar-
time at least THEE nf chnndrncytes are viable}1 Ideally ticular cartilage—restnring prncedure used tn treat 2 tn
the graft is frnm the same side and cnmpartment as the 4 cm1 nr larger full-thickness chnndral defects cf the
recipient defect and is size matched. knee {Figures T and 8]. AC] is a twp-stage prncedure in
The technique is similar tn that fnr BAT except that the which an initial arthrnscnpic cartilage binpsy is fnllnwed
cylinder nhtained frnm the dnnnr cadaver hemicnndyle by 4 tn 6 weeks nf in vitrn chnndrncyte expansinn and

Eb Iflli‘i American Academy nf Urthnpaedjc Surgenns Drthnpaedic Knnwledge Update: Spnrts Medicine 5
 Sectien 3:Ilinee audLeg

G
Figure 5 Schematic drawings shew steps in esteechend ral alleg raft tra nsplantatien. A, The size and shape at the chendral
defect are determined. I. The defect is reamed te remeve abnennal cartilage and E tn 1e mm at subchendral
bene. C. The dener esteechendral cylinder is ebtained frem the fresh alleg raft specimen. D. The dener cylindrical
plug is inserted inte the recipient tunnel using a press fit.

re
'I.
I." _.-:. _ ' ' _.

‘— | I 'i. - ' :-

Figure 5 Phetegraphs shew.r steps in esteechendral allngrait transplantation. A. Unhealthy cartilage and underlying
subchendral bene have been remeved in preparatien fer insertien ef the esteechendral allegraft cylinder. E, The
fresh fe meral hemicendyle is prepared fer ebtaining the dener esteechen dral cylinder. I2. The esteeche ndral
aliegraf't cylinder has been placed inte the recipient tunnel using a press 'iit.

reimplantatien. The first-generatien technique required
harvesting ef prescimal tibia periesteum fer use as a patch
te centain the chendrecyte suspensieu within the defect.
Secend—geueratien techniques use a synthetic type Ir'III
cellagen membrane. The advantages ef using the type LI"
III cellagen membrane include sherter surgical time, less
merbidity, and fewer pestsurgical cemplicatieus such as
graft patch hypertrephy.“ A third-generatien technique
DI
is being used in Eurepe but has net yet been appreved
cu
._I fer use in the United States.
T:
I:
us
The purpeses ef the initial arthrescepy are te evaluate
ca
Iii-1 the size and lecatien ef the defect and determine whether
I:
a: the lesien has a stable ritn ef surrenudiug healthy carti—
lage. If the defect is determined te be amenable te ACI,
H
added that allews implantatien te be delayed as much as
2 years. The reimplantatien precedure requires a medial
er lateral parapatellar arthretemy. The defect is identi-
fied and eutlined using a scalpel te centain the defect by
establishing a stable rim ef surreunding cartilage. Ring
curettes are used te remeve all remaining unhealthy ea :-
tilage in the centained defect while aveiding penetratien
ef fl'lE subchendral plate. The defect is traced ente sterile
gleve paper er feil te create a template fer the type Ir'III
cellagen membrane. The membrane is trimmed te the
desired size and shape and sutured te the stable rim ef
cartilage using a Iii-{l pelyglycelic acid suture in a simple
interrupted fashieu. A small epening is left se that an
iii-gauge plastic angiecatheter can be inserted beneath the

a full-thick ness Zflfl- te Slim-mg cartilage biepsy is ta ken
frem the superelateral intercendylar netch er the periph—
ery ef the trechlea. The biepsy material is transperted in
special medium fer espansien in the iaberatery. After 4
tn 6 weeks, the cells usually are ready te be reimplanted.
Fer mest patients, hewever, a cryepreservatien stage is
membrane. Befere inserting the cells, fibrin glue is applied
te the perimeter ef the membrane except fer the area te
be used for cell insertien. After cell injectien, this small
epening is ciesed using an additienal suture and fibrin
glue te create a watertight seal. Due ef the advantages ef
this technique is that there is an limit te the size er shape

flrdtepaedie Knewiedge Update: Sparta Medicine 5 El 1016 American Aeadem1r ef Cirtbepaedic Surge-ens
 lChapter 13: Articular Cartilage ef the Knee

a,

Figu re Ir' Schematic drawings shew steps in autelegeus chendrecyte implantatien. A. Cartilage biepsy tissue is ebtained
frem the intercendylar regien ef the lateral trechlea. B, The chendral defect is prepared with a ring curette te
create stable berders. C. Type lrlll cellagen membrane has been secured in place. and chendrecytes are injected
beneath the membrane.

K,
A -.

Figure 5 Steps in autelege us ch en drecyte impla ntatien. A, Arthrescepic view shews cartilage biepsy tissue taken frem the
interce ndylar regien ef the femur. B, Pheteg ra ph shews the defect prepared by remeving unhealthy cartilage
and creating a centained Iesien with stable berders ef healthy cartilage. 1:. Fheteg raph sh ews injectien ef
chendrecytes beneath the membrane that has been sutured inte place using multiple interrupted sutures. [Panel A
repreduced frern Gemell AH: Autele-geus chend recyte implantatien, in Amendela A, Gemell AH, eds: Let’s Discuss:
Jer'nt Preservatien ef the Knee. Resement. IL. American Academy ef Drthepaedic Surgeens. 2D15, in press.)

ef the lesien treated as lung as the defect is centained.
Any lecatien in the knee can be treated, altheugh the
US FDA dees net censider patellar er tibial lesiens te be
appreved indicatiens.
The meet current technique is cell-seeded AG], in which
the cellagen patch is sized and cut tn shape while dry and
subsequently seeded with the chendrecyte suspensien in
the eperating teem. 1Within 5 te 10 minutes, the cells
attach themselves re the membrane, which is placed inte
the defect and secured circumferentially with a running
6-D reserbahle suture. The suture line is waterpreefed
with fibrin glue, but ne additional injectien ef cells is
required. This technique is less invasive than standard
AC1 and decreases the surgical time, but it has net been
appreved fer use in the United States. The results appear pg
te be cemparable te these ef standard MIL“ FT.
:5
Rehabilitatien after AC1 begins with immediate me- re
re
er
tien. A CPM machine is used 6 te 3 hears a day fer the 3
El.
first Ii weeks with pregressien reward 90° ef knee fleicien.
After treatment ef a defect in the femeral cendyle, tee- E
teuch weight bearing is used fer 6 weeks, after which the
patient pregresses reward weight hearing as telerated.
After treatment ef a patellefemeral defect, the patient
can bear weight frem the beginning as telerated in full
extensien. Running is net allewed fer 12 menths, and
ether strenueus sperts activity is restricted fer 13 menths.

El Ifllli American Academy ef Urthepaedic Surgeeus Drrhepaedic Knewledge Update: Sperrs Medicine 5
 Sectinn 3:1Cnee and Leg
Outcn mes
Until recently, little high—quality evidence was available nn
articular cartilage surgery. In 11113, a review nf cartilage
surgery studies fnund the methndnlngic quality tn be
generally pnnr hut tn have imprnved within the preceding
10 years.” Several recent high-quality studies were nnt
included in the reviewdifl
Micrnfracture
At 11-year fnllnw—up nf 9'2 patients whn underwent mi—
crnfracture fnr a full-thickness defect nf the knee, sub-
stantial imprnvement in Lyshnlm Knee Questinnnaire
and Tegner Activity Level Scale scnres was repnrted, and
scnres cm the Medical |Dutcnmes Study 36-Item Shnrt
Farm Health Survey and Western Untarin and McMas-
ter Universities Ostenarthritis Index were gnnd tn ex—
cellent.“ At 9-year fnllnw-up, 36% nf patients repnrted
imprnvement. A review cf the results after treatment cf
53 athletes with a mean 4—cm2 defect fnund that 90%
had a nnrmal nr near-nnrmal Internatinnal Knee Uncu-
mentatinn Cnmmittee {IKDC} Subjective Knee Evaluatinn
Fnrrn scnre at 6-year fnllnw-up.” Patients ynunger than
40 years and with a lesinn smaller than 2 cm?- were mnst
likely tn return tn high-impact spurts. Annther study alsn
repnrted that patients had imprnved clinical scnres after
micrnfracture surgery.35f Hnwever, the results nf micrnf~
racture may deterinrate with time. A systematic review cf
23 studies invnlving Innre than 3,900 patients repnrted
imprnved knee functinn at 24-mnnth fnllnw—up, but data
were insufficient fnr evaluating lnnger term nutcnmes.”
A systematic review repnrted that micrnfracture fnr a
small lesinn in patients with lnw physical demands had
gnnd nutcnrnes at shnrt-term fnllnw-up but that treatment
failure cnuld he expected after 5 years, regardless nf lesinn
size.“ Similarly, micrnfracture fnr small lesinns imprnved
symptnms, hut deterinratinn nf clinical nutcnmes was
fnund tn he expected 2 tn 5 years after surgery.42 Even
with prnper surgical technique and apprnpriate patient
sclectinn, the results nf micrnfractnre were found tn de-
DI
terinrate nver time.“3
m
._I
T:
I:
m Dsten-chnndral Autngraft Transfer
m
III-1 At an average 9.6-year fnllnw-up nf patients treated with
I:
E BAT [mnsaicplasty}, gnnd tn excellent nutcnrnes were
fnund in 91% nf thnse with a fernnral cnndyle lesinn,
H
36% cf these with a tihia] lesinn, and ?4% cf thnse with
a patellnfemnral lesinn.“M Patellnfemnral pain related tn
graft harvest was fnund in 5% nf patients. These data
suggest that DAT shnulrl he cnnsidered fnr cnmpetitive
athletes with a 1— tn +c lesinn. Annther study repnrted
that at an average 9-year fnllnw-up, 61 nf 69 patients whn
flrfltnpaedic Knnwledge Update: Spnrts Medicine 5
underwent DAT {33%) said that they wnuld chnnse tn
undergn the surgery again.“ Hnwever, a deterinratinn
nf results was nbserved frnm the 11-mnnth tn the 5- tn
9-year fnllnw-up. At 10- tn 14-year fnllnw—up cf the same
patients, 49% had a pnnr nutcnme {defined as later knee
arthrnplasty nr a Lyshnlm scnre nf 64 nr lnwer].‘l‘5 The
pnnr nutcnrnes were assnciated with patient age nlder
than 413' years {59%}, female sex {61%}, and a defect larger
than 3 cm1 {59%}. Patients ynunger than 40' years with a
defect smaller than 3 cm: had a failure rate nf nnly 12.5%
and a favnrable mean Lyshnlm scnre nf SZ.
nstenchnndral Allegraft Transplantatinn
Dstenchnndral allngraft transplantatinn has been used
fnr 4t] tn 50 years. Several studies fnund satisfactnry nnt-
cnmes.”"*5' A recent lung-term nutcnme study repnrted the
results nf fresh nstenchnndral allngraft transplantatinn
in 53 patients at a mean 22-year fnllnw-up.” At the time
nf surgery, the patients were ynunger than 5|] years and
had a unipnlar nstenchnndral nr nstenchnnd ritis dissecans
defect nf the distal femur larger than 3 cm in diameter
and 1 cm in depth. Graft survival at It}, 15, 1f), nr 25
years was 91%, 34%, 69%, nr 59% respectively. Patients
with surviving grafts had a mean mndified Hnspital fnr
Special Surgery scnre cf 36.
A systematic review nf 19 studies evaluated the nut-
cnmes nf nstenchnndral allngraft tra nsplantatinn in 644
knees at a mean 5B -mnnth fnllnw-upfi1 The mean patient
age was 3? years, and the mean defect size was 6.3 emf.
The defects were idinpathic nr related tn trauma, nsten-
chnndritis dissecans, nr nstennecrnsis. The nverall patient
satisfactinn rate was 36%, and 65% nf patients had little
nr nn nstenarthritis. The shnrt-term cnmplicatinn rate was
2.4%, and the nverall failure rate was 18%.
Despite the cnmplexity nf nstenchnndral allngraft
transplantatinn in the patellnfemnral jnint, encnuraging
nutcnrnes have been dne umented. A retrnspective review
nf 14 fresh patellnfemnral allngraft transplantatinns in
11 patients fnund that at an average 10—year fnllnwvup
(range, 2.5 tn 1?.5 years), 3 grafts were in place.’2 Fnur
grafts survived lnnger than 10 years, and 2 survived lnn-
ger than 5 years. Three allngrafts survived mnre than 1f}
years hut did nnt survive until final fnllnw-up. Ten nf the
11 patients stated that they wnuld undergn the prncedure
again. Annther study fnund that 5 nf 20 fresh nstenchnn-
dral allngrafts used tn treat patellnfemnral lesinns in IS
patients did nnt survive at an average fnllnw-up cf 94
mnnths.”
Autnlognus Chendrntyte Implantation
Since the first descriptinn nf AG] in 1994, shnrt- tn
immediate-term studies have fnund favnrahle
El 1016 American Academ1r nf Drthnpaedic Surge-ens

outcomes?“ Several long-term studies have recently
become available. At a mean 12.3-year follow—up, 74% of
patients reported their status as better than or unchanged
from that of preceding years.” Ninety-two percent were
satisfied and would have the procedure again. In a 12-
year study of 213 patients, the average defect size was
3.4 emi.” At 10-year follow-up, graft survivorship was
71%, and 25% of patients reported improved function.
At least one graft had failed in 53 of the patients {25%).
A subgroup analysis revealed that concurrent osteotomy
significantly increased graft survivorship {33% with oste-
otomy, 56% without osteotomy}. A study of the results
of AC1 for chronic chondral and osteochondral defects
followed 134 patients {mean age, 33.2 years} for an aver—
age lfl.4 years}? The patients were considered difficult to
treat; their mean duration of symptoms was 7.3 years, and
they had undergone an average 1.3 cartilage procedures
before ADI. Twenty-seven patients {26%} had graft failure
at a mean 5.? years. DI the T3 patients with surviving
grafts, S4 {33%} reported a good to excellent result.
Until recently, no outcome data have been available
to support the use of AC] in the patella. In a large mul-
ticenter study, IICI patients were treated with AC1 for a
cartilage defect of the patella and were followed for at
least 4 yearsf"fl There were statistically significant and
clinically important improvements in all physical outcome
scales, IKDC scores improved from 4D to 69, modified
Cincinnati Knee Rating System scores improved from
3.2 to 6.2, and Western Dntario and McMaster Univer—
sities Dsteoarthritis Index scores improved from 50.4 to
13.6. |Due hundred one patients (92%] stated they would
undergo the procedure again, and 95 {35%} rated their
knees as good or excellent at final follow-up.
Newer data suggested that earlier bone marrow stim-
ulation procedures such as microfracture may have a
detrimental effect on outcomes after ACI. A review of
more than 300 consecutive patients compared outcomes
based on whether the patient had undergone a bone
marrow stimulation procedure before AC1.“ Graft failure
occurred in 26% of patients who had undergone earlier
bone marrow stimulation compared with 3% of patients
who had not had a bone marrow stimulation procedure.
Similar results were found in a comparison study of
ADI after unsuccessful microfracture or as a first-line pro-
cedure.“ Significantly more graft failures were associated
with ADI after microfracture i? of 23} than with ACI as
a first-line treatment {1 of 23}. Inferior clinical outcome
also was associated with ADI after microfracture.
D 2316 American Academy of Drthopaedir. Surgeons
Chapter 13: Articular Cartilage of the Knee
Comparative Dutcome Studies
Microfracture Versus |liltiIHIiT
A level I randomized controlled study of Sill patients com-
pared microfracture to DAT in athletes {mean age, 24.3
years}:52 After 321 months, patients in both groups had
significant clinical improvement. However, at 12, 14, and
SIS months, those treated with DAT had statistically sig
nificantly better Hospital for Special Surgery and Interna-
tional Cartilage Repair Society scores than those treated
with microfracture. In addition, 93% of patients treated
with DAT were able to return to sports activity at the pre-
injury level at an average 65-month follow-up, compared
with 52% of patients who underwent microfracture. In
13-year follow-up data, the same patients had signifi-
cant clinical improvement in follow-up International
Cartilage Repair Society scores compared with scores
before surgery.{“3 However, patients in the DAT group
had significantly better scores compared with patients
in the microfracture group. Similar trends were found in
patient activity levels. Fifteen of 23 patients in the DAT
group {33%} were able to maintain the same preinju-
ry activity level compared with 3 of 22 patients in the
microfracture group (32%}. In patients who underwent
DAT, lesions smaller than 11 em1 were associated with a
significantly higher rate of return to sports compared with
larger lesions. No difference was found between DAT
and microfracture in muscle strength, patient-reported
outcomes, and radiographic outcomes at a mean 9.3-
year follow-up.“ This study involved only 25 patients,
and therefore it is difficult to draw firm conclusions from
the data.
Microfracture Versus ACI
Because few high-powered studies have compared ADI
and microfracture, outcome data conflict. A randomized
study of 30 patients found no difference in clinical out-
comes at 2- and 5-year fltillow-upfii‘i"IE However, defects
larger than 4 cm1 were associated with a worse outcome
after microfracture than smaller lesions. A similar trend
was not observed after ACI, and ADI was recommended to
for treatment of large lesions. This study was criticized F.
:5
because most of the involved surgeons had little or no re
re
tn
prestudy experience with ADI. A randomized controlled 3
El.
study with 2—year follow—up compared matrix-applied
ADI with microfracture in 144 patients with a mean le- .3
sion size of 4.3 CHIS-E? The important exclusion criteria
included malaligmnent requiring osteotomy. The assessed
outcomes included the Knee Injury and Dsteoarthritis
Dutcome Score, knee-related quality of life, and repair
tissue quality as based on histologic and MRI findings.
For cartilage defects larger than 3.- cm1, treatment with
Drthopaedie Knowledge Update: Sports Medicine S
 Sectien 3:1Cnee andLeg
matrix-applied AC1 was statistically and clinically better
than micrefracture, with similar structural repair tissue
and safety eutcemes.
ACI Versus OAT
A prospective study cf 40 patients cempared AC1 te
DAT.” lvfeyers, Lyshelm, and Tegner activity sceres
were ebtaincd at 3, 6, 12, and 24 menths, and biepsy
specimens were ebtained fer histemerphelegic evalu-
atien. Beth surgical preccdnres led te imprevement in
symptems, but recevery after AC1 was slewer than after
DAT, as indicated by Lyshelm sceres. After AC1, biep'
sied tissue primarily was filled with fihrecartilage, but
after DAT, hyalinelike tissue with an interface between
the transplanted and eriginal cartilage was maintained.
This study lacked a preeperative radiegraphic evaluatien
ef mechanical alignment. Seven ef the 20 patients whe
underwent AC1 had undergene earlier abrasien arthre-
plasty, cempared with 4 cf the Eli patients whe underwent
DAT. Cell culturing was dene by the investigaters rather
than a cemmercial entity with experience in chendrecyte
culture precesses.
At a mean l.?—year fellewdup, a prespective randem-
iaed study ef lfll} patients with an esteechendral defect
feund that 33% cf these treated with AC] had geed te
excellent medificd Cincinnati and Stanmerc Functienal
Rating scercs cempared with 69% cf these treated with
mesaicplasty.“ In additien, arthrescepy at 1 year feund
that 32% ef the patients treated with AC1 had a geed
er excellent repair cempared with 34% cf these treated
with mesaicplasty. The leng—term eutcemes ef the same
patients were reperted at a minimum 10-year fellewsup.”
Graft failure had eccurred in 10 cf the 53 patients treated
with AC1 {17"}3} and 23 cf the 42 patients treated with
mesaicplasty {55%}. Nene ef the five patellar mesaicplasu
ty precedures were successful.
Bielegic Techniques
Each ef the available articular cartilage—restering prece-
DI
dures is hampered by specific limitatiens, and this facter
as
._I has led te increased interest in new hielegic techniques
T:
I:
re
using allegrafts, stem cells, and scaffelds.
re
III-1
I:
a: Particulate-cl Juvenile |Itiartilage
It has been preved in animal and human medels that
H
juvenile cartilage is superier te adult cartilage in chen-
drecytic activity, cell density, and healing petential."'“"“
DeNeve NT Natural Tissue Graft {Zimmer} was cem-
mercially intreduced recently as a particulated juvenile
allegraft cartilage frem deners age 13 years er yeung—
er. The surgical technique requires a medial er lateral
flrthepaedic Knewledge Update: Sperts Medicine 5
parapatellar arthretemy, identificatien ef the defect,
and initial preparatien similar te the AC1 technique. In
a multicenter prespective study, 25 patients treated with
juvenile particulated cartilage had statistically significant
imprevements in IKDC and Knee Injury and Dsteear—
thritis Clutceme Scere at 2-year fellew-upf'l Histelegic
analysis ef hiepsied material frem eight patients revealed a
mixture ef hyaline cartilage and fibrecartilage with mere
type 11 than type I cellagen.
Platelet-Rich Plasma
Autelegeus platelet-rich plasma {PEP} has been used te
treat musculeslceletal cenditiens such as lateral epicendy-
litis and retater cuff tears. Animal studies have identified
petential uses fer PRP alene er as an augmentatien ef eth-
er hielegic treatments fer repairing hyaline cartilagefi'“
Hewevcr, uncertainty remains as te the in vive efficacy
ef PEP. A systematic review cf 10 studies ef PEP used in
degenerative knee and hip disease did net find evidence ef
a shert—tcrm clinical benefit.” High-quality cemparative
studies with lenger term fellew-up are needed te deter-
mine whether PRP ceuld he efficacieus fer treatment ef
articular cartilage cenditiens.
Cerrl Bleed Stem Cell Transplants
Cartistcm ll'viedipest} is a stem cell drug used te treat
articular cartilage defects and estcearthritis. This drug
centains mesenchymal stem cells derived frem umbilical
cerd bleed. In 2012, Cartistem was appreved fer clini-
cal use by the Feed and Drug Administratien ef Kerea,
and it has been appreved fer clinical study at certain US
institutiens.
Amnietic Stem Cell Transplants
The use ef amnietic tissues has attracted censiclerable
attentien. Arnnienic stem cell transplants are reutinely
used in the treatment ef eye and diabetic feet disease
and are being investigated fer use in cartilage repair and
esteearthritis applicatiens.
Next-Generatien Chendrecyte lmplantatien
The currently used chendrecyte implants censist ef au-
telegeus cells, but cencern as te cell quality variability
ameng deners has led te investigatien ef allegeneic chen-
drecyte preducts. Allegeneic implants ceuld be derived
frem dener chendrecytes that express high levels ef chen-
dregcnic petential.
SL1 tn mary
Articular cartilage repair is a rapidly devcleping erthepae—
dic subspecialty. The rate ef pesitive eutcemes generally
El ll] 16 American AcadMy ef Drthnpaedic Surge-ens

exceeds 30% if the technique is carefully matched to
specific patient and defect characteristics. Débridement is
useful for temporary pain relief and reduction of mechan-
ical symptoms. Microfracture is indicated for treating a
small acute femoral condyle defect in a young patient.
DAT has better outcomes than microfracture but is lim-
ited by donor site morhidity. Osteochondral allograft
transplantation can he used to treat large osteochondral
defects and revise an unsuccessful earlier cartilage repair
procedure, but its use in the patellofemoral compartment
is complicated by the difficulty of matching the varied
anatomy. AC1 can more easily be used to treat multiple
patellofemoral defects, but it requires intact suhchundral
hone. Numerous techniques and products are under de-
velopment and are expected to be ready for clinical use
within 5 to it} years.
I-{oy Studyr Points
I Initial evaluation of chondral defects requires a
thorough history, physical examination, and radio-
graphic assessment.
1* Associated injuries, malalignment, age, activity level,
and expectations should all he considered when
formulating a definitive treatment plan.
1* For patients on whom nonsurgical treatment fails
and who are candidates for cartilage repair andJ'or
restoration surgery, DAT or microfracture should
be considered for smaller lesions {c 2—4 emf] and
AC] or osteochondral allograft transplantation for
larger lesions {=- 1-4 cmzi.
' Lesions resulting in abnormal or deficient suhchon-
dral hone may he hest treated with procedures that
address the entire osteochondral unit, such as DAT
or osteochondral allograft transplantation.
Annotated References
1. Newman AP: Articular cartilage repair. rim I Sports Med
1993;16fljz3fl9-324. Medline
2. U’Driscoll SW: The healing and regeneration of articular
cartilage. J Bone joint 3mg Am 1993:ED{11}:1T95-1311.
Medline
3. Shapiro F, Koide 5, Glimcher M]: Cell origin and differ-
entiation in the repair of full-thickness defects of articu-
lar cartilage. J Bone Joint San-g Am 1993;T5{4J:531-553.
Medline
4. FuruItawa T, Eyre DR, Koide S, Glimcher M]: Biochemical
studies on repair cartilage resurfacing experimental defects
Eb Iflli'i American Academy of Urthopaedic Surgeons
lEhapter 13: Articular Cartilage of the Knee
in the rabbit knee. I Bonejoim 3mg rim 1930;62{1}:?9-39.
Medline
Heath CA, Magari SR: Mini-review: Mechanical factors
affecting cartilage regeneration in vitro. Hiotechnoi Bio-
eng 1996;59H]:430-43?. Mediine DUI
flhsan T, Lottman Li'v'I, Harwood F, Amiel D, Salt EL: In-
tegrative cartilage repair: Inhibition by heta—aminopropio-
nitrile. J Orthop Res 1999;1?{o}:35fl-351 Medline DUI
Curl WW, Krome J, Gordon ES, Rushing J, Smith BP,
Poehling GG: Cartilage injuries: a review of 31,516
knee arthroscopies. Artist-occupy 199T;13H}I:456-4fifl.
Medline DID]
nraen A, Laken S, Heir S, et al: Articular cartilage lesions
in 993 consecutive lcnee arthroscopies. Am J Sports Med
lflfl‘l-gdljljflll—IIS.Mcdline DDI
Hjelle K, Solheim E, Strand T, l'vIuri IL, Erittherg M: Ar-
ticular cartilage defects in 1,0 {11“.} knee arthroscopies. Ar-
throscopy Zflfl2;13{?]:?3fl-?34. Medline DUI
10. Flanigan DC, Harris JD, Trinl'i TQ, Sistou RA, Erophy
RH: Prevalence of chondral defects in athletes“ knees: A
systematic review. Med Sci Sports Ettore 2010;42i1flj:1?95-
1801. Medline DUI
A systematic review of 11 level IV studies determined the
prevalence of full-thickness chondral defects in athletes‘
knees to he 36%. Patellofemoral defects accounted for
3T%, femoral condyle defects for 35%, and tibial plateau
defects for 25“513.
11. Brophy RH, Zeltser D, 1Wright RT, Flanigan D: Anterior
cruciate ligament reconstruction and concomitant articu—
lar cartilage injury: Incidence and treatment. Arthroscopy
2D10;26[1]:112-120.Medline DUI
A systematic review of five studies revealed a 115% to 46%
incidence of severe articular cartilage injury in acute an-
terior cruciate ligament tears.
12. Lewandrowslti KU, Miiller J, Schollmeier G: Concomi-
tant meniscal and articular cartilage lesions in the fem-
orotihial joint. Am I Sports Med 1997:25i4}:436-494.
Medline D01
13. Nomura E, Inoue M, Kurimura M: Chondral and osteo-
chondral injuries associated with acute patellar disloca- to
tion. Arthroscopy 2fi03;19{?}:?1?—?21. Medline Dfll F.
:15
re
re
14. Lefltoe TP, Trafton PG, Ehrlich MG, et al: An exper- cu
3
imental model of femoral condylar defect leading to El.
osteoarthrosis. J firthop Trauma 1993;?{5}:45 3-461
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E
15. Messner K, Maletius W: The long-term prognosis for
severe damage to weight-bearing cartilage in the knee:
A 14—year clinical and radiographic follow-up in 13
young athletes. Acre flrrhop Sound 1996:E?{1J:165-163.
Medlirle DflI
Drrhopaedic Knowledge Update: Sports Medicine 5
 Section 3:1fnee andLeg
15. Gomoll AH. Yoshiolca H. 1iS'i'atanabe A. Dunn JC. Mines
T: Preoperative measurement of cartilage defects by MRI
underestimates lesion size. Cartilage 2011;2{4}:339—393.
Medline DUI
Seventy-seven patients had ltnee MRI before arthroscopic
surgery for a cartilage defect. Defect size was determined
on MRI and at time of arthroscopy. MRI underestimated
the defect area an average 65% of the time compared with
arthroscopic visualization. Leml of evidence: II.
1?. Montgomery SR. Foster ED. Hgo 55. et al: Trends in the
surgical treatment of articular cartilage defects of the knee
in the United States. Knee Snrg Sports Tranmrttof Arthrosc
2fl14;22{9i:2fl?fl-2fi?5.Modline DUI
Microfracture and chondroplasty accounted for more than
93% of 163.443 knee articular cartilage procedures over a
6-year period. usually in patients age «Ii-CI to .59 years. Uther
procedures were more often done in patients younger than
40 years. Level of evidence: IV.
IS. 1i'lll'illiams E] III. Harnly HW: Microfracture: Indications.
technique. and results. instr Course Lect 2002;56:419-
423. Medline
19. Chen H. Chevrier A. Hoemann CD. Sun J. Cluyang W.
Buschmann MD: Characterization of subchondral bone
repair for marrow-stimulated chondral defects and its
relationship to articular cartilage resurfacing. do: 1 Sports
Med 2011;35i3]:1?31-1?4fl. Medline DUI
Bone marrow stimulation procedures were done on 16
skeletally mature rabbits. Repair led to an average bone
volume density similar to that of control subjects but the
repaired bone was more porous and branched. Relatively
deep drilling induced a larger region of repairing and
remodeling of subchondral bone that was positively cor-
related with cartilage repair.
2:1}. Chen H. Hoemann CD. Sun J. et al: Depth of subchondral
perforation influences the outcome of bone marrow stim-
ulation cartilage repair. I Cirtbop Res 2011;29{S}:11?ii-
1134. Medline DUI
This study used a rabbit model to compare depth {6 mm
versus 2 mm} and type of marrow stimulation [drilling
versus microfracture} on cartilage defects. Clutcomes
included quantitative histomorphometry and histologic
scoring. Results demonstrated that deeper versus shal-
low drilling produced a greater fill of the cartilage defect
UI
with a more hyaline—lilte repair tissue. Microfracture and
to
._I drilling to 2 mm resulted in similar quantity and quality
T:
I:
of cartilage repair.
rn
a:
Iii-1
I: 21. Chen H. Sun J. Hoemann CD. et a]: Drilling and micro-
:e
H
fracture lead to different bone structure and necrosis
during bone—marrow stimulation for cartilage repair.
__i Urtfrop Res 20fl9:2?{11]:1432-1433. Medline DCII
Chondral defects were treated with bone marrow stimula-
tion in a mature rabbit model. Microfracture was found to
produce fractured and compacted bone around holes. seal-
ing them off from bone marrow content. Drilling cleanly
removed bone from the holes and provided access channels
Clrfltopaedie Knowledge Update: Sports Medicine 5
to marrow conteot. hilicrof'racture was associated with
more osteocyte death than drilling.
22. Eldracher M. Urth P. Cucchiarini M. Pape D. Madry
H: Small subchondral drill holes improve marrow stim-
ulation of articular cartilage defects. An: I Sports Med
2D]4:42{11i:2?41-2?Sfl.Medline DUI
Suhchondral drilling was done in 13 adult sheep. Cisteo-
chondral repair was assessed at 6 months. Compared with
1.3-mm drill holes. the application of Lil-mm subchondral
drill holes led to significantly better histologic matrix
staining. cellular morphologic characteristics. subchondral
bone reconstitution. average total histologic score. immu-
noreactivity to type [I collagen. and immunoreactivity to
typeI collagen in the repair tissue.
23. IZiohhi a. Nunag P. Malinowslti R: Treatment of full thick-
ness chondral lesions of the knee with microfracture in a
group of athletes. Knee Snrg Sports Trnnrnntof Arthrosc
2flfl5;13[3}:213-221.Medline DUI
24. Garretson RB III. Katolilt LI. Verma N. Beclt PR. Each ER.
Cole H]: Contact pressure at osteochondral donor sites in
the patellofemoral joint. An: I Sports Med 2flfl4:32i4j:9ti?-
9'24. Medline DUI
25. Hangody L. Rathonyi CK. Duska Z. Visarhelyi G. Fflles P.
l'vfodis L: Autologous osteochondral mosaicpiasry: Surgi-
cal technique. ] Bonejofnt Snrg Ant 2Dfl4;fi S{Suppl 11:65-
?2. Mcdlinc
2S. Jamali AA. Emmerson BC. Chung C. IConvery FR. Eugbee
WU: Fresh osteochondral allografts: Results in the patel—
lofemoral joint. Citn Grthop Refer Res 2D flS:43?:1?6-135.
Medline DUI
2?. Pylawka TK. Wimmer M. Cole H]. 1iI.i'irdi..'5:fi. Williams M:
Impaction affects cell viability in osteochondral tissues
during transplantation. }' Knee Snrg 2DD?;2D[2}:1DS-11i}.
Mcdlinc
2E. Gfirtz S. Eugbee WI): Allografts in articular cartilage
repair. Instr Coarse Lect 2Dfl?:S{i:469-4Sii. Medline
25‘. Koh JL. liiii'irsing K. Lautcflschlager E. Zhang LU: The
effect of graft height mismatch on contact pressure fol-
lowing osteochondral grafting: A biomechanical study.
Am I Sports Med 2004;32i2}:31?—32fi. Medline DUI
3f}. Hangody L. Kish U. Kdrptiti Z. Udvarhelyi I. Szigeti I.
Eély M: Mosaicplasty for the treatment of articular carti-
lage defects: Application in clinical practice. Drtfropedfcs
1993:21{?l:251-TSS. Medline
31. Bugbee WD. Convery FR: Usteochondral allograft
transplantation. Cfin Sports Med 1999;13{1i:fi?-?5.
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32. LaPrade RF. Bother J. Herzog M. Age] J: Refrigerated
osteoarticular allografts to treat articular cartilage defects
of the femoral condyles: A prospective outcomes study.
1' Bone joint Snrg rim zoosa 1i4}:3i]5-311. Medline DD]
El 2016 American AcadMy of Cirrhopaedie Surgeons

Twenty-three censecutive patients were treated with refrig‘
erated esteechendral allegra fts fer chendral defects. The
average age ef implanted graft was 23.3 days. At 3-year
fellew-up, medified Cincinnati and IKDC sceres revealed
a statistically significant imprevement. There were ne graft
failures. Level ef evidence: IV.
33. ISemell AH, Prebst C, Farr], Cele I3], Minas T: Lise ef a
type IIIII bilayer cellagen membrane decreases reepera-
tien rates fer symptematic hypertrephy after autelegeus
chendrecyte irnplantatien. Am ] Speeds Med 3303;33i3up-
pl 1,1:233335. Medline DUI
In a multicenter cemparisen study ef 330 patients treated
with periesteum-cevered AC] and 131 patients treated
with cellagen membrane—cevered ACI, the 1-year failure
rates were similar but there was a significantly higher
reeperatien rate fer graft hypertrephy after periesteum-
cevered ACI {153%} than after cellagen membrane-
cevered AC1 {5 3'3}.
34. Hiemeyer P, Lena P, Kreua PC, et a1: Chendrecyte-seeded
type LI'III cellagen membrane fer autelegeus chendre—
cyte transpla ntatien: Prespective 2-year results in patients
with cartilage defects ef the knee jeint. Arthrescep'y
2313;23{3l:13?4—1332.Medline eel
A prespective study ef 59 patients treated with AC1 using
a cellagen membrane te seed the chendrecytes feund that
the percentage ef patients with knees rated nermal er near
nermal increased frem 33.9% befere surgery te 32.5% at
24—mentb fellew—up en the ebjective Internatienal Car—
tilage Repair Seciety rating. IKDC and Lyshelrn sceres
increased frem 50.1 peints and 313.5 peints, respectively,
he 36.] peints {P c 3.031} and 32.5 peints {P c 3.031}.
Level ef evidence: IV.
35. Ha rrisJD, Ericksen E], Abrams {3121, et a1: Methedeiegic
quality ef knee articular cartilage studies. Arrbvescepy
1313;29{?}:1243-1252.e5.Medline DUI
A review ef 194 level I re IV studies feund that ACI was the
meat cemmenly reperted technique {62% ef studies}. The
mest cemmen study weaknesses were related te blinding,
subject selectien precess, study type, sample size calcula-
tien, and eutceme measures and assessment. There was
imprevement in study quality after 2334.
36. I'vh'nas T, Gemell AH, Resenberger R, Reyce 110, Bryant
T: Increased failure rate ef autelegeus chendrecyte im-
plantatien after previeus treatment with marrew stimu-
latien techniques. rim ,7 Sperts Med 1033;33i5iflflla903.
Medline DUI
In a study ef 3.11 censecutive patients treated with ACI,
263:3 ef grafts were unsuccessful ameng these whe had
undergene an earlier bene marrew stimulatien precedure
cempared with 3% ameng these whe had net had a bene
marrew stimulatien precedure.
3?. Heras U, Pelinkevic D, Herr G, Aigner T, Schnettler R:
Autelegeus chendrecyte impla ntatien and esteechendral
cylinder transplantatien in cartilage repair ef the knee
jeint: A prespective, cemparative trial. J Burns jeirrt Sui-g
Am lflfl3;35[2}:135-192. Medline
I3! 2316 American Academy ef flrtbepaedic Surgeens
Chapter 13: Articular Cartilage ef die [line-e
33. Steadman JR, Briggs KK, Redrige J], Kecher M5, Gill T],
Redkey WC: IE’Iutcemes ef micrefracture fer traumatic
chendral defects ef the knee: Average 11-year fellew-up.
Arthrescepy 2333:19i5]:4?7-434. Medline DUI
39. Mitheefer K, 1Williams E] III, 1|Warren RF, et al: The micre-
fracture technique fer the treatment ef articular cartilage
lesiens in the knee: A prespective cehert study. _I Rene
jefflt 5333 Am lflflfi;3?{9}:1911-192{i. Medline DUI
4D. Mitheefet K, McAdams T, Williams R], Kreu: PC,
Mandelbanm ER: Clinical efficacy ef the micrefracture
technique fer articular cartilage repair in the knee: An
evidence—based systematic analysis. Am } Sparta Med
2339:3Tflfliflflfi3-2353.Medline DUI
A systematic review ef 33 studies including 3,133 patients
whe underwent micrefracture fer cartilage injury [average
fellew-up, 41 menths] feund that micrefracture previtles
effective shert-term imprevement ef knee fu nctien but
that insufficient data were available en leng-term results.
41. IE‘reyal D, Keyhani S, Lee EH, Hui JH: Evidence-based
status ef micrefracture technique: A. systematic review ef
level I and II studies. Arrbrescepy 1313:23[9}:15?9-1533.
Medline D0]
A systematic review ef 15 level I er II studies cempated
the clinical eutcemes ef micrefracture with these ef ACI
and esteechendral cylinder transfers. Mest studies re-
perted peer clinical eutcemes. Twe studies reperted the
absence ef any significant difference in the results. Small
lesiens and relatively yenng patients had gee-d shert-term
results, but at 5— te 13—year fellew—up there was a high
rate ef esteearthritis.
41. Gebbi A, Karnataikes G, Kumar A: Leng—term results
after micrefracture treannent fer full-thickness knee chen-
dral lesiens in athletes. Knee Snrg Sperts Trustmdtei Ar-
thresc 2314;12i9}:193E—1336. Medline DUI
Sixty-ene cf 6? patients {91%} were available at an av-
erage final '13.1~year fellew~up after micrefracture. Pain
and swelling during strenuens activity was reperted by
3 patients at 1-year fellew—up and 35 patients at final
fellew—up. Clutceme sceres deterierated ever time. The
cenclusien was that deterieratien ef the clinical eutceme
sheuld be expected after 2 re 5 years. Level ef evidence: IV.
43. Eedi A, Feeley ET, Williams E] III: Management ef artic-
ular cartilage defects ef the knee. ] Bette feirrt Surg Am
2310;93i4j:994-1339.Medline DUI H
F:
This review article fecused en management and eutcemes 5
re
related te articular cartilage defects ef the knee. re
ru-
3
Hangedy L, Debes J, Bale E, Panics G, Hangedyr LR,
D.
Eerkes I: Clinical experiences with autelegeus estee- 3
chendral mesaicplasty in an athletic pepnlatien: A 1'?-
year prespective multicenter study. Am ] Speeds Med
2310:33lfi}:1125-1133.Medline DUI
In a multicenter study, 354 ef 333 patients whe underwent
mesaicplasty were fellewed fer an average ef 9.3 years.
Gee-d te excellent results were feund after 91% ef femeral,
363i: ef tibial, and H33 ef patellefemetal mesaicplasties.
Drtbepaedic Knewledge Update: Sperts Medicine 3
 5ecfien3:l€neeand1eg
Patellefemeral pain related te graft harvest was ebserved
in 5% ef patients. Level ef evidence: IV.
45. Eelheim E, Hegna J, flyen J, nustgulen DE, Harlem T,
Strand T: Gsteechendral autegrafting lmesaicplasty] in
articular cartilage defects in the knee: Results at 5 tn
9 years. Knee Efllfl;l?{1}:S4-3?. Medline DUI
Sixtyrnine patients {median age, 33 years] were available
after mesaicplasty fer a full-thickness chendral defect.
Mean Lyshelm and visual analeg scale pain sceres im-
prevcd frem 43 and 61, respectively, at the time ef sur-
gery te 31 and 24 at 12-menth fellew-up {P e [1.001).
Sceres deterierated te 63 and 32 at 5- tn 9-year fellew-up
{P e {1.01111}.
4S. Selheim E, Hegna J, flyen J, Harlem T, Strand T: Results
at 10 te 14 years after esteechendral autegrafting {me-
saicplasty} in articular cartilage defects in the knee. Knee
2fl13;20{4}:23?-29fl.Medline DUI
Seventy-three patients {median age, 34 years} were avail-
able after mesaicplasty fer a full—thickness chendral
defect. Baseline mean Lyshelm and visual analeg scale
pain sceres impreved significantly at mid- and lung-term
fellew-up. Ferty percent ef patients had a peer eutceme
at lung-term fellew-up; mest ef these patients were age
40 years er elder {59%}, were wemen {513’s}, er had a
defect ef 3 cm1 er larger {5?‘i'r‘bl. In men yeunger than
412} years with a defect smaller than 3 cm1, the failure rate
was 12.5% and the mean Lyshelm scerc was 32.
4?. Gress AE, Shasha M, Rubin P: Lung—term fellewup ef the
use ef fresh esteechendral allegrafts fer pesttraumatic
lenee defects. Gift: Drtbep Reint Res lflfl5;435:?9-3?.
Medline DUI
43. Gress PIE, Kim W, Las Heras F, Backstein I}, Safir D, Fritz-
ker KP: Fresh esteechendral allegrafts fer pesttraumatic
knee defects: Lung-term fellewup. Cilia: Drtbep Refer Res
2008;46:5{31flflfi3-131'fl.Medline DUI
49. Eakay A, Csenge L, Papp G, Fekete L: Gsteechendral
resurfacing ef the knee jeint with allegraft: Clinical
analysis ef 33 cases. Int Ortbep 1993;233:3131.
Medline DU]
50. Raa G, Sal-i: DA, Eacksteiu D], Lee PT, Gress ALE: Dis-
tal femeral fresh esteechendral allegrafts: Fellew'up
at a mean ef twenty-twe years. I Bette Jeiut Surg Am
2014;36f13}:11l31-11fl?.Medline DUI
5‘
'U In a study ef leng-term eutcemes after fresh allegraft
E
I'D transplantatien fer pesttraumatic esteechendral and es-
I11
I11 teechendritis dissecans defects ef the distal aspect ef the
I:
be: femur, 53 patients were fellewed fer a mean 11.3 years.
H
Thirteen patients required further surgery, three under-
went graft remeval, nine underwent cenversien te tetal
knee arthreplasty, and ene underwent multiple débride-
ments fellewed by amputatien abeve the knee.
51. Chahal J, Gress HE, |ll'I'rress C, et al: Dutcemes ef estee-
chendral allegraft transplantatien in the knee. Armres-
cepy 2fl13;29{3]:5?5-533. Medline DUI
firthepaedic Knewledge Update: Sperts Medicine 5
Nineteen studies ef a tetal ef E44 knees {mean fellew-up,
53 menths} were included in a systematic review. All pa-
tients underwent esteechendral allegra ft transplantatien.
Petty-sis: percent ef patients had cencemita ut precedutes,
and the mean defect size was 6.3 cm1. The everall satis-
factien rate was 35%.
52. Terga Spak R, Teitge RA: Fresh esteechendral allegrafts
fer patellefemeral arthritis: Leng-term fellewup. Cfffl
Drtbep Refer Res 2fl065444rl 93-100. Medline D01
53. Petersen L, Minas T, Brittberg M, Nilssen A, Sjfigren-
Janssen E, Lindahl A: Twe— te 9-year eutceme after an-
telegeus chendrecyte transplantatien ef the knee. Gift:
Urtfaep Refer Res lflfifl;3?4:212-134. Medline DUI
54. Petersen L, Erittberg M, Kiviranta I, flkerlund EL, Lindahl
A: Autelegeus chendrecyte transplantatien: Eiemechanics
and leng—term durability. A»: I Sperts Med 2002;3{1l11fl-
12. Medline
55. Minas T: Autelegeus chendrecyte implantatien fer fe-
cal chendral defects ef the knee. Elie Drtbep Rein: Res
EDIE]1;391{Suppl}:5349-5361. Medline DUI
56. McNickle AG, L’Heureua: DR, Yanke AB, Cele E]: flut-
cemes ef autelegeus chendrecyte implantatien in a diverse
patient pepulatien. Am ] Sperts Med 2009;3T{T]:1344-
135i]. Medline DUI
After 13? patients {If-ll] knees} underwent ACI fet a knee
defect {mean size, 5.1 cm‘i}, eutcemes were assessed at
4.3—year fellew-up. A significant imprevement after sur—
gery was ebserved en all eutceme measures. Level ef
evidence: IV.
57’. Petersen L, Vasiliadis H5, Brittberg M, Linda hl A: Antel-
egeus chendrecyte implantatien: A leng-term fellew‘up.
Am J Sperts Med .2fl10;33l5}:111?—1124. Medline DUI
Questiennaires with eutceme measures were sent te 341
patients whe alse were asked te grade their status during
the past 10 years as better, werse, er unchanged; 124
patients replied. At an average ef 11.3 years after surgery
34% ef the patients reperted their status as better er the
same as in previeus years, and 92% were satisfied and
weuld have the ACI again.
53. Minas T, 1|li-"en Keudell A, Bryant T, Gemell AH: A min-
imum 10-year eutceme study ef autelegeus chendrecyte
implantatien. CH1: firteep Reia: Res 1014;4flt11fll-fl.
Medline DD]
At final 12-year fellew-up after ACI fer a symptematic
cartilage defects, 53 ef 210 patients {15%} had at least
ene failed AC1 graft. Nineteen patients went en te at—
threplasty, 2? patients had revisien cartilage repair, 1'
patients declined further treatment, and 3 patients were
lest te fellew—up. ACI previded durable eutcemes with a
survivership ef 751% at 10 years and imprevcd functien
in 1'5 33 ef patients. A histery ef bene marrew stimMatien
er treatment ef a very large defect was asseciated with an
increased risk ef failure.
fl 213115 American Academy ef Orthepaedic Surge-ens

59'. Biant LC, Bentley G, Vijayan S, Skinner JA, Carringten
11W: Leng—tcrrn results ef autelegeus chendrecyte implan-
tatien in the knee fer chrenic chendral and esteechen-
dral defects. Am ] Spar-ts Med 2D14;42{9}:21?3-2IS3.
Mcdline DUI
In 1134 patients whe underwent AC1 fer a symptematic
cartilage lesien, the mean duratien ef symptems hefere
surgery was 2.3 years. The mean number ef previeus sur-
gical pre-cedures en the cartilage defect was 1.3, and the
mean defect sire was 422.1 mmi. Twenty-seven patients
{26%} had graft failure at a mean 5.? years after ACI.
Uf the remaining 23 patients, 46 {-53% cf patients with a
surviving graft} had an excellent result, 13 {25%} had a
geed result, a {3%} had a fair result, and 3 {4%} had a peer
result; 93 cf the Iflfl were satisfied and wenld underge the
precednre again.
Si}. Gemull AH, |ISillee SD, Cele B], et al: Autelegeus
chendrecyte implantatien in the patella: A multicenter
experience. Arr: j Sperrs Med 2014;42{5}:Ifl24-1IJEI.
Medline DUI
In a multicenter study {if III:I patients treated fer a car-
tilage defect ef the patella and fellnwed at least 4 years,
eutceme sceres impreved, 92% cf patients weuld cheese
te underge ACI again, and 86% ef patients rated the knee
as geed er excellent.
til. Pestka JIvI, Ee-de G, Salamann G, Sfldkamp NP, Niemeyer
P: Clinical eutceme ef autelegeus chendrecyte implani
tatien fer failed micrefracture treatment ef full—thickv
ness cartilage defects ef the knee jeint. Am ] Sperrs Med
2fl12;4fl{2}:325-33I. Medline DUI
Patients treated with ACI after unsuccessful micrefracture
had significantly mere failures {2 ef 23 patients} than
these whe received ACI as a first-line treatment {I ef 23
patients].
62. Gudas R, Kalesinskas R], Kimtys V, et al: A prespec-
tive randemised clinical study {if mesaic esteechendral
autelegeus transplantatien versus micrefracture fer the
treatment ef esteechendral defects in the knee jeint in
yeung athletes. Arthrescepy 2Dfl$t2l{9}:1fl5E-1fl?fi.
Medline DDI
.53, Gndas R, Gudaite A, Pecins A, et al: Ten-year fellew-np ef
a prespective, randemised clinical study ef mesaic estee-
chendral autelegeus transplantatien versus micrefracture
fer the treatment ef esteechendral defects in the knee jeint
ef athletes. Am ] Spurts Med 201 2,4I}{I 1 1:249? -25DE.
Mcdline DUI
In a randemised centrelled study, 6D athletes {mean age,
24.3 years] underwent UAT er micrefracture. Statistically
significantly better results were detected in patients in the
UAT greup at 10 -}'car fellew-up {P c {3.0135}. UAT failed
in 4 patients {14%}, and micrefracture failed in 11 {33%}
{P -: 0.0.5}. Level ef evidence: I.
64. Ulstein S, Areen A, Retternd JH, Leken 5, Engehretsen
L, Heir 5: Micrefracture technique versus esteechen-
dral autelegeus transplantatien mesaicplasty in patients
with articular chendral lesiens ef the knee: A prespec-
tive randemised trial with Icing-term fellew-up. Knee
IE! 2Illfi American Academy ef Urthepaedic Surgeens
Chapter 13: Articular Cartilage ef the Knee
Sarg Sperts Tremrmtef Arthresc 2fl14;22{6]:12fl?‘1215.
Mcdline DUI
Eleven ef 25 patients with a full-thickness chend ral lesien
ef the femur were randemly assigned te micrefracture, and
14 were assigned te mesaicplasty. At a median 33-year
Iellew—up, there were ne significa nt hetween—greup differ-
ences in eutceme measures, isekinetic muscle strength, er
radiegrapbic esteearthritis. Level c-f evidence: II.
65. Knutsen G, Engehretsen L, Ludvigsen TC, et al: Antel-
egens chendrecyte implantatien cempared with micre-
fracture in the knee: A randemiaed trial. }' Eerie jeirst See-g
Arr: 20U4;3fi{3]t455-454. Medline
66. Knutsen {I}, Dregset JU, Engehretsen L, et al: A randem-
ised trial cempa ring autelegeus chendrecyte implantatien
with micrefracture: Findings at five years. ] Burrs faint
3mg Arr: 2DflT;39{Ifl}:2Il35-2112. Medline DUI
6?. Saris I3, Price A, 1ifli'idnchnwslci W, et al: Matrix-applied
characterized autelegeus cultured chendrecytes versus
micrefracture: Twe-year fellew-up ef a prespective ran-
demised trial. Am ,7 Sparta Med 2DI4;42{5}:1334-I394.
Medline DUI
In a randemised centrelled study cemparing the use ef
micrefracture and matrix-applied ACI fer symptematic
cartilage defects, the 2-year assessment was cempleted by
I32r ef the 144 patients {mean age, 33.3 years; mean lesien
size, 4.3 cm-i). Uutcemes sceres favered matrix-applied
ACI. Repair tissue quality was geed but did net vary
by treatment. The rates ef treatment failure were 12.5%
after matrix—applied AC1 and 31.9% after micrefracturc.
Level ef evidence: I.
63. Bentley G, Biant LC, Carringten 11W, et al: A prespective,
randemised cemparisen ef autelegeus chendrecyte im-
plantatien versus mesaicplasty fer esteechendral defects
in the knee. ] Berra faint. Sarg Br 2flfl3,35{2}:223—23fl.
Medline DUI
{59. Bentley {3, Eiant LC, Vijayan 5, Macmull 5, Skinner JA,
ILitarringten KW: Minimum ten-year results ef a prespective
randemised study ef autelegeus chendrecyte implantatien
versus mesaicplasty fer symptematic articular cartilage
lesiens ef the knee. I Bees jeint Sarg Br 2fl12:94{4}:51'l4-
509. Medline DUI
A randemiaed study fellewed 1013 patients {mean age,
31.3 years} fer at least 10 years after ACI er mesaicplasty.
Ten ef 53 patients [12%] had failure ef AGI, and 23 ef 42 H
{55%} had failure ef mesaicplasty {P c {1.0131}. Patients F:
5
with a surviving graft had significantly better functien af- re
re
ter ACI than mesaicplasty {P = 1102}. Level ef evidence: I. ru-
3
D.
Ti}. Liu H, Zhae E, Clarke RE, Gan J, Garrett IR, Margerri-
sen EE: Enhanced tissue regeneratien peteetial ef invenile A
articular cartilage. Am ] Sperrs Med 2013:41I11l:2653-
266?. Medline DUI
In a laberatery study, articular cartilage was harvest-
ed frem juvenile and adult bevine femeral cendyles and
cultured fer 4 weeks te meniter chendrecyte migratien,
glycesamineglycan cuntent censervatien, new tissue
Urthepaedic Knewledge Update: Sperrs Medicine .‘i
 Sectionfitlfneeantlleg
formation, cartilage cell density, and proliferative activity.
|Compared with adult cartilage, juvenile bovine cartilage
had significantly greater cell density.I cell proliferation rate,
cell outgrowth, glycosaminoglycan content. and matrix
metallopeptidase-Z activity. |Dnly juvenile cartilage was
able to generate new cartilaginous tissues in culture.
3'1. Adkisson HI} IV. Martin Jet. Amendola RL, et al: The
potential of human allogeneic juvenile chondrocytes
for restoration of articular cartilage. Am J Sports Med
2H1fl;33{?j:1324-1333.Medline DUI
In a laboratory study. cartilage samples were obtained
from juvenile and adult human donors. The chondrogenic
activity of chondrocytes and expanded cells after mono-
layer culture was measured by proteoglycan assay, gene
expression analysis, and histology. Juvenile human chon-
drocytes were found to have greater potential to restore
articular cartilage than adult cells and can be transplanted
without fear of rejection.
TE. Farr J, Tabet SK, Margettison E. Cole E]: Clinical. radio-
graphic, and histiological outcomes after cartilage repair
with particulated juvenile articular cartilage: A 2-year pro-
spective study. An: } Sports Med IDH;42{E}:141?—1415.
Medline DID]
Twenty-five patients {mean age, 31!] years; mean lesion
size, 23c} were treated with particulated juvenile artic-
ular cartilage for a symptomatic chondral defect. Clinical
outcomes were significantly improved 2 years after surgery
compared with baseline. TZ-weighted MRI suggested that
cartilage was approaching a normal level. The repair tis-
sue in biopsy samples from 3 patients was composed of a
mixture of hyaline and fihrocartilage. Staining revealed
a higher content of type II than type I cartilage. Level of
evidence: I‘v’.
7'3. Milano G, Deriu L, Satma Passino E, et al: Repeated
platelet concentrate injections enhance reparative response
of microfractures in the treatment of chondral defects of
the knee: An experimental study in an animal model.
Arthroscopy 2fl12513{5j:ESS-?fl1. Medline DID]
A full-thickness ehondral lesion on the medial fem—
oral condyle was created in 3!} sheep and treated with
E
'U
E
I'D
Ill
I1!
I:
he:
H
Clrthopaedic Knowledge Update: Sports Medicine 5
microfracture. Cine group of animals received five postop-
erative weekly injections of autologous conditioned plas-
ma. The postoperatively treated animals had significantly
better macroscopic, histologic. and biomechanical results
than the nontreated animals at 3., 6. and 12 months.
3’4. Milano C, Deriu L, Sauna Passino E, et al: The effect of
autologous conditioned plasma on the treatment of focal
chondral defects of the knee: An experimental study. hat
I tininnnopatirol Pharrnacoi 2011;14j1, Suppl 211 11114.
Medline
The effect of local application of autologous conditioned
plasma on full-thickness knee cartilage was investigated
in 30 sheep. Cine group of animals received five post-
operative weekly injections of autologous conditioned
plasma. Histologic evaluation at 3 and ti months showed
that these animals had significantly better total scores
than the untreated animals. At 11 months, there was no
significant between-group difference. The local injections
did not produce hyaline cartilage but did promote a re-
parative response of the cartilage defect until 6 months
after treatment.
3’5. Dold AP, Zywiel MG, Taylor DW, Dwyer T, Theodore—
poulos J: Platelet-rich plasma in the management of artic-
ular cartilage pathology: A systematic review. Cfin I Sport
Med 2D14;14I[1}:31—43. Medline not
Analysis of 1D studies found that most assessed the use
of PEP in the treatment of degenerative osteoarthritis of
the ltnee or hip. Most patients were treated with intra-
articular injections, but two studies used PRP as an ad-
junct to surgical treatment. Significant improvements in
joint-specific clinical scores. general health scores, and
pain scores were reported at 6-month follow-up, but few
studies provided longer term data. No studies reported
worse scores compared with baseline at final follow-up.
Video Reference
13.1: Chalmers F. Yankc A. Sherman S, Karas "it". Cole B]: Video.
Cornhineii Cartilage Restoration and Distal Realignment for
Patelfar and Troeftfear Chonrfraf Lesions. Chicago, IL, lflll.
fl lfllfi American Academy of Orthopaedic Surgeons
Chapter 19
Nonarthroplasty Management
of Osteoarthritis of the Knee
Ljiljana Bogunovic. MD lEharles A. Bush—Ioseph. MD
The knee is the most common site of osteoarthritis. With
an aging population, the prevalence of this progressive
disease is increasing. The management of symptomatic
osteoarthritis of the knee can be challenging. Although
joint arthroplasty generally is effective after unsuccess-
fnl nonsurgical management, several other treatment
modalities can be successfully implemented before joint
arthroplasty is considered.
Keywords: osteoarthritis of the knee:
nonarthroplasty management of osteoarthritis
Introduction
Osteoarthritis of the knee is a common source of pain
and disability in adults who are middle aged or older.
According to BEIGE estimates, knee osteoarthritis affected
33% of people older than 65 years in the United States.‘
Lifestyle changes such as weight loss and exercise as
well as medications, injections, and, in some patients,
joint-preserving surgery can help minimize the progress
of knee osteoarthritis, manage pain, and delay the need
for joint arthroplasty.
Patient Evaluation
History and Physical Examination
The evaluation of symptomatic osteoarthritis of the
knee begins with a detailed patient history and physical
examination. The patient’s symptoms and response to
Neither of the foiiowing authors nor any immediate family
member has received anything of vaiue from or has stock or
stock options held in a commercialI company or institution
reiated directly or indirectiy to the subject of this chapter:
Dr. Bogunovic and Dr. Hush-Joseph.
fl lflld American Academy of Drtbopaedic Surgeons
Table 1
Key Information From the Patient History
Current medications
History of injury or prior surgery
Instability
Mechanical symptoms
Medical tomorbidities
Location of pain {unicompartmental or global}
Response to previous treatments
Swelling
Symptom duration
previous therapy will help guide future treatment and
allow an accurate prognosis to be determined {Table 1}.
A patient who is overweight should be asked about any
recent weight gain or loss and current weight-maintenance
strategy. A comorbidity such as renal or peptic ulcer dis-
ease and social factors that could affect the treatment
strategy, such as residence in a nursing home, also should
be determined.
The patients gait as well as lower body alignment,
range of motion, and ligamentous stability should be
assessed and documented {Table 2}. Catching or lock-
ing, instability, or an effusion can signal the presence of
a mechanical pathology warranting surgical treatment.
The lumbar spine and hips should be examined because
H‘
pathology in one of these locations often appears as pain F:
5
referred to the knee. The lower extremities should be or
m
ru-
examined for evidence of muscular atrophy or weakness, 3
D.
with particular attention to hip abductor and quadriceps
strength. Distal sensation and vascular perfusion {periph- s
eral pulses} should be assessed in all patients, and any
abnormalities should be documented.
Imaging
Baseline weight—bearing radiographs should be obtained
in all patients with symptomatic osteoarthritis of the
Drthopaedic Knowledge Update: Sports Medicine 5
 SectionS:Kne-eand1eg

knee. A standing PA view obtained with the patient’s knee progression of osteoarthritis of the knee.3'i'Dhesity
in 45" of flexion often is preferred over the standard stand- has been identified as an independent risk factor for
ing AP view.2 The flexion view allows better evaluation osteoarthritis of the knee; it increases the likelihood of
of the posterior femoral condyles and earlier detection symptomatic disease as much as threefold.” Patients with
of subtle joint-space loss than the AP view2 {Figure 1). coexisting lrnee malalignment, particularly genu varum,
Additional radiographs should include a lateral view of have an even greater susceptibility to the negative effect
the affected side and a Merchant or sunrise view of the of excessive body weights" A clinical practice guideline of
patellofemoral joint. the American Academy of Orthopaedic Surgeons [AAG 5}
recommends weight loss for patients who have symptom—
atic osteoarthritis of the knee and are overweight {deli ned
Nonsurgical Management
as a body mass index above 25 kgi'm'lii” {Table 3}. Forces at
Weight Loss the knee are magnified to three to seven times the actual
Maintenance of a healthy body weight is effective for body weight, and therefore even a small change in body
decreasing the severity of symptoms and slewing the weight can have a significant effect on joint loading at
the knee.3 At a minimum, the patient who is overweight
should strive to lose 5% of his or her current body weight
and to maintain the decreased weight with a combination
Key Information From the of diet and exercise.”"”
Physical Examination
Alignment [va rus or valgus, rigid or flexible}
Exercise and Activity
Regular physical activity was found to improve physical
Effusion
function and quality of life in patients with symptom-
Instability
atic osteoarthritis of the knee.1'13'” AADS strongly rec-
Ipsilateral hip comparison
ommends patient participation in a self-management
Joint line tenderness
program such as the Arthritis Foundation exercise
Lower extremity strength (guaclricelflr. ‘ElluteusfilI
programfib” Such programs typically extend over 6 to
Peripheral pulses and sensation
3 weeks, are offered at a local hospital or community
Previous incisionis}
center, and focus on lower extremity and core muscu-
Range of motion lature strengthening, low—impact aerobic activity, and

S
'U
E
I'D
Ill
I1!
I:
hr:
H

a 'v ! r. l
Figure 1 Standing AP {A} and 45" fIExion PA weight-bearing {Rosenberg} {Bi radiographs of a patient with osteoarthritis.
Wear on the left posterior lateral con dyle can be seen in B.

firthupaedic Knowledge Update: Sports lviedich'ie 5 fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 19: Nonartbreplasty Management of Clsteomtln'itis of the Knee

Summary of AADS Clinical Practice Guideline Recommendations

Modality Recommendation Strength'
Activity and lifestyle
Lateral wedge insole for medial osteoarthritis Cannot suggest Moderate
Physical activity Recommend Strong
Unloader bracing for medial osteoarthritis Unable to recommend Inconclusive
Weight loss (patient with body mass index of Suggest Moderate
25 Icglr‘m2 or higher}
Medications and supplements
Acetaminophen Unable to recommend lnconclusive
Glucosamine andior chondroitin Cannot recommend Strong
NSAIDs {oral and topical} Recommend Strong
Clpioids or pain patches Unable to recommend Inconclusive
Tramadol Recommend Strong
Alternative treatments
Acupuncture Cannot recommend Strong
Electrotherapeutic and manual therapy Unable to recommend lnconclusive
Intro-articular injections
Corticosteroids Unable to recommend lnconclusive
Growth factors, platelet-rich plasma Unable to recommend lnconclusive
Hyaluronic acid Cannot recommend Strong
Needle lavage Cannot suggest Moderate
Surgical treatments
Arthroscopic lavage andl'or debridement Cannot recommend Strong
Arthroscopic partial meniscectomyr Unable to recommend lnconclusivt.I
Valgus proximal tibial osteotomy for medial Might recommend Limited
compartment osteoarthritis
' lnconclusive = A laclr. of compelling evidence has resu tied in an unclear balance between the benefits and potential harm; practitioners
should not be constrained from following the recommendation. Limited = The quality of the supporting evidence is unconvincing, or well-
Cond uctecl studies show little clear advantage to one approach over another; practitioners should exercise clinical judgment when following
the recommendation. Moderate = The benefits exceed the pets ntlal harm {or the potential harm clearly exceeds the benefit in a negative
recom mendationl. but the quality or applicability of the supporting evidence is not strong: practitioners generally should follow the
recommendation but remain alert to new information and be sensitive to patient preferences. Strong - The quality of the supporlj ng evidence is
high; practitioners should follow this recommendation unless there is a clear and compelling rationale for an alternative approach.

Data from American Academy of firth opaedic Surgeons: Featment of Dsteoarthritis of the Knee: Evidence-based Guidelines, ed 2. Hosemont.
IL, American Academy of Drthopaedic Surgeons, 1m El. http:irwww.aaos.orgfflesea rdliguidelinesll'Treatmentofflsteoarthrifisoftheltneet‘i uideline.
pdt. Accessed Dctober 31. 101-1. H
F:
5
re
re
ru-
neuromuscular training. Patients receive information on such as water aerobics, walking, swimming, cycling, and 3
D.
activity modification, healthy eating, stress management, tai chi can increase cardiovascular endurance, lower esc-
and disease progressionP-“Ji trcmity strength, mobility, and balance, with minimal a
General activity recommendations for patients with impact on the knees?“
osteoarthritis of the lcnee include avoidance of high—im—
pact activities and repetitive heavy lifting, squatting, Physical Therapy
crouching, or climbing.” Patients can safely undertake A patient who is sedentary or has a persistent deficit in
at least 150 minutes of moderate activity each week with strength or mobility after completion of a self—manageu
no risk of worsening the disease progre-ssion.“l+111 Activities ment program can benefit from a course of prescribed

IE! EUIE American Academy of Clrchopaedic Surgeons Drtbopaedic Knowledge Update: Sports Medicine 5
 Section a: Knee and Leg

——
Summary of AADS Appropriate Use Criteria Recommendations
Modality lilecommendationil
Actlvlty and lifestyle
Hinged knee brace andror unloading brace May be appropriate
Prescribed physical therapy Appropriate
Self-management program Appropriate
Medications
Acetaminophen Appropriate
Intra-a rticular corticosteroid Appropriate
Narcotic for refractory pain Rarely appropriate
HSAIDs {topical or oral} Appropriate
Trarnadol May be appropriate
Surgical treatments
Meniscectomy or loose body removal Rarely appropriate”
Realignment osteotomy Rarely appropriate
" Appropriate I The treatment is generally acceptable, reasonable for the indications, and liltely to improve the patient's health outcome or
survival. May be appropriate = The treatment may be acceptable and reasonable for the Indication. but uncertainty Implles that more researd1
andror patient information is needed to further classify the indication. Ra rely appropriate = The treatment rarely is appropriate for patients
with symptomatic osteoarthritis of the ltnee because of the Iaclc of a clear benefitvrislc advantage; the clinical reasons for proceeding with the
treatment should be documented in case of an exception.

” May be appropriate for patients with mechanical symptoms.

Data from American Acaderny of llilrthopaeelic Surgeons: Appropriate Use Criteria for Hon-arthropi'asty Treatment of Osteoarthritis of the Knee.
Rosemont. IL. American Academy of orthopaedic Surgeons. 21113. http:rAvww.aaos.orgrResearchrApprop-riateJJseroaltaucfu|l.p-df. Accessed
October 31. 2011i.

physical therapy?“ Extensor mechanism weakness is
common in patients with symptomatic osteoarthritis
of the knee and has been associated with exacerbation
of symptoms and disease progression.”'35 Therapist-su-
pervised exercises directed at quadriceps strengthening
can be helpful in alleviating pain, decreasing subjective
instability, and improving overall function?5 Physical
therapy also can be helpful in improving proprioception
and neuromuscular control. Dnly limited data support the
use of physical therapy to improve range of motion and
flexibility in patients with osteoarthritis of the knee.” If
possible, a prescribed physical therapy program should
E
'U
include a transition to a patient-directed home program
E
I'D
at the completion of formal therapy.
Ill
all
i:
be: Bracing
The routine use of a brace is not recommended for man—
H
unicompartmental medial or lateral osteoarthritis, re-
spectively?“ Unloader braces exert an external moment
at the joint during gait and thereby shift axial joint forces
preferentially toward the normal compartmentM {Fig-
ure 2]. A biomechanical study found that the greatest
load reduction occurred during stair ascending and de-
scendingf'B Au unloader brace can be helpful for an active
patient who wants to delay surgical treatment {osteotomy
or arthroplasty}.
Pain relief during a trial of brace wea ring was found to
predict a favorable outcome of realignment ostcotomy.“
Medial-side disease was found to be more responsive
to bracing than lateral-side disease.2F Bracing can be
effective in the setting of fixed deformity, but most brace
manufacturers recommend bracing only for patients with
no more than lfl'“ of vatus or valgus deformity.“ Insta—
bility, especially excessive medial or lateral collateral

aging the symptoms of osteoarthritis of the knee, but in
some patients the use of an unloader brace was found to
decrease pain and improve functionf'df-H'” According
to the 2(113 AAGS Appropriate Use Criteria [Table 4),
treatment with a valgns- or yarns—producing unloader
brace may be appropriate for a patient with symptomatic
laxity in the affected compartment, is a contraindication
to unloader bracing. Concomitant arthritis of the patel-
lofemoral joint is not considered a contraindication.“
lCustom braces were found to be slightly more effective
than off—the—shelf braces, and a custom brace may be
required to achieve the desired fit and force generation

firthopaedic Knowledge Update: Sports Medichie S Q lflld American Academy of Orthopaedic Surgeons
 Chapter 19: Nonarthroplasty Management of Dsteoarthritis of the Knee
Figure 2 Photographs shows flte use of a varus unloader brace to treat valgus malalignment {A} and lateral compartment
osteoarthritis {B}.
for a patient who is obese.” Patient tolerance is one of
the main limitations of unloadcr bracing. The load dis—
tribution depends on the stiffness and angulation of the
brace, and the brace specifications required to achieve a
load reduction of more than 25% are not well tolerated
by most patients.IEI
Taping and Insoles
Therapeutic taping can be helpful in managing the symp-
toms of patellofemoral osteoarthritisfilfl The use of a
taping technique such as McConnell taping generates a
medially directed force across the patella, provides short-
term pain relief, and improves function?“33 The use of
a lateral heel—wedge insole for symptomatic medial com-
partment osteoarthritis was not found to be effective and
is not recommended?”
Alternative Therapy
High-quality studies did not find acupuncture to be ben—
eficial in the treatment of symptomatic osteoarthritis of
the knee, and it should not be recommended? Little or
no benefit was documented when an electrotherapeutic
modality such as electrical stimulation was nsed.35~3‘5 The
IE! Ellie? American Academy of flrthopaedic Surgeons
risks and benefits of manual therapy and tlltl'tlfllflngraphy
have not been establishedfiifidl'
Medications
Monsteroidal Anti-inflammatory Drugs
NSAIDs are recommended as a first-line treatment for
patients with osteoarthritis of the knee. Both oral and top-
ical HSAID preparations are effective in alleviating pain
and swelling.T Because of their possible renal, cardiovas-
cular, and gastrointestinal adverse effects, HSHIDs should
be used with caution in patients older than Ell years and
those with a medical comorbidity. The gastrointestinal
H
effects of a nonselective oral NSAID can be minimised F:
5
in patients with moderate risk factors by coprcscribing a re
to
ru-
proton-pump inhibitor or substituting a selective cyclo- 3
D.
oxygenaseHZ inhibitor.35 Complete avoidance of all oral
NSAIDs is recommended for patients at significant risk s
for an adverse effect.35
Acetaminophen
The 2fl13 FLAGS clinical practice guideline on manag-
ing osteoarthritis of the knee reported a lack of compclu
ling available evidence to support acetaminophen use.5+
Drthopaedic Knowledge Update: Sports Medicine 5
 ssmsnsmsssansteg
Nonetheless, FLAGS still considered treatment with ac-
etaminophen to be appropriate for patients with osteo-
arthritis of the knee because of its favorable safety profile
and potential analgesic effects?” Acetaminophen can
be particularly helpful in patients who are older than
69 years or have a comorbidity that precludes long—term
NSAID use. Treatment and dosage should be maintained
within the prescribed limits to prevent hepatotoxicity.“
Tramadol
Tramadol was found to he as effective as NSAIDs for
alleviating the pain associated with osteoarthritis of the
knee.?~”~39 This atypical opioid analgesic medication can
be particularly useful in patients who are older than fill]
years or have a medical comorbidity because it has no
cardiovascular, renal, or gastrointestinal adverse effects.
Unlike NSAIDs, tramadol has no effect on the inflam—
mation associated with osteoarthritis.”
flpioids
The routine use of oral or transdertual narcotic medica-
tions is not recommended for patients with osteoarthritis
of the knee."'35 A recent systematic review found a sig—
nificant risk of adverse events that far outweighed the
relatively insignificant pain control benefit.‘m
Nutritional Supplements
Data from several high-quality studies showed no benefit
from the use of a daily glucosamine andfor chondroitin
sulfate supplement?~”~”~“ Ginger was found to be mod-
erately effective in alleviating arthritis pain.“- Avocado
soybean unsaponifiables also had moderate to high ef-
ficacy for short-term pain relief in osteoarthritis of the
knee, but a long-term effect has not been established.”=‘*3
Injections
Corticosteroids
lntra-articular corticosteroid injection is effective for
managing the symptoms of osteoarthritis of the knee,
and the AADS considers it to be an appropriate treat—
ment option.” Corticosteroid injection can be a helpful
f
'U
treatment adjunct after unsuccessful nonpharrnacologic
E
I'D
or oral NSAID or analgesic therapy. Reliable pain relief
Ill
I1! lasting approximately 4 weeks can be expected after in-
I:
I jection.“"'*‘15 Treatment with corticosteroid injection can
reduce symptoms sufficiently to allow initiation of life—
H
style changes such as increased activity. The minimal
interval between injections is 3 months; if more frequent
pain relief is needed, other treatments should be consid-
ered.“ I{Zomparisous of intra-articular hyaluronic acid
and corticosteroid injections found that corticosteroid
was more effective in alleviating painfi‘mf
firthopaedic Knowledge Update: Sports Medicbie 5
Hyaluronic Acid
The benefit of intra-articular hyaluronic acid remains
debatable. Several studies found that viscosupplementa-
tion led to a statistically significant improvement in pain,
but recent analysis, including an evidence-based review
by HAD 5, suggested that treatment with hyaluronic acid
did not meet the threshold for a minimum clinically im-
portant differencefdiif Reliance on this criterion as a
primary metric for treatment efficacy is controversial,
however, and the AACIS guideline was criticized for re-
lying on it.“ The effect of intra-articular hyaluronic acid
probably depends on several factors including the severity
of osteoarthritis, the patient’s age, and limb alignment.
In a comparison of infra—articular corticosteroid and by
aluronic acid injections, corticosteroid appeared to be
more effective in alleviating pain during the first 4 weeks
after injection, but hyaluronic acid was more effective
beyond 3 weeks after injection.“ A recent systematic
review reported a small and clinically irrelevant improve-
ment in pain after hyaluronic acid injection as well as a
significant increase in the risk of serious adverse events
including a postinjection flare reaction.” The addition
of corticosteroid to a viscosupplementation injection was
found to decrease the postinjection pain associated with
viscosupplementation alone.“ Practitioners should exer-
cise clinical judgment when considering this treatment
modality by weighing the potential for improving the
patient’s pain against the risk of adverse events.
Growth Factors and Platelet-Rich Plasma
The benefits of using growth factors or a biologic agent
such as platelet-rich plasma (PEP) or mesenchymal stem
cells in treating osteoarthritis has not been established.
In theory, these agents provide biologic stimulation for
articular cartilage maintenance and possibly repair. A sys-
wmatic review of level I and II studies found a short-term
{6-month} beneficial effect of PEP treatment on subjective
outcomes in patients with mild to moderate osteoarthritis,
but the risk of nonspecific adverse events was increased.”19
A ra ndomiaed controlled study comparing treatment with
PRP and treatment with hyaluronic acid found no signifi-
cant between-group difference in patient-rated outcomes
at 12-month follow—up.m Subgroup analysis revealed a
trend toward better patient function after PRP treatment in
patients with mild osteoarthritis {defined as KellgrenuLaw-
rence grade 1 or 2}. The rate of adverse reactions, par-
ticularly postinjection pain, was higher in patients who
received PEP than in those who received hyaluronic acid.”
The use of PEP for the treatment of osteoarthritis of the
knee is not currently approved by the US FDA, and its
off—label use typically is not covered by insurance plans.
More investigation into the efficacy, safety, and optimal
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 19: Nonarthroplasty Management of Deteomtbritis of the Knee
preparation of PRP is needed before it can be routinely
need for the treatment of osteoarthritis of the knee.
Surgical Treatment
Arthroscopic Debridement and Lavage
Arthroscopic debridement and lavage of the knee is not
recommended for a patient with a primary diagnosis of
osteoarthritis?” Cine high-level study found no benefit
to using this treatment modality.51 In patients with me-
chanical symptoms secondary to the presence of a loose
body, knee arthroscopy with loose body removal may be
beneficial, especially if the patient has mild to moderate
osteoarthritis.
Arthroscopic Menistectomy
The effectiveness of arthroscopic partial meniscectomy
for patients with osteoarthritis of the knee and a con-
comitant meniscai tear remains an area of debate. In a
randomised controlled study comparing partial arthro-
scopic meniscectomy with physical therapy, an inten-
tion-to-treat analysis found no between-group differences
in patient—rated outcomes at 12—month follow—up?2 There
was a 35% crossover from the physical therapy group
to the surgery group, however. A second randomised
controlled study compared arthroscopic partial menis—
cectomy with diagnostic arthroscopy and found no differ-
ence in patient-rated outcomes at 12-month follow-up.”
Exclusion of patients with a traumatic meniscai tear,
lateral tear, acnte tear, acnte-on-chronic tear, or radio-
graphic evidence of osteoarthritis limited the relevance
of the study results for the general population of patients
with osteoarthritis of the knee.” Additional data sug-
gested that the benefits of partial meniscectomy may be
limited to patients with mild to moderate osteoarthritis
who have a large, unstable meniscai tear and mechanical
symptoms-”'5“ These patients may experience symptom—
atic improvement after partial menisectomy. Given the
limited indications, nonsurgical treatment including
physical therapy, NSAIDs, and injection should be tried
before surgical intervention is considered for patients with
osteoarthritis and meniscai pathology?
Realignment Osteotomy
Knee malalign ment is a known risk factor for the develop-
ment and progression of osteoarthritis.“*“ Realignment
osteotomy rarely is indicated but can be considered for
a patient who is active, younger than 55 years, and not
obese and who has moderate varus or valgus deformity,
mild to moderate unicompartmental disease, stable co]-
lateral ligaments, and a near—normal range of motioni-IH'
{Table 5}. A trial of unloader bracing can be helpful in
IE! lfllfi American Academy of flrtbopaedic Surgeons
_
Contraindications to Realignment Dsteotomy
for Symptomatic Dsteoarthritis of the Knee
Relative Contraindications Absolute
Contraindications
|IZ'lbesity Contralateral
Moderate to severe compartment
osteoarthritis of the knee DF'ZEUEI rth “115
Age older than 5i] years “$3333 flf IEES than
Patellofemoral arthritis
Collateral laxity Fleslon contracture of
more than 10”
predicting response to surgical realignment.” Arthrosco-
py before osteotomy often is recommended to confirm the
absence of osteoarthritis in the remaining compartments
and to allow any concomitant meniscai or chondral pa-
thology to be treated.
A medial opening wedge high-tibial osteotomy is be-
coming the preferred realignment technique for isolated
medial compartment disease'i"""'3 {Figure 3}. A ra ndomired
controlled study comparing medial opening wedge and
lateral closing wedge high-tibial osteotomies found no
differences in patient-rated outcomes or maintenance
of alignment at 6—year follow—up.“- At 5—year follow—up,
the medial opening wedge technique was associated
with more postoperative complications but 14% fewer
conversions to total knee arthroplasty than the lateral
closing wedge technique {3% versus 11%}. The medial
opening wedge technique is more sensitive to sagittal
plane alterations of the tibial slope than closing wedge
techniques {Figure 4). Overall survivorship of a high-tib-
ial osteotomy for medial compartment disease was found
to range from 33% to 96% at 5-year follow-up, from
63% to 9?% at lfl-year follow-up, and from 5?% to
90% at 15—year follow—updm'fi“I Neither medial not lateral
high-tibial osteotomy affected the functional outcomes
or survivorship of a subsequent total knee arthroplasty.“
In patients with lateral compartment disease and val-
gus deformity, a lateral opening wedge distal femoral oste-
H
otomy can be used.if The outcome of the yarns-producing F:
5
osteotomy appears to be less affected by concomitant to
to
to
patellofemoral arthritis than patients with medial com- :l‘
D.
partment arthritis undergoing a valgus producing oste-
otomy.“ A 50% conversion rate to total knee arthroplasty s
was reported within 15 yearsfiI-Ei'
S u rn Ina ty
The nonarthroplasty treatment of symptomatic osteo-
arthritis of the knee is a common clinical challenge.
Drtbopaedic Knowledge Update: Sports Medicme 5
 Section 3: Knee and Leg

1
Figure 3 Full-length standing AF radiographs of a patient with left knee medial compartment osteoarthritis and varus
alignment. A, The mechanical axis is drawn from the center of the femoral head to the center of the ankle. The
line passes through the medial compartment. indicating va rus alignment. B. Preoperative tem plating for a high-
tihial osteotomy of the left leg. The goal is to shift the mechanical axis to a point at 62.5% of the width of the
tibial plateau. as measured from the medial edge. A line is drawn from the center of the ankle [a] to this point
and from the center of the femoral head [hi to this point. The angle formed by the intersection of these two lines
represents the angle of correction [14"]. The osteoton'iy cut (dash ecl line] starts on the medial cortex at a point
approximately 4 mm from the joint line and continues laterally to the level of the fibular head. The lateral cortex
is left intact. Cine millimeter of opening corresponds to one degree of correction. C. The left knee after a medial
opening wedge high=tibial osteotomy.

of biologic therapies such as PEP is under investigation.

In selected patients, nonarthroplasty surgical procedures
such as realignment osteotomy can help to alleviate symp-
toms. In the absence of mechanical symptoms. arthro-
scopic débridement has not been shown to be an effective
treatment strategy.

Key Study Points

I A variety of nonsurgical treatment modalities can

Figure 4 Schematic drawings show alteration of the
tibial slope with plate positioning in a medial
opening wedge osteotomy. A. Direct medial
placement of a rectangular wedge plate does
not change the slope. B. In a knee with a
deficiency in the anterior cruciate ligament.
anterior translation of the tibia can be
reduced by decreasing the tibial slope with
E posterom edial placement of a rectangular
wedge plate {left} or with a taper wedge
'U
E plate {right}. I2. Increasing the tibial slope
I'D
with anteromedial placement of a rectangular
Ill
all wedge plate can decrease posterior tibial
I:
hr: translation in a knee with a deficiency in the
posterior cruciate ligament.
H
he used to treat the symptoms and decrease the pro-
gression of symptomatic osteoarthritis of the knee.
I Weight loss for patients with a body mass index
above 25 ltgi’mI is effective in decreasing pain and
minimizing the progression of symptomatic osteo-
arthritis of the knee.
I Intra-articular corticosteroid injections are effective
for symptomatic management of osteoarthritis of
the knee.
I Ural supplementation with glueosamine andr'or
chondroitin sulfate has no benefit for management
of symptomatic osteoarthritis of the knee.
I Continued study is needed to identify the benefits
of PRP and stem cell therapy in the treatment of
osteoarthritis of the knee.

I In the absence of mechanical symptoms, knee

arthroscopy with débridement is not effective in
Patients may experience substantial pain and disability. treating osteoarthritis of the knee.
Lifestyle modifications including weightless and exercise
as well as the use of NSAIDs or intra—articular injections
can reliably decrease pain and improve function. The role

firthopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons
 Chapter 15-": Nenarthreplasty Management ef Dsteeartluitis ef the Knee
Annetated References
. Helmick CG, Felsen DT, Lawrence RC, et al; Natienal
Arthritis Data Werkgreup: Estimates ef the prevalence
ef arthritis and ether rheumatic cendin'ens in the United
States: Part I. Arthritis Rheum Zflfl'flfi31:11:15-25.
Medline DDI
. Resenherg TD, Paules LE, Parker RD, l{Inward DB,
Scett 5M: The ferty-five-degree pestereauterier flexieu
weight-hearing radiegraph ef the knee. J Bene Jeint Surg
Am 1933;?0t1fl}:14?9-1433. Medline
. Yates A] Jr, McGrery B], Sta rs "1W, 1|Itincent KR, McCar-
del E, Gelightly TM: AADS apprepriate use criteria: Dpti-
miaing the nee-arthremasty management ef esteearthritis
ef the knee. J Am. Aced Drthep Surg 2014;22H}:261-261
Medline DDI
The 2013 AADS apprepriate use criteria fer the nenar-
threplasty management ef esteearthritis ef the knee were
reviewed and applied te examples.
. Changulani fvi, Kalairaiah ‘1', Feel T, Field RE: The re-
latienship between ehesity and the age at which hip and
knee replacement is undertaken. J Bene jeint Surg Br
aeeseenpseeessmeetm: net
. Blagejevic I'vl, Jinks C, Jeffery A, Jerdan KP: Risk facters
fer enset ef esteearthritis ef the knee in elder adults:
A systematic review and meta-analysis. Dsteeerthritis
Cartilage 2U1fl;13{1}:24-33. Medline DUI
A systematic review feund an increased risk ef estee-
arthritis ef the knee with ehesity ledds ratie, 2.63} and
previeus trauma {edds ratie, 3.36). Level ef evidence: ”it.
. Gandhi R, Wasserstein D, Raaak F, Davey JR, Ma—
hemed NH: EM] independently predicts yeunger age
at hip and knee replacement. Dhesity (Silver Spring}
aeiensciayessa—asss.Medusa net
A retrespective review ef patients undergeing hip and knee
replacement feund that ehesity [hedy mass index greater
than 25} was asseciated with signifies ntly decreased age at
the time ef hip er knee arthreplasty. Level ef evidence: IV.
. Bruyiere ID, Ceeper C, Pelletier J-P, et al: An algerithm rec-
emmendatien fer the management ef knee esteearthritis
in Eurepe and internatieeally: A repert frem a task ferce
ef the Eurepean Seciety for Clinical and Ecenemic As-
pects ef Dsteeperesis and Dsteearthritis [E SEED}. Semin
Arthritis Rheum lfll4:44{3k253—163. Medline DUI
Guidelines fer the nenarthreplasty management ef es—
teearthritis ef the knee were established by the Eurepean
Seciety fer Clinical and Ecenemic Aspects ef Usteeperesis
and Dsteearthritis, which is cnmpnsed ef rheumatelegists,
clinical epidemielegists, and clinical scientists.
. Sewers ivi: Epidemielegy at risk facters fer esteearthritis:
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451. Medline DDI
ID lfllfi American Academy ef Drthepaedic Surgeens
9. American Academy ef lDrthepaedic Sn rgeens: Treatment
esteeerthritis efthe Knee.- Euidente-heseci Guidelines,
ed 2. Resement, IL, American Academy ef Drthepaedic
Surgeens, 2013. http:iiwww.aaes.ergiResearchiguide-
liuesiTreatmentefDsteearthritiseftheliueefluideline.pdf.
Accessed Dcteher 31, 2014.
The AADS evidence-based guidelines included methed-
elegy and guidance fer the nenarthreplasty management
ef esteearthritis ef the knee.
111}. Richmend J, Hunter D, Irrgang J, et al._'I American Acad-
emy ef Drthepaedic Surgeens: American Academy ef
Drthepaedic Surgeens clinical practice guideline en the
treatment ef esteearthritis {DA} ef the knee. J Bene Jeint
SurgAm 2fl10592{4}:99fl-993. Medline DE]
The first editien ef the American Academy ef lDrthe-
paedic Surgeens evidence—based guidelines fer the
nenarthreplasty management ef esteearthritis ef the knee
was reviewed.
11. Christensen R, Bartels EM, Astrup A, Eliddal H: Effect
ef weight reductien in ebese patients diagnesed with knee
esteearthritis: A systematic review and meta-analysis. Ann
Rheum Dis BUDAEAHHJS-Afifl. Medliue DDI
12. Felsen DT, Zhang Y, Antheny lf, Naimark A, Andersen
JJ: Weight less reduces the risk fer symptematic knee
esteearthritis in wemen: The Framingham Study. Ann
intern Med 1952;116[?}:335-539. Medline DD]
13. Messier 5P, l'viihalke 5L, Legault C, et al: Effects ef inten-
sive diet and exercise en knee jeint leads, inflammatien,
and clinical eutcemes ameng everweight and ehese adults
with knee esteearthritis: The IDEA randemieed clinical
trial. ye are seisgsieunnaesaavs. Medline ecu
A randemiaed centrelled study ef adults whe were ever-
weight and had esteearthritis ef the knee feund that
cembined diet and exercise led tn impreved weight less,
reductien ef interleukin-e levels, and impreved quality-
efnlife sceres cempared with diet er exercise alene. Level
ef evidence: I.
14. Messier 5P, Leeser 11F, Miller GD, et al: Exercise and
dietary weight less in everweight and ebese elder adults
with knee esteearthritis: The Arthritis, Diet, and Activity
Premetien Trial. Arthritis Rheum 212104;?Elli}:1501 —1 51i].
Medline DUI
15. American Academy ef IDrthepaedic Surgeens: Apprepri— H1
site use criteria fer nen-nrthrepiesty treatment ef estee- F:
5
urthritis ef the hnee. Resement, IL, American Academy re
re
ef Drthepaedic Surgeens, H.113. l'Ittpaf'iwww.aaes.ergiIf ru-
ResearchiApprepriate_Useieakaucfull.pdf. Accessed Dc-
3
D.
teher 31, 2fl14.
s
The AADS apprepriate use criteria included methedelegy
and guidance fer the nenarthreplasty management ef
esteearthritis ef the knee.
16. IIL'leleman S, Briffa Nit, Ca rrell G, Inderjeeth 1'3, Geek N,
McQuade J: A raedemised centrelled trial ef a self-man-
agement educatien pregram fer esteearthritis ef the knee
Drthepaedic Knewledge Update: Sperts Medicme 5
 seasonasassaneteg
delivered by health care preiessienals. Arthritis Res Ther
2fl12:14{1]:R21.Medline III-DI
A randemized cnntrnlled study feund better patient-
repnrted nutcnmes in patients with esteearthritis whn
underwent a self-management pregram, in cemparisen
with centrel subjects. Level ef evidence: II.
1?. Jevsevar D5: Treatment ef esteearthritis ef the knee:
Evidence-based guideline, 2nd editic-n. f Arrt Acad Cir-
tbnp Stirg 2fl13;21{9}:521-5?E. Medline DflI
The secend editinn ef the AACIS evidence-based clinical
practice guideline en the nenarthreplasty treatment ef
esteearthritis ef the knee was reviewed.
13. Euckwalter JA, Lane NE: Athletics and esteearthritis. Am
I Sperts Med 199?;25ifi]:8?3-831. Medline DID]
15'. Earbeur FIE, Heetman JM, Helmick CG, et a1: Meeting
physical activity guidelines and the risk nf incident knee
nsteearthritis: A pepulatien-based prespective cehert
study. Arthritis |Care Res {Hebekers} 2014;66[1}:139-H6.
Medline DUI
A. retrnspective review of 1,522 adults feund ne asse-
ciatien between high levels nf physical activity and the
dcvelepmeut ef symptnmatic estcearthritis ef the knee.
Level ef evidence: IV.
2E. Fransen M, McEennell 5: Exercise fer esteearthritis ef the
knee. Cecivrarte Database Syst Rev 2|Jfl H;fl[4}:CDDfl-‘-l326.
Medline
21. Barrels El'vl, Lund H, Hagen KB, Dagfinrud H, Chris-
tensen R, Danneskield—Samsae B: Aquatic exercise fer
the treatment ef knee and hip esteearthritis. Cecbrerte
Database Syst Rev 200?:4:CDDG5523. Medline
22. Kang 11?, Lee MS, Pesadaki P, Ernst E: T‘ai chi fer
the treatment ef esteearthritis: A systematic review
and metaaanalysis. BM] Upset 2fl11;1{1}:eflflfl035.
Mcdline DUI
A systematic review ef randemised clinical studies inves—
tigated the use ef tai chi as a treatment ef esteearthrin's
and identified evidence nf effectiveness in centrnlling pain
and impreving physical functien. Level ef evidence: III.
23. Hertebiigyi T, |Garry J, Hnlbert D, Devita P: Aberratinns
in the ceutrel ef quadriceps muscle ferce in patients with
E
'U
knee esteea rthritis. Arthritis Rheum 2Dfl4:51{4}:562-569.
Medline DUI
E
I'D
Ill
I1! Sega] NA, Glass NA, Turner ], et a1: |Quadriceps weak-
I:
be: ness predicts risk fer knee jeint space narrewing in
H
wemen iu the MUST cehert. Usteeartbritis Eartiiege
2fllfl:13{61:269-225.Medline DUI
A prespective lengitudinal study feund an asseciatien
between quadriceps weakness and tibiefemeral jnint space
narrewing in wemen ever time. Level ef evidence: III.
25. Segal NA, Glass NA, Felsnn DT, et al: Effect uf quad-
riceps strength and preprieceptien er: risk fer knee
firtbepaedic Knewledge Update: Sperts Medichie 5
esteearthritis. Med Sci Sperts Esters lfllflgflflliflfllib
11133. Medline DUI
A prespective study ef 1,329 patients feund that quadri-
ceps muscle strength had a pretective effect against the
develepment ef symptnmatic estcearthritis ef the knee.
Le::e1 ef evidence: II.
2d. Deyle GI), Hendersen NE, Matekel RL, Ryder MG, Garber
ME, Allisc-n 5C: Effectiveness ef manual physical therapy
and exercise in estenarthritis cf the knee: A randemised,
centrelled trial. Am: Iuterrs Med ace 0:] 32t3}:1‘i’3 431.
Medline IJflI
2?. HuleattJE, Campbell K], Laprade RF: Neneperative treat-
ment appreach tn knee esteearthrin's in the master athlete.
Sperts Heaiti: 2D14;5{1]:56-52. Medline DUI
The management ef active patients with symptnmatic
esteearthritis ef the knee was reviewed.
23. Kuttner I, Kiither S, Heinlein E, et a]: The effect {if valgus
braces en medial cempartmcnt lead ef the knee jeint:
In vive lead measurements in three subjects. ,i Biemech
2011;44{?]:1354-1360.Medline net
An in viva hie-mechanical study feund significant reduc-
tiens in jeint leading in stair ascending {26%) and stair
descending {24%) with the use ef a valgus unleader brace.
29. Draganich L, Reider E, Rimingten T, Pietrewski G, Mal-
lik K, Nassen S: The effectiveness ef self-adjustable custem
and eff-the-shelf bracing in the treatment ef varus gnnar-
thresis. ] Eerie jeiut Stirg Aer: 2i] [16:3 3(12}:2 6452652.
Medline III-DI
3!]. Minalaff P, Saier T, Erucker PU, I-Ialler E, Imheff AE,
Hinterwimrner S: Valgus bracing in symptnmatic var-
us malalignment fur testing the expectable I“"unlcllading
effect" fellewing valgus high tibial estcetemy. Hrtee
Stirg Sperts Treematei Artbresc 2015:23[?}:I 964-1520.
Medline DO]
A prespective study cf 43 patients with medial cnmpart-
ment esteearthritis feund that temperary relief with
unleader bracing ceuld predict pain relief after valgus-
preducing high-tibial nsteetemy. Level ef evidence: III.
31. Pelle FE, Jacksen RIF: Knee bracing fer unicemparnnental
estenarthritis. I Am Acad Drtbep Surg 2flfld;14{1]:.5 -11.
Medline
32. Hinman R5, |Cressley KM, McCennell J, Bennell KL:
Efficacy ef knee tape in the management ef estee-
arthritis ef the knee: Blinded randemised centrelled trial.
EM] 2flfl3;32?[24fl2}:135. Medline DUI
33. We rden 5], Hinman R5, 1iiiiatsen MA Jr, Avin KG, Eiale-
cerknwski AE, |IErInIssley KM: Patellar taping and bracing
fur the treatment ef chrenic knee pain: A systematic review
and meta-analysis. Arthritis Rheum 2|] fl3:59{1}:?3-33.
Medline DD]
fl lfllfi American Academy ef Urthepaedic Surge-ens
 Chapter 15-": Nunertbrnplasty Management cf Cstenartltricis cf the Knee
34. Malvankar S, Khan W5, Mahapatra A, ad GS: Htiw
effective are lateral wedge nrthntics in treating medial
cempartment estenarthritis cf the knee? A systematic re-
view cf the recent literature. Dpert Drthnp I 2D12;fi:544-
54?. Medline DUI
A systematic review feund II'D lung—term benefit uf using
lateral shee wedge nrthc-ses fer the symptnmatic treat-
ment flf medial cnmpartment nstenarthritis. Level ctf
evidence: IV.
3.5. McAlindnn TE, Bannuru RR, Sullivan MC, et al: UARSI
guidelines fer the nun-surgical management nf knee estee-
arthritis. Clstenerthritis Ccrtiiege 2fl14;22{3}:363-338.
Medline DUI
The |[flame-arthritis Research Society Internatinnal es-
tablished guidelines fer the nnnsurgical treatment nf
symptematic estcearthritis cf the knee.
36. 1t’ilmaa CICI, Senecak D, Sahin E, et al: Efficacy.r c-f
EMC-binfeedback in knee esteearthritis. Rhenmetni Ittt
lfllflfifliihflfllflfiz.Medliue D-DI
A randnmited clinical study nf patients with nstenarthritis
fnund imprnvement in functinnal nutcnmes and repnrted
pain with regular lewer extremity strengthening exercise
but nn additinnal benefit crf electrnmyc-graphic hie-feed-
back therapy. Level nf evidence: II.
3?. Rutjes AW, jfini P, da Cnsta ER, Trelle S, Niiesch E, Fle-
ichenhacb S: Viscnsupplementatinn fnr nstenarthritis nf
the knee: A systematic review and meta—analysis. Arne
ire-tern Med lflllfliflfiiflflfl-IBI. Medline DDI
A systematic review nf randnmited clinical studies found
a small, clinically irrelevant benefit nf intra-articular
viscnsupplementatinn fer the symptcmatic treatment cf
esteca rthritis cf the knee.
33. Craig DC, Bates CM, Davids-an J5, Martin KC, Hayes
PC, .Simpsen K]: Staggered nverdnse pattern and delay to
hnspital presentatinn are assnciated with adverse nutcnmes
fellewing paracetamnl-induced hepatntniticity. Br I Ciin
Phermecei 2012;?3t2j:235-294. Medline DDI
A retrnspective review cf {563 patients with paracetamel-
induced liver injury emphasized the danger nf staggered
dnsing in nlder patients.
39. Cepeda M5, Camargn F, Zea C, Valencia L: Tramadnl
fer nstecarthritis: A systematic review and metaanalysis.
j Rheametni 2fl0?:34{3}:543-555. Medline
4G. da Cesta ER, Niicsch E, Kasteler R, ct al: Oral nr nansden
ma] epic-ids fer estenarthritis cf the knee er hip. Ceehmrte
Database Syst Rey 21".! 14:9:{313003115 . Medline
A systematic review fnund a significantly increased risk
cf adverse events with the use ef nnntramadel npinids
fer the treatment cf cstena rthritis cf the knee ccmpared
with a small, pnssibly clinically irrelevant reductitm in
patient—repnrted pain. Level nf evidence: II.
41. Tang 5, Eatnn CE, McAlindnn TE, Lapane KL: Effects
nf glucnsamine and chnndreitin supplementaticm en
ID EDIE American Academy nf Drtbnpaeclic Surgeens
lcnee nstenarthritis: An analysis with marginal struc-
tural mc-dcls. Arthritis Rhenmetni IDIS:E?{3]:?14-?33.
Medline DIDI
A systematic review fnund nu benefit tn glucnsarnine-
chnndrnitin supplementaticm fnr relieving patient symp-
tcms er mndifying disease prngressinn. Level nf evidence: I.
41. Barrels EM, Fnlmer VH, Eliddal H, et al: Efficacy and
safety ef ginger in nstcearth titis patients: A meta—analysis
ef randcrmired placebe-cnntrnlled trials. Osteoarthritis
Certiinge 1015;23i1}:13-21. Medline [101
A systematic review fnund mndest pain reductitm in pa-
tients with esteearthritis whe were treated with supple-
mental ginger. Level ef evidence: II.
43. Camcrcn I'vI, Chrubasik 5: IDtal herbal therapies fer
treating estenarthritis. Cechrttrte Den-these Syst Rev
2U14;5:CDDG194?. Medline
A systematic review fnund a painurelieving benefit frnnl
supplementatinn with avncade-scybean unsapnnifiables
fer symptemstic treatment ef estecarthritis cf the knee
ccmpared with placebn. Level nf evidence: I.
44. Cheng CIT, Seuadalnitski D, Vrenman B, Cheng J:
Evidence-based knee injectinns fer the management nf
arthritis. Pairs Med lflllgldifilfidlI—Tfid. Medline DUI
A systematic review feund benefit in intra-articular stereid
injectinns fer relief nf symptnms in estecarthritis cf the
knee. Level cf evidence: II.
45. Bellamy N, Campbell J, Rebinsnn V, Cree T, Enume R,
Wells G: Intraarticular curticnsternid fnr treatment nf
esteeatthritis cf the knee. Cnchmne Dntehese Syst Rev
2i] flfitlilltflflfl 05323. Medlinc
46. Eannu ru ER, Natev N5, Dbadan IE, Price LL, Schmid
CH, IvIcAlinden TE: Therapeutic trajectnry cf hyalurcmic
acid versus certiccrsternids in the treatment cf knee eaten-
arthritis: A systematic review and meta—analysis. Arthritis
Rheum 2DG9;61{IEJ:I?U4-I?IL Medline DDI
A systematic review cempared hyalurenic acid tn certi-
cnsternids fur the treatment cf nstenarthritis cf the knee.
Pain relief was better at 4 weeks after stereid treatment
but better beynnd 3 weeks after hyalurenic acid treatment.
Level cf evidence: I.
4?. Bannuru RR, Vaysbrc-t EE, McIntyre LF: Did the Amer-
ican Academy nf |Drthtipaetlic Surgenns nstenarthritis H
guidelines miss the mark? Arthrnscnpj' 2fl14:3fli1}:Efi-39. F:
5
Mcdline DCII re
re
ru-
Cemmentary en the EDIE: AADS clinical practice guideline 3
D.
argued against the use cf the minimum clinically imper-
tant imprnvement criterinn in assessing the efficacy nf e
viscnsupplementatinn fer the treatment nf cetenartbtitis
cf the knee.
43. de Campus CC, Reecnde MU, Paile AF, Frucchi R, Ca-
margn DP: Adding triamcinelcme imprcves viscesupple-
mentatinn: A randnmiaed clinical trial. Cit'tt [3|tt Relnt
Res 1013:4?1{21:613—52fl. Medline DCII
Drthnpaedic Knnwledge Update: Spnrts Medichie 5
 Sectiundfl‘fneeandleg
A pruspective cuhurt study uf 1fl4 patients fuund impruve-
ment in patient-rated uutcumes during the first week after
curticusteruid injectiun cumbined with viscusupplemen-
tatiun cumpared with viscusupplementatiun alune. Level
uf evidence: II.
4.9. Rhushbin A, Leruus T, Wasserstein D, et al: The efficacy
uf platelet-rich plasma in the treatment uf symptumatic
knee usteuarthritis: A systematic review with quanti-
tative synthesis. Artfrruscupy 2fl13519{12]:2fl3?-1{i43.
Medline DUI
A systematic review fuund impruved patient-rated functiun
with intra-articular PEP injecriun cumpared with nurmal
saline ur hyalurunic acid iniectiun in patients with usteu-
artbritis uf the knee. Level uf evidence: II.
50. Filardu G, Run E, Di Martinu A, et al: Platelet-rich plasma
vs hyalurunic acid tu treat knee degenerative pathulugy:
Study design and preliminary results uf a randumized
cuntrulled trial. EMU Mnseufusiaeiet Dfsurri' 2fl12;13:229.
Medline DUI
A pruspective study uf If]? patients fuund a trend tuward
clinical impruvement 1 year after PEP injectiun cumpared
with hyalurunic acid injectiun in patients with mild us-
teuartbritis uf the knee, but there was nu difference in
uutcumes in patients with muderate disease. Level uf
evidence: III.
51. Siparsky P, Rysewica M, Petersen E, Bart: R: Arthruscupic
treatment uf usteuarthritis uf the knee: Are there any
evidence—based indicatiunsi' Eiia Urtfaup Reins Res
Zflfl?:455{455}:ID?-112.Medline DUI
52. Kata JN, Eruphy RH, Chaissun (IE, et al: Surgery versus
physical therapy fur a meniscal tear and usteuartbritis. N
Eng! ] Med 2fl13;363{13}:16?5-1fifi4. Medline DUI
A multicenter pruspective study fuund nu difference in
uutcumes in patients with usteuartbritis and a degenerative
meniscal tear based un treatment with physical therapy ur
arthruscupic meniscectumy. Level uf evidence: I.
53. Sihvunen R, Paavula M, Malmivaara A, et al: Finn-
ish Degenerative Meniscal Lesiun Study {FIDELITY}
l[.iruup: Arthruscupic partial meniscectumy versus sham
surgery fur a degenerative meniscal tear. N Eng! j Med
.2013;369{25}:1515-2524.Medline DUI
A multicenter pruspective study fuund nu difference in
patient-rated uutcumes at 1-year fulluw-up in patients
E with usteuartbritis and a degenerative medial meniscal
'U
E tear based un treannent with sham surgery er arthruscupic
I'D
medial meniscectumy. Level uf evidence: I.
Ill
I1!
I:
he:
54. Dervin GF, Stiell IG, Rudy K, Grahuwski J: Effect uf
H
arthruscupic débridement fur usteuartbritis uf the knee
un health—related quality uf life. ] Buae jellies Sarg Am
lflfl3:E5-R{I]:1l}-19. Medline
55. Khan M, Evaniew bi, Bedi A, Ryeni UR, Ehandari
Iv'I: Arthruscupic surgery fur degenerative tears uf the
meniscus: A systematic review and meta-analysis.
EMA] 2fl14;136i14i:105?-1l]64. Mudline DUI
Drtbnpaedic Knuwledge Update: Spurts Medich'ie 5
A systematic review fuund nu benefit tu arthruscupic me-
niscal débridement fur degenerative meniscal tears cum-
pared with nunsurgieal treatment ur sham surgery. Level
uf evidence: I.
56. Eruuwer GM, van Tul AW, Eergink AP, et al: Assuciatiun
between valgus and varus alignment and the develupment
and prugressiun uf radiugraphic usteuartbritis cf the knee.
Arthritis Rheum Eflfl?;56{41:11fl4-1111. MetlIine DUI
5?. Shanna L, Sung], Felsun DT, Cahue S, Shamiyeh E, Dun-
Iup DD: The rule uf knee alignment in disease prugres-
siun and functiunal decline in knee usteuartbritis. IA MA
Zflfl1;236{2}:ISE-195.Mcdlinc DUI
53. Bunasia DE, Dettuni F, Site (I, et al: Medial upening
wedge high tibial usteutumyr fur medial cumpartment uver-
luadiarthritis in the varus knee: Prugnustic facturs. Am
I Spurts Meal 2fl14;42{3j:dfifl-593. Medline DUI
A study uf 113 patients fuund that patient age ulder than
56 years and pustuperative flesiun uf less than Ill)“ were
risk facturs fur a puur uutcume after high-tibial usteutumy
fur medial cumpartment arthritis. Level uf evidence: V.
59. Flecher K, Parratte S, Auhaniae JIv'I, Argensun IN: A
IZ-EE—year fulluwup study uf clusing wedge high tibi—
a] usteutumy. Effie Urtbup Refer Res 2fl06:452:91-96.
Medline DUI
60. Akiruki S, Shihakawa A, Takinawa T, Yamanaki I, Huri-
uchi H: The lung-term uutcume uf high tibial usteutumy:
A ten— tu 1i] —year fulluw—up. I Be as juint Surg Br
lflflfltflflfi 1:592'596. Medline DUI
. Amendula A, Eunasia DE: Results uf high tibial usteutumy:
Review cf the literature. Int Urriiup 2i] 1G:34i2}:155-16{l.
Medline DUI
A review uf the lung-term survival uf high-tibial usteutumy
fuund that the facturs assuciated with a successful uutcume
in patients yuunger than {it} years were isulated medial
cumpartment usteuartbritis, guud range uf mutiun, and
ligamentuns stability.
62. Duivenvuurden T, Eruuwer RW, Eaan A, et al: lliEum-
parisun uf clusing—wedge and upening—wedge high tibial
usteutumy fur medial cumpartment usteuartbritis cf the
knee: fl. randumiaed cuntrulled trial with a six-year ful-
luw-up. ] Burrs juint Surg Am lfl]4;96{1?}:1415-1432.
Medline DUI
A randumised study cumpared medial upening wedge
high-tibial usteutumy with lateral clusing wedge uste-
utumy and fuund nu difference in clinical uutcume ur
radiugraphic alignment at 6-year fulluw—up. Medial upen-
ing wedge usteutumy was assuciated with a luwer rate uf
cunversiun tu tutal knee arthruplasty but a higher rate uf
early cumplicatiuns. Level uf evidence: I].
63. Ilussi E, Eunasia DE, Amendula A: The rule uf high tibial
usteutumy in the varus knee. } Am Reed Urtbup Sarg
lflllfl 9i]fl]:5.9fl'595. Medline
D lflld American Acadmny uf Urthupaedic Surge-ens
 Chapter 15-": Nflflflflhl'fl-Plflfltf Management nf Detenartbriris cf the Knee
The indicatic-us, surgical technique, and cnmplicatiuns cf
high-tibial DEtEfltflmy in tbe earns knee were reviewed.
64. ‘r’asuda K, Majima T, Tsucbida T, Kaneda Ii: A ten- tn
15-year fellnw-up e-bserratinn nf high tibial nsteiitnm}r in
medial cnmpartment nstenarthrnsis. Gift: 01'1“p Refnt
Res 1992;232:135-195. Medline
65. Prestun 5, Hnward J, Naudie D, Snmertille L, McAuley
]: Tntal knee arthrnplast}? after high tibial nstec-tnmy:
Nu differences between medial and lateral nstentnm‘jtr apv
prcraches. Cffrt Drtbnp Refer Res lfll4;4?2{1]:195-11fi.
Medline DUI
A retrnspective review nf 16.5 patients fnund nn differ-
ence in functinnal nutcnme e-r survival-ship in patients
when had undergene a medial npening wedge er lateral
clnsiug wedge high-tibial Dfitfifltflmfir befnre tntal knee
arthrnplasty. Level cf evidence: IV.
IE! lfllfi American Academy nf flrthnpaeclic Surgeries
66. Eackstein D, Mnrag G, Hanna 5, Safir 0, Grass A:
Lang-term fullnw-up ef distal femnral tarus nstentnmjr
of the knee. J Artbrnpfnsty ZflflTflEH, Suppl 11:2-6.
Medline DUI
6?. Wang JW, Hsu CC: Distal femnral varus nstentnm}?
fur nstenarthritis {if the knee. ’1' Butte Jail-rt Surg Am
Zflfl5;3?[1}:12?-133.Medline DUI
63. Knsashvili Y, Safir D, Grass A, Mnrag G, Lakstein D,
Backstein D: Distal femnral 1.rarns estentnmjt fnr lateral
nsteuarthritis nf the knee: A minimum ten-year fellnw-up.
Int Grtbnp lfl 1i};34{2}:149-154. Medline DUI
A retrnspectitre review {if an reitnrship and nutcume after
distal femnral earns ester-tam}? fur lateral campartment
nsteearthritis and valgus alignment found that at 15-year
fulluw-up appreeI-rimatellir half {if patients had undergcrue
cemrersinn tn tntal inint artbrnplastt. Level nf evidence: W.
l"'"."
E
5
re
re
ru-
3
D.
Drthnpaedic Knnwledge Update: Sparta Medicine 5
®
Chapter 20

Meniscal Injuries
Stephanie W. Mayer. MD Johnathan A. Bernard. MD. MPH Scott A. Rodeo, MD

The menisci are fibrocartilaginous structures with gross and microscopic structural properties that provide load
distribution, lubrication, and stability to the knee joint. Diagnosis of a symptomatic meniscal tear requires a thor—
ough patient history, a physical examination with meniscus-specific tests, and often, imaging studies. The anatomy,
function, and vascular supply of the menisci have implications for the treatment of a meniscal tear. The long-term
outcome after a total or subtotal meniscectomy is likely to include osteoarthritis. Biomechanical studies found
an increase in contact pressure after subtotal meniscectomy or a high-grade radial tear causing loss of the ability
to absorb hoop stresses. Strain on the anterior cruciate ligament {AOL} in medial meniscus—deficient knees and
strain on the medial meniscus in ACL—deficient knees proves the important stabilising function of the meniscus.
These results have led to an increase in the number of meniscal repairs performed to preserve load absorption and
stabilization. Clinical and mdiographic healing rates of sex. to 35% have been reported after repair. Meniscal
repair with concomitant ACL surgery leads to a higher rate of healing than isolated meniscal repair, probably
because of the release of bone marrow—derived stem cells during tunnel reaming. Irreparable tears and postmenis-
cectomy pain syndrome are common in young patients and are difficult to treat. Collagen scaffold implants and
synthetic polyurethane scaffolds have had promising results in animal and human studies for filling large defects
after partial meniscectomy. Relatively young patients who need to undergo total or subtotal meniscectomy as a
primary procedure may be candidates for meniscal allograft transplantation. Biomechanical studies found that
strain on the ACL is reduced and knee kinematics and contact pressures are improved to near-baseline levels after:
transplantation. 1

He ords: meniscus; meniscal trans lant . . .

yw p Importance of radial, horizontal, and root tears of the
lntrod uction
The medial and lateral menisci have important roles in
the knee joint. Their unique anatomic structure provides
both static and dynamic stability to the knee. The hisr
tologic and biologic composition of the menisci allows
load distribution, proprioception, and lubrication, and
biomecbanical and clinical results have confirmed the
Dr. Rodeo or an immediate family member serves as a
meniscus. Advances in imaging have improved the char-
acterixation of normal and pathologic menisci. Research
into biologic and meniscal collagen implants is expanding
the treatment options for patients with meniscal pathol-
ogy. Short-term and long-term studies of meniscal al-
lograft transplantation have led to improvements in this
technique for carefully selected patients.
l-‘r'
FT.
:5
re
re
tn
The menisci are wedge-shaped fibrocartilaginous struc- 3
tures situated between the femoral condyles and the tibial
El.

paid consultant to Rotation Medical and has stock or stock
options held in Cayenne Medical. Neither of the following
authors nor any immediate family member has received
anything of value from or has stock or stock options held
in a commercial company or institution related directly
or indirectly to the subject of this chapter: Dr. Mayer and
Dr. Bernard.
plateau. These structures have many functions in the .E
knee including proprioceptive feedback, load distribu-
tion during physiologic loading, joint lubrication during
motion, and maintenance of tibiofemoral joint stability
and congruity.“ The substance of the menisci is a solid
extracellular matrix and water. Fibrochondrocytes are
the predominant meniscal cell type, and they produce the

@ lfllfi American Academy of Drthopaedic Surgeons Orthopaedic Knowledge Update: Sports Medicine 5
 Section 3:1Cnee antlLeg
Flandom ooliagen fiber
MHHF‘“
cross-aeolian
l'iEll'ilrol'l-i at suites-a
Ciroimierential
oollagen
fiber bundles
Figure 1 Schematic drawing shows the collagen fibers
of the meniscus. The superficial collagen fibers
are randomly oriented to resist sheer stress. The
deeper fibers are oriented circu mferentially
to dissipate loads as hoop stresses. The
circumferential fibers are secured by radially
oriented tie fibers.
extracellular matrix. Type I collagen comprises most of
the extracellular matrix; smaller amounts of types II, III,
V, and VI collagen also are present. Dther components
are proteoglycaus such as aggrecan. Proteoglycans consist
of a protein core covalently bound to negatively charged
glycosaminoglycan polysaccharides. Proteoglycans attract
and bond to water, which comprises 65% to 75% of the
meniscal volume. Type I collagen is most abundant in the
superficial zones of the menisci to provide tensile strength.
Proteoglycans and water are found in the deeper zones
and provide compressive strength.
The collagen fibers are randomly oriented on the su—
perficial aspects of the menisci. In the deeper zones the
collagen fibers are oriented in a circumferential pattern
and stabilized by intermittent radially oriented tie fibers
that anchor the circumferential fibers {Figure I}. This ori-
DI
entation provides tensile strength superficially as well as
a:
._I absorption and dissipation of the hoop stresses from axial
T:
I:
m
loading during weight hearing by 5(1% in knee extension
to
Iii-1 and as much as 35 '3’l- in flexion. In these ways the menisci
i:
as protect the articular cartilage from excessive loads and
contribute to joint congruity during weight hearing.
H
The medial and lateral menisci have different gross
anatomic features (Figure 2}. Each has an anterior horn,
a body, and a posterior horn. The medial meniscus is
semicircular or C shaped, and it covers sex. to fifl'iia of the
medial tibial plateau. The posterior horn is approximately
11 mm wide, and the anterior horn is slightly smaller. The
Drtbopaedic Knowledge Update: Sports Medicme 5
Figure 2 Illustration shows the menisci and the proximal
tibial plateau. The medial meniscus [MM] is I:
shaped. The insertion ofthe posteromeclial
meniscal root lpMMl {arrows} is shown just
anterior to the posterior cruciate ligament
[PC L}. The insertion of the anterom eclial
meniscal root laMM} is shown on the anterior
tibial plateau extending down the anterior
proximal tibia. The lateral meniscus is more
circular in shape than the medial meniscus. and
the anterolate ral meniscal root {aML} inserts
just lateral to the anterior cruciate ligament
[ACLi on the tibial plateau. The posterior
lateral meniscal root {pM L} is shown with its
anterior meniscofemoral ligament {ligament
of Humphrey] laMFL). The most common
lntermeniscal ligament. the transverse ligament
{TL}. is shown connecting the anterior horns of
the medial and lateral menisci. MEL = medial
collateral ligament.
medial meniscus is attached to the deeP medial collateral
ligament fibers and the joint capsule, and its mobility
therefore is limited. The inferior aspect of the posterior
horn also is attached to the tibia by the meniscotibial liga-
ment or coronary ligament.3 The lateral meniscus is more
circular in shape than the medial meniscus, and it has
equal-size anterior and posterior horns. At the posterior
lateral meniscal attachment the popliteomeniscal fascicles
extend from the meniscus to the posterior capsule and cre-
ate the popliteal hiatus as the popliteus tendon becomes
intra—articular. The meniscofemoral ligaments connect
the posterior horn of the lateral meniscus and the medial
femoral condyle. The anterior meniscofemoral ligament
of Humphrey courses anterior to the posterior cruciate
ligament, and the posterior meniscofemoral ligament of
1i'Iiirisherg courses posterior to the posterior cruciate lig-
ament. Because the lateral meniscus has less continuous
attachment to the capsule than the medial meniscus it
El 1016 American Academ1r of Cirrhopaedic Surgeons

has mere mebility, which may cenfer a pretective effect.
The mest cemmen cennectien between the medial and
lateral menisci is the transverse intermeniscal ligament,
which is present in 60% te 94% ef knees. A pesterier
and medial er lateral eblique intermeniscal ligament alse
can he presents”l
The vascular supply ef the menisci cemes frem the
superier, middle, and inferier geniculate arteries. The
peripheral 10% te 3D% ef the meniscus is well vascu-
larized by synevial and capsular branches {Figure 3].
The anterier and pesterier reet attachments are well
vascularized by synevial branches."r Zenes ef the me—
nisci are described based en this vascular anatemy. The
euter third, the well—vascularized regien, is called the
red-red zene. The middle third is the herder between
the vascularized and avascular zenes and is called the
red—white zene. The inner third is deveid ef a vascular
supply and is called the white-white zene. The lecatien
ef a meniscal tear threugh the zenes partly determines
the treatment because the petential fer healing increases
with vascularity. The pertien ef the menisci that is net
well vascularized receives nutritien threugh diffusien
during leading. Neural elements are feund mestly in the
periphery ef the anterier and pesterier herns. The menisci
are believed te have a rele in preprieceptien because ef
this cenfiguratien.
111e Hele ef the Menisci in Lead Sharing
During weight bearing, the menisci effect and diffuse the
lead between the femur and tibia threugh develepment
ef heep stresses that rely en intact circumferential cel-
lagen fibers. Biemechanical studies feund that a partial
meniscectemy necessitated by the presence ef a buck
et-handle er peripheral lengitudinal tear increases peak
tibiefemeral centact pressure by 65% te 110% and that
a tetal meniscectemy increases the pressure by as much
as 235%} In a cadaver study, an incremental increase in
peak centact stress and a decrease in centact area were
found as the size ef radial tears increased and as a larger
ameunt ef meniscal tissue was remeved.‘5 a radial tear
5fl% er ?5% ef the width ef the medial meniscus and a
partial er tetal meniscectemy caused a substantial change
frem the intact state. Dnly a radial tear mere than 90%
ef the width ef the medial meniscus er a partial menis-
cectemy ef such a radial tear substantially increased peak
centact pressure and caused the peak centact te shift re
a mere pesterier lecatienF A lateral radial meniscal tear
Eifl‘it': ef the width ef the lateral meniscus and a partial
meniscectemy were feund te significantly increase cen-
tact pressures.fl These biemechanical data explain the
clinical ebservatien ef meniscal extrusien and pregres—
sive degenerative esteearthritis in knees with a radial er
El Ifllii American Academy ef flrdtepaedie Surgeries
Chapter ll]: Meniscal Injuries
Image shews a cress-sectien ef the medial
meniscus. The vascular supply penetrates the
euter 10% te ssss ef the meniscus {the red-
red rene}. The middle third ef the meniscus is
the tra nsitien zene between the vascular and
avascular regiens [the red-white zene}. The
inner third at the meniscus is avascular {the
white—white zene]. PCP = perimeniscal capillary
plexus, F = femur, T = tibia. {Repred uce-d with
permissien trern Arneczlty 5P. Warren HF:
Micrevasculature et the human meniscus. Am J
Sperts Med 1932;10I2]:9[l-95.}
cemplex meniscus tears"
The Medial and Lateral Menisci as Stabilizers
Biemechanical studies have centrihuted te insight inte the
functien ef the menisci as dynamic stabilizers under spe-
cific cenditiensJ'l Sectiening ef the medial meniscus led te
increased tibial translatien and strain en the ACL during
anterier tibial translatien that eccurs with Lachman test-
ing.2 hnether sectiening study feund that in the absence
ef an intact ACL, the medial meniscus acts as a secendary
stabilizer during anterier tibial translatien.l The lateral
meniscus was fun nd te be an impertant stabilizer fer re-
tatery and valgus leads during the pivet shift maneuver in
BEL-deficient knees.‘ The anterier translatienal stability
cenferred by the ACL pretects the pesterier hern ef the
medial meniscus. These results emphasize the impertant
static and dynamic rele ef the menisci in knee kinematics.
pg
FT.
:5
re
re
as
A thereugh patient bistery is impertant fer beth the di- 3
El.
agnesis ef a meniscal tear and treatment decisien mak-
ing. The patient’s demegraphic prefile, preinjury level ef E
activity, earlier symptems er injuries, and mechanism ef
injury can guide the examiner teward an accurate diag~
nesis and an apprepriate treatment plan. Patients with
a traumatic tear may have pain enset during a twisting
mechanism er deep flexien. Dccasienally a pepping sen-
satien is reperted. Appreximately ene-half te twe-thirds
Drrhepaedic Knewledge Update: Sparta Medicine .5
 Section 3:1i2nec andLeg
A I I . Sal-Ir]!
Figure 4 Proton density—weighted magnetic resonance images show meniscal tears. A, Sagittal view shows a complex
medial meniscal tea r; the signal extends to the articular surface. B. Coronal view shows a horizontal cleavage tear
of the medial meniscus at the junction of the body and posterior horn. C. Sagittal view shows the double-posterior
cruciate ligament sign, which is consistent with a bucket—handle tear with the fragment displaced into the notch.
of patients have knee swelling. Mechanical symptoms
such as catching or frank locking were observed in 12%
to 69% of patients in two recent studies; these are impor—
tant symptoms because they suggest an unstable teardfl'v11
The physical examination should begin with assess-
ment of overall lower limb alignment and inspection for
external signs of trauma or the presence of an effusion.
Active and passive range of motion is recorded with a
notation of any mechanical block to motion. The status
of the collateral and cruciate ligaments is important to
test because the presence of an injury affects treatment
decision making. Palpation of the joint line may elicit
tenderness in the region of a tear. Posterior horn tears are
most prevalent, and therefore the posterior joint line is a
common location for tenderness. The meniscususp-ecific
Mchdurray, Apley, and Thessaly tests should he interpret-
ed for pain as well as mechanical signs. The McMurray
test involves taking the knee through a range of motion
while internally and externally rotating the tibia relative
to the femur and applying an axial load. For the Apley
test, the patient is prone with the knee flexed to 9i)”; the
examiner applies an axial load while the tibia is rotated
internally and externally. For the Thessaly test, the patient
UI
stands on the affected leg and performs a one-legged
to
._I squat of approximately 20”. During flexion and exten—
T:
I:
m sion the patient also rotates the torso to create intents]
to
III-1 and external rotation of the tihiofemoral joint. Each of
I:
as these functional tests is designed to trap the pathologic
meniscus under axial load and rotation, and pain andfor
H
mechanical symptoms should be recreated. In a patient
with an isolated meniscal tear, joint line tenderness was
found to be an accurate test in 31% to Qfl‘if. of patients
compared with 5TH: to WEE: for the Melviurray test and
61% to SG% for the Thessaly test.‘“*” With associated
ligamentous or ehondral injury, the physical examination
Drthopaedic Knowledge Update: Sports Medichie .5
L‘r -. .-..' 1 . I -'.-.'. fa.
can he particularly challenging because the tests lose their
accuracy for meniscal jgiathology.”L11 However, the combi-
nation of joint line tenderness and a positive McMurray
or Thessaly test has sensitivity and specificity approaching
those of an isolated meniscal tear.IEI
Radiographic evaluation of a patient with knee pain
should begin with weight—bearing radiographs includ-
ing AP in extension, lateral, and PA 45“ flexion views in
addition to a Merchant view of the patellofemoral joint.
Signs of osteoarthritis or trauma can provide clues to the
internal environment of the knee and the status of the
meniscus before the onset of acute pain. Osteoarthritis
can signify a degenerative meniscal tear, and trauma can
be associated with an acute tear. MRI is useful for con--
firming a clinical suspicion of a meniscal tear. Meniscal
tears can he well evaluated with proton density—weighted
MRI. A tear can be described as longitudinal {vertical},
horizontal, radial, flap, parrot beak, bucketbhandle, de-
generative, or complex. The criteria for MRI diagnosis
of a meniscal tear include increased signal intensity ex-
tending to the articular surface from within the normally
lowvsignal meniscal substance; distortion of the shape
or size of the meniscus, which signifies missing meniscal
tissue; or a displaced meniscal fragment” {Figure 4}. The
sensitivity and specificity of 1.5-Tesla {T} and 3.0-1" MRI
diagnosis of medial meniscal tears, as confirmed with
arthroscopy, were found to be 93% to 96% and 33%
to 913%, respectively.” MRI was less sensitive {T?% to
81%} but more specific {93% to 99%} for lateral meniscal
tears. In general, 1.5-T MRI was slightly less sensitive
and specific than 3.0—T MRI, but the difference did not
reach significance. A report of Sfl-T MRI for detecting
posterior meniscal root tears found sensitivity of T?%
and specificity of 3%.” These findings may be attrib-
utable to the radial orientation of many posterior root
El 1016 American AcadMy of Cirrhopaedic Surgeons

tears, which makes them mnre difficult tn see an MRI.
The patient histnry and physical enaminatinn remain
the mnst impnrtant diagnnstic tnnls. Tn be cnnsidered a
pertinent finding, a meniscal tear seen cm MRI shnuld
cnrrespnnd tn the patient's histnry and pnsitive clinical
eaaminatinn findings.
The treatment nptinns fnllnwing diagnnsis nf a sy mptnm-
atic meniscal tear include nbservatinu, excisinu (a partial
meniscectnmy}, repair, and replacement. The treatment
shnuld be tailnred tn the patient and the type nf tear. Db-
servatinn can be chnsen fnr stable peripheral tears smaller
than 5 tn 10 mm, snme degenerative tears that dn nnt
cause mechanical symptnms, and tears in the setting at
substantial nstenarthritis. Unstable tears causing mechan—
ical symptnms; tears in the avascular anne, such as radial
nr flap tears; and degenerative tears withnut substantial
nstenarthritis can be treated with partial meniscectnmy.
During partial meniscectnmy, the unstable pnrtinu nf
I:he meniscus is identified and excised, and the adjacent
tissue is shaped intn a smnnth and stable cnntnur leading
iutn the excised segment. The surgenn shnuld preserve
as much meniscal tissue as pnssihle and avnid creating a
defect traversing the entire width cf the meniscus. Clinical
studies with lnng~term fnllnw-up nf partial meniscectnmy
fnr the treatment nf meniscal tears fnund an increase in
nstenarthritic changes within the affected cnmpartment.
Partial meniscectnmy fnr the treatment nf radial tears that
were within 1 cm cf the pnsterinr hnrn insertinn led tn
prngressinn nf nstenarth ritis in 35% nf patients at a mean
?7rmnnth fnllnw—up.” At 5- tn T—year fnllnw—up nf 46
patients, nue-third had prngressinn nf Kellgren-Lawrence
grade 1'} tn 2 nstenarthritis tn grade 3 nr 4 nstenarthritis.
Althnugh the mndii'ied Lyshnlm Knee IQuestinnnaire scnre
nften significantly imprnved after partial meniscectnmy,
nnly 56% nf patients repnrted pain imprnvement.
In a systematic review nf treatment fnr traumatic mer
niscal tears, both the shnrt- and lnng-term renperatinn
rates were higher after meniscal repair than after menis-
cectnmy {16.5% versus 1.4% and 203% versus 3.9%,
respectively)?“ Hnwever, there were nn plain radingraphic
degenerative changes in 73% nf knees after meniscal re-
pair, cnmpared with {54% nf knees after meniscectnmy.
These results were cnrrnhnrated hy annther study that
cnmpared partial meniscectnmy and inside-nut repair at
lnngitudinal tears.” Almnst 30% nf patients with arthrn-
scnpic meniscal repair had an nstenarthritis prngressinn
cnmpared with nnly 40% nf patients with meniscectnmy
at 3— tn Ill-year fnllnw—up. Mnre than 96% nf the patients
whn underwent arthrnscnpic meniscal repair returned tn
Eb Ifllti American Academy nf Urthnpaedic Surgenus
Chapter 1i]: Meniscal Injuries
Figure 5 Arthrnscnpic views shnwing a lnngitudinal
tear in the vascular red—red anne cf the medial
meniscus {A} and repair nf the tear with vertical
mattress sutures {E}.
their preinjury level nf spnrts activity cnmpared with nnly
half nf thnse whn underwent a partial meniscectnmy.”
Similarly, at 4-year fnllnw—up, patients whn underwent
repair nf a medial meniscal rnnt tear had less prngressinn
nf nstenarthritis and better clinical scnres than thnse whn
underwent partial medial meniscectnmy.IE Preservatinn
nf the integrity cf the articular cartilage nn quantitative
MRI has been assnciated with healed meniscal repairs.”
This finding suppnrts the repnrted clinical results.
With increasing evidence that hath meniscal injury
and partial meniscectnmy are linked tn the develnpment
nf nstenarthritis, there has been a shift tnward meniscal
repair as the treatment nf chnice fnr meniscal tears. The
gnal nf meniscal repair is tn prnvide the meniscus with
structural suppnrt and the ability tn heal and therefnre tn
preserve its integrity and functinn. In general, traumatic
lnngitudinal tears nccurring in the red-red {vascular} acne
in patients ynunger than 30 years age are believed tn be
mnst amenable tn a successful repair, althnugh gnnd re-
sults alsn were fnund in reduwhite anne repairs in ynung
patients" {Figure 5}. Because nf their blnnd supply, tears
in the red-red anue are mnst likely tn heal, fnllnwed by
tears in the reduwhite anne.‘I Whiteuwhite anne tears are
avascular and thus have limited pntential fnr healing.
The failure and renperatinn rate was fnund tn be higher
fnr medial than lateral meniscal repairs at sbnrt- and
medium—term fnllnw—up."f'*1l"11 Enncnmitant ACL recnn-
structinn pnsitively cnrrelated with healing, “~13 and age
ynunger than 3'3 years trended tnwa rd a pnsitive cnrrela- pg
tinn with healing.” Tears lnnger than 1 cm and tnbaccn FT.
:5
smnking negatively affect healing rates.” m
m
tn
3
El.
Viden 20.1: All-Inside Meniscus Repair -
FAST-FIX. Walter R. Sheltnn, MD (1?. min) :5
1|Illiclen 20.2: All-Inside Meniscus Repair -
MarFire Maeen. Keith W. Lawhnrn,
MD (3 min]
Drthnpaedic Knnwledge Update: Spnrts Medicine 5
 Sectinn 3:1I'inec andLeg
flpen repair has largely been replaced by arthrnscnpic
repair unless an arthrntnmy is needed fnr annther injury,
such as a tibial plateau fracture. Arthrnscnpic repair can
be dnne using an nutside-in, inside-nut, nr all-inside tech-
nique. flutside—in repair nften is chnsen fnr an anterinr
hnrn nr meniscal bndy tear, which is difficult tn reach
using an inside-nut nr all-inside technique. Spinal needles
are placed frnm nutside the jnint thrnugh the meniscal
tear, and suture is shuttled thrnugh the needles under
arthrnscnpic nbservatinn. A small skin incisinn is made,
and a knnt is tied directly nn the nutside nf the capsule
with care tn avnid entrapping any superficial snft tissue.
An inside-nut repair cnmmnnly is used fer a pnstcrinr hnrn
nr pnstcrinr meniscal bndy tear. Lnng, flexible needles
are placed with the use nf specialised guides thrnugh the
meniscal tear and are retrieved nutside the jnint. Suture is
shuttled thrnugh the tear and tied nver the capsule thrnugh
the npen pnstcrinr incisinn. Accessnry incisinns are nec-
essary fer needle retrieval and [met tying. Retractnrs are
used in the accessnty incisinns tn prntect the pnpliteal
neurnvascular structures as well as the saphennns nerve
and vein medially er the pernneal nerve laterally. MRI
at an average 43-mnnth fnllnw-up after inside-nut me-
niscal repair with vertical mattress suturing shnwed a
130% healing rate fnr partial tears and a 30.3% rate
fnr full—thickness tears.” All—inside meniscal repair has
the advantage nf being less invasive than inside—nut nr
nutside-in techniques, with nn required accessnry pnrtal
and therefnre less risk nf superficial vessel nr nerve injury.
Multiple devices are cm the market, each nf which is insert—
ed thrnugh a standard anterinr pnrtal using a guide. The
trajectnries pnssible thrnugh an anterinr pnrtal make the
allrinside devices mnst suitable fnr tears in the pnstcrinr
hnrn nr midbndy nf the meniscus. Despite the small risk nf
injury tn pnpliteal fnssa structures if the device penetrates
the pnstcrinr capsule tnn deeply, a recent review nf patients
treated with smnnd-generatinn all-inside devices repnrted
nn neurnvascular cnmplicatinns."-‘l The secnnd-generatinn
insertinn devices currently nn the market mimic inside—nnt
suture cnnfiguratinns tn make the device mnre user-friend-
DI
ly and safe fnr the articular cartilage. The imprnved suture
an
._I fixatinn mechanism reduces the risk nf device migratinn nr
T:
I:
[I'll
lnnsening. Midterm nntcnmes are prnmising; at an average
tn
III-1 75-year fnllnw-up nf 33 all-inside meniscal repairs, 34%
I:
as were healed accntding tn clinical criteria.“
Binmechanical studies cnmparing the strength nf
H
inside-nut and nutside-in all-suture repairs had cnnflict-
ing findings. A systematic review cf 41 studies cm the
lnad tn failure nf suture repairs cnmpared with repairs
using all-inside devices found a higher lnad tn failure
with suture repairs.” A vertical mattress suture cnnfig—
uratinn was fnund tn have a greater lnad tn failure than
Drrhnpaedic Knnwledge Update: Spnrts Medians: 5
a hnrisnntal mattress cnnfiguratinn. nnnther study sim-
ulated inside-nut vertical mattress suture fixatinn and
cnmpared it with fixatinn using several available all-in-
side devices; inside-nut repair had a failure lnad nf F3
tn 33 N and a mean displacement nf 2.5 3 tn 2.15 mm
after 130 cycles, and all except nne all-inside device had
cnmparable perfnrmance:15 The clinical results nf all-su-
ture and all—inside techniques were generally equivalent
in several recent systematic reviews and meta-analyses.
A systematic review nf heterngenenus meniscal repairs
with nr withnut cnncnmitant ACL recnnstructinn fnund
that 613% nf repairs cnmpletely healed." The cnmplete
healing rate was 62% fnr inside-nut repairs, 56% for
nutside—in repairs, and 33% fnr all—inside repairs. A me-
ta-analysis nf studies with mnre than 5 years nf nutcnrne
data repnrted a success rate nf T6.1% when the nutside-in
technique was used fnr isnlated meniscal repairs.12 In-
side-nut repairs nf ACL-intact and ACL-recnnstructed
knees had a ??.?% success rate, and all-inside repairs had
a T5.?% success rate. A systematic review nf insideanut
and all-inside repairs nf isnlated bucket-handle meniscal
tears withnut cnncnmitant ACL recnnstructinn fnund
clinical healing rates nf 33% and 31% fnr inside-nut and
all—inside repairs, respectively.” All—inside repairs led tn
mnre lncal snft-tissue irritatinn and implant migratinn,
and inside—nut repairs had a higher rate nf nerve injury.
The ability tn return tn spnrts after meniscal repair has
been investigated. A study nf elite athletes fnund that 31%
were able tn return tn spnrts an average nf 5.6 mnnths
after surgery.m In this active pnpulatinn, the failure rate
was 26.?% at an average nf 41.?r mnnths. A study nf
highslevel snccer players fnund that 39.6% were able tn
return tn the same activity level an average nf 4.3 mnnths
after surgery. At 5-year fnllnw—up, 45% were still partic-
ipating in snccer.2E4
It can be difficult tn interpret imaging after meniscec-
tnmy nr meniscal repair. The diagnnstic criteria fnr a
retear after a meniscectnmy in which less than 25% nf
the native meniscus was remnved are the same as fnr a
primary tear, and the diagnnstic accuracy is similar. Tears
requiring a mnre extensive meniscectnmy nr a meniscal
repair may reach the vascular xnne nf the meniscus, and
these tears heal with fihrnvascular tissue that can mimic
the hyperintense signal nf a retear. Based nn MRI ap-
pearance, tears are classified as fully healed if there is
nn fluid signal in the repair site, partially healed if fluid
extends intn less than 50% nf the width nf the repair site,
and nnt healed if fluid extends intn mnre than 53% nf
the repair site width.
Failure nf meniscal repair can be attributed tn inade-
quate meniscus fixatinn strength, pnnr vascular supply at
the repair site, nr cnncnmitant knee instability caused by
El 1016 American AcadMy nf Drrhnpaedic Surge-ens

ligamentous laxity. The medial and lateral menisci have
a secondary role in stabilizing the knee. and repairing a
posterior horn meniscal tear in an ACL—deficient knee
without correcting anterior laxity can lead to a retear or
compromised healing.‘ The reason for the failure should
be considered in deciding whether a revision meniscal
repair or a partial meniscectomy is preferable. Revision
meniscal repair was evaluated in 15 patients who had
undergone primary repair using different techniques.“
The revision repair failed in five patients at an average
of 25 months after surgery. The presence of degenerative
changes at all five revision repair sites suggested that avas—
cularity or instability played a role in the degeneration
of the meniscal tissue. In the patients who did not have a
retear after the revision repair, the average Lysholm score
improved to 9‘14 of 100.
@ Video 20.3: Posterior Horn Medial Menis-
cus Hoot Repair. Dharmesh Was. MD. and
|t'lhristopher D. Harner. MD [14 min]
Hoot Tears
The role of the posterior meniscal root attachment and
the underestimated prevalence of this injury have received
attention recently. Both degenerative and traumatic tears
can occur. A traumatic tear often is associated with mul-
tiligamentous knee injury or injury occurring during deep
knee flexion. The medial posterior root is less mobile
than the lateral root and therefore is more susceptible
to isolated injury; in contrast, a lateral root tear is most
common in association with ligamentous injury. Tears of
the posterior medial meniscal root can increase contact
pressure, external rotation, and lateral tibial translation,
which are corrected with repair of the posterior medial
meniscal root”!31 Similarly, a lateral root avulsion or a
radial tear within 9 nun of the root substantially decreases
the contact area and increases contact pressure in the
lateral compartmentfi‘L“ Repair of medial and lateral
root tears substantially decreases the contact pressures
within the medial and lateral compartments.
Biologic Treatnents
The mechanism of healing in the vascular portion of the
meniscus involves an initial inflammatory response and
fibrin clot formation followed by migration of undifferw
entiated mesenchymal cells from the vasculature, which
leads to new matrix formation and healing through E—
brous scar tissue. Synovial cells also can participate in the
repair response. This process has led to a recommendation
that trephination of the peripheral meniscus and capsule
and synovial abrasion should be done during meniscal
IE! Elllti American Academy of flrthopaedic Surgeons
|iiillapter 1d: Meniseal Injuries
repair to increase vascularity and resulting migration
of vascular-derived undifferentiated cells to the repair
site. There also is interest in the direct application of
pluripotent stem cells into the joint for augmentation of
healing in meniscal repair.“ In animal models. synovial
mesenchymal stem cells injected intra-articula rly during
meniscal repair adhered well to sites of meniscal injury
and differentiated into meniscal fibrochondrocytes, thus
improving the amount of meniscal tissue formation 1 to 4
months later.“ A human study of intra-articular injection
of bone marrow—derived mesenchymal stem cells found
that the meniscal volume substantially increased in 24%
of patients within 1 week of meniscectomyf55 Patients who
also had osteoarthritis had substantial improvement in
pain. In a rabbit model, adipose-derived stem cells deliv-
ered to the site of a longitudinal meniscal tear were found
to improve the healing rate and amount of regenerated
meniscus in both the vascular and avascular zones.“ The
effect of adipose-derived stem cells was most apparent
after acute repairs.
Concomitant ACL reconstruction was found to be
positively correlated with meniscal healing rates, prob-
ably because bone marrow—derived meseuchymal cells
were released during tunnel reaming.”13 Bone marrow
stimulation achieved by drilling a 5-mm hole into the in-
tercondylar notch recently was reported for augmentation
of healing of avascular horizontal cleavage tears.“ The
clinical healing rate was 91%, and 3% of patients had
complete healing at secoudplook arthroscopy. A relatively
short duration of meniscal symptoms was associated with
a superior clinical outcome score.
E. 1H'ideo 2114: All Arthroscopic Meniscus
Repair with Biological Augmentation.
Nicholas A. SgaglaE, MD, and Eric Chen,
M D [23 min}
Platelet-rich plasma {PEP} is a source of anabolic
growth factors such as insulin-like growth factor—1,
vascular endothelial growth factor, fibroblast growth
factor—2, transforming growth factor—l3, and platelet-de-
H
rived growth factor-AB, all of which have been isolated F:
5
from meniscal repair tissue.” There is evidence that PRP to
re
ru-
application at the site of meniscal repair increases the 3
D.
adherence and content of fibroblasts and chondrocytes
and improves the histologic appearance of the healing s
meniscus both in vitro and in vivo.” Only small retro-
spective studies have compared meniscal repair with and
without the application of PRP.“'3'1"1 Cine study found no
between-group difference in clinical outcomes scores, re-
operation rate, or the proportion of patients who returned
to work or sports.“ Another study reported no difference
Drthopaedic Knowledge Update: Sports Medichre .‘i
 5ecfion3:Kneeand1eg
in reoperation rate or overall clinical outcome scores but
did find improvement in pain and sports parameters in
patients who received PEP. Improvement in the MRI
appearance of PEP-treated repairs also was reported; 0
of 1? control patients and 5 of ’1? repairs supplemented
with PRP had a normal meniscus signal intensity.“
Collagen Implants
For patients with irreparable meniscal injury and sub—
stantial meniscal loss, synthetic scaffolds may pmvide a
new treatment option. A composite type I bovine colla-
gen—glycosaminoglycan scaffold was found to support
the formation of meniscus-like tissue when attached to a
meniscal rim.“- The scaffold was infiltrated by synovial
andl'or vascular-derived cells and replaced by host me-
niscuslike tissue. Long-t clinical data are promising.
A retmspective review found that patients treated with
collagen meniscal implants fer an irreparable medial me-
niscal tear had better clinical, radiologic. and functional
outcomes at lfl-year follow—up than patients treated with
partial medial meniscectomy alone.“2 A prospective co-
hort study of 33 patients compared a medial collagen
meniscal implant with a partial meniscectomy. At an
average 133-month follow-up, patients who received the
medial meniscal implant had substantially better visual
analog scale pain scores as well as significantly higher
functional outcomes as measured using the Tegner Ac-
tivity Level Scale. International Knee Documentation
Committee Subjective Knee Evaluation Form, and Med
ical Outcomes Study Sid-Item Short Form Health Survey
scores.41 Patients with an irreparable lateral meniscus tear
or a history of partial lateral meniscectomy also had sub-
stantial improvement in clinical outcome scores at 2-year
follow-up, with no progressive cartilage degeneration.43
In a prospective randomised study of the use of collagen
implants, patients with no history of surgery and patients
who had undergone previous meniscal surgery received a
collagen scaffold implant or a partial meniscectomyl"l Pa-
tients who received the collagen implant had significantly
increased meniscal volume at second-look arthroscopy,
compared with baseline. Patients with a history of me-
E niscal surgery gained 42% of lost activity 5 years after
'U
E collagen scaffold implantation, which was substantially
I'D
Ill more than those who received meniscectomy alone.“
I1!
I:
be! An acellular. biodegradable, synthetic polyurethane
scaffold has been developed for medial and lateral me-
H
niscal defects. This scaffold is highly porous and allows
vascular and fibrochondrocyte ingrowth. In animal mod—
els there was vascular ingrowth and matrix deposition
onto the scaffold at 2 weeks. and by 3 months the pores
were filled with fibmvascular tissue.“ At 2-year follow—up
patients who were treated with the polyurethane scaffold
Drrhopaedic Knowledge Update: Sports Medicine 5
for postmeniscecromy syndrome after medial or lateral
partial meniscectomy had significant improvement in all
clinical outcome scores, and 92.5% had stable or im-
proved International Cartilage Repair Society cartilage
status.“ In 9 of 52 patients {113%} treatment failed, but
2 of these patients were asymptomatic and the failure
was discovered during protocol-stipulated second-look
arthroscopy. Six of the nine treatment failures were a
lateral tear, where mobility and the complex anatomy
of the meniscal attachments create a biomechanically
challenging procedure. Another recent study on the use
of a polyurethane scaffold for lateral meniscal defects and
postmeniscecromy pain found substantial improvement in
pain and clinical outcome scores at 24-month follow-up.“
Three of the 54 patients {5.5%} required reoperation be-
cause of persistent pain, and 2 of these patients were
found to have a small tear at the edge of the scaffold.
Meniscal Allegraft Transplantation
Meniscus replacement with allograft tissue appears to
be a viable treatment for patients younger than 5D years
with pain and dysfunction from meniscal pathology war-
ranting subtotal or total meniscectomy. A biomechanical
study found that meniscal allografr transplantation re-
stores normal knee contact mechanics and restores strain
on the ACL with anterior translation to baseline?” The
described techniques include arthroscopically assisted and
open procedures as well as methods of fixation such as
transplantation with bone plugs attached to the anterior
and posterior horns, a common bone bridge attached to
both horns, and suture fixation only {Figure 6}.
Video 20.5: Lateral Meniscus Transplanta-
tion. Benjamin 5. Shaffer, MD {6 min}
Video 20.5: Lateral Meniscus Transplan-
tation - Bridge-in-Slot. Brian J. Cole, MD,
IVIBA (15 min}
Video 10.1: Medial Meniscus Transplan-
tation - Double Bone Plug. Thomas E.
Carter. MD (11 min}
Video 20.3: Medial Meniscus Transplan-
tation During AEL Repair. John C. Hich-
mend. MD II? min}
Three- to 4-year outcomes were reported for medial
and lateral meniscal allograft transplantation in patients
with or without a history of meniscal surgerydi-i“ After
fl lflld American Academy of Urrhopaedic Surge-ens

Figure IE Schematic drawings shew {A} medial meniscal allegraft transplantatinn using hene plugs and {I} lateral meniscal
allngraf'i transplantatinn using a lame bridge secured tn the capsule th rnugh trartsnssenus tunnels and peripheral
sutures.
meniscal allngraft transplantatinn, patients had substan-
tial irnprnvement in clinical nutcnme scnres en the mean
Lyshnlm, Knee Injury and Dsteearthritis IDutcnme Scnre,
internatinnal Knee Dncumeutatinn Cnmmittee, Tegner,
and Knee Seciety Scnre measures as well as radingraphic
measures nf nstenarthritisfhm Seventy-seven percent nf
high schnnl and higher level athletes were able tn return
tn spnrts activity.“ Based nn secnnd—lnnk arthrnscnpy
and MRI, 31.3% nf patients had a satisfactnry nutcnme.
Midterm fnllnw—up nf arthrnscnpically assisted meniscal
allngraft transplantatinn alsn fnund prnmising results.“
Patients had imprnvement nver baseline scnres en the
Knee Injury and Dstenarthritis |l.'3Iutcnme Scnre subscnres
for pain, ether symptnms, activities nf daily living, spurts
activity, and Quality ef life as well as the visual analng
pain scale, Medical lI'Ciutcnmes Study Shnrt Perm—36, and
Lyshnlm scnres. Lnng-term fellew-up nn npen meniscal
allngraft transplantatinn using crynpreserved allngraft
fnund a 29% failure rate.52 Ebert—term nutcnme scnres
were better than baseline scnres but deterinrated at lnng-
term fnlinw-up. The mnst impnrtaut factnr determining
nutceme was the extent nf cnncnmitant articular cartilage
degeneratinn; better results were reported in patients with
minimal degenerative changes.
Summary
The menisci have been shnwn tn prnvide lnad distributinn,
lubricatinn, and bnth translatinnal and rntatnry stability
tn the knee jnint. Studies shnwing an increase in centact
pressure en the articular cartilage and increased strain nn
IE! lfllfi American Academy nf Cirrhnpaedic Surgenna
Chapter as: Meniseal Injuries
Medial k. I"—-
B
the ACL fniinwing subtntal meniscectnmy nr high-grade
radial tear have led tn an increase in the number nf me—
niscal repairs perfnrmed tn preserve the lead ahsnrptinn
and stabilizatinn prnperties nf the menisci. I{Slinical and
radingraphic healing rates nf 60% tn 35% are repnrted af~
ter repair. Meniscal repair with cnncnmitant ACL surgery
leads tn a higher rate nf healing than isnlated meniscal
repair, and tears repaired in smnkers and tears larger than
1|] mm have a lnwer rate nf healing. Irreparahle tears
and pnstmeniscectnmy pain syndrnme are cnmmnn in
ynung patients and are difficult tn treat. Cnilagen sca ffnld
implants and synthetic pnlyurethane scaffnids have had
prnmising results in animal and human studies fer filling
large defects after partial meniscectnmy. Relatively ynung
patients whn undergn tntai nr suhtntal meniscectnmy'
as a primary prncedure may be candidates fer meniscal
allngraft transplantatinn. Binmechanical studies found
that strain en the ACL is reduced and knee kinematics
and centact pressures are imprnved tn near-ba seline levels
after transplantatinn.
H
F:
Key Study F'nints 5
re
in
ru-
Ir The menisci are impnrtant lead-distributing and 3
D.
stabilizing structures in the knee. s
I Repairs nf tears in the red-red aene and repairs with
cnncnmitant ACL recnnstructinn are the must likely
tn cempletely heal.
' Results nf meniscal scaffnld implantatinn and
allngraft transplantatinn have shnwn prnmising
results.
Drthnpaedic Knnwledge Update: Spnrts Medicbse 5
 Sectinn s: Knee and Leg
Annotated References
1. Musahl V, Citak M, D'Lnughlin PF, Chni D, Eedi A, Pearle
AD: The effect nf medial versus lateral meniscectnmy nu
the stability cf the anterier cruciate ligament-deficient
lrnee. Am ] Sperts Med lfllfl;33{3}:1591-159T.
A binmecha nical study evaluated the effect nf the medial
and lateral menisci en ACLadeficient lrnees. The media]
meniscus was fnund tn he a secendary stabilizer tn anterier
translatien, but the lateral meniscus was a mere impertant
stabilizer during the pivnt shift test.
. Spang JT, De rig HE, Masseeca A, et al: The effect ef me-
dial meniscectnmy and meniscal allngraft transplantatinn
nn knee and anterier cruciate ligament binmechanics.
Artbrnscepy Zfl'lfi;lfiili:191-Efll. Medline DUI
A binmechanical study evaluated strain at the ACL with
tibial displacement in intact, tetal meniscectnmy, and
medial allngtaft transplantatinn cnuditiens. Medial me—
niscectemy ptnduced the greatest tibial displacement and
strain nn the ACL. Medial meniscal allngraft transplan-
tatieu restnred unrmal cnnditinns.
fimigielski R, Becker R, Zdannwica U, Cisaelt E: Medi-
al meniscus anatnmy: Frnm basic science tn treatment.
Knee Serg Sperts Traumatel Artfiresc EDIS;E3{I}:3-I4.
Medline DUI
This anatcrmic study nf the medial meniscus fncuses nu
the peripheral attachments nf the medial meniscus tn di-
vide it intn five distinct annes. An understanding ef the
peripheral anatemy ef the meniscus is impertant during
meniscal repair.
. Arnncaky 51", Warren RF: Micrnvasculature nf the hu-
man meniscus. r'lnt _,I Spnrts Med 1931;1fll21flfl-95.
Medline DD]
Barata ME, Fu FH, Mengatn R: Meniscal tears: The effect
ef meniscecteruy and ef repair nu iuttaarticular ceutact
areas and stress in the human knee. A preliminary repert.
Am] Spnrts Med 1935;14l4]:2?l}-2?5. Medline DUI
Lee S], Aadalen K], Malaviya P, et al: Tibiefemnral centact
mechanics after serial medial meniscectnmies in the hu-
man cadaveric knee. An: 1 Sparta Med Eflflfi;34{li}:1334-
1344. Medline DUI
i‘
'U
. Bedi A, Kelly NH, Baad M, et al: Dynamic centact me-
chanics ef the medial meniscus as a functinn nf radial tear,
E
I'D repair, and partial meniscectnmy. I Enne Inert Surg Am
Ill 1fl10592{6}:1393-14flfi.
I1!
I:
hr:
H
A biemechanical study fnund that radial tears invelving
fifl‘i-i. ef the width ef the meniscus caused an increase in
peak cnutact pressure and alteratien nf its lncatinn. Par-
tial meniscectemy further increased pressures. Inside-nut
repair reduced pressures re a level similar te that ef the
intact state. Medline DUI
. Bedi A, Kelly M, Bead M, et al: Dynamic eentact mechan-
ics nf radial tears nf the lateral meniscus: Implicatinns
Drthepaedic Knnwledge Update: Sperrs Medicine 5
fnr treatment. Artbrnscepy lflll:23{3}:3?2-331.
Medline DUI
.fi. binmechanical study fnund that a radial tear nf the pns-
terinr tnnt fill ‘34:. nf the width ef the meniscus er a partial
meniscectemy ef such a tear significantly increased ceutact
pressures and decreased centact area. Repair significantly
decreased peak centact pressure.
Badlani JT, Eerrere C, lGnlla S, Harrier CD, Irrgang J]:
The effects nf meniscus injury en the develnpment nf lrnee
esteearthritis: Data free: the esteearth ritis initiative. An:
I Spur-ts Med 3013;41ifiislli’13-1244. Medline DUI
A case centre] study fnund that medial meniscus extru-
sinn, cnmplesr tears, and large radial tears were mnte
cnmmnn in patients with nsteeatthritis than in centre]
subjects. Level ef evidence: III.
10. Knnan 5, Rayan F, Haddad F5: De physical diagnnstic
tests accurately detect meniscal tears? Knee Serg Sperts
Trenmntni Arthrnsc 1Dfl9;1?{?l:fiflfi-SII. Medline DUI
Jnint line tenderness was fnund tn he superinr tn the
McMurray er Thessaly test fer the diagnnsis nf iselated
meniscal tears cenfirmed at arthrnscnpy. The cnmbiua-
tinn nf jnint line tenderness and nne nther test imprnved
diagnnstic accuracy.
11. Gnessens P, Keijsers E, van Geeuen R], et al: Validity nf
the Thessaly test in evaluating meniscal tears cnmpated
with arthrnscnpy: A diagnnstic accuracy study. I Drtfiep
Spnrts Phys Ther 2015;45{1]:13-24, El. Medline DUI
Per the evaluatinn nf pnssible meniscal tears the Thessaly
test had sensitivity nf 64% and specificity nf 53%, the
McMurray test had sensitivity ef Tfl‘iis and specificity nf
45%, and eembined testing had sensitivity ef 53% and
specificity cf 62%. These values were lnwer than repnrted
in the nriginal descriptieu.
12. Mirsatelneei F, Tekta Z, Bayaaidchi M, Ershadi 5,
Afshar A: Validatinn ef the Thessaly test fer detecting
meniscal tears in anterier cruciate deficient knees. Knee
101D;1?I{3}:221-223.Medline DDI
In patients with cnmbined ACL and meniscal injury, jeint
line tenderness was mnst sensitive and the McMurtay test
was mest specific fer diagnnsis ef the meniscal tear.
13. 1iii'an Dyck P, Va nhnenacker PM, Lambrecht V, er al: Pre—
speetive cemparisen ef 1.5 and Bail-T MRI fer evaluat-
ing the knee menisci and ACL. f Enne fninr Surg Am
1013;95llfllfllfi-914.Mcdline DUI
Sensitivity and specificity fnr diagnnsis nf medial and
lateral meniscal tears was higher when 3.fl-T MRI was
used rather than 1.5-T MRI, but the difference was nnt
significant. Sensitivity was higher fnr medial tears, and
specificity was higher fer lateral tears. Level ef evidence: I.
14. LaPrade RF, He CP, James E, Crespe B, LaPradc CM,
Matheny LM: Diagnnstic accuracy ef 3.!) T magnetic
resnnance imaging fur the detectinn nf meniscus pnsterinr
rnet pathnlegy. Knee Burg Spnrts Trestmntnl Arrhrnsc
lfllfi;23{1j:152—151Medline DUI
fl lfllfi American Academy ef Urthnpaedic Surge-ens

Mederate sensitivity and specificity was fennd fer MRI
diaguesis ef men iscal reet tears cenfirmed at arthrescepy.
Level ef evidence: II.
15. Han SE, Shetty GM, Lee DH, et al: Unfaverahle results
ef partial meniscectemy fer cemplete pesterier medial
meniscus reet tear with early esteearthritis: A .5 — te 3-year
fellew-up study. ‘Arthreseepy lfllfl;13{lfl}:1326-1332.
Medline DDI
At a mean 5-year fellew-up, a retrespective study cf
46 patients whe underwent arthrescepic partial menis-
cectemy ef a pesterier medial meniscal reet tear feund
imprevement in clinical parameters after arthrescepic
meniscectemy but a 35% radiegraphic pregressien ef
esteearthritis. Level ef evidence: IV.
16. Fasten E3, Steclt MV, Brephy RH: Meniscal repair versus
partial meniscectemy: A systematic review cemparing
reeperatien rates and clinical eutcemes. Artbrescepy
2311;2?{9}:12?5-1233. Medline DUI
A systematic review ef partial meniscectemy and menis-
cal repair feund that partial meniscectemy resulted in a
lewer reeperatien rate but a higher rate ef pregressien ef
radiegraphic degeneratien. Meniscal repairs cencemitant
with ACL recenstructien had a lewer failure rate. Level
ef evidence: IV.
1?. Stein T, Mehling AP, Welsch F, ven Eisenhart—Rethe R,
J3ger A: Lung-term eutceme after arthrescepic meniscal
repair versus arthrescepic partial meniscectemy fer trau-
matic meniscal tears. An: ] Sperts Med 2313;33f3}:1541-
1543. Medline DD]
A cehert study cempared the eutcemes ef arthrescepic
meniscal repair and arthrescepic partial meniscectemy in
31 patients. At mid- and leng-term fellew up, patients whe
underwent repair had better sperts activity and ne estee-
arthritic pregressien cempared with these whe underwent
partial meniscectemy. Level ef evidence: III.
13. Kim 53, Ha JR. Lee 3W, et al: Medial meniscus met tear
refixatien: Cemparisen ef clinical, radielegic, and arthre-
scepic findings with media] meniscectemy. Arthrescepy
lflll;2?{3}:34E—354.Medline no:
A retrespective study cempa red medial meniscus reet re—
pair and partial meniscectemy in 53 censecutive patients.
At a mean 43.5-menth fellew-up, arthrescepic repair
yielded better clinical and radiegraphic results than partial
meniscectemy. Lewl ef evidence: III.
19. Neyes FR, {Eben RC, Barber-Westin 5D, Fetter HG: Great-
er than IH-year results ef red-white lengitudinal meniscal
repairs in patients 23' years ef age er yeunger. An: I Sperts
Med 1311;39{5}:1333—1311 Medline DDI
The success rate was 62% after repair ef lengitudinal tears
extending inte the red-white acne in patients age 30 years
er yeunger. In healed repairs. quantitative cartilage sceres
en MRI were net significantly different frem these ef the
uninjured knee. Level ef evidence: IV.
II}. Legan M, Watts M, Gwen J, Myers P: Meniscal repair
in the elite athlete: Results cf 45 repairs with a minimum
I3! 2313 American Academy ef flrthepaedic Snrgeens
|Iiiihapter ED: Meniscal Injuries
Seyear fellew—up. Am I Sperts Med 2339:3Ti6]:1131e1134.
Mcdline DUI
After meniscal repair 31% cf elite athletes were able te
return te sperts at a preinjury level, despite a 243i:- retear
rate. Medial repairs had the highest failure rate. Level ef
evidence: IV.
21. Lyman 3, Hidalta C, Valdez AS, et al: Risk factel's fer
meniscectemy after meniscal repair. Am I Sperts Med
2313:41t12}:2??2-2??3.Medline I101
The everall rate ef meniscectemy after meniscal repair was
3.9%. A regressien analysis feund that cencemitant REL
recenstructien was a risk facter fer meniscectemy after
repair. Patients whe underwent iselated meniscal repair
were at lewer rislt if they were elder than 43 years er had
nndergene lateral repair er if the surgeen had perfermed
a large number ef meniscal repairs. Level ef evidence: III.
. Nepple J], Dunn WR, Wright RW: Meniscal repair
eutcemes at greater than five years: A systematic liter-
ature review and meta-analysis. I BDHE Jeirtt- Surg Am
2312;94f24'Jfllll—2121Medline DUI
A systematic review ef studies reperting eutcemes ef me-
niscal repair with a minimum 5—year fellew—up feund
that the everall rate ef failure was 23.1% There was en
statistical difference in eutcemes ameng patients whe
underwent medial er lateral repair, and simultaueeus ACL
recenstructien did net affect results. Level ef evidence: IV.
23. I-Ialtlar U, Den mes F, Basaran SI-I, {Ian beta MK: Results
ef arthrescepic repair ef partial- er full-thickness lengi-
tudinal medial meniscal tears by single er deuble vertical
sutures using the inside-eut technique. An: ] Sperts Med
2013;41f3}:595-533.Medline DUI
A retrespective review ef inside-nut repair ef lengitudinal
medial meniscal tears with er withent ACL recenstructien
fennd that at an average 49.3-menth fellew—up, 33.4%
were healed by clinical and radiegraphic analysis. Patients
whe had undergene ACL recenstructien er had a tear
smaller than 2 cm er whe did net smelce tebacce had a
higher rate ef healing. Level ef evidence: IV.
24. Eegunevic L, Kruse LM, Haas AK, Husten L], Wright
R‘IV: Uutceme ef all-inside seceud-generatien meniscal
repair: Minimum five-year fellew—up. ] Rene Jeiut Surg
Am 2014;96t15]:1333-1331 Medline DGI
A retrespective review ef the 5-year eutcemes ef T5 pa-
tients treated with the all-inside FAST—FIR meniscal repair H
system {Smith 3: Nephew} feund a 16% failure rate. There F:
was ne difference between iselated meniscal repairs and 5
ta
repairs with cencemitant ACL recenstructien. Level ef m
u:-
evidence: IV. :1
D.
15. M Eucltland D, Sadeghi P, Wimmer MD, et al: Meta—anal—
3
ysis en biemechanical preperties ef meniscus repairs: Are
devices better than sutures? Knee 3mg Sperts Tranmdtef
Artfaresc 2315,23f1l:33-3R Medline DUI
Meta-analysis ef biemechanical studies cemparing all-su-
ture meniscal repairs and all-inside devices feund that
all-suture devices had a higher lead te failure and stiffness
Drthepeedic Knewledge Update: Sperts Medicine 5
 sectionattnseanateg
than all-inside devices. Vertical mattress suture config-
uration was stronger than horizontal mattress suture
configuration.
1S. Barber FA, Herbert MA, Eava ED, Drew DR: Biome-
chanical testing of suture-based meniscal repair devices
containing ultrahigh-molecular-weight polyethylene su-
ture: Update 2:011. Arthroscopy EDIE:ES{E‘J:SZ?-SS4.
Mediine DUI
A biomechanical study of the load to failure of all-su-
ture constructs and all-inside devices found that vertical
mattress sutures were stronger than all-inside devices,
but there was no significant difference between all-suture
devices and all except one all-inside device.
2?. |Grant Jill, 1||Wilde J, Miller ES, Bedi A: Comparison of in-
side-out and all-inside techniques for the repair of isolated
meniscal tears: A systematic review. An: J Sports Med
2011;40j2]:459-4SS.Medline DUI
A systematic review of 15' studies comparing inside-out
and all—inside repairs found a Hit: rate of clinical fail-
ure for inside-out repairs and a 19% rate for all-inside
repairs. Patient-reported outcomes were similar. Herve
irritation was more prevalent with inside-out repairs, and
implant-related complications were more prevalent with
all-inside repairs. Level of evidence: I‘v".
23. Alvarez-Dian P, Alentorn-Geli E, Llobet F, lII'iranados N,
Steinbacher G, Cugat R: Eemrn to play after all-inside me-
niscal repair in competitive football players: A minimum
5—year follow—up. Knee Snrg Sports Trantnatoi Arthrosc
Ii] 14. Medline DDI
A retrospective review of the rate of return to sport of 39
male soccer players who underwent all-inside repair of a
complete longitudinal tear found that 39.6% returned to
the same level after initial recoveryr and 63% required
meniscectomy before return to sport. At 5-year follow-up,
4.5% continued to play soccer, of whom 23% were playing
at the same level. Level of evidence: IV.
29. Imade S, Kumahashi N, Kuwata S, Kadowaki M, Ito
S, Uchio Y: Clinical outcomes of revision meniscal re-
pair: A case series. An: 1 Sports Med 213 14;42{l}:350-351
Medlinc DUI
A retrospective study compared 1.5 revision meniscal re-
pairs and 96 primary repairs. Five revision repairs were
unsuccessful, but patients with a successful revision had
significant improvement in their clinical outcome scores.
3‘ Degenerative meniscal tissue was found at the repair site
'U
E
in all unsuccessful revision repairs. Level of evidence: IV.
I'D
Ill
I1!
I: 3f}. Allaire R, Muriuki M, Gilbertsou L, Harner CD: Biome—
but:
chanical consequences of a tear of the posterior root of the
H
medial meniscus: Similar to total meniscectomy. ] Bone
joint Snrg ritn Eflflflflflifljdffll—ISSI. Medline DUI
31. Muriuki MG, Tuason DA, Tucker 13G, Harner |ED: Chang-
es in tihiofemoral contact mechanics following radial split
and vertical tears of the medial meniscus an in vitro in-
vestigation of the efficacy of arthroscopic repair. 1 Bone
Joint Sttrg Ant 1fl11;93{12}:1fl39-1fl95. Mcinc DUI
Drthopaedic Knowledge Update: Sports Medicine 5
A controlled laboratory study compared knee contact
pressures in intact medial menisci and medial menisci with
a radial split tear, vertical tear, or repaired tear. Repair of
a meniscal tear created contact pressure and area similar
to that of the intact meniscus.
32. LaPrade CM, Janssou K5, Dornan G, Smith SD, Wijdicks
CA, LaPrade RF: filtered tihiofemoral contact mechan-
ics due to lateral meniscus posterior horn root avuisions
and radial tears can be restored with in situ pull-out su-
ture repairs. I Bone Joint Snrg An: 2fl14:96[S}:4?1-4?9.
Medline DDI
A cadaver biomechanical study compared contact area
and pressures in intact lateral menisci, lateral menisci
with a footprint teat, root avulsion, or radial tear 3 mm
or 6 mm from the posterior root, with repair of each of
the injured states. Avulsion of the root and the radial tears
significantly decreased the contact area and increased
the peak pressure. In situ pullout suture repair decreased
peak pressures.
33. Padalecki JR, Jansson KS, Smith SD, et al: Biomechanical
consequences of a complete radial tear adjacent to the
medial meniscus posterior root attachment site: In situ
pull-out repair restores derangement of joint mechanics.
An: I Sports Mari 2014;42i3}:699-?fl1 Medline DUI
ii. cadaver biomechanical study compared contact area and
pressures in intact lateral menisci, lateral menisci with a
footprint tear, root avulsion, or radial tear 3.- mm, S mm,
or 9' mm from the posterior root, with repair of each of
the injured states. flvnlsion of the root and the radial tears
significantly decreased the contact area and increased the
peak pressure. In situ pullout suture repair decreased peak
pressures and increased contact area to a level similar to
that of the intact meniscus.
34. Horie M, Driscoll MD, Sampson HW, et a1: Implantation
of allogenic synovial stem cells promotes meniscal regen—
eration in a rabbit meniscal defect model. I Bone joint
Snrg Atn 2012;94i3}:?i}I-?IE. Medline DUI
Injection of synovial stem cells into meniscal defects in
rabbits increased the quantity of regenerated meniscal
tissue 4 and 12 weeks after implantation. Tissue quality
scores were improved 12 and 24 weeks after implanta-
tion. Implanted cells adhered to the defects and became
differentiated into type I and II collagen—expressing cells.
35. Vangsness CT Jr, Farr] II, Boyd ], Dellaero DT, Mills
ER, LeRoun-Williams M: Adult human mesenchymal
stem cells delivered via intra-articular injection to the
knee following partial medial meniscectomy: A random-
ized, double—blind, controlled study. f Bone joint Snrg An:
2014:9Sl2]:9fl-SS. Medline DUI
A randomised, controlled study found that 6% to 24% of
patients who received one of two different concentrations
of allogeueic stem cells had a 1.5% or greater increase in
meniscal volume after partial medial meniscectomy. None
of the control subjects reached this level. Patients with
osteoarthritis had a significant reduction in pain. Level
of evidence: I.
fl lfllfi American Academy of Orthopaedic Surgeons

36. Ruiz—[bin MA, Diaz—Heredia J, Garcia-des I, Gonzas
Isa-Lisan F, Elias-Martin E, Abraira V: The effect of the
addition of adipose'derived mesenchymal stem cells to a
meniscal repair in the avascular zone: An experimental
study in rabbits. Arthroscopy 2011;2?{11}:IESS-1696.
Medline DUI
An animal study found that the addition of adipose-de-
rived allogeneic stem cells to acutely repaired longitudi-
nal tears in the avascular zone of the medial meniscus
significantly improved histologic properties at 12 weeks
compared with those of control animals. The difference
was less robust after delayed repair.
3?. Ahn JH, Kwon D], Nam TS: Arthroscopic repair of hot-
izontal meniscal cleavage tears with marrow-stimulating
technique. Arthroscopy 1015:31{1}:92-BS. Medline DDI
In a retrospective review, 32 horizontal cleavage tears
extending into the avascular sons were treated with repair
and augmentation with bone marrow stimulation through
drill holes in the intercondylar notch. Clinical outcomes
scores improved, and 91% of patients were clinically
healed. At second-look arthroscopy ?S% were healed
and 13% were partially healed. Level of evidence: IV.
SS. Braun H], Kim H], lChu CR, Dragon JL: The effect of
platelet-rich plasma formulations and blood products on
human synoviocytes: Implications for intra-articular in-
jury and therapy. do: I Sports Med 2014;42i5}:1204 -121Il.
Medline DIDI
This review article on the current use of PEP discusses its
use in tendinopathy as well as the early results of use in
meniscal and ligament healing. Although there are prom-
ising results in preliminary studies, no conclusive evidence
on the use of PEP for meniscal or ligament healing has
been proven.
39. Kwalt HS, Nam J, Lee JH, Kim H], 1foo J]: Meniscal rev
pair in vivo using human chondrocyte-seecled PLEA mesh
scaffold pretreated with platelet-rich plasma. I Tissue Eng
Regen Med [Published ouline ahead of print June 19,
2fl14]. http:iids.doi.orgi1fl.IfifllftermdSSS DDI
PRP pretreatment on a polyilactic-co-glycolic acid] mesh
scaffold enhanced the healing capacity of the meniscus
with human chondrocyte—seeded scaffolds in an animal
model. Sis: of IS menisci healed and 9 partially healed
when implanted with the PEP-treated scaffold.
4D. Griffin J‘W, Hadeed MM, Werner BC, Diduch DR, Carson
ET, Miller MD: Platelet-rich plasma in meniscal repair:
Does augmentation improve surgical outcomes? CH1: Cir-
Iibop Refer Res EDIS;4?3[S}:IfifiS—Ifi?l. Medline Dfll
A retrospective comparative study found no between—group
differences in reopetation rate, functional outcomes
scores, return to work, or return to sports in patients
treated with or without PEP during meniscal repair. Level
of evidence: III.
41. Puiol N, Sallc Dc Chou E, Boisrenoult P. Beaufils P:
Platelet-rich plasma for open meniscal repair in young
patients: Any benefit? Knee 5mg Sports Trenmatof Ar-
throsc 2fl15;23{1]:SI-SS. Medline Dfll
ID EDIE American Academy of Drthopaedic Surgeons
|Killsmter ED: Meniscal Injuries
A case-control study found that patients treated with re-
pair of a horizontal cleavage tear augmented with PRP
injection had higher Knee Injury and Dateoarthritis Dut-
come Score {EGGS}, and EGGS pain and sports subscores
were significantly higher. Five patients treated with PRP
had complete resolution of MRI findings of meniscal in-
jury. Level of evidence: III.
42. Eaffagnini S, Marcheggiani l'vIuccioli GM, Lopomo N, et
al: Prospective long-term outcomes of the medial collagen
meniscus implant versus partial medial meniscectomy:
A minimum I'D—year follow—up study. Am J Sports Med
2fl11;39{5 i:9??—SSS. Medline DUI
A prospective cohort study compared the results of medial
meniscal collagen implantation and partial meniscectomy.
Clinical outcome scores and MRI findings were better
after medial meniscal collagen implantation at III-year
follow-up.
43. Zaffagnini S, Marcheggiani Muccioli GM, Eulgheroni
P, et al: Arthroscopic collagen meniscus implantation for
partial lateral meniscal defects: A 2—year minimum fol-
low-up study. Am I Sports Med 2fl12:40{1fl}:2231-223 3.
Medline DUI
A case study evaluated 2-year outcomes of lateral me-
niscal collagen implantation. Pain was decreased pain
and function was improved compared with preoperative
levels without significant change to cartilage in the lamral
compartment. Level of evidence: IV.
44. Rodltey WU, DeHaven HE, Montgomery WH III, et al:
Comparison of the collagen meniscus implant with partial
meniscectomy: A prospective randomized trial. 1 Bone
Joint Sarg Am lfifl3;9fl{?}l:1413-1426. Medline DflI
45. Maher sa. Rodeo sa. Doty SB, et al: Evaluation of a
porous polyurethane scaffold in a partial meniscal de-
fect ovine model. Arthroscopy 2fl1fl;26{11}:15 1D—1519.
Med’line DUI
Lateral meniscal defects were created in sheep, and a poly-
urethane scaffold was implanted into half of the animals.
There was no significant chondral damage beneath the
scaffold. Fibrochondrocytes were well integrated inm the
scaffold within 3 months.
46. 1ii'erdonlst P, Beaufils P, Bellemans J. et al; Actifit Study
IGroup: Successful treatment of painful irreparable par-
tial meniscal defects with a polyurethane scaffold: Two-
year safety and clinical outcomes. Am ,i' Sports Med H
2fl12:4fl[4}:344-SSS.Medline DUI F:
5
re
A retrospective review of patients with postmeniscectomy re
ru-
syndrome who were treated with polyurethane scaffold 3
implantation found clinically and significant improvement D.
in clinical outcomes. Implantation failure occurred in s
113%, and stable or improved cartilage grading was noted
in 92.5% of patients. Level of evidence: IV.
4?. Eouyarmane H, Beaufils P, Pujol N, et al: Polyurethane
scaffold in lateral meniscus segmental defects: Clinical
outcomes at 24 months follow—up. flrtbop Trenmstoi
Surg Res 2fl14;1{lfl{1}:lSS-IST. Medline DUI
Drthopaedic Knowledge Update: Sports Medichse S
 Sectien 3:Knee andLeg

A prnspective rnulticenter studyr cf 54 patients with lateral
pnstnieniscecuctnvfpr svndrnme whn were treated with pulv-
urethane scaffnld implantatinn feund significant imprnve-
ments in clinical nutceme scares. Level nf evidence: IV.
43'- Paletta GA Jr, Manning T, Snell E, Parker It, Eergfeld
J: The effect nf allngraft meniscal replacement en intra-
articular cuntact area and pressures in the human knee: A
hinrnechanical study. An: I Spurts Med 199?,15i5}:691-
693. Medline DUI
51. van der Wal R], Thcmassen B], van Arkel ER: Lung-
tern1 clinical cutcnme nf npen meniscal allugraft trans-
plantatien. An: 1 Sports Med 1009;31i11}:1134-1139.
Medline DUI
A case stndv cf 63 npen meniscal ails-graft transplanta-
tinns evaluated the clinical uutcnmes and failure rate at
13.0-vear fullnw—up. The punrest results were nhservcd
after medial ails-graft transplantatien and in wemen. Level
cf evidence: IV.

45'. Chalmers PM, Karas V, Sherman 5L, Cele B]: Return te-
high-level spurt after meniscal allngrafl: transplantatinn.
Artizrnscnpv 1013;19:353-544. Medline DUI
A retrnspective case stud}r evaluated return tc: spurts cf 13
patients after meniscal allugrai't transplantatiun. At a mean
3.3-}rcar fullnw—up, 11% had returned tn their appruved
level cf return tn plav and had cnncnmitant imprevement
in clinical nutcutne scnres. Level uf evidence: IV.
.50. Kim JM, Lee HS, Kim KH, Kim KA, Bin SI: Results nf
meniscus allugraft transplantatiun using hcne fixatinn:
110 cases with nhjective evaluatinn. Ann } Spurts Med
2011;40l5]:101?—1034.Medline DUI
A retrnspective case stud},r e]? 115 knees after meniscal al-
lngraft transplantatinu fennel significant clinical and func-
tinnal nutccune imprcvements at 49.4-rnnnth fulluw-up.
Level e-f evidence: IV.
51. Vundelincltx E, Bellernans J, Vanlauwe J: Arthrlljscnpicall‘}.r
assisted meniscal allngraft transplantatiun in the knee:
A medium-term subjective, clinical, and radingraphical
nutcnme evaluatinn. Am I Spurts Meci 1010;3fl{11}:1140-
1141'. Medline DDI
A case stud].r cf 50 meniscal allngrafr transplantatiuns
feund imprnvement in measured clinical nutcnme scares
and functinn. There was an increase in nstenarthritis in
53% nf patients. Level nf evidence: IV.
1iiieleu References
10.1: Sheltc-n WE: Aii-Insicie Meniscus Repair - FAST-FIE
[viden excerpt]. Jacksun, M5, 1011.
10.1: Lawhnrn KW: Aii-Insirie Meniscus Repair - MaxFire
Maeen [viden excerpt]. Fairfax, VA, 1011.
10.3: Vvas D, Harner CD: Pnsieriar Hnrn Medial Meniscus
Rant Repair [viden excerpt]. Elawnnx, PA, 1011.
10.4: Sgagliene HA, Chen E: Aii-Artiirnscnpic Meniscus Re-
pair witir Biaingical Augmentaiinn [viden excerpt]. Rnsetnunt,
IL, American Academy.r nf Drthepaedic Surgenns, 1011.
10.5: Shaffer BS: Laterai Meniscus Transpianiaiiun [viden
excerpt]. Easement, IL, American Academy,r cf Orthnpaedic
Surgeens, 1011.
10.6: Cale E]: Laserai Meniscus Transpiantatian - Bridge-
in-Sins [viden excerpt]. Easement, IL, American Aeademv cf
flrthc-paedic Surgeuns, 1011.
10.1: Carter TR: Media! Meniscus Transpianiaiinn - Dnubie
Bane Ping [viden excerpt]. Phennix, AZ, 1011.
10.3: Richmnnd JC: Mea'iai Meniscus Transpianiasinn During
ACL Repair [viden excerpt]. Enstnn, MA, 1011.

DI
:u
._I
T:
I:
a:
a:
III-1
I:
a:
H

Drrhnpaedic Knnwledge Update: Sparta Medicine 5 El 1016 American Academy at Drrhnpaedic Surge-ans
Chapter 21
Leg Pain Disorders
Iustin Shu "Fang. MD Thomas M. DeBerardino. MD
Abstract
Exertional leg pain can be a difficult spectrum of disor-
ders to diagnose and treat. Medial tibial stress syndrome,
tibial stress reaction, and tibial stress fractures are
overuse disorders that can cause substantial time away
from competition. The keys to preventing stress fracture
include adequate dietary consumption of calcium and
vitamin D, and ether targeted interventions in at-risk
populations. Nonsurgical management usually allows
patients to return to their earlier activity level, although
prolonged rest often is needed. Surgical intervention
can be considered for a patient with a recalcitra nt stress
fracture or a high-risk fracture of the anterior tibia or an
athlete who needs to remrn to sports quickly. Current
diagnostic criteria for chronic exertional compartment
syndrome can lead to high rates of false-positive results.
Criteria using improved standardized excrcise testing
may have greater sensitivity and specificity. Surgical
release is successful for pain relief in chronic exertional
compartment syndrome but may not lead to a return
to full sports activity or active military duty. Early
recognition and treannent of popliteal artery syndrome
is critical to a good outcome.
Keywords: chronic esertional compartment
syndrome: leg pain: medial tibial stress syndrome;
popliteal artery entrapment syndrome; tibial stress
fracture; tibial stress reaction
Dr. fleEerardino or an immediate family member has re-
ceived royalties from Arthreic serves asa paid consultant to
Arthrex; has received research or institutional support from
Arthrer, Histogrenics. and the Muscuioslteletal Transplant
Foundation; and serves as a board member; owner; officer;
or committee member of the American Drthopaedic Society
for Sports Medicine. Neither Dr Yang nor any immediate
family member has received anything of value from or
has stuck or stock options held in a commercial company
or institution related directly or indirectly to the subject
of this chapter.
@ lfllfi American Academy of Drthopaedic Surgeons
Introduction
Eacrtion—rclated leg pain is common among people who
are physically active. As many as Sfl‘iiis of collegiate ath-
letes seek health care for leg pain.1 Leg pain can present
a clinical conundrum because the symptoms of several
disorders are similar, and a meticulous workup is re-
quired to reach the correct diagnosis. Medial tibial stress
syndrome {MTSS}, stress reaction and fracture, chronic
exertional compartment syndrome {CECE}, and popliteal
artery entrapment syndrome {PRES} should be considered
in the differential diagnosis. Recent research has exam-
ined the clinical characteristics, risk factors, diagnostic
modalities, treatment options, and outcomes of conditions
causing leg pain.
Medial Tibial Stress Syndrome
l'vlTSS, often called shin splints, is a common cause of leg
pain. The incidence in athletic and military populations
is 20% to 44%?" MTSS is characterised by pain on
the medial border of the tibia, typically near the origin
of the soleus, posterior tibial tendon, and flea-cor digito-
rum longus.” This posterior medial pain has led some
authors to conclude that traction of these muscles leads
to an enthesopathy, periostitis, and pain.” However, in
some patients dual—energy :cvray absorptiometry and CT
reveal relative osteopenia of the anterior tibia.” This
finding suggests that MTSS is on a spectrum of tibial
stress injuries that includes tendinopathy, periostitis, peri-
osteal remodeling, and tibial stress reaction.5 Pain with
palpation and the presence of edema are highly sensitive pg
for this spectrtnn of disorders.”I FT.
:5
Although MTSS is common in running and jumping m
m
athletes, the pool of at-t‘isk individuals has been expand- or
3
ed. A prospective study of naval recruits found that MTSS
El.
was twice as likely to develop in women as in men.‘ Elt- E
cessive pronation of the foot was found to be a key risk
factor in two biomechanical studies of foot posture during
walking and running.”ll Patients with l'vlTSS had greater
medial longitudinal arch deformation while walking or
standing than healthy control subjects. Early heel rise,
forefoot abduction, and apropulsive gait were significantly
Orthopaedic Knowledge Update: Sports Medicine 5
 Sectien 3:1i'inee audLeg
different in patients with MTSS. Relatively small internal
and external hip range nf mntinn, high bndy mass index,
and lean calf girth as well as a histnry nf MTSS alsn have
been identified as risk factersfih13E Anthrepemetric para m-
eters including thigh length, leg length, fnnt length, and
leg circumference as well as limb length alignment had nn
asseciatien with MTSS.”~” Individuals whe had partic-
ipated in an athletic activity fer fewer than 5 years were
fnund tn be substantially mnre likely tn have MTSS than
these whe had participated fer a lenger peried ef time.-1
Individuals whn used a fnnt nrthnsis were fnund tn be
at increased risk fer MTSSF Multivariate analysis fnund
that tebacce smelcing cenferred a ninefeld increased risk
nf MTSS.”
MTSS is self-limiting with prnper treatment. In a pre-
spective cehert study, 3? ef 33 runners with MTSS had
cemplete recnvery at an average nf ?2 days (range, 15 tn
531 days}." Recnvery frem injury was defined as absence
ef pain in the affected anatemic lecatien after twe cen-
secutive sessiens nf running at least 50H m. In a study
nf Dutch military recruits, the average time tn recnvery
was 53 days.” I'viest treatment regimens censist ef active
rest fnllnwed by a gradual return tn running, which be-
gins nnly when lnw—impact activity such as walking nr
cycling predeces ne pain.” Return-te-running pregrams
vary, but implementatien shnuld be gradual. Running
distance sheuld increase ne mnre than 10% per week
and sheuld he immediately decreased if symptems return.
In a randnmized cnntrnlled study, an benefit was fnund
tn adding calf strengthening and stretching er the use nf
cempressien steckings tn a return-te-running pregram.”
Rehabilitatinn taping was fnund tn decrease lnading nf
the feet in patients with MTSS, althnugh it did nnt relieve
the symptnms.m Using a fnnt nrthnsis was fnund tn be
helpful during a 3-week study perind.21 Fain was reduced
by 50% in 15 nf 2i} rtmners with MTSS, but this effect
might have been prnduced by rest alnne. Lew-energy
extracerpnreal sbnck wave therapy (ESWTI was fnund
tn be a treatment nptinn fer patients with MTSS ef mnre
than 6 mnnths’ duratinnfi‘l ESWT is believed tn induce
DI
perinsteal detachment and micrnfractures nf the trabecu-
as
._I lae, which can stimulate healing. At 15—mnnth fnllnw—up
T:
I:
in
nf 4'? patients with chrnnic MTSS whn underwent ESWT
cu
Iii-1 in additinn tn a hnme therapy prngram, 40 had returned
i:
S: tn spurts at the preinjury level. In cnmparisnn, nnly 22
nf 4? patients whn underwent hnme therapy alnne had
H
returned tn the prcinjury spert level.
Tibial Stress Fteactinn
011 the spectrum ef tibial stress disnrders, the severity
nf tibial stress reactinn is between that nf MTSS and
flrrhepaedic Knewledge Update: Sperts Medicine 5
-_
The Fredericseu MRI Grading System
fer Bene Stress Reactien and Fracture
Hill Grade Descriptien
iJ i'iinrmal MRI findings
1 Mild tn mederate perinsteal
edema en T2-weighted images
enlyr
hie fecal bene marrew
abnnrmelity
1 Severe perinsteal edema and bene
marrew edema en TEE-weighted
images enly
3 Mederate te severe edema ef
bnth the perinsteum and bene
marrew en T1- and T2-weighted
images
4 Lew-signal fracture line en all
sequences
Severe bene marrew edema
en heth T1- and T2-weighted
images
Adapted with permissinn frnm Fredericsnn M, Bergman AG, Huffman
KL, Dillingham M5: Tibial stress reactien in runners: Cerrelatien ef
clinical symptems and scintigraphy with a new magnetic resenance
imaging grading system. Am .i' Spurts Med 1995;23[4}:472-4B1.
tibial stress fracture. Radiegraphs may shew a perinsteal
reactinn and certical thickening?! An MRI study iden-
tified a pregressinn ef injury frnm perinsteal edema tn
pregressive bene marrew invelvement and ultimately
tn certical stress fracture”l [Table I}. |Ulstenpenia in the
anterinr cnrtesr nf patients with MTSS alsn may be part
nf the prngressinn.” The etielegy is believed tn be inad-
equate bnne remndeling after damage. Figure 1 shnws a
theeretic cascade ef events.15'
Tibial stress reactiens nften are asymptnmatic. A study
nf 21 cellegiate lung-distance runners whn were asymp-
tnmatic fnund that 9 (43%} had grade I, 2., er 3 MRI
changes indicative ef a tibial stress injury.” Hnne had
grade 4 changes. Five patients had bilateral invelvement.
The mnst cnmmnn finding was severe perinsteal edema
and bene marrew edema with T2 weighting, as is cnnsis-
tent with a grade 2 injury. Nnne nf the patients became
symptnmatic during the subsequent year. This study
highlights the value nf the clinical histnry and physical
examinatinn in treating tibial stress reactinn {Figure 2},
Tibial Stress Fracture
Stress fractures are the meet severe bene stress injuries.
The histery and physical examinatien are characteristic,
El II] is American Academ~y ef Cirrhepaedic Surge-ens

nanny-ans
relnndeilru
l _
Mind shill-l maul-Inn
prep-flee alumnae
' {bane were
Illdfflf l fracture. In a binmechanical study, runners whn had an
malarial} Imiuflnnl
l
| W
bnnafracu's
Prnpnseel pathnphysinlngy nf tibial strem injury.
and the diagnnsis is made with radingraphs, CT, bnne
scan, and MRI. Apprnximately half nf all stress fractures
nccur in the tibia.13 The repnrted incidence nf tibial stress
fractures was fnund tn range frnm 4% tn lfl'ih based cm
the pnpulatinn; thnse at risk typically include lnng-dis-
tance runners, track and field athletes, jumping athletes,
and military recruitsffi'“ A year-lnng prnspective- study
nf elite Israeli military recruits fnund that almnst all tib-
ial stress fractures nccurred during the first 6 mnnths nf
training.” In cnntrast, stress fractures cf the metatarsal
were mnst likely tn nccur during the secnnd ti mnnths
nf training.
a bnne mineral density, lnw bndy mass in the lnw-
er extremities, menstrual imbalance, and a lnw-fat diet
are assnciated with stress fractures as well as MTSS in
wnmeuJEJ-UE-fl The Female Athlete Triad Cnalitinn and
Eb Ifllii American Academy nf flrflinpaedic Surgenns
Chapter 11: Leg Pain Disnrders
the Internatinual Dlympic Cnmmittee recently prnpnsed
guidelines fnr the evaluatinn nf risk factnrs, treatment,
and return tn play fnr at—risk female athletesfif'ri" The
Female Athlete Triad Cnalitinn Cnnsensus Statement in-
cludes a scnring system fnr an athlete‘s diet, bndy mass
index, age nf first menarche, menses regularity, bnne
mineral density, and previnns stress fractures.“ The re-
sulting scnre can guide the physician in deciding whether
the athlete shnuld be returned tn play. The Internatinnal
Olympic Cnmmittee guideline is similar in that it includes
many aspects cf the athlete’s health by calculating the
sn-called relative energy deficiency {which emphasizes
maintaining energy availability by the fnllnwing fnrmu-
la: energy availability = energy intake — exercise energy
expenditure}, but it is related tn bnth male and female
athletes?1 A similar mndel has been created for predicting
the risk nf stress fracture in military recruits?2
A study nf 391 recruits at the United States Military
Academy fnund that the incidence nf stress fracture was
almnst fnur times higher in wnmen than in men.“ Hav-
ing a relatively small tibia and femur increased the risk
nf stress fracture. A histcry nf physical training lnwered
the risk, particularly in men. aen with a relatively
shnrt time since menarche had an increased risk nf stress
earlier tibial stress fracture had greater peak hip adduc-
tinn and rearfnnt eversinn angles during the stance phase
nf running than healthy cnntrnl subjects. These factnrs
may lead tn altered lnading within the lnwer extremity
and thus predispnse the persnn tn stress fracture.33 Similar
binmechanical studies fnund that varying fatigue patterns
in lnng~dista nce runners cnntribute tn a reduced tnletance
fnr impact.M Psychnlngical stressnrs alsn were fnund tn
increase the risk nf tibial stress fracture.”
The shnckuabsnrbing effect cf the fnnt may have a
rnle in tibial stress fracture. Runners whn had an earlier
stress fracture were fnund tn have greater plantar flexnr
musculntendinnus stiffness, greater Achilles tendnn stiff-
ness, and less Achilles tendnn elnngatinn during maximal
isnmetric cnntractinn in cnmparisnn with healthy run-
nets.“5 The use nf a treadmill fnr running and increased 1.4.}
fnnt prnnatinn may reduce the risk nf tibial stress frac- FT.
:5
turefiwv“HI Hnwever, a systematic review fnund that the re
cu
in
use nf fnnt insnles were nf nn benefit in preventing tibial 3
El.
stress fracture.“
Recent research has emphasized the impnrtance nf E
calcium and vitamin D hnmenstasis in preventing and
treating stress fractures. High levels nf circulating para-
thyrnid hnrmnne with subsequent bnne turnnver is an es-
tablished risk factnr fnr nstenpnrntic fracture, and a high
parathyrnid level may be an independent risk factnr fnr
stress fracture.“ Several randnmiaed placebn-cnntrnlled
Drrhnpaedic Knnwledge Update: Spnrrs Medicine 5
 Sectien 3:1Cnee andLeg
Bh tunic eaertianal
eurnpartment
ayndreme
Drawing shewing cemmnn causes and Iecafiens ef eaartienal-relatad leg pain.
studies suggested that daily censumptien ef LUCIE mg of
supplemental calcium and Ltlflfl IU ef vitamin D reduces
the risk ef stress fracture by 2.0% and impreves bcme
mineral density.‘”-“.2 Same bene remedeling was found tn
be critical tn repairing accumulated micredamage; phar-
macelcgic inhibitien cf bene tu rnever did net reduce the
incidence nf stress fractures.” These studies suggest that
military recruits and running athletes age 14 te 50 years
should ensure sufficient calcium and vitamin D intake te-
meet er exceed the currently recemmended dietary al-
lewanees [1,Dflfl tn 1,300 mg and Silt} II], respectively}.“
The use cf rest. restricted weight bearing, and im»
mebiliaatien has led an geed lung—term results. Df 26
military recruits with a tibial stress fracture whe were
treated with rest and immebiliaatien, 13 were available 10
years after initial injury tn answer questiens en the lung—
term censeqnenees ef the fracture. Nnne reperted any
DI
limitaticm c-f active military duty er separatien frem the
a:
._I military as a result cf the stress fracture.” Modalities such
T:
I:
at
as pulsed ultrasnnnd have been prnpnsed fer managing
ca
It: stress fractures. Altheugh the exact mechanism cf pulsed
I:
a: ultrasnnnd is unlcnewn, it is believed tn induce aggrecan
and pruteeglyean synthesis in ehnndrneytes, leading te-
H
increased endechendral essificatien. Hewever, in a ran-
demiaed deuble—blind study, 43 patients with tibial stress
fracture were assigned to pulsed ultraseund er placebe
treatment. There was an significant between-greup dif-
ference in healing time.“6 Further study ef this medality
may be needed.
flrritnpaedic Knnwledge Update: Sparta Medicine 5
Paptlteat altary
entrapment
syndrome
Marital
Tibial stress syndmma
Tibial stress reaction
Tibial atraaa traehire
ESWT has been effective in treating athletes with a
recalcitrant stress fracture. A study ef five athletes treated
with ESWT fer a stress fracture cf mere than 6 months"
duratien reperted that ESWT was effective.” A ra ndem-
ieed placebo-centralled cemparisen study nf capacitively
ceupled electric field stimulatien used 15 hc-urs a day to
stimulate bene grewth after acute stress fracture fnund nu
between-greup difference in time ta healing.” Hewever,
cempliance with rest was asscIciated with reduced time tu
healing, and nencempliance with rest was assnciated with
increased time tn healing. The study suggested that capac-
itively cuupled electric field stimulatien can be indicated
for a severely injured nr elite athlete er military recruit
whe is metivated te rest by a desire tn return te- activity.
Surgical interventic-n has been suggested te treat a
high—risk stress fracture in athletes whe must return to
spa-rt quickly. An anterier tibial stress fracture is less
cemmc-n but carries greater risk than a pesteremedial
tibial stress fracture. Hennnien rates higher than 513%
and healing delayed as much as 11 menths have been
reprcrrtedd‘i“jfl Such a difficult at lung recevery can be ca-
reer ending fer a prufessienal athlete. Intramedullary
nailing nf ehrenie anterinr tibial stress fractures eften is
effective fer relieving pain and increasing healing, but the
asseciated cemplicatiens include infectien and insertion
site pain?I
Recent studies fecused en anterinr tensien-ba nd plating
with a cumpressinn plate at the anterelateral tibial surface.
The thenretic advantage nf this technique ever the use nf
El 1016 American Academ~y ef Drrhnpaedie Surge-ens

an intramedullary device is that the plate placed anterier
te the central axis ef the bene has a mechanical advantage
in neutralizing tensile ferces and fracture micremetien.
Full healing and return te activities was reperted at an
average ef lfl' weeks te 3 menths after surgery.51=fl Drill-
ing and anterier laminefixatien alse were reperted, with
healing rates cf 50% and 93%, respectively.“
|Ehrenic Exertienal Cempartment Eyndreme
CECE is a relatively cemmen cause ef leg pain. The an-
nual incidence ef CECE ranges frein 2.7% re 33% and is
secend enly tc that ef l'viTEE {13% tc «111943).1 A patient
with CECE usually reperts pain during exercise that is
relieved by rest, and subsequent examinatien ef the pa-
tient typically is nermal. The symptcms ccmmenly are
bilateral. CECE has been defined as a painful cenditien
in which exercise induces high pressure within a clesed
myefascial space, with a resulting decrease in tissue per-
fusien and ischemia. CECE semetimes is accempanied
by temperary neurelegic impairments. A biepsy exam-
inatien ef the stiffness and thickness ef leg fascia in pa-
tients with CECE and nermal centrel subjects detected
ne between-greup differences.55 This finding suggests
that CECE is net determined by structural and mechan-
ical preperties ef the leg. In the military pepulatien, an
elevated risk ef CECE was cerrelated with increasing age,
female sex, white race, junicr enlisted rank, and Army
service.“5 Wemen and running athletes are at particular
risk in the civilian pepulatien.” CECE in the anterier er
lateral cempartment is mest cemmen and has the best
treatment and recevery pregnesis. The deep pestericr
cempartment can be invelved, but the results ef surgery
are likely te he inferier cempared with these ef CECE in
ether cempartments.“
The mest cemmen diagnestic teel fer CECE is mea—
surement ef intramuscular cempartment pressure {IMCP}.
Invasively measured IMCI’ rese with a typical clinical
picture ef CECE in 45 ef 131 patients {34%} with exer—
cise-induced leg pain. The widely used Pedewita criteria
fer the diagnesis ef CECE are based en IMCP measured
with the patient supine at discrete time peints befere and
after an exercise challenge. A pesitive test is defined as
a pressure measurement abeve 15 mm Hg befere exer-
cise, abeve 3i] mm Hg 1 minute after exercise, and abeve
2!] mm Hg 5 minutes after exercise.” Recent systematic
reviews questiened the validity cf these criteria fer cen-
firming a diagnesis ef CECE because ef a lack ef centre]
and uermative IMCP datafifl'“ In a recent cemparisen
ef patients with CECE and nermal centrel subiects, the
diagnestic usefulness ef IMCP was impreved when it
was measured centinueusly during exercise. The greatest
Ci Iflld American Academy ef Crthepaedic Eurgeens
Chapter 11: Leg Pain Diserders
between-greup difference eccurred while patients and
centrel patients carried a 15-kg backpack, the treadmill
incline was increased re 5%, and the treadmill walking
pace was set at 6.5 kmr‘h fer 5 minutes.” A cuteff ef 105
mm Hg during this specific treadmill exercise had better
diagnestic accuracy than the Pedewits criteria.
The use cf MRI and ultraseund has been suggest-
ed fer suppertiug a CECE diagnesis. In a study ef 79
censecutive patients, abnermal signal en pestexercise
Til-weighted MRI was well cerrelated with increased
intracempartmental pressures, with 95% sensitivity and
3?% specificity.“ An ultraseund study feund an increase
in anterier cempartment fascial thickness during exercise
in patients with CECE cempared with nermal centrel
patients.” Ultraseund dees net appear te be necessary fer
guiding reutine deep er superficial pestericr leg cempart-
ment pressure testing because direct palpatien is similarly
accurate fer needle tip placement.““'5
The symptcms cf CECE appear tc be persistent. At
an average 4—year fellew—up ef 12 military recruits in
whem CECE was diagnesed and managed nensurgically,
the initial ICMP measurements {taken immediately after
exercise} remained elevated in 16 cf the 21 affected legs,
and all 11 patients still had typical symptems.“ Neusur—
gical treatment with betulinum texin A injectien recently
had geed shert—term results in 16 patients with CECE.“
Injectien inte the anterier and lateral cempartments led
te an Il'vlCP reductien ef appreximately 60% at an aver-
age 4—menth fellew-up. Exertienal pain was cempletely
eliminated in 15 ef 16 patients {94%}, but there was a
statistically significant decrease in muscle strength. It is
unknewn whether the strength reductien was clinically
significant.
Surgical release ef the cempartment affected by CECE
has been the treatment ef cheice, altheugh its effective-
ness has been questiened. In a retrespective study ef 611
patients with CECE in a military pepulatien, 44.73%
reperted symptem recurrence and 2?.?% were unable
te return te full activity.” Decumeuted surgical cem-
plicatiens eccurred in 153%, 113% were referred for
medical discharge because ef CECE, and 5.9% required 1.4.}
surgical revisien er repeat release.“ These data were ten- FT.
:5
sistent with earlier studies that feund a 20% re 3fl% e
m
a:
rate ef inability te return te active duty ameng military 3
CI.
recruitsf'il'i'1 In a study ef 13 elite athletes, 11 (34%] were
able te return te their spert at the same level at a mean E
ef 1fl.6 weeks after surgical fascietemy. Patients whe
had a feur—cempartment release required mere than 3.5
weeks lenger te return te full sperts activity. Surgical
technique may play a rule. A recent study in a swine
medel feund a streng cerrelatien between fascietemy
length and reductien in intracempartmental pressure. The
Drthepaedic Knewledge Update: Eperrs Medicine 5
 Sectien 3:1l'2uee andLeg

researchers. suggested that a Efl‘i’fs er greater fascia] release
is necessary te return the intracempa rtmental pressure te
a value at er near its baselinef’3| Hewever, ether experts
have recemmended a limited release in scme patients?1
In a retrespective study ef T3 patients with CECS, these
yeunger than 23 years {high scheel er cellege athletes} had
a better surgical result than elder patients. In additien,
an iselated anterier cempartment release led te greater
patient satisfactien and a better functienal eutceme than
a cemhined anterier and lateral release.”
Pepliteal Artery Entrapment Syndreme
PAES is a rare but painful and petentially limb—threat—
ening diserder that predeminantly eccurs in athletes
yeunger than 3l} years. The pepliteal artery becemes
centpressed by the varieus seft tissue against the medial
femeral cendyle during ankle plantar flexien. fiver time,
the intimal wall ef the pepliteal artery can be damaged,
leading teaneu rysms er stenetic lesiens. Several anatemi—
cal variatiens can cause PAES, the meat cemmen being an
ahnermal attachment ef the medial head cf the gastrecne-
ntius muscle; ether variatiens include a medial ceurse ef
the pepliteal artery, medial gastrecnemius hypertrephy,
and aberrant fibreus baudsfhi'i' PAES and CECE eccur in
the same patient pepulatiens, and they must be differenti—
ated with cempartmenr pressure testingfffl-fl The diagnesis
mest eften is based en prevecative resting.”Ell Ferced
ankle plantar flexien and a single—leg hep can repreduce
the symptems. These tests alse can reveal a decrease in
arterial bleed flew with direct palpatieu, duplex ultra-
seund, angiegraphy, er the ankle-brachial index?‘1
Early detectien and interventien can limit the preg-
ress ef PAES and lead re a mere faverable eutceme by
minimizing arterial damage.“ At 2-year fellewuup, beta
ulinum texin A iniecrien inte the medial head ef the gas—
trecnemius was feund te lead te cemplete reselutien ef
symptems in a patient with an earlier bilateral pepliteal
arterielysis witheut resectien ef the medial gastrecnemius
head.”M Surgical interventien is the standard treatment ef
patients with ischemic symptems, altheugh the rarity ef
DI
as
._I the cenditien means that ne highrlevel eutceme studies
T:
r:
in exist. Decempressien ef the lesien by releasing the medial
re head ef the gastrecnemius eften is necessary te prevent
III-1
I:
E recurrence.El In patients with leng—standing entrapment,
H
activities after surgical interventien; these whe underge
decempressien alene tend te have better eutcemes than
these whe underge decempressien plus bypass.”3'“r35
Summary
The spectrum ef tihial stress diserde rs can he distin-
guished by histery, examinatien, and imaging. Hensur—
gical management usually allews patients re return re
their earlier activity level, altheugh prelenged rest eften is
needed. The widely used Pedewits criteria fer the diagne-
sis ef CECS may have a high false'pesirive rate; a walking
treadmill test en an inclined surface while carrying a 15-
kg weight may have better diagnestic accuracy. Surgical
release ef the cempartment affected by CECS has been
the treatment ef cheice, altheugh its effectiveness has been
quesriened in the military pepulatien. Early detectien and
interventien can limit the pregress ef PAES and lead re a
mere faverable eutceme by minimising arterial damage.
Decempressien alene is eften eneugh if diagnesed early;
and bypass grafting is eften needed in the ch renic setting.
Key Study Peints
It MTSS, tibial stress reactien, and tibial stress frac—
tures are everuse diserdcrs that particularly affect
wemen, endurance athletes, and military recruits.
The keys te preventing stress fracture include ade-
quate dietary censumptien ef calcium and vitamin
D. Nunsurgical management usually allews patients
te return te their earlier activity level, altheugh
prelenged rest eften is needed. Surgical interventien
can he censidered fer a patient with a recalcitrant
stress fracture er a high—risk fracture ef the anterier
tibia er an athlete whe needs re return te sperts
quickly.
* Current diagnestic criteria fer CECE use IMCP and
can lead re high rates ef false-pesitive results. Cri-
teria using impreved standardised exercise testing
may have greater sensitivity and specificity. Surgical
release is successful fer pain relief in CECE but may
net lead te a return te full sperts activity er active
military duty.
it Early detectien and treatment ef PAES are critical
fer preventing chreuic vascular disease and relieving

the pepliteal artery may have irreversible damage and symptems.

atherescleresis, aneurysm, and thrembesis can devel-
ep. In these patients, bypass grafting is the treatment ef
cheice ameng vascular surgeens. With bypass grafting,
leng-terrn arterial patency frern Fife te 10fl% has been
reperted, and results are best after iselated pepliteal ar-
tery ecclesienfifa'l‘ Many patients return re their previeus

flrdtepaedic Knnwledge Update: Sperrs Medicine 5 El 1016 American AcadMy ef Urrhnpaedic Surgenns

Annatated References
Gearge EA, Hutchinsan MR: Chmnic exertianal cam-
partment syndrame. Cite Sparta Med 201 2:3 1f2}:3 [11319.
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The literature an the epidemialagy, diagnasis, and treat-
ment af CECE was reviewed.
Hubbard T], Carpenter EM, lEardava ML: Cantributing
factars ta medial tibial stress syndrame: A praspcctive
investigatian. Med Sci Sparta Exerc 2G0?;41I{3}:45 [1496.
Medline Ill-DI
The factars mast influencing the develapment af MTSS
were faund ta be a bistary af MTSS and stress fracture,
years af running experience, and use af arrhases. Level
af evidence: III.
1t'agi 5, Muncta T, Scltiya I: Incidence and risk factars far
medial tibial stress syndrame and tibial stress fracture in
high schaal runners. Knee Snrg Sparta Tranmataf Ar-
thraac amsansyaas—asa. Medline bar
A significant relatianship was fannd between ba-dy mass
index, internal hip ratatian angle, and MTSS in female
athletes. Leml af evidence: II.
1fates B, White S: The incidence and risk factars in the
develapment af medial tibial stress syndrame amang
naval recruits. Am I Sparta Med lflfl4;31|{3]:??2-Tflll.
Medline DUI
Galbraith RM, Lavallee ME: Medial tibial stress syn-
drame: Ganaervative treatment aptians. Curr Ree Mas-
cnlaakefet Med lflflfigllfilflllfll Medline DUI
The literature an nansnrgical treannent aptians far MTSS
was reviewed.
Maen MH, Tel JL, Weir A, Steunebrink M, De Winter TC:
Medial tibial stress syndrame: A critical review. Sparta
Med 2fl09539{?}:513-546. Medline D0]
The literature an MTSS was reviewed.
Bauché RT, Jahnsan CH: Medial tibial stress syndrame
[tibial fasciitis}: A prapased pathamechanical mad-
el invalving fascial tractian. _,I An: Padt‘atr Med Asaac
2Dfl?;9?{1]:31-36.Medline DUI
Gaeta M, Minutali F, Scribana E, et al: CT and MR im-
aging findings in athletes with early tibial stress injuries:
Camparisan with bane scintigraphy findings and emphasis
an carrical abnarmalities. Radiafagy EU US#35{11:553—
.561. Medline DD]
Magnussan HI, Westlin NE, Nyqvist F, Giirdsell P, See-
man E, Karlasan MK: Abnarmally decreased regianal
bone density in athletes with medial tibial stress syndrome.
An: ,1 Sparta Med 1001;29l6]:?11-?1S. Medline
1i]. Newman P, Adams I1, Waddingtan G: Twa simple clinical
tests far predicting anset af medial tibial stress syndrame:
4D Ifllti American Academy af Drrhapaedic Surgeaas
Chapter .11: Leg Pain Disarders
Shin palpatian test and shin aedema teat. Br 1 Sparta Med
2012;46{12}:361-Sfi4.Medline DUI
The relatianship between twa clinical test results and a
future diagnasis af MTSS in military recruits was exam-
ined. Level af evidence: II.
11. Tweed JL, Campbell 191., Avil 5]: Eiamecbanical risk
factars in the dcvelapmcnt af medial tibial stress syn—
drame in distance runners. I An: Padictr Med Assac
lflflfl;93[fi}:436-444.Medline DUI
12.. Bandhalm T, Baysen L, Haugaard S, Zebis MK, Eenclre
J: Feat medial langitudinaI-arch defarmatian during
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Risk factars and pragnastic indicatars far MTSS were ex-
amined. Decreased hip internal range af matian, increased
ankle plantar flexian, and pasitive navicular drap were
assaciated with MTSS. fl. higher bady mass index was
assaciated with an increased time ta full recavery. Level
af evidence: II.
14. Sabeti V, Khashraftar Yaadi bl, Biaheh bl : The relatianship
between shin splints with anthrapamcttic characteristics
and same indicatars af bady campasitian. ,1 Sparta Med
Phys Fitness [published anline ahead af print Dctab-er ii,
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Anthrapc-metric characteristics and budy campasitiar:
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15. Eaissi GR, Cherati AD, Mansaari FED, Raai MD: The re-
Iatianship between Iawer extremity alignment and medial
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A significant relatianship was fannd bervveen navicular
drap and MTSS. There was na significant relatianship
between Iawer extremity alignment and MTSS. Level af
evidence: II.
16. Sharma J, Gallic:ir J, Greeves J, Spears III: Eiamechani-
cal and lifestyle rial: factars far medial tibia stress syn- 1.4.}
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m
n:
fin imbalance in feet pressure with greater pressure an e:
3
the medial side than an the lateral side was the primary El.
rislc factar far MTSS. Level af evidence: II. E
1?. Nielsen RD, Rannaw L, Rasmussen S, Lind M: A pre-
spective study an time ta recavery in 2.54 injured navice
runners. PLaS Cine 2014;9{51m9933’1 Medline DUI
MTSS was the mast camman injury amang runners, fal-
Iawed by patellafemaral pain, medial meniscal injury, and
Achilles tendinepathy. Half cf the patients were unable
Drrhapaedic Knawledge Update: Sparta Medicine .5
 5ectien3:1fneeand1.eg
te run 500 m twice witheut pain 111} weeks after injury.
Almest 5% cf patients received surgical treatment.
18. Ualle RA, Plakke M, Silvis ML: Cemmen leg injuries ef
lung-distance runners: Anatemical and hiemechanical ap-
preach. Sperts Health 2D11;4I[6}:43 5-495. Medline DUI
15'. Meen MI-I, Heltslag L, Eakker E, et al: The treatment ef
medial tibial stress syndreme in athletes: A tandemized
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2fl12:4:12. Medline DUI
A cemparisen ef three functienal rehabilitatien pregrams
fer MTSS is graded running pregram alene, with stretch-
ing and strengthening exercises fer the calves, er with a
spurts cempressien stecking] feund ne eutceme differ-
ences. Level ef evidence: I.
2f}. Griebert MC, Needle AR, Mc’Cennell J, Kaminski TW:
Lewer—Ieg Kinesie tape reduces rate ef leading in par-
ticipants with media] tibial stress syndreme. Phys Ther
Spert 2014 Jan 29. Epub ahead ef print. pii: 51466-
353Kl14}flflflfll-9.Medline DUI
Rehabilitatien taping decreases the rate ef medial leading
in patients with MTSS and may he a useful adjunctive
treatment. Level ef evidence: III.
21. Leuden JE, Delphine MR: Use ef feet ertheses and calf
stretching fer individuals with medial tibial stress syn-
dreme. Feet Ami: fe Spec 2010;3[1h15 -2l}. Medline DUI
Uff-the- shelf ertheses and calf stretching may be effective
in the initial treatment ef runners with MTSS.
Rempe JD, Cacchie A, Furia JP, Maffulli N: Lew-en-
ergy extracerpereal sheck wave therapy as a treatment
fer medial tibial stress syndreme. Am ,1 Sperts Med
2fl1fl;33{1]:125-132.Medline DUI
Ferty cf 41" patients whe received ESWT fer MTSS
were able te return te their spurt at the preinjury level
15 menrhs after injury, cempared with 22 ef 4? centrel
subjects. Level ef evidence: III.
13. Warden 5], Davis 15, Fredericsen M: Management and
preventien ef bene stress injuries in lengrdistance run-
ners. J Urtfsep Sperts Phys Ther 2014;44llfl}:?49-?65.
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The literature en management and preventien ef bene
stress iniuries in leng~distance runners was reviewed.
DI
ts
._I
T:
1: 14. Fredericsen M, Bergman AG, Heffman KL, Dillingham
re
:11 M5: Tibial stress reactien in runners: IZlerrelatien ef
III-1
I: clinical symptems and scintigraphy with a new magnet-
E ic resenance imaging grading system. Am J Sperts Meal
H
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Urthepaedic Knewledge Update: Sperts Medicine 5
26. Tenferde AS, Sayres LC, McCurdy ML, Sainani KL, Fred-
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fractures in adelescent runners. Med Sci Sperts Exerc
2fl13;45[1{l]:1343-1351.Medline DUI
Earlier fracture is the mest rebust predicter ef stress frac-
tures in heth wemen and men. Lew bedy mass index, late
menarche, and earlier participatien in gymnastics er dance
were identifiable risk facters fer stress fractures in girls.
Participatien in basketball appeared te be pretective in
buys and may represent a medifiable risk facter fer stress
fracture. Level ef evidence: 111.
2?. McCarthy MM, Vees JE, Nguyen JT, Callahan L, Han-
nafin JA: lniury prefile in elite female basketball athletes
at the Wemen‘s Natienal Basketball Asseciatien Cemhine.
Am J Sperts Med 2013;41l3]:645-65L Medline DUI
The percentage ef players at the Wemen's Natienal Eas-
ketball Asseciatien Cembine whe reperted a histery ef
stress fracture was 13%. Level ef evidence: III.
13. Finesmne A, Milgrem U, 1|llll'elf U, Petrev K, Evans R, Me-
me D: Epidemielegy ef metatarsal stress fractures versus
tibial and femeral stress fractures during elite training.
Feet Ankle Int 2011;32l1}:16-ED. Medline DUI
The incidence ef stress fracture ameng military recruits
was highest during the first 6 menths ef training but de
creases after 6 menths, pessibly because ef individual
adaptatiens. Level ef evidence: III.
29. Eesman F, Ruffing J, Zien M, et al: Determinants ef stress
fracture risk in United States Military Academy cadets.
BDHE 2013;55l2}:359-365. Medline DUI
Earlier physical training in men, length ef estregen ex-
pesure in wemen, and leg bene dimensiens in beth sexes
were fen nd te have enly a miner rule in the develepment
ef stress fractures in physically fit military cadets. Level
ef evidence: III.
311}. De Seusa MJ, Nattiv A, Jey E, et al; Female Athlete Triad
Cealitien; American Cellege ef Sperts Medicine; Ameri-
can Medical Seciety fer Sperts Medicine: American Bene
Health Alliance: 2014 Female Athlete Triad Cealitien
censensus statement en treatment and return te play ef
the female athlete triad: lst Internatieual Cenference held
in San Francisce, GA, May 2012, and 2nd Internatien-
al Cenference held in Indianapelis, IN, May 2313. ln
J Spert Med 1014;14{1J:95-11fl. Medline
A scering system was presented in which a female athlete’s
diet, bedy mass index, age ef first menarche, menses regu-
larity, bene mineral density, and histery ef stress fracture
were tabulated. Level ef evidence: II.
31. Meuntiey M, Sundget-Bergen J, Burke L, et al: The [DC
censensus statement: Beyend the female athlete triad. Rel-
ative energy deficiency in spert [RED -5}. 1311”,]r Sperts ill-liedl
2fl14t4fllflt491-491Medline DUI
The Internatieual Ulympic Cemmittee guideline calc ulat-
ed the se-called relative energy deficiency te assess risk
facters in female athletes. Level ef evidence: [1.
El ll] 16 American AcadMy ef Urthepaedic Surge-ens

32. Meran DS, Finestene as, Arbel ‘t’, Shabshin N, Laer A:
it simplified medel te predict stress fracture in yeung elite
cembat recruits. I StrengthI Cenri Res 1011;16{9]:2535-
2592. Medline DUI
A yeung male recruit fer an elite cembat unit was at a
greater risk ef develeping stress fracmre if he had a histery
ef aerebic training less than 2 times per week fer mere
than 4i] minutes per sessien and had a waist circumference
smaller than 3’5 cm. Level ef evidence: III.
.33. Milner CE, Hamill J, Davis IS: Distinct hip and rearfeet
kinematics in female runners with a histery ef tibial stress
fracture. J Urtisep Sperts Phys Ther lfllfl:4fli2}:59-EE.
Medline DUI
Runners with a histery ef tibial stress fracture had greater
peak hip adductien and rearfeet eversien angles during
the stance phase ef running than healthy centre] subjects.
fl: censequence may be altered lead distributien within
the lewer extremity, creating a predispesitien te stress
fracture. Level ef evidence: III.
34. Clansey AC, Hanlen M, Wallace ES, Lake M]: Effects ef
fatigue en running mechanics asseciated with tibial stress
fracture risk. Med Sci Sperts Esterc 2&12:44{10}:191?-
1923. Medline DUI
The identified risk facters fer impact-related injuries such
as tibial stress fracture are medified by fatigue, which is
asseciated with a reduced telerance fer impact. These
findings are impertant fer identifying individuals at risk
fer injury frem lewer limb impact leading during running.
Level ef evidence: III.
35. Meran DS, Evans R, Pirhel '1’, et al: Physical and psyche-
legical stressers linked with stress fractures in recruit
training. Scand J Med Sci Sperts 2013:23{4J:443-4SD.
Medline DUI
Psychelegical facters may have a rule in predicting stress
fracture develepment. Level ef evidence: IV.
3S. Pamukeff UN, Blackburn JT: lCemparisen ef plantar-
fleiter musculetendineus stiffness, geemetry, and archi-
tecture in male runners with and witheut a bistery ef
tibial stress fracture. I App! Biernech 2015:31i1}:41-4?.
.Medline DUI
Runners with a histery ef stress fracture had greater plan-
tar fleiter musculetendineus stiffness, greater Achilles ten—
den stiffness, and less Achilles tenden elengatien during
maximal isemetric centractien than healthy runners. Lem]
ef evidence: IV.
3?. Hetsreni I, Finestene fl, Milgrem C, et al: The rele ef
feet prenatien in the develepment ef femeral and tibial
stress fractures: A prespective biemechanical study. Ciin
I Spert Med Eflflfltlflflitlfi-ZSJ. Medline DUI
33. Milgrem C, Pinestene A, Segev S, Ulin C, Arndt T,
Ekenman I: Are evergreund er treadmill runners mere
likely te sustain tibial stress fracture? Br J Sperts Med
lflfl3,3?il}:16fl-163.Medline DUI
4D Ifllti American Academy ef Urthepaedie Surgeens
Chapter .11: Leg Pain Diserders
39. Snyder RA, Deflngelis JP, Keester MC, Spindler KP,
Dunn WR: E'Iees shee insele medificatien prevent stress
fractures? A systematic review. HSS J lflfl9;5[2]:92-93.
Medline DUI
The use ef shee inseles fer preventien ef stress fracture
was systematically reviewed.
40. Vilima ki Vii, Alfthan H, Lehmuskallie E, et al: Risk fac—
ters fer clinical stress fractures in male military recruits:
A prespective cehert study. Berle lflflS;3T{E}:2i’i?—2T3.
Medline DUI
41. Lappe J, Cullen I}, Haynatski G, Recket R, Ahlf R,
Thempsen K: Calcium and vitamin D supplementa-
tien decreases incidence ef stress fractures in female
Navy recruits. J Bene Miner Res 2DDS:23{S}:741-T49.
Medline DUI
42. Gaffney-Stemberg E, Lute L], Reed JC, et al: Calcium
and vitamin D supplementatien maintains parathyreid
hermene and impreves bene density during initial military
training: it randemited, deuhle-hlind, placehe centrelled
trial. Bene 2D14:53:4E-Sfi. Medline DUI
Calcium and vitamin D supplementatien can maintain and
impreve bene health during perieds ef elevated bene turn-
ever such as initial military training. Level ef evidence: I.
43. Milgrem C, Finestene A, Hevack V, et al: The effect ef
prepbylactic treatment with risedrenate en stress fracture
incidence ameng infantry recruits. Bene 20 (14:35[2}:413-
424. Medliue DUI
44. Institute ef Medicine: Dietary Reference intrtftes fer Cai-
cinrn and Vitamin D. Washingten, DC, Natienal Picademy
ef Sciences, 201i].
Dietary intake ef calcium sheuld he 1,0043 te 1,3 Eli] mg and
dietary intake ef vitamin D sheuld be EGG l'U accerding
te current guidelines.
45. Kilceyne KC, Dickens JP, Rue JP: Tibial stress fractures
in an active duty pepulatien: Lung-term eutcemes. J' Snrg
Urthep ass 1fl13;21i1}:5fl-53. Medline DUI
Tibial stress fractures in military recruits mest eften were
iselated, and they did net affect the ability re cemplete
military training er lead te decreased physical activity at
10-year fellew-up. Level ef evidence: IV.
4S. Rue JP, Armstreng Dill? III, Frassica FJ, Deafenhaugh 1.4.}
.l'vI, Wilckens JH: The effect ef pulsed ultraseund in FT.
the treatment ef tibial stress fractures. Urinepedics :5
rs
rs
EDU4;27{II}:1192-1195. Medline tn
3
CI.
4?. Taki M, Iwata U, Shiene M, Kimura M, Takagishi I-i:
Entracerpereal sheck wave therapy fer resistant stress
s
fracture in athletes: A repert ef .5 cases. ArnJSperts Med
1Dfl?;35{?}:1133-1192. Medline DUI
4S. Eeclc ER, Mathesen GU, Bergman G, et al: De capaci-
tivelyT ceupled electric fields accelerate tibial stress fracture
healing? A randemieed centrelled trial. Am J Sperts Med
2Dflfl;3fi{3}:S4S-SS3.Medline DUI
Urrhepaedie Knewledge Update: Sperrs Medicine 5
 Eection 3:Rnee andLeg
45'. Beals REC, Cook RD: Stress fractures of the anterior tibial
diaphysis. Urtlanpedfcs 1991;14lE}:EEE-E?S. Medlirle
SD. Bart ME, Kemp E, Kerslalte R: Delayed union stress frac-
tures of the anterior tibia: Conservative management. Br
J Sports Med 2Gfl1;35{1}:?4—??. Medline DD]
51. Young AJ, McAllister DR: Evaluation and treatment of
tibial stress fractures. Cliu Sports Med EGGEESIIHII‘L
123, x. Medline DDI
.52. Borens CI, Een MK, Huang RC, et al: Anterior tension
band plating for anterior tibial stress fractures in high-per-
formance female athletes: A report of 4 cases. J Clrtlaop
Trauma lflflfi;2fl{5}:425-430. Mndline D‘DI
53. Crux HE, de Hollanda JP, Duarte A Jr, Hungria Nero
JE: Anterior tibial stress fractures treated with anterior
tension band plating in high-performance athletes. Knee
Surg Sports Trdxmntnl Arllrrnsc 2fl13;21lli}:144?-14Sl}.
Medline DCII
Anterior tibial tension-hand plating was found tn lead to
prompt fracture consolidation and was a good alterna-
tive treatment of anterior tibial cortmt stress fractures.
Bone grafting was found to be unnecessary. Level of
evidence: I'll.
S4. Liirnatainen E, Earimn J, Hulkltn A, Ranne J, Heilrltilii
J, lDrava E: Anterior mid—tibial stress fractures: Results
of surgical treatment. Scand J Sarg lflfl?:93i4}:244~249.
Medline
Surgical treatment of nonnnited tibial stress fractures with
laminnfixatinn may be superior tn tibial fracture site drill-
ing. Level of evidence: I‘v'.
55. Dahl M, Hansen P, Etdl P, Edmundssnn D, Magnussnn
EP: Stiffness and thickness of fascia do not explain chronic
exertinnal compartment syndrome. Clin Drtlvop Refer Res
2fl11;469{12h3495-35i}fl.Medline DDI
bln difference was found in fascial thickness and stiffness
between patients with CECE, with or without diabetes,
compared with healthy individuals. This finding suggests
that structural and mechanical properties are unlikely tn
explain CECE. Level of evidence: II.
SE. Waterman ER, Liu J, Newcnmb R, Echnenfeld AJ, Cl'tt
JD, Belmont P] Jr: Risk factors for chronic exertinnal
UI
compartment syndrome in a physically active military
to
._I population. Ass Jr Sports Med 2fl13;41{11}:254S-254E.
T:
I:
Medline DDI
n:
to
III-1
The epidemiology of CECE was examined in a physically
I:
E:
active military pnpulatinn. Eex, age, race, military rank,
H
and branch of service were important factors associated
with the incidence of CECE in this at-rislt population.
Level of evidence: II.
57. Davis DE, Railrin E, Carras DH, 1|Il'itanao P, Labrador
H, Espandar R: Characteristics of patients with chrnn-
ic exertinnal compartment syndrome. Foot Ankle Int
2fl13;34llfl}:1349—1354.Mcdlinc DUI
Clrthopaedie Knowledge Update: Eports Medicine 5
The average age of patients with CECE was 14 years.
Women accounted for 60.1% of those with elevated pres-
sures. Anterior and lateral compartment pressures were
elevated in 43.5% and 35.5% of patients, respectively.
Level of evidence: III.
SB. 1iiiii'inltes MB, Hoogeveen AR, Hourerman E, Ciesberts A,
Wijn PF, Echeltinga MR: Compartment pressure curves
predict surgical outcome in chronic deep pnsterinr com-
partment syndrome. Am ,i' Sports Med 201 2:4GIE}:IEEE'
IRES. Medline DCII
Preoperative intracompartmental pressures measured at
rest and after a standard exercise test may predict the
success of surgery for deep posterior compartment CECE
of the lower limb. Lewl of evidence: I‘ll.
59. Pedowita RA, Hargens AR, Mubarak E], Gershuni DH:
Modified criteria for the objective diagnosis of chron-
ic cnmpartment syndrome of the leg. Arr: J Sports Med
199fl;13{1}:35—4D.Medline DCII
fill. Tiidus PM: Is intramuscular pressure a valid diagnostic
criterion for chronic exertinnal cnmpartment syndrome?
Clln fSporr Med lfl14;24{11:E?-33. Medline nor
A systematic review concluded that use of the currently ac-
cepted diagnostic criteria for anterior tibial intramuscular
pressure before, during, and after exercise would include
many individuals without symptoms of CECE.
51. Roberts A, Franklyn-Miller l‘L: The validity of the diag-
nostic criteria used in chronic exertinnal compartment
syndrome: ll systematic review. Scand I Med Sci Sports
2012:22i5}:EES-SEE.Medline DDI
In a systematic review of the validity of diagnostic criteria
for CECE, the use of protocol-specific upper confidence
limits was recommended to guide the diagnosis after on-
successful nonsurgical management.
61. sweid D, De] Euono A, Malliaras P, et al: Systematic
review and recommendations for intracompartrnental
pressure monitoring in diagnosing chrnnic exertinnal
compartment syndrome of the leg. Clin J Sport Med
ZDIZflZHJfiEE-ETU.Headline DCI'I
A systematic review concluded that new diagnostic criteria
should be established for CECE.
63-. Roscoe D, Roberts A], Hulse D: Intramuscular compart-
ment pressure measurement in chronic exertinnal cnmpart-
ment syndrome: blew and improved diagnostic criteria.
Am 1 Sports Med lfllS:43l2}:392-393. Medline DDI
In patients with symptoms consistent with CECE, the
diagnostic utility of IMCP was improved with continuous
measurement during exercise. Level of evidence: II.
E4. Ringler MD, Litwiller DV, Felmlee JP, et al: MRI accu-
rately detects chronic exertinnal compartment syndrome:
A validation study. Skeletal Radiol 2013:41{3]:335-392.
Medline DDI
ID ll] 16 American AeadMy of Drthopaedie Surgeons

Exercise-based MRI was mederately reliable and repre-
ducible as a neninvasive screening test fur CECE. Level
ef evidence: III.
65. Eajasel-taran E, Beavis C, Aly AR, Leswiclc D: The utility
ef ultraseund in detecting anterier cempartment thickness
changes in chrenic exertienal cempartment syndreme:
A pilet study. Clin I Epert‘ Med 2fl13;33{4]:3fl5-311.
Medliue DUI
Patients with CECE had an increase in anterinr cempart-
ment fascial thickness en ultraseund cempared with cen-
trel subjects. It is unclear whether this finding can be used
fer reliable neninva sive screening. Level ef evidence: III.
66. Peck E, Finneff JT, Smith], Eurtiss H, Muir], Hellman
JH: Accuracy ef palpatien-guided and ultraseund-guided
needle tip placement inte the deep and superficial pesterier
leg cempartments. An: } Spur-ts Med 2011;39ifljflfiififl-
19M. Medline 'DDI
Needle tip placement inte the deep and superficial peste-
rier leg cempartments was relatively accurate with pal-
patien guidance, regardless ef the practitiener’s level ef
experience, and accuracy did net impreve with the use ef
ultraseund guidance. Level ef evidence: II.
6?. Van der 1iiiial “WA, Heesterbeelt P], 1|vian den Brand JG,
Verleisdenlt E]: The natural ceurse ef chrenic exertien-
al cempartment syndreme ef the lewer leg. Knee Eurg
Siberia Trenntnt‘ni Artnresc 2015;13{?}:2136-1141.
Medline DUI
The natural ceurse ef CECE appears te include persistent
symptems. Level ef evidence: W.
63. IsnerrHerebeti ME, Dufeur SP, Blaes C, Lececq J: Intra-
muscular pressure b-efere and after betulinum texin in
chrenic exertienal cemparnnent syndreme ef the leg: A
preliminary study. Am J Sperts Med 2fl13;41{11}:1553-
2556. Medline DUI
Injectien with betulinum tesin A reduced intramuscular
pressure and eliminated exertienal pain in patients with
anterier er anternlareral CECE as leng as 9 mentbs later.
The mede ef actien ef betulinum teszin A is unclea r. Level
ef evidence: IV.
69. Waterman BR, Laughlin M, Kilceyne K, Camemn KL,
flwens ED: Surgical treatment ef chrenic exertienal cem-
partment syndreme ef the leg: Failure rates and pestep-
erative disability in an active patient pepulatien. j Bene
Jeni-n: Enrg Ans 2fl13;95{?}:592-596. Medline DDI
CECE- is a substantial centributer tn the rate ef lewer es—
tremity disability in the military pepulatien. Almest half
ef all service members undergeing fascietnmy reperted
persistent symptems, and ene in five had unsuccessful
surgical treatment. Invel ef evidence: IV.
TU. Dunn JD, Waterman BR: Chrenic enertienal cempart-
ment synd reme ef the leg in the military. Ciin Sperts Med
Efl14;33{4}:593-T05.Medline DUI
Clinical success has been dncumented in civilian patients
treated fer CECE, but surgical treatment in military
Eb Iiilii American Academy ef flrdtepaedic Eurgeena
Chapter 11: Leg Pain Diserders
service members has net been reliably successful. |[Iinly
half ef military service members had cemplete reselutien
ef symptems, and at least 25% were unable te return tn
full active duty. Level ef evidence: IV.
‘FI. McCallum JR, Ceelt JE, Hines AC, Ehaha JE, Jest JW,
Circbewski JR: Return te duty after elective fascietemy
fer chrenic exertienal cempartment syndreme. Feet Ankle
Int 2014;35i9}:ETI-E?5. Medline DUI
A return In full military duty was repnrted fer 41% ef
patients whe underwent elective fascietemy fer CECE.
Uverall, F'fl ‘i’u ef patients remained in the military, and the
subjective satisfactien rate was i’l'i’s. Level ef evidence: IV.
T2. Reberts A], Krishnasamy P, Quayle JM, Heughten JM:
Outcemes ef surgery fer chmnic exertienal cempartment
syndreme in a military pepulatien. I R Army Med Cerps
1015:161{1}:41-45.Medline DUI
Many miliary patients with CECE de net return te full fit-
ness after fasciectemy. The lack ef a relatienship between
intramuscular pressure and eutcnme calls inte questien
the rele ef pressure in CECE. Level ef evidence: IV.
3'3. Mathis JE, Echwarts BE, LesterJD, Kim W], Watsnn JN,
Hutchinsen MR: Effect ef lewer extremity fascietemy
length en intracempartmental pressure in an animal med-
el ef cempa rtment synd reme: The impertance ef achiev-
ing a minimum ef 90% fascial release. Arn Jl Sperts Med
ID15;4E{I}:TE-TE.Medlinc DUI
This study feund a streng cnrrelatinn between fascietemy
length and a reductien in intracempartmcntal pressures
in a swine medel. A 90% fascial release may represent a
pessible watershed acme fer returning intracempartmental
pressure te its baseline. Level ef evidence: II.
3'4. Finestene AE, Neff M, Nassar Y, Meshe E, Agar G, Tamir
E: Management ef chrenic exertienal cempartment syn-
dreme and fascial hernias in the anterier lewer leg with
the ferefeet rise test and limited fascietemy. Feet Ankle
Int 1014;351:31235—191. Medlitte DUI
Selected patients with CECE were feund re benefit frem
a limited fascietemy. Level ef evidence: IV.
T5. Packer JD, Day ME, Nguyen JT, Hebart E], Hanuafin
JA, Metal JD: Functienal eutcemcs and patient satisfac-
tien after fascietemy fer chrenic exertienal cempart-
ment syndreme. An: ] Sperts Med 2013;41i2}:43D-436.
Medline DUI
1.4.}
Age yeunger than 23 years and iselatetl anterier cempart- FT.
:5
ment release were facters asseciated with impreved sub- re
re
jective functien and satisfactien after fascietemy. Lateral a:
3
release sheuld be aveided unless symptems er pestestertien El.
cempartment pressures clearly indicate lateral cempart-
ment invelvement. Level ef evidence: III.
E
T6. Pillai J, Levien L], Haagensen M, Candy '3, Clever MD,
Velier MG: Assessment ef the medial head ef the gastrec-
nemius muscle in functienal cempressien cf the pepliteal
artery. }' Vase Enrg Eilfifly-IEIEHIRE-1196. Medline DUI
Drrhepaedic Knewledge Update: Eperrs Medicine .5
 Sectien 3:1I'inee andLeg
T1 Alttan Iltia EA, Ucerler H, nur E: Anatnmic variaticns
nf pcpliteal artery that may be a reascn for entrapment.
3mg Radial Anal 20 0953ll9}:595-?Dfl. Medline DUI
Anemaleus anatemic relatie-nships between muscle and
arteries in the pepliteal fessa were fennd re lead te arterial
cnmpressinn.
TE. Pelitane AD, Bhamiclipati CM, Tracci MC, Upchurch GR
Jr, Cherry K]: Anatnmic pnpliteal entrapment syndrnme
is c-ften a difficult diagncsis. 1Vase Endevascalar Burg
2012;46l?l:542-545. Medline DUI
In the diagnestic algerithm fer feur patients with PAES,
angingraphy with forced plantar flexinn against resistance
was useful fnr eliciting pathngnnmnnic images nf arterial
ucclusien. Level of evidence: IV.
7’9. Turnipseed WI): Functicmal pnpliteal artery entrapment
syndmme: A pearly understand and eften missed diagncsis
that is frequently mistreated] 1Vase Sarg 2fl09:49{5}:1139-
1195. Medline DUI
PAEE and CECE nccur in the same pnpulatinns and have
similar symptnms, but they require different treatments.
El}. Emil G, Tay KH, Hnwe TC, Tan BS: Dynamic cnmputed
tnmngraphy angingraphy: Rnle in the evaluatinn nf pnp—
liteal artery entrapment syndreme. Cardieeasc Interveat
Radial 2fl11;34[2}:259-2?fl. Medline DUI
Dynamic CT angingraphy is a useful tcnl fer diagnnsing
PRES.
31. t-ng H, Gan J, Zhacr Y, et al: Rule crf CT anging-
raphy in the diagnnsis and treattnent cf pcrpliteal vas-
cular entrapment syndreme. AJR Am ] Reenrgenei
2fl11:19?{fil:W114?-W1154.Medline D01
Digital snbtractien angiegraphy was fen nd te have limited
value in the evaluaticn nf PAES and has been replaced by
nnninvasive imaging techniques such as apler snnng-
raphy, CT angingraphy, MRI, and magnetic resenance
angiegraphy.
El. Lane R, Nguyen T, lfluxailla M, Unmens D, Mehabbat
W, Haaelten 5: Functicnal pepliteal entrapment syn-
drnme in the spnrtspersnn. Eur ] 1lifasc Endnnasc Snrg
2fl11543{1]:31-fi?.Medline em
DI
m
._I
T:
E
m
m
Ill-1
:
a:
H
flrrhnpaedie Knnwledge Update: fipnrrs Medicine 5
PAEE can be characterised by prnvncative nnninvasive
clinical tests, particularly hnpping. A pnsitive clinical
cutccme ef surgery can be predicted by abnermal pre—
surgical nltrasenic findings and cenfirmed by a similar
nnrmal pnstsurgical study. 1While standing, patients may
have cnncnmitant venous cnmpressitm related rc- muscle
hypertrephy. Level of evidence: IV.
33. Ziind G, Brunner U: Surgical aspects cf pnpliteal artery
entrapment syndreme: 26 years cf experience with 26 legs.
Vasa 1995:24l1):29-33. Medline
34. Isner—Herebeti ME, Muff G, Masat J, Daussin JL, Dufeur
5P, Lecccq J: Entulinum tnxin as a treatment fer functic-n-
al pnpliteal artery entrapment syndrnme. Med Sci Sprints
Exerc amswrreeuaa—nax Medline ntn
Betulinnm tcxin treatment cculd be an alternative tc sur—
gery fer patients with in nctienal PAES. Betulinum tcxin
ctmld reduce functional ccmpressinn and cnnsequently
reduce exercise-induced pain by decreasing gastrncnemius
muscle velume. Level nf evidence: IV.
3.5. Him 511’, Min SK, Ahn 5, Min 51, Ha], Kim 5]: Lung-term
cutcemes after revascularieaticn fer advanced pepliteal
artery entrapment synd reme with segmental arterial cc-
clusinn. ] 1lirasc 3mg 2012;55l1}:9fl-91 Medline DUI
After surgery fnr advanced PAES, a relatively lnng arterial
bypass with superficial femeral artery inflew had peer
lcng—term graft patency. Graft patency was excellent in
patients with pnpliteal artery ncclusinn nnly after pnpli-
teal interpcsitinn graft with a reversed saphennus vein. A
lcnger bypass extending heyend the pcplitcal artery may
be indicated in patients with critical limb ischemia c-nly if
the extent {if disease dues net allnw a shnrt interpc-sititm
graft. Level cf evidence: IV.
36. Yamamntn S, Heshina K, Hnsalta A, fihigematsu K,
Watanabe T: Lang—term nutcemes cf surgical treatment in
patients with pepliteal artery entrapment synd reme. 1.i'as-
cedar 2.014 New 1? [Epub ahead cf print]. Medline BID]
The lfl-year cumulative patency cf 13 limbs treated with
bypass fer PAEE was 100%, althc-ugh 2 cf these limbs had
an ecclusien that eccurred 12 nr 13 years after surgery.
Level cf evidence: IV.
El ll] 16 American AcadMy ef Drrhnpaedie Surge-ens
Chapter 22
Ankle and Foot Injuries
and Other Disorders
Thomas {1 Clanton, MD Norman E. 1i'llhldrop III. MD
Abstract
The most common foot and ankle injuries and ether
conditions in athletes are ankle sprains, syndesmosis
injuries, osteochondral injuries, ankle impingement,
heel pain, Lisfranc injuries, turf toe, stress fractures,
and Achilles tendon disorders. The diagnostic and
treatment recommendations are based on a review of
the current research.
Keywords: Achilles tendon; ankle: ankle sprain:r
ankle impingement; foot; heel pain: Lisfranc injury:
osteochondral lesion; sesamoid: stress fracture:
syndesmosis: turf toe
Introduction
The foot and ankle are the most commonly injured body
parts in athletics, and these injuries often result in loss
of playing time."2 A study of intercollegiate football
Dr. Clanton or an immediate family member is a member
of a spealrers‘r bureau or has made paid presentations on
behalf of Arthrex, Small Bone lnnova tions, Strylrei; and
Wright Medical Technology: serves as a paid consultant
to Arthrea. Small Bone innovations, Strykei: and Wright
Medical Technology; has received research or institution-
al support from Arthrer; and serves as a board member.
owner. officer; or committee member of the American
Orthopaedic Foot and Ankle Society Dr: Waldrop or an
immediate family member is a member ofa speakers“ human
or has made paid presentations on behalf of Arthrer and
Wright Medical Technology and serves as a paid consultant
to Arthreir. Neither of the following authors nor any imme-
diate family member has received anything of value from
or has stock or stock options held in a commercial company
or institution related directly or indirectly to the subject of
this chapter: Dr. Johnson and Dr. Whitiow.
@ 1016 American Academy of Drthopaedic Surgeons
Nicholas 5. Iohnson, lD Scott 11. 1Flull'iitlow, MD
players in the National Football League Scouting Com-
bine found that T2.% had a history of foot or ankle injury,
the most common of which were lateral ankle sprain
{40%}, syndesmosis sprain {1?%}, metatarsophalangeal
{MTP} joint injury {13%}, and fibula fracture {9%)} Such
findings have led to increased interest in the diagnosis,
treatment, and rehabilitation of these injuries. Acute
traumatic and chronic overuse athletic injuries can often
be treated nonsurgically, though many of these disorders
are often challenging for both the athlete and physician.
Nevertheless, it is imperative for the physician to quick-
ly recognize a pathology or circumstance that requires
surgical intervention.
Ankle. Injuries
The incidence of ankle sprains in the United States was
reported as 2.15 per 1,000 person-years.‘* Almost half
of all sprains occurred during athletic activity; basket-
ball {41.1%}, football {9.3%}, and soccer {19%} were
responsible for the most ankle sprains. In contrast, a
similar study found an ankle sprain rate of 53.4 per 1,000
personuyears; 64.1% of the sprains occurred during an
athletic activity, most commonly men’s rugby, women’s
cheerleading, men’s andlor women’s basketball, soccer,
and lacrosse.E Lateral ankle sprains account for 35% of
ankle sprains, syndesmosis sprains account for 10%, and
medial sprains account for 5%.5
Ankle stability is a function of extrinsic elements such 1.4,:
as ligaments and tendons and intrinsic elements such as F.
the geometry of the articular surface. The contribution
:ii
on
or
of each element varies with the load level, the direction cu
3
in which force is applied, and the integrity of the liga—
El.
ments. In general, the ankle is most stable in dorsiflestion :5
and when loaded and is least stable in plantar fleaion
and when unloaded. When the ankle is loaded, articular
geometry provides 100% of translational stability and
60% of rotational stability. The unloaded ankle, however,
relies on the ligaments. Between ?0% and 30% of anterior
stability is provided by the lateral ligaments, 50% to 80%
Orthopaedic Knowledge Update: Sports Medicine 5
 Secticn 3: Knee and Leg

Figure 1 Phntngraphs shew the primary lateral ankle ligaments in antercilateral {A} and pnsternlateral [E] views at a left
ankle. ATFL = anteriur talufibular liga ment. EFL = calcane-ufibular liga ment. PTFL = pusteriur talcdibular ligament.

clf pnsterinr stability is previded by the deltnid ligaments,

and 50% tn llfl'iti cf rntatic-nal stability is pmvided by the
lateral and deltnid ligaments.E

Lateral Ankle Injury

The lateral ligamentuus cnmplert cf the ankle jnint in-
cludes the anterinr talnfibular ligament (ATFLJ, the cal-
canecfibular ligament {EFL}, and the pusterinr talcifihular
ligament {PTFL} {Figure 1}. Relatively recent anatcimic
research pruvided impnrta nt infnrmatinn an the qualita—
tive and quantitative characteristics at these ligaments?
The ATFL, which is the primary restraint tn inversiun
in plantar flea-{inn and has the least strength cf the lateral
ligaments (133.9 N], resists anterinr translatinn and inter-
nal rntatic-n cf the talus in the mcIrtise“ {Figure 2]. 1When : ‘ eral
the ankle is in neutral pnsitinn nr dnrsiflercinn, the lEFL talar prucess
is the primary restraint tn inversicin; its average strength
is 345.? bl“ {Figure 3}. The CFL spans the tibic-talar and
subtalar jciints, thereby restraining subtalar inversinn.
The PTFL, which is the largest cf the lateral ligaments,
DI
rarely is injured.I 9 Radingraphic parameters have been Figure 2 Schematic drawing shews the erigln and
insertiun sites of a twin—ha nd anterinr
er
._I defined tn quantitatively describe these anatnmic nrigins talcifibular ligament in a right ankle. with the
T:
I:
in and insertinns ed the lateral ankle ligaments.” distances frcrn landmarks. [Repreduced with
tu Injury tn the lateral ankle ligaments typically fiEEUTS permissinn frnm Elantnn TD, Campbell ltJ,
Iii-1
I: Wilsun it]. et al: Qualitative and quantitative
as during plantar fleetinn and supinatinn, which cumbine anatcirnic investigation at the lateral ankle
inversic-n and addnctic-n. In this type nf injury, the antern-
H

ligaments fur surgical recn nstructinn

lateral jnint capsule tears first, fcllcwed by rupture cf the
ATFL and EFL as the farce pf injury progresses laterally.
The ATFL is injured in 35% ed lateral ankle sprains,
and the CFL is injured in was tn 40%. A grade I lateral
ankle injury invnlves stretching pf the ATFL with mild
tenderness, nn evidence nf mechanical instability, and
precedures. J Bane Jaint Surg' Am
2fl14;95[12]:e93.l
ability tn bear weight with minimal discemfert. A grade
II injury is a cnmplete tear cf the ATFL, usually accum-
panied by a partial injury cf the CPL. A grade III injury

flrrhnpaedic Knnwledge Update: Sparta Medicine 5 El 1016 American Academ~y nf Drrhnpaedjc Surge-ans

is cnmplete rupture cf the ATFL and CFL. Symptnms
nf severe tenderness and pain are cnnunnn, and weight
bearing is difficult}
In an effnrt tn reduce the incidence and severity cf lat-
eral ankle sprains, numernus studies nf varying quality
have fncused nn identifying the risk factnrs. A level II
study identified age, sex, race, and athletic invnlvement
as risk factnrs.‘l The highest risk nf ankle sprains was if]
tn 14 years nld in females and 15 tn 19 years nld in males.
Bnys and men age 15 tn 24 years had a higher incidence nf
lateral ankle injury than their female cnunterparts. a-
en age 3i] tn 9? years had a higher incidence than men in
that age range. Athletic invnlvement was respnnsihle fnr
45% tn 50% nf ankle sprains. The same database shnwed
a race-based disparity; the incidence was substantially
higher amnng thnse identified as black nr white than
amnng thnse identified as Hispanic. Several factnrs may
be related tn the race-based differences in injury rate,
including nbesity, eapnsure tn high-risk athletic activity,
cnnnnctive tissue prnperties, and skeletal fnnt mntphnlngy
{specifically as related tn the cavnvarus fnnt}. Additinnal
risk factnrs assumed tn be irnpnrtant include strength,
prnprinceptinn, range nf mntinn, and balance, but there is
an high—quality evidence tn suppnrt these assumptinus.”
The best evidence suppnrts the belief that an earlier ankle
injury is a significant risk factnr fnr a secnnd ankle sprain
in the same nr the cnntralateral ankle.11
Extrinsic risk factnrs are related tn specific spurt par-
ticipatinn, level nf cnmpetitiveness, playing surface, and
shne wear. Accnrding tn level II evidence, sports injury tn
the lateral ankle is mnst cnmmnn during wall climbing,
rnck climbing, indnnr vnlleyball, basketball, wnrnen‘s
cheerleading, and field spnrts such as rugby, snccer, lap
crnsse, and American fnntball. Game cnmpetitinn places
an athlete at greater risk fnr an ankle sprain than practice
participatinnF'"
Meta-analyses have evaluated the nptimal treatment nf
acute lateral ankle sprains.”*” llCIurrent npininn, practice
patterns, and research studies suppnrt functinnal nnnsur—
gical management as the preferred methncl nf treating all
lateral ankle sprains. This cnnclusinn is well suppnrted
for grade I and II sprains, but many variables can affect
the nutcnme and nest-benefit ratin fnr a severe grade III
sprain. Surgery fnr a severe sprain leads tn a slightly better
functinnal nutcnme than nnnsurgical treatment. Hnwev—
er, surgery is mnre cnstly and has a higher cnmplicatinn
rate than nnnsurgical treatment, with a slightly higher risk
nf nstenarthritic change nn MRI. Functinnal nnnsurgical
treatment leads tn a higher incidence nf reinjury; hnwever,
rates nf return tn preinjury status are similar after surgical
nr nnnsurgical treatment.“ Nnnsurgical treatment was
unsuccessful in 10% nf japanese athletes, and athletes
El Ifllii American Academy nf Urthnpaedic Surgenns
Chapter 22: Ankle and at Injuries and Either Disnrders
Schematic drawing shnvvs the calca nenfi bular
ligament nrigin and insertinn sites in a right
ankle, with the distances frnm landmarks.
{Fieprnduced with permissinn frnrn Clantnn
TU. Campbell it]. Wilsnn Ki. et al: Qualitative
and quantitative anatnmic investigatinn
cf the lateral ankle ligaments fnr su rgical
recn nstructinn prncedures. J Bone .lnint Surg
Am 2014:96I12]:e93.]
whn underwent surgery had a mere rapid return tn ath-
letic activity.” Only level V evidence suggests that surgical
treatment is preferable fnr prnfessinnal nr elite athletes.llEi
In patients whn received nnnsurgical treatment fer a
severe sprain, the nutcnme was better after cast immnbili-
aatinn fnr 1i] days than after use nf a rigid stirrup brace nr
walking bnnt.” lDrher evidence-based treatments nf ankle
sprains include supervised early exercise, unsupervised
balance—bnard training, NSAIDs, and the traditinnal
rest-ice-cnmpressinn-eievatinn prngram.“ bin scientific
evidence suppnrts the use nf ultrasnund, laser therapy,
electrntherapy, manual mnbilisatinn, estracnrpnreal
shnck wave therapy {ESWT}, hyperharic nxygenatinn,
nr platelet-rich plasma {PEP}.“ Evidence exists tn sup- 1.4,:
pnrt bracing nr taping during the pnstinjury perind until FT.
:5
rehabilitatinn is cnmplete.” re
re
tn
Acute surgical repair nf a lateral ligament rupture nf 3
El.
the ankle is nnt always cnntrnversiai. The indicatinns
include an npen injury, a large av ulsinn, nr annther assnci- E
ated pathnlngy such as dislncated pernncal tendnn, nsten-
chnndral fracture, nr hima llenlar fracture variant with a
cnmplete tear nf the medial and lateral ligaments. Even
an avulsinn fracture cf the distal fibula heals readily with-
nut late instability cnmpared with a purely iigamentnus
injury.” Snme evidence suppnrts surgical treatment nf a
Drthnpaedic Knnwledge Update: Spnrns Medicine 5
 Sectinn 3:1Cnee andLeg
Tibi- -:leaneal liga - :
Pnstarin, ‘ distal
tibintal. .Igament
De- pnsterinr.
tibir larllgame
A
Schematic drawings shnvv superficial {A} and deep {B} ligaments nf the medial ankle.
severe lateral ankle sprain, particularly in an elite athlete
nr a patient whn dncs haeardnus wnrk and cannnt risk
persistent instability nr reinjury.“*~15
Evidence frnrn high-level randnmiaed studies can firms
that the use nf lace~up ankle braces reduces the incidence
but nnt the severity nf acute ankle sprains in basketball
and fnntball players.”"*m Evidence alsn suppnrts the val—
ue nf neurnmuscular educatinn and balance training in
reducing the incidence nf recurrent ankle sprains."~”
Residual disability after ankle sprain is repnrted tn be
present in 32% tn THEE nf patients.5~“'” The disability
usually is in the fnrm nf residual swelling, pain, andl'nr
instability. Elucidating the cause nf disability can be a
cnmplen and challenging prncess requiring a histnry and
physical enaminatinn as well as stress radingraphy, CT,
MRI, nr ankle arthrnscnpy.
A disability resulting frnm instability must be identi—
fied as functic-nal nr mechanical. Functinnal instability
has been defined as “the nccurrence nf recurrent jnint
instability and the sensatinn nf jnint instability due tn
the cnntributinns nf any neurnmuscular deficits?“ The
DI
primary cause is injury tn the jnint mechannreceptnrs and
a:
._I afferent nerves resulting in impaired balance, reduced
T:
I:
re
jnint pnsitinn sense, slnwed firing nf the pernneal muscles
a:
III-1 in respnnse tn inversinn stress, slnwed nerve cnnductinn
I:
s: vein-city, impaired cutanenus sensatinn, strength deficits,
and decreased ankle dnrsiflestinn. Functienal instability
H
typically imprnves in respnnse tn a well-designed reha-
bilitatinn prngram. Mechanical instability, hnwever, is
“laxity nf a jnint due tn structural damage tn ligamentnus
tissues which suppnrt the jnint"?l Mechanical instability
can lead tn altered jnint kinematics and arthritic changes,
which nften require surgical cnrrectinnFE-l‘
flrdtnpaeclic Knnwledge Update: Sparta Medicine 5
I anterinr
“bl-I'm. inament
Deep l! '
tibintalar _--=
Bnth anatnmic and nnnanatnmic surgical techniques
are used fnt treating recurrent instability. The standard
treatment nf chrnnic lateral ankle instability has been the
Gnuld mndificatinn nf the Brnstrcim prncedure, which is
an anatnmic recnnstructinn nf the ATFL and IEFL that
has had gnnd lung-term results.El This prncedure has lim-
itatinns related tn pnnr tissue quality, hyperflenibility, the
stresses impnsed by large nr elite athletes, and aggressive
early rehabilitatinn.” Several mndificatinns nr recnmmen-
datinns shnuld be cnnsidered when the Brnstrnm—Gnuld
prncedure is used, such as the use nf an augmentatinn
methnd fnr reinfnrcemeat and prntectinn, anatnmic al-
lngraft recnnstructinn if lncal tissue is inadequate, and
immnbiliaatinn fnr an adequate perind nf time befnre
aggressive rehabilitatinn.15'3"
Medial Ankle Injury
The deltnid ligament cm the medial side at the ankle is
cnmpnsed nf distinct superficial and deep layers. The
ligament cnnsists nf a maximum nf sin bands, nf which
nnly the tibinnavicular ligament, tibinspring ligament,
and deep pnsterinr tibintalar ligament are cnnstant. The
superficial layer is a brnad, band-like structure that nrig~
inates frnm the anterinr cnlliculus and fans nut tn insert
intn the navicular, neck nf the talus, sustentaculum tali,
and pnsternmedial talar tubercle {Figure 4}. The deep
pnrtinn nf the deltnid is the primary medial stabilizer nf
the ankle jnint. Unlike the superficial pnrtinn, the deep
pnrtinn is nrganiaed intn twn shnrt, thick, discrete bands:
the deep anterinr tibintalar ligament and deep pnsterinr
tibintalar ligament, which are intra-articular but estra-
synnvial. The deep pnsterinr tibintalar ligament is the
largest band at the deltnid cnmplex.“
El ll] 16 American Acadenw nf Drthnpaedic Surge-ans

The primary function of the deltnid ligament as a
whole, and specifically the tibinspting and tibiocalca-
neal ligaments, is to prohibit eversinn and abduction.
The deep deltnid, primarily the deep posterior tibiotalar
ligament, also resists external rotation when the foot is
dorsiflexed, and it is responsible for the greatest restraint
against lateral translation. Valgus tilting of the talus
within the mortise requires complete rupture of both
the superficial and deep deltnid. As a multicomponent
ligament, the deltnid requires considerable force for dis-
ruption. The deep deltnid ligament was found to have
a greater load to failure $13.3 hi [:I: 69.3 NH than the
lateral collateral ligamentsf“E The dominant mode of
failure of the deep deltnid ligament is an intrasubstance
rupture near the talar insertion; the superficial deltnid
ligament most commonly fails at its insertion into the
anterior colliculusfi'3
Rupture of the deltnid ligament is rare in the absence
of lateral ligamentous or fibula injury. In all patients, the
physical examination must exclude associated syndesmo—
sis injury, lateral ligamentous injury, or fibula fracture
{including high fibula fracture or proximal tibiofibular
joint injury}. The posterior tibial, flexor digitnrum longus,
and flexor hallucis longus tendons also must be evaluated.
Any associated neurologic pathology such as tibial or
saphennus nerve injury should be noted.
Anterior and posterior translation, medial and lateral
translation, internal and external rotational instability,
and varus—valgus instability should be carefully evalu—
ated. The patient can be seated, supine, or prone, but
it is beneficial to test in more than one position and to
be certain the patient is fully relaxed. Comparison with
the normal contralateral extremity is key to appreciating
subtle differences. The criteria for the diagnosis of medial
instability are medial ankle joint pain, a subjective feeling
of giving way, and a valgus or pronation deformity that
is correctable with posterior tibial muscle activation:H
The diagnosis is reinforced by an examination indicating
excess motion in external rotation, eversion, valgus, or
posterior translation.
Radiographs may suggest deltnid ligament injury, espe-
cially if there is an associated syndesmosis injury or fibula
fracture. The presence of small av ulsion fragments at the
tip of the medial mallenlus may indicate an acute injury
in association with the history and physical examination
findings. In a complete deltnid ligament injury, a valgus
AP stress radiograph shows a talar tilt. i'viost such injuries
are incomplete, and standard radio-graphs appear normal.
As a result, the traditional gold standard for evaluating
medial ankle instability is stress radiography.” A gravity
stress radiograph may be useful in the office setting for
detecting an acute injury. MRI increasingly is the imaging
Eb Ifllti American Academy of flrdiopaedic Surgeons
Chapter 22: Ankle and Foot Injuries and Ether Disorders
modality of choice for defining injury to the deltnid lig-
aments and associated structures?5
Most deltnid ligament injuries can be treated nonsur-
gically. Treatment is dictated by the associated injuries.
Usually there is no need to repair the injured deltnid lig-
ament because stabilisation of the concomitant injuries
stabilizes the ankle and allows the deltnid ligament to
heal. Functional management of grade I and most grade II
isolated deltnid sprains with a pneumatic brace, a walking
boot, or rarely, a walking cast is sufficient for adequate
healing, although the delay before return to sports usually
is greater than after a lateral ankle sprain. A grade II or
III medial sprain does not require surgery if an anatomic
reduction can be maintained by immobilization in a cast
or walking boot.“
After the repair of an associated injury, such as fibula
fracture or syndesmosis rupture, stress flunrnscnpy oc-
casionally reveals persistent medial instability. Primary
repair of the deltnid ligament is warranted in this cir-
cumstance. The use of suture anchors or a suturednnly
construct often is sufficient to stabilize the medial side
of the ankle.
Syndesmosis Injury
The ankle syndesmosis is continuous with the interosse-
nus membrane proximally and is located at the level of
the tibial plafond. In most patients, the ankle syndesmosis
forms a synovium-lined joint space. Several recent studies
clarified the important anatomic features of this region
of the ankle and provided valuable information related to
injury interpretation, method of treatment, and anatomic
reconstructinn.33'“ Although the distal fibula and tibia
are congruent, most of the stability in the syndesmosis
comes from its ligamentous support, which includes three
welludefined ligaments: the anteroinferinr tibiofibular lig-
ament [AITFLL the posteroinferior tibiofibular ligament,
and the interosseons tibiofibular ligament {Figure 5}.
The motion that occurs between the distal tibia and
distal fibula is limited but includes an increase in the inter-
malleolar distance of approximately 1.5 mm as the ankle
moves from plantar flexion tn dorsiflexion, rotational to
movement in the horizontal plane of approximately 12" FT.
:5
to 1?“, and an average 1.4 mm of distal migration of the m
m
tn
fibula. 1When a force overstresses these limits of motion, 3
El.
ligaments tear andfor the bone fractures. Several mech-
anisms can produce such an injury, the most common of E
which is internal rotation of the leg and body on a foot
that is firmly planted, causing an external rotatory force
on the fibula.
The wide spectrum of injuries to the syndesmosis
complex ranges from subtle sprain to complete diastasis
and instability {Figure 6}. Local swelling and tenderness
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectien 3:1Cnee andLeg

Interesseeus Grceve ter tlbliaiis

membrane — pesterier and Heater
lnteresesttue digiterum Iengus
Peeierelateral tibial
Anterelateral tihi- 'rrernhrane Welltmann} __
('l'tllautt-Chstput . — tubercle
tubercle Fresnel
aceeseery band Pereneal

Capsular Primary band{s}

ridge DiEt-al EEUEESUW AITFL Deep PITFL
:e‘ band [Bassett ligament} F I iur tip _ -_ “‘1 {Interier transverse
fiatemln—R.
ligament}
“‘ Antaremedial fibular allaclus 1
- ' ' 3 _ {Wagetafie} tubercle CFL’
..---r' .

.;. _
. r— . ., " sTFL

It...“

A
Figure 5 Schematic drawings shew the ligaments ef the ankle syndesmesis in the anterelateral {A} and pesterier {I} views.
AITFL = antereinferler tibie'fibular ligament. ATFL - anterier tale'fihular ligament. lEFL = calcanee'libular ligament.
PITFL = pestereinferier tibiefibular liga ment. PTFL = pesterier talefibular ligament. {Repred uced with perrnissien
trem Williams BT, Ahrberg AB, Geldsmith MT. et al: An ltle syndesntesis: A qualitative and quantitative anatemic
analysis. Am J Sparts Med 2015;43l1lflfle51}

after the acute injury quickly give way te diffuse signs

and symptems that make the diagnesis less ebvieus. The
Cetten, prettimal fibular squeeze, external retatien stress,
hep, weighted retatien, and cressed-leg gravity stress
tests specifically are designed tci detect syndesmesis injury
and instability, but neither these tests ner the standard
imaging methedelegies {plain and stress radiegraphs,
CT, ultraseund, and MRI} are cempletely reliable. Mere
than iii mm ef widening ef the tibiefibulat clear space an
the AP radiegraph indicates a syndesmesis injury, but
significant injury can be present in the absence ef this
finding. MRI has beceme the preferred diagnestic study
fer a suspected syndesmesis injury in a prefessienal er
DI
cellegiate athlete in the United States.“1 MRI is useful fer
cu
._I cerrelating physical esaminatien findings with syndesme-
T:
I:
a: sis injury and predicting time missed frem spurts based
tu
ill en the severity ef findings.“
I:
a: Neusurgical treatment is preferred fer a stable syndes—
mesis injury. Rest, immebiliaatien, NSAIDs, and ice are
H

Figure 6 AP anltle racliegraph shews a type W

used. PEP was feund te be a useful additienal treatment 51; ndesmesls injury. {Hep reduced with
fer stable injuries.“3 A syndesmesis injury requires almest permissien frem Clanten TD, Waldrep ME;
Athletic injuries te the raft tissu as at the
twice as much time hefere return te play as a severe lat- feet and ankle. in Eeughlin Mi. Saltzman
eral ankle sprain. A systematic review ef the literature i:L, Andersen RB, eds: Mann‘s Surgery ef the
feund that time last from spurts after a syndesmesis Feet andAnlcle, ed 9. Philadelphia, PA. Meshy
Elsevier, 20'“.- pp 1531-1681}
sprain ranged frem {i te 13? days and that die average

flrdtepaedic Knewiedge Update: Sperts Medicine 5 El ll] 16 American AcadMy ef Ctrrhepaedie Surge-ens

Figure I Ftadingra phic mnrtise view shnws titanium
buttnn stabilizatinn nf a type l"v" synd esmnsis
injury. {Her-reduced with permissinn irnm
Clantnn TD. 1tl'li'altlrnp HE: Athletic injuries
In the snft tissues nf the tent and ankle, in
Cnughlin Ml. Saltzman L'L. Andersen HE. eds:
Mann’s Surgery nt the at and Ankle, ed El.
Philadelphia, PA, Mnsby Elsevier, It'll 4, pp 1531-
163?.)
lnss ranged frnm 1i] tn 52. days.“ Residual symptnms are
nnt uncnmmnn. Dne smdy fnund gnnd tn excellent ankle
functinn in 36% nf patients at an average 4T-n1nnth fel-
lnw-up, althnugh nneuthird nf patients had mild stiffness
and nne-fnurth had mild activity-related pain.“
Surgical treatment is indicated fnr patients whn have
nbvinus diastasis nn plain nr stress radingraphs nr whn
have undergnne unsuccessful rehabilitatinn. Highvlevel
athletes with subtle diastasis andinr an MRI-cnnfirtned
tear nf syndesmntic ligaments may benefit frnm surgical
stabilizatinu, although this treatment is cnntrnversial.
Ankle arthrnscnpy usually is warranted tn inspect the
jnint and evaluate it fnr cartilage lesinns. After the jnint
is déhrided, it is sta biliaed with a screw nr a sutttre—buttnn
cnnstruct. There is mnunting evidence that suture-huttnn
stabilizatinn is mnre beneficial than screw fixatinn‘mi‘”
{Figure 3"}. A screw typically is remnved .3 tn 4 mnnths
after implantatinn, althnugh the need fnr screw remnval
has been questinned by recent studiesfhii Nevertheless,
screw remnval has been shnwn tn imprnve a malreduced
syndesntnsis and imprnve pain and functinn.-“"l-Jil Despite
cnnsiderahle research related tn syndestnnsis injury and
treatment, significant cnntrnversy remains, and there
is a lack nf high-level evidence nn nptimal methnds fnr
El Ifllti American Academy nf flrflinpaedic Surgenna
Chapter 12: Ankle and at Injuries and Either Disnrders
Figure B Arthrnscnpic phntngraph shnws an
nstenchnndral lesinn nf the lateral talar dnme
after a shearing injury tn the rig ht anltle.
diagnnsis and treatment.
nstenchnndral Lesinns at the Talus and Distal Tibia
An nstenchnndral lesinn nf the talus {0LT} is a cnmmnn
injury that is challenging tn treat because nf the peer
healing capability nf articular cartilage and the difficulty
nf access tn all areas nf the ankle jnint {Figure 3). Talar
cartilage is thinner than articular cartilage in the hip and
knee (“H.353 mm thick, cnmpared with 23], 3.33, nr 2.92
mm thick fnr the femur, patella, nr tibial plateau, respec-
tively”).“” The mechanical prnperties nf talar articular
cartilage make it mnre resistant tn the effects nf aging,
including develnpment nf stiffness and nstenarthritis, in
cnmparisnn with hip nr knee cartilage.51
The characteristic finding in an {3LT is pain aggravated
by weightrbearing exertinn. A histnry nf print injury is
cnmntnn in the diagnnsis nf I.ClLT. It is impnrtant tn define
the BLT as the snurce nf the pain thrnugh a thnrnugh his-
tnry and physical examinatinu, diagnnstic imaging, and
nccasinnally an anesthetic injectinn tn the ankle jnint.”
Staging nf the lesinn is helpful in determining the treat- pg
ment. The Berndt—Hardy-Lnnmer radingraphic system is F.
:5
cnmmnnly used.“ 55 Type I is suhchnndral cnmpressinn, re
re
tn
type II is a partially detached nstenchnndral fragment, 3
El.
type III is cnmpletely detached, type IV is a cnmpletely
detached and displaced nstenchnndral fragment, and type 3
V is a cystic lesinn.“+55 CT— and MRI-based elassifieatinn
systems alsn have been described. MRI is helpful in iden-
tifying additinnal pathnlngy, but it tends tn exaggerate
the extent nf the BLT. CT dnes nnt define snft-tissue
pathnlngy but prnvides an accurate picture nf the struc-
tural character nf the IZZ'IILT and any cystic dimensinns.53
Drrhnpaedic Knnwledge Update: Sperrs Medicine .5
 Section 3:1i'2nee ancg

The arthroscopic classification of ULTs follows the sys-

tem established by the International Cartilage Research
Society.‘IE1 The combined use of radiographs, CT andi'or
MRI, and arthroscopy is essential for optimal treatment
of these lesions.
Articular cartilage injuries are common in both se—
vere sprains {acute or chronic} and fractures of the ankle.
The incidence of articular cartilage injuries ranged from
63% to 95% in studies of both acute and chronic lateral
ankle sprains and was as high as 30% in unstable an-
kle fractures.5”3 If an 0LT is left untreated, the risk of
posttraumatic ankle osteoarthritis increases significa ntly:
approximately 50% of untreated |IIIiLTs were found to
have later degenerative changes within the ankle joint-m”
Nonsurgicsl treatment of l[ZILTs is successful in fewer than
50% of patients, and this factor as well as the risk of
significant long—term effects requires an effective surgical
treatment strategy.‘1 Figure 9 Arthroscopic photograph shows microfra cture
treatment of an osteochondral lesion of the
talar clome.
Video 22.1: Autologous Ch rond rocyte
Implantation. Richard D. Ferkel, MD, and
Kyle David Stuart, MD {13 min} a 26% success rate. Bone marrow stimulation was rec-
ommended as the first-line treatment because of its high
success rate, low morbidity rate, and relatively low cost.
Video 22.2: Conventional Treatment -
Debridement Abrasion Microfracture Supplementation of bone marrow stimulation with vis-
Drilling. Mark Glaze-brook. MD {4 min) cosupplementation, PEP, micronised cartilage allograft,
or mesenchymal stem cells had better results than bone
marrow stimulation aloneff'fii'
Video 22.3: OATS Procedure. Laszlo Several factors may have a role in the success of treat-
Hangody, MD, PhD, D5: {10 min) ment for lIZIILT. Talar defects larger than 15l} mm1 were
found to be relatively unlikely to have a satisfactory out-
come, as indicated by an American Drthopaedic Foot and
Arthroscopic drilling or curettage, bone marrow Ankle Society score lower than 3D.“ The location of the
stimulation using microfracture, mosaicplasty, osteo- lesion as well as the patient‘s age, sex, body mass index,
chondral autograft or allograft transplantation, and history of trauma, and duration of symptoms also can
autologous chondrocyte implantation have been used affect the clinical outcome, but discrepancies in results
to treat C'ILTs'E'l“53 {Figure 9}. A systematic review of 52 have made it difficult to confirm other predictors of the
studies compared the outcomes of treatments of artic- success or failure of BLT treatment!“I
ular cartilage lesions of the talus including nonsurgical A large lesion, including a lesion with a large cys-
treatment, excision, curettage, bone marrow stimulation tic area, typically requires complex treatment such as
UI
{microfractnre}, autogenons bone graft, transmalleolar autologous chondrocyte implantation with or without
to
._I drilling, osteochondral autologous transplantation, au— simultaneous bone graft, autologous osteochondral
T:
I:
in
tologous chondrocyte implantation, retrograde drilling, transplantation with single or multiple plugs, or fresh
to
Iii-1 and fixation. The primary outcome measure was the talar osteochondral allograft53 l[Figure 1'3}. Treating an
I:
s: American firthopaedic Foot and Ankle Society hiudfoot DLT after unsuccessful bone marrow stimulation can be
score.“ Corettage had a ??% success rate, and drilling challenging, but autologous chondrocyte implantation
H

had an approximately 66% success rate for the treatment
of DLTs. In addition, 13 studies reported that 35% of
patients had an excellent outcome after bone marrow
stimulation. Usteochondral autologous transplantation
had a good to excellent outcome in approximately ST'h':
of patients, and autologous chondrocyte implantation had
was mported to be successful in 23 of 2.9 patients at a
mean 3.3-year follow—up, and osteochondral autologous
transplantation was effective in 13 of 22 patients who
had undergone earlier treatment of an ULTF": 7" Dou-
ble-plug osteochondral autologous transplantation and
mosaicplasty were found to be effective for large lesions,

28-1 flrthopaedic Knowledge Update: Sports Medicine 5 El 2016 American Academ1r of Urthopaedie Surgeons

Figure 1D Coronal [A1 and sagittal {5} CT images of a large osteochond ral lesion of the talar dome.
in comparison with fresh talar ostcochondral allograft,
which often leads to osteolysis, subchondral cysts, and
degenerative changes?1
Tibial osteochondral lesions are much less common
than talar lesions; only one tibial lesion occurs for every
14 to El] talar lesionsfi’3 No single area of the plafond is
a particularly common site for these lesions?“ The lim—
ited available reports suggest that techniques similar to
those used for the talus are effective.F3 Many patients in
the study had a concomitant procedure such as removal
of soft tissue or osseous anterior impingement without a
substantial reported change in outcome.
Ankle lmpingement Syndromes
Anterior Bony lmpingement
Anterior ankle impingement is a common source of pain
in athletes and is related to osteophytes on the dorsome-
dial aspect of the talar neck and the anterolateral aspect
of the distal tibia. Athletes often have a palpable spur
of bone that is painful to palpation and interferes with
performance, particularly during cutting, push-off, and
maximum dorsiflexion, which can be critical in sports
such as alpine skiing. It is believed that bony impingement
in the anterior ankle is a consequence of athletic activity
that consistently places the ankle in extreme positions
over a long period of time. A laboratory study of 15D
kicking actions by 15 elite football players found that
maximal plantar flexion and stretching of the capsule
occurred in only 39% of the kicks but that direct trauma
El Ifllti American Academy of Urthopaedic Surgeons
Chapter 21: Ankle and Foot Injuries and flther Disorders
to the anteromedial tibia occurred in Tfi'il'fn.” A cadaver
study found that the anterior capsule attaches to the distal
tibia on average 6 mm proximal to the anterior cartilage
rim rather than near the spurring at the distalmost tibia.“
Lateral radiographs of the ankle reveal osteophytes
on the anterior tibia and talar neck, often described as
kissing lesions, although CT studies found that these
osteophytes usually do not contact one another during
dorsiflexion.” Chronic changes in the talar surface can
be caused by osteophytes. A divot sign of the talar neck
and a tram track fissure of the talar dome articular car-
tilage surface were found to correspond to the offending
spursfit The ScrantonuMcDermott classification of ankle
bony impingement is based on the radiographic size and
location of the spurs, and the van Dijk classification is
based on the extent of osteoarthritis.” MRI can be used
to define additional pathology, articular cartilage injury,
intra-articular effusion, and bone contusions.
1.4,:
Video 21.4: Anterior Ankle Impingement. FT.
:5
Q J. Chris Coetzee, MD l? min) m
m
tn
3
El.
The treatment includes rest, ice, range-of-motion ex- E
ercises, and corticosteroid injections for van Dijk grade I
impingement {osteophytes without joint space narrowing}.
If nonsurgical measures are unsuccessful, arthroscopic
débridement of the ankle is recommended. According to
one study, 90% of patients without joint space narrowing
(van Dijk grade I, l], or III} and T3% of patients with pain
Drrhopaedic Knowledge Update: Sports Medicine 5
 Section 3:1Cnee andLeg
of less than 1 years’ duration improved significantly.EIJI
These patients typically do not have osteoarthritic an—
kles and therefore have a good response to arthroscopic
treatment with spur excision. However, the presence of
other symptoms, such as those from an 0LT, can affect
long-term outcome. The outcome most commonly is re-
lated to the age of the patient, sire of the osteophyte,
ankle morphology, or an associated condition such as a
chondral lesion.El Although osteophyte lesions commonly
recur, the improvement in function remains."l
Posterior Bony Ankle lmpingement
Posterior ankle impingement is caused by irritation of
the posterior structures of the ankle, usually as a result
of compression in maximum plantar flexion. The bony
impingement may involve the posterior malleolus, the
posterolateral talar process {trigonal or Stieda process},
an os trigonum, the posterior subtalar joint, or the pos-
terior calcaneal tuberosity. The os trigonum, which is an
ununited lateral tubercle of the posterior process of the
talus, and the posterolateral tubercle are most commonly
involved in the impingement syndrome.“
Posterior impingement is seen in athletes who exten-
sively use the extreme plantarflexed position, as is com~
mon in dance as well as kicking and jumping sports.
The athlete reports a deep pain anterior to the Achilles
tendon during specific activities such as jumping, kicking,
or a push-off maneuver. A traumatic incident can he an
inciting event, as in fracture of the os trigonum or poste—
rior talar process, but usually the symptoms are caused
by overuse. The initial diagnosis is based on the patient
history and physical examination. The standard workup
includes radiographs, which may reveal the presence of an
os trigonum or posterior talar process. MRI can detect
the soft-tissue and bony edema that commonly occurs
with posterior ankle impingement.
Q' Video 22.5: Posterior Ankle Arthroscopy -
Impingement Us Trigonum FHL Tenosyno-
vitis. Johannes J. WIEQEFIHEk, M5c, PhD;
Peter de Leeuw, MD; and C. Niel: van
UI Dijk, MD {3 min]
to
._I
T:
I:
ll'.'l
to
III-1 The treatment of posterior ankle impingement begins
I:
a: with rest, ice, HSAIDs, and avoidance of extreme plan—
tar flexion. Physical therapy can be useful, as can selec-
H
tive posterior injections to calm the local inflammation.
Nonsurgical treatment was successful in sex. of patients
with posterior impingement symptoms, and 35% of pa-
tients who received an injection reported pain relief.“
“5 Surgical treatment is indicated after 3 to 6 months
of unsuccessful nonsurgical treatment. The traditional
flrdtopaedic Knowledge Update: Sports Medicine 5
procedure involves open excision of the trigonal process
or os trigonum through a posteromedial or posterolateral
approach. Although open surgery has been successful,
arthroscopic excision and decompression of the poste-
rior ankle has become popular during the past decade
and is as successful as open surgery. All 16 patients who
underwent posterior ankle arthroscopy had good to ex-
cellent health-related quality of life and functional out‘
come scores at a mean 32-month follow-up, and 93%
had returned to their preinjury athletic level.“E High-level
athletes had a significant decrease in visual analog pain
scale scores, with an average return to the preinjury level
46.9 days after arthroscopic decompression surgery.”
Soft-Tissue lmpingement of the Ankle
Inflammation within the ankle joint is common after
injury and often becomes chronic as a result of repeated
injury. Recurrent ankle sprains can cause repeated hem-
orrhage into the joint, leading to synovitis and subsequent
scarring of the ligaments. This often leads to soft-tissue
impingement in the ankle. Although impingement lesions
most commonly are found in the anterior ankle, they can
occur in almost any part of the ankle.
Ankle impingement most commonly is anterolateral.
Thickening of the ATFL or the inferiormost portion of
the AITFL and the surrounding soft tissues is the most
common cause. The Bassett ligament, a well~described
accessory band of the AITFL, and the extensor tendons
can be the source of soft—tissue impingement in the ante‘
rior ankle. Posterior soft—tissue impingement results from
repeated plantar flexion that traps the tissue between
the calcaneus and the tibia. Stenosing tenosynovitis of
the flexor hallucis longus, hypertrophy of the posterior
capsule, and enlargement of the posterior intermalleolar
ligament also are common causes of softbtissue impinge-
ment in the posterior ankle. Medial impingement is less
common but was found to affect athletes.“ The patient
history and physical examination play an important role
in the diagnosis of softrtissue impingement. Patients re~
port a history of chronic injury to the ankle or partici-
pation in a sport that predisposes them to impingement,
such as basketball, volleyball, or gymnastics. Typically,
there is tenderness to palpation along the anterolateral
gutter or the inferior aspect of the AITFL. In posteri-
or impingement, maximum plantar flexion reproduces
the symptoms. Radiographs are necessary to rule out
bony pathology but rarely reveal positive findings. MRI
is more useful than radiographs for detecting soft-tissue
impingement.
Nonsurgical treatment is unlikely to be successful in
athletes. A regimen of rest, ice, and NSAIDs is the start-
ing point, but immobilization with a controlled ankle
El 1016 American AcadMy of Cirrhopaedic Surgeons
 Chapter 12: Ankle and Fuut Injuries and Either Disnrders

muvement walking bunt can be used tn prevent the ex-

tremes nf mntinn that elicit symptums. lntra-articular
-_
Differential Diagnnsis fur Plantar Fasciitis
steruid injectiuns alsn can pruvide relief. After nnsnc-
cessfui ucnsurgical treatment, arthrcscupy is the surgical Skeletal Disorders
treatment nf chuice.
Calcaneal cyst
Calcaneal epiphysitis
Funt Disurders Calcaneal stress fracture
Heel Pain and Plantar Fasciitis Infectiun
The plantar fascia is dense cnnnective tissue that suppul'ts Subtalar usteuarthritis
the arch uf the funt. The medial and lateral bands, the Systemic arthritis (lupus, psuriatic, rheumatuid}
twn main bands uf the plantar fascia, run frum the cal-
caneal tuberusity and insert en the plantar plates cf the
MTP juints and the base nf the prnximal phalanges. This Heurulugic Disurders
strung band uf tissue pruvides stabilizatiun fur the plantar Abductur digiti quinti nerve entrapment
arch cf the funt as well as the first MTP juint thruugh the Lumbar spine pathnlngy
windlass mechanism. The apuneurusis functinns frum Heurupathy
heel strike tn tne-uff in the nurmal gait cycle tn achieve
Tarsal tunnel syndrnme
hindfcnt inversiun, tibial external rutatinu, and transverse
tarsal jnint stabilizatiun.
ln athletes, the plantar fascia is susceptible tn injury Soft-Tissue Disurelers
primarily thruugh nveruse. Lung-distance running and Fat pad atruphy
prulunged training regimens can lead tn repetitive, chrnn- Fleitur hallucis brevis tear
ic trauma that can damage the plantar fascia. Acute injury Heel pacl atruphy
alsn is pussible and results in a partial cr cumplete tear cf
Plantar fascia rupture
the plantar fascia that can lead tn chrnnic iniury. Patients
typically repnrt murning ur activity~related pain specific Hetrucalcaneal bursitis
tn the plantartnedial aspect uf the heel at the nrigin cf the
medial band nf the plantar fascia. Pain is aggravated by Dther Disurslers
direct palpatinn ur by initial weight bearing and stretch— Euut
ing cf the plantar arch.
fisteumalacia
Cavuvarus funt defurmity and Achilles tendun cnnu
Paget disease
tractnre are believed tn have a rule in the pathnlngy uf
plantar fasciitis. Dbesity and wurlc-related weight bearing Tumur
were fuund tn be independent variables cnntributing tn 1si'ascular disurd er
plantar fasciitis.” In evaluating a patient with heel pain,
it is impnrtant tn keep in mind the numeruus cnnditinns
that must be cnnsidered in the differential diagnusis {Ta- is the Ba Itfil’ nerve {the first branch cf the lateral plantar
ble 1}. Calcaneal stress fracture and tarsal tunnel synr nerve], which is a mixed mutur and sensury nerve tn the
drume are the cnnditinns must likely tn mimic plantar abductur digiti quinti and the lateral burder uf the plantar
fasciitis. A calcaneal stress fracture shnuld be suspected surface cf the fnnt. Must cummunly, the nerve becnmes 1.4.}
with an acute exacerbatiun uf heel pain nr pain elicited entrapped between the deep fascia cf the abductur hallucis F.
:i
by cumpressiun cf the heel. The diagnusis is cunfirmed by and the quadratns plantae. The wurkup typically invulves re
in
en
heel radiugraphs un which the classic findings uf a stress electrnmyngraphic ur nerve cnnductinn velucity studies a
El.
fracture can be seen after several weeks. A bune scan ur tn cunfirm the diagnusis.
MRI nften is indicated tn rule nut stress fracture and help Nunsurgical treatment is the mainstay fur almust all E
in determining the severity cf plantar fasciitis. furms uf heel pain. The treatment cf plantar fasciitis fu-
Tarsal tunnel syndrnme nr nerve entrapment cf the cnses un HSAIDs, activity mudificatiun, and a dedicated
first branch cf the lateral plantar nerve alsn shnuld be stretching prugram uf the plantar fascia and Achilles ten-
ruled nut. Patients with tarsal tunnel syndrnme repnrt dun cumpleit. A custum-made nr nff-the-shelf cushiuned
radiating pain and paresthesia, and they nften have a in—shne urthnsis is used tn cuntrul heel mutiun and prevent
pnsitive Tinel sign. The must cummunly invnlved nerve splaying uf the heel pad, alung with a dursiflesciun night

Eb Iflld American Academy uf Urthupaedic Surgenns Drthnpaedic linuwledge Update: Sparta Medicine 5
 Sectien 3:1Cnee andLeg
splint. lviere invasive treatments include ientepheresis,
certicnsternid nr PEP injectinns, and ESWT. High—quality
studies have suppnrted use nf NSAIDs, plantar fascia
stretching witheut weight bearing, calcaneal taping, and
a night splint.9"'95 ESWT, cnrticnsternid injectinn, and
PRP injectinn alsn were supperted by research evidence,
but little suppert was feund fer the leng-term use ef an
nrthnsis in treating plantar fasciitis.“'99
Medial plantar fascintnmy typically is recnmmended
after unsuccessful nensurgical treatment. The medial
third nf the plantar fascia is excised, with maintenance cf
the lateral band tn prevent cnllapse nf the arch. The ben'
efits ef epen and endescepic release have been debated,
but snme surgenns prefer endnscnpic surgery tn decrease
recnvery time and lnwer assnciated mnrbiditydfl'" Recently,
ether surgeens have beceme prepenents ef gastrecnemius
recessinn alnne as a treatment nf chrnnic plantar fasciitis
because it has better nutcnmes than traditinnal fascintn-
rnyJ“ lviest evidence supperting the efficacy ef surgical
treatment nf plantar fasciitis is nf nnly fair quality, and
nn randnmized cnntrnlled study results are available.
Rupture ef the plantar fascia repertedly eccurs after
sudden acceleratinn during an athletic activity. This injury
typically is painful. Patients repnrt a lnud, painful pnp~
ping sensatien in the arch ef the feet. Little evidence is
available tn guide treatment, altheugh the injury usually
is managed nnnsurgically. Twn tn 3 weeks nf immnbili~
eatien with a nen—weight-bearing cast er beet with arch
suppert allews the inflammatinn and pain tn subside.
Gradual weight bearing is initiated with a return tn ac—
tivity as pain and swelling allew. One study feund that
nene nf the '13 patients with a plantar fascia rupture whn
were treated with this regimen sustained reinjury, had
pnstinjury sequelae, nr needed surgery!“
Lisfranc Fracture-Dislecatinn
The Lisfranc nr tarsnmetatarsal {TMT} jnint is the at-
ticulatinn between the base nf the five metatarsals and
the three cuneiforms and cubeid. Stability primarily is
prnvided by the heme and ligament anatemy. There is
DI
nn ligament between the bases nf the first and secend
a:
._I metatarsals, and stability in this area mnstly depends en
T:
I:
re
the recessed base nf the secend metatarsal, the aan
re
III-1 arch wedged shape cf the midfnnt arch, and the strnng
I:
a: Lisfranc ligament, which cennects the medial cuneifnrm
tn the base nf the secend metatarsal.
H
Injuries tn the TlT jeint are caused by indirect er
direct forces. The indirect fnrces invnlve axial leading
nr twisting en a plantarflexed feet, and direct injury nc-
cnrs when a lead is applied tn the midfeet. Ligamenteus
Lisfranc injury cnmmnniy nccnrs in athletes as an injury
tn the ligaments nf the TMT jnints that may extend tn
283 flrthepaedic Knnwledge Update: Sperts Medicine 5
the intertarsal jnints. These injuries range frem a sprain
tn an avulsinn fracture but usually are net the types nf
fractures nr dislncatinns that nccur in high-energy injury
frem a meter vehicle crash er a fall frem a height. The
spectrum nf sprains in athletes ranges frnm a stable sprain
withnut radingraphic displacement tn a severe sprain with
ebvieus widening bets-teen the base ef the first and secend
metatarsals nr further intn the midfn-nt. A classificatinn
system described in a 21102 study has been feund tn be
useful in treating athletes with a relatively mild injury.‘”3
In a stage I injury, the patient is unable tn participate in
spnrts because nf pain in the Lisfranc jnint; weight-bear-
ing radingraphs shew ne displacement, and bene scan er
MRI findings may be negative. A stage II injury has first tn
secend metatarsal diastases nf 1 tn 5 mm but nn evidence
ef less ef arch en weight-bearing radiegraphs. Stage III
injury has first tn secend metatarsal diastases nf mere
than 5 mm and evidence nf less nf arch nn weight-bear-
ing radiegraphs. The cemmen radingraphic appearance
nf the misalignment can be classified as transverse nr
lnngitudinal, depending nn whether the Lisfra nc ligament
is tern and whether the Patbelegy extends heriaentally
acrnss the MTP jnints nr vertically intn the intercu neifnrm
space and perhaps thrnugh the naviculncnneifnrm jnintJf"
Injuries tn the TlT jeint efteu are misdiagnesed, and
therefnre a high index nf suspicinn is required. The diag—
nnsis nf a severe injury with displacement usually is nbvi~
eus, but a ligamenteus injury with minimal displacement
is likely tn be missed. Pain with weight bearing shnuld
be the first sign if it is accnmpanied by lncal swelling and
tenderness at the midfeet. Even with a mild injury, the
athlete has difficulty pushing nff. Prnnatinn~abductinn
nr supinatinn—adductinn stress usually is painful. The
physical examinatinn shnuld include evaluatinn nf the
dnrsalis pedis pulse and deep pernneal nerve functinn as
well as assessment fer a fnnt cnmpartment syndrnme in
severe Lisfranc fracture-dislncatinn. Predispnsing factnrs
fnr Lisfranc injury include a ratin nf secend metatarsal
length tn fnnt length nf less than 29% and a greater sec-
nnd metatarsal length relative tn the depth nf the mnrtise
fnrmed by the cuneifnrms.”5
Diagnnstic imaging nf a feet with a suspected Lisfranc
fracture-dislncatinn begins with AP weight-bearing ra-
dingraphs as well as nblique and lateral views [Figure 11}.
Cnmparisnn with a weight—hes ring AP rad ingraph nf the
uninjured fnnt nften is helpful. Ten cemmen radingraphic
findings are indicative ef midfeet injuryIlls {Table 2}.
If a Lisfranc injury is suspected and plain radingraphs
are net diagnnstic, CT nr MRI is useful. If rnutine ra-
dingraphs are net diagnnstic in a mild injury, stress ra-
dingraphs taken with the patient under anesthesia may
be helpful.
El 1016 American deadeniy nf Drtbnpaedic Surge-ens

g B
Figure 11 Hon-welght-bea rlng {A} and weig ht-bea ring {Bl AP radiog raphs show a subtle Lisfranc injury {arrow}.
{Reproduced with permission from Haytmanelt CT. Ela nton Tfl: Ligamentous Lisfanc injuries in the athlete. flper
Tech Sports“ Med 2014;21j4]:313-32fl.}
‘
Radiographic Findings Indicative
of Midfoot Injury
Diastasis of first and second metatarsal bones
First and second cuneiform diastasis
Widening between second and third metatarsals
Widening between middle and lateral cuneiforms
Avulsion fracture at the base of the second
metatarsal on CT or other advanced imaging {Fleck
sign). representing Lisfranc ligament avulsion
Misalign ment of ta rsometata rsal joints on lateral
images
Misalignment of second metatarsal medial border to
align with medial border of middle cuneiform
Misalignment of fourth metatarsal medial border to
align with medial edge of cuboid
Loss of congruity of metatarsal bases
Compression fracture of the lateral edge of the
cuboid
Anatomic reduction is the key to a good outcome in
a Lisfranc injury. A short leg non-weight-hearing cast
is effective in patients with a truly nondisplaced, stable
Lisfranc sprain until tenderness resolves at approximately
El Ifllfi American Academy of flrfliopaedic Surgeons
Chapter 11: Ankle and Foot Injuries and flther Disorders
WEI
6 weeks, with subsequent functional rehabilitation. If
displacement is present, rigid internal fixation is recom-
mended for the first through third Tl'vlT joints as neces-
sary for stability. Temporary stabilization in an anatomic
alignment is preferable for the fourth and fifth TMT joints
to preserve their mobility. There is little debate about
the need to perform an arthrodesis in TMT joints with
significant articular damage or preexisting arthritis, but
controversy remains as to the treatment of young athletes
with purely ligamentous injury to the Lisfranc joint (Fig-
ure 12}. At least two high-quality studies suggested that
arthrodesis is preferable for purely ligamentous Lisfranc
injuries, but a systematic review of studies including 193
patients found no statistical difference in outcomes after
open reduction and internal fixation or arthrodesis.‘”?'1"9 1.4.}
Other points of discussion in the treatment of Lisfranc F.
:5
fracture-dislocations relate to methods of fixation and re
m
to
the timing or necessity of hardware removal. Lisfranc 3
fracture—dislocations traditionally have been rigidly fixed
El.
with transarticular screws, but bridge plating to immobi- E
line the TMT joints is gaining favor because the articular
cartilage is preserved. The standard method for restabi-
liaing the first and second TMT joints is the placement of
a so~called Lisfranc screw between the medial cuneiform
and the base of the second MT. The newer use of a suture
button device has had good results, may provide a more
Drrhopaedic Knowledge Update: Sports Medicine .5
 Sectien 3:1Enee and Leg
Figure 12 Radiographs shew a severe Lisfranc injury with articular damage hefere {A} and after (Bl arthreclesis. {Rec-reduced
with permissien frem Haytma neit CT, Clenten TD: Liga menteus Lisfa nc injuries in the athlete. Dper Tech Sperts
Med 2fl14:22[4]:313-32fl.]
physielegic fixatien than screw fiaatien, and dees net ne-
cessitate remeyal."” Regardless ef ether facters, heweyer,
it appears that the must impertant negatiye pregnestic
facters in these injuries are severe seft—tissue injury and
nenanatemic reductien.
Turf Tee
Turf tee eriginally was described as a hyperesttensien
injury tn the first MTP jeint caused by wearing fleeti—
ble shees en hard artificial surfaces, but the definitien
has eyelycd te encempass almest any injury te the first
MTP jeint caused by spurts participatien. The primary
injury inyelyes the plantar plate, er capsuleligamenteus
DI
cemplett ef the first MTP jeint, which typically is injured
as
._I in skill—pesitien feetball players whe axially lead their
T:
I:
es
heels when the ferefeet is listed en the turf!” 1F«liarus and
tu
Iii-1 yalgus ferces alse can centribute te a turf tee injury,
I:
a: further destabilizing the jeint with less ef integrity ef the
cellateral ligaments.
H
Afte: an acute injury, the athlete has pain, swelling,
ecchymesis, and stiffness at the first MTP jeint, which
are classified by their severity111 [Table 3}. The initial
radiegraphs are standing weight-hearing AP and lateral
yiews ef the feet, which eften appear nermal. The radie—
graphic pesitien ef the sesameids sheuld be cempared
flrfltepaetlic Knewledge Update: Sperts Medicine 5
with the centralateral nermal side te detect any retractien.
An ayulsien fracture, sesameid fracture, er diastasis ef
bipartite sesameids alse may be feund. MRI is reliable
fer assessing the extent ef seft-tissue injuryr113 {Figure 13}.
Eiemechanical studies feund that stress fluerescepy is
reliable fer diagnesing an unstable injury. Injury te at
least three ef the feur ligaments is indicated by a 3-mm
difference in sesameid excursien cempared with the un-
injured side en stress dersiflc‘sien fluerescepy.”"
Nensu rgical treatment ef a turf tee injury begins with
the rest-ice-cempressien-eleyatien pretecel. Immebili-
satien is used te centrel acute swelling and rest the tee.
Heweyer, early jeint mebilizatien is essential because
stiffness is a cemmen sequels ef this injury. Further
treatment includes restricting dersifletsien ef the first
MTP jeint by stiffening the shee er using carben fiber
er graphite inserts te reduce the ameunt ef energy trans-
fer frem the feet during push—eff. Taping ef the hallust
alse is useful.
As seen as symptems allew, the rehabilitatien pregrant
begins with actiye and passive nen—wcight—bearing and
weight-bearing range-ef-metien exercises fer the feet
and ankle. The ability te return te play is dictated by
symptems and functien. The use ef anesthetics er stereid
injectiens te allew the athlete te return te play is net
El 1016 American Acadenw ef Cirthepaerlic Surge-ens
 Chapter 12: Ankle and Foot Injuries and Either Disorders

Table 3 ,

Classification of Turf Toe Injury

Grade Dbjective Findings Activity Level Pathology Treatment
| Local plantar or medial Continued athletic Stretching of Symptomatic
tenderness participation capsuloligamentous
Minimal swelling CDmPIEI
No ecchymosis
II More diffuse, intense Loss of S to 14 days Partial tear of Walking boot
tenderness of playing time capsuloligamentous and cmtches as
Mild to moderate swelling complex "field?“
Mild to moderate ecchymosis “'3 articular injury
Painful, restricted range of
motion
||I Severe, diffuse tenderness Loss of 2 to 5 Complete tear of Long-term
Marked swelling weelrs of playing capsuloliga mentous boot or cast
Moderate to severe ecchymosis time complex Immobilization or
surgical repair
Extremely painful, limited range
of motion
Adapted from Elanton TD. Butler E, Eggert A: Injuries to the metatarsophalangeal joints in athletes. Foot Ankle tEEfifllSiflliZ-li'fi: Eoughlin ME:
Biomedianics efthe foot and anlrle linkage in DeLee it; Dre: D .Ir, eds: Drtbopaedic Sports Medicine. Philadelphia, PA, WE Saunders, 1994, p
1552: Rodeo SA. Warren HF. O'Brien 5]. et al: Diastasls of bipartite sesamoids of the first metatarsophala ngeal joint. Foot Ankle 1593;14:425—434.

recommended because of the potential for further joint

deterioration or injury.
If the injury is severe, first MTP joint stability is com—
promised. iii. complete plantar plate tear, sesamoid retrac—
tion, sesamoid fracture or diastasis, traumatic bunion,
progressive halluir valgus or varus, or dislocation of the
MTP joint can indicate instability that requires surgical
intervention. The joint is stabilized by repairing the pa-
thology, including associated chondral lesions, fractures,
and torn ligaments as well as removal of loose bodies.
lDuly limited evidence is available on the outcomes of
surgical treatment of these injuries.

Sesamoid Disorders
The sesamoids of the great toe, which are part of the
plantar plate complex, often are involved in acute trau—
matic and over use injuries. These two small bones under-
Figure 13 Sagittal MFtl shows a planter plate tear.
go considerable force with weight bearing and can be a {Courtesy of Jena Ieeiin. MD, Ath erton, CM pg
source of pain from traumatic fracture with displacement, FT.
:5
Stress reaction or fracture, sesamoiditis, osteonecrosis, re
re
tn
or osteoarthritis. Radiographs, including weight-bearing 3
El.
AP comparison views, should be obtained and can be and can provide the patient with significant relief. These
useful in acute injury. A dedicated bone scan and MRI modifications are used with NSAIDs, physical therapy, E
can confirm the diagnosis and determine the site and and perhaps anesthetic and steroid injections to provide
extent of the injury. significant pain relief. If necessary, immobilization with
Treatment of a sesamoid disorder can be difficult. a controlled ankle movement walking hoot or toe spica
Activity and shoe wear modifications are used, with an cast can he used.“ Surgery is the last resort, although
orthosis if necessary. Shock—absorbing shoes with dancer satisfactory outcomes have been reported, especially
pads can be used to offload the stresses on the sesamoids among athletes!”

Eb Ifllti American Academy of flrdiopaedic Surgeons Drrhopaedie Knowledge Update: Sports Medicine S
 Section 3:1Cnee audLeg
Figure 14 The classification of fifth metatarsal fractures
by zones. zone 1 = lateral tuberosity {avulsion
fracture}. acme 2 = metaphysis or metaphyseal-
clia physeal junction (1 ones-type fracture}, zone
3 = proximal diaphysis lfiacturel.
Stress Fractures
Stress fractures are considered to be the result of “exces—
sive, repetitive, submaximal leads on bones that cause
an imbalance between bone resorption and formation“
and are a common overuse foot and ankle injury in ath—
letes.“"' These injuries typically occur after a change in
footwear or training {such as an increase in intensity} or
use of a hard playing or running surface. Pain is generally
insidious at onset and can be vague or point specific in
the location of the stress fracture. Initial radiographs
often are negative, and a high index of suspicion should
be maintained so the injury can be diagnosed and treated
in a timely fashion.
Stress fractures have been described in most bones
of the foot and ankle, and most heal with rest and
weight-bearing limitations. Three specific stress frac-
tures are particularly problematic: stress fracture of the
proximal fifth metatarsal [a Jones fracture}, the tarsal
navicnlar, and the medial malleolns. These areas are
considered to be highurisk stress fractures that often
progress to complete fracture, leading to delayed union
or nonunion, and occurring along the tension side of the
bone. These injuries necessitate aggressive treatment in
the form of surgery or strict non—weight hearing?“ A
delay in diagnosis can exacerbate the risks associated
DI
with these fractures.
cu
._I
T:
I:
m
Fifth Metatarsal Fracture
cu
III-1 Fractures of the base of the fifth metatarsal are classified
I:
a: by xone119 {Figure 14}. Zone 1 represents an avulsion
fracture of the lateral tuberosity, zone 2 is a Jones-type
H
fracture of the metaphysis or the metaphyseal-diaphyseal
junction, and zone 3 is a proximal diaphyseal fracture.
A stress fracture can occur in zone 2 or 3, and some
experts recommend combining these two zones because
they carry a similar risk of delayed union or nonunion
and refracture, and the surgical treatment and outcomes
flrrltopaedic Knowledge Update: Sports Medicine 5
are similar.”“~ ‘31 Proximal fifth metatarsal stress fractures
are most common in athletes who participate in a sport
such as basketball, football, or soccer. The patient has
worsening activity-related pain along the lateral aspect
of the midfoot over a period of several weeks. Physical
examination may reveal point tenderness over the base of
the fifth metatarsal as well as pain with passive inversion
of the foot. The fracture often is apparent on radiographs
and can be classified based on appearance as an acute
traumatic fracture, stress-related fracture, delayed union,
or nonunion.1‘11
Treatment selection often is guided by the Torg clas-
sification of fractures in zones 2 and 3 as well as by the
patient’s goals and athletic participation.112 Although
nonsurgical management with strict non-weight bearing
in a short leg cast for 6 to 3 weeks is an option for a Torg
type I fracture [an acute fracture with sharp fracture line
margins and no sclerosis), many active individuals and
elite athletes opt for surgical fixation. The goals of early
surgical fixation include minimising the risk of nonunion
and refracture as well as allowing a more rapid return
to sport. If there is evidence of delayed union or non-
union l[Torg type II or III], surgical fixation generally is
recognized as the standard of care with selective open
débridement and bone grafting. Fixation usually is done
with an intramedullary screw and has a good to excellent
result {Figure 15).
The challenges of intramedullary screw fixation pri-
marily are related to the shape and contour of the bone
itself. A recent radiographic study examined the fifth
metatarsal in great detail using three-dimensional CT of
119 patients.113 The average straight~segment length was
found to be 52 mm, which was 63% of the overall length
of the metatarsal from the proximal end; the medullary
canal was found to be elliptical; the average coronal ca-
nal diameter at the isthmus was 5 mm; and in 31% of
men the diameter was greater than 4.5 mm. The use of a
solid, partially threaded screw with a 4.5-, 5.5-, or 6.5-
mm diameter was recommended. The partially threaded
configuration was found to provide compression across
the fracture site. Headed screws were recommended over
headless screws because of their superior pullout strength
and easier removal.
The so-called plantar gap is a possible prognostic in-
dicator, according to a study that found a significantly
increased time to bony union in fractures with at least
1 mm of fracture margin separation, regardless of Torg
classification.114 A recent systematic review of surgical
and nonsurgical treatment of high-risk stress fractures
of the lower leg concluded that additional prospective
research on fifth-metatarsal base fractures would be of
great use in treatment decision making.1M In addition,
El ll] 16 American AcadMy of Urrhopaedic Surgeons

A it
B
Figure 15 AP {A} and lateral {I} radiegraphs shew intramedullary screw tisatien et a fifth metatarsal fracture.
the review feund a weighted mean return te spert ef 14
weeks after surgical treatment and 19 weeks after nen-
surgical treatment.
Tarsal Navicular Fracture
Stress fractures ef the navicular are mest cemmen in par
tients whe participate in estplesive running and jumping
activities, as in basketball er track and field. Menuspetts
related facters that may play a rele in the develepment ef
navicular stress fracture include the presence ef a leng sec-
end metatarsal er a shert first metatarsal, anteriet ankle
impingement, er decreased ankle metien. The symptems
are similar te these ef ether stress fractures; the pain eften
is vague, insidieus in enset, exacerbated by activity, and
relieved with rest. Altheugh the usual lecatien ef the pain
is at the dersal aspect ef the midfeetflI the patient may
describe ankle pain and this may be tender te palpatien
during physical erraminatien. The relatively avascnlar
central third ef the navicular bene predispeses it re stress
fracture and subsequent nenunien er esteenecresis. The
use ef a lecal vasculariaed pedicle bene graft fer fractures
with evidence ef delayed unien, nenunien, er esteene-
cresis has had enceuraging results.125 Negative initial
radiegraphs and vague initial symptems were reperted
te lead te a 1- te T—menth delay in diagnesisJ“ A high
El Ifllti American Academy ef Urthepaedie Surgeena
Chapter 12: Ankle and Feet Injuries and IEither Diserders
indes: ef suspicien as well as MRI, CT, er bene scanning
is useful in the diagnesis {Figure 16}.
The traditienal treatment ef a stress fracture ef the
navicular is nen—weight-bearing cast immebiliaatien fer
6 tn 3 weeks. Attempts at limited weight bearing and
sherter perieds ef immebiliaatien have led an persistent
pain and inability te return te activity.”” The thresheld
fer surgical treatment has decreased in the hepe ef allew-
ing a mere rapid return te play, especially in highvlevel
athletes. Unfertunately, ne high-quality studies have in-
vestigated the treatment ef navicular stress fractures. A
CTvbased study reperted that 3 ef ID surgically treated
fractures went en te beny unien and that cemplete, dis-
placed fractures had an increased risk ef nenunien. ”T A 1.4.}
meta—analysis ef surgical and nensurgical treatment ef F.
:l
cemplete, nendisplaced navicular stress fractures feund re
re
tn
ne statistically significant differences related te time te 3
El.
return te activity er successful eutceme rates, but the
likeliheed ef a successful result was decreased after early s
weight hearing!” The methedelegic flaws ef this analysis
were painted eat in a mere recent systematic review ef
navicular stress fractures that used the ZT-item Preferred
Reperting Items for Systematic Reviews checklist fer
the centent ef a systematic review er meta—analysis.‘3” A
systematic review ef surgical and nensurgical treatment
Drthepaedic Knewledge Update: Sparta Medicine .5
 Secticm 3:1Enee and Leg
Figure 15 Advanced imaging fer navicular fracture. A. MRI shcirt tau inversicn reccwergn,r sequence shc-ws increased signal in
the navicula r. E, Eercinal CT image shnws fracture ncinuninn crl‘ the dnrsal navicular extending intn the bndy.
nf high-risk stress fractures nf the lnwer leg cnnclndecl
that nn strnng recemmendatinns cnnld be made fer the
treatment nf navicular stress fractures based cm the liter-
ature!” The weighted mean return tn spurt was 16 weeks
after surgical treatment and 22 weeks after nonsurgical
management‘“
Medial Mallenlus Fracture
Stress fractures cf the medial mallenlus represent nnly
fl.6% tn 4.0% cif all lnwer extremity stress fractures.131
These injuries mnst nften nccnr in athletes whn partic-
ipate in a running, jumping, nr high-impact spnrt such
as track and field cir gymnastics. Several intrinsic factnrs
are believed tn predispnse individuals tn medial mallenlar
stress fracture {althnugh nnne have been prnved} includ-
ing the presence of a narrnw tibia, increased external
hip rntatinn, fnrefnnt varus, snbtalar varus, limb-length
discrepancy, tibial varus, pes cavus, and anternmedial
DI
nstenphytesfii- Patients ciften repnrt medial ankle pain
as
._I during activity. The nnset nf pain is gradual, but the pain
T:
I:
in
may acutely wnrsen after a pericid nf chrnnic medial an-
as
III-1 kle pain. Physical examinatinn may reveal an effusinn
I:
as: as well as pain nn palpatinn alnng the anternmedial tib—
ial plafnnd. Diagnnsis can be challenging; cmly 30% of
H
stress fractures ef the medial mallenlus are identified an
initial radingraphs, and CT, MRI, er a bnne scan may
he helpfulfiii A study nf medial mallenlar stress fracture
diagnnsis and surgical treatment found that initial radiu-
graphs were negative in all 10 patients.”i MRI did reveal
the fracture line in all patients, hnwever, and the study
flrdtnpaeclic Knnwledge Update: Sparta Medicine 5
recnmmended early MRI whenever there is suspicinn nf
a medial mallenlar stress fracture.
Because nf the paucity nf high-quality research and
the relative rarity nf medial mallenlar stress fracture, nn
treatment methnd is clearly preferred. Several factnrs
sheuld be cnnsidered in deciding whether nnnsurgical
cir surgical treatment is preferable: the presence of a
fracture line, cyst, nr lncal nstenpenia nn radingraphs;
fracture displacement; level nf athletic participatinn;
and the timing nf injury {in seasnn nr tiff seasnnl.”1
Nnnsnrgical management nften cnnsists nf 6 weeks nf
nnn-weight-bearing cast immnbiliaaticin fellnwed by
prngressive weight bearing and a gradual return tci ac-
tivity. Surgical treatment cnnsists nf cnmpressinn screw
fiscatinn perpendicular acrnss the fracture as well as re-
mnval nf any anternmedial nstenphytes. A recent liter-
atnre review included studies that recnnnnended b-nth
nnnsurgical and surgical management. A study that cem-
pared nnnsta ndardised grnups nf patients suggested that
these whn were surgically treated had an earlier return tn
spurt [4.5 weeks versus 7' weeks} and mere rapid uninn
{4.2 mnnths versus 6.? mnnths} than these whn were
nnnsurgically treated!“
Achilles Tenclcin Diserclers
As the largest tendnn arising frnm buth the snleus and gas-
trncnemius muscles, the Achilles tendcm can be affected
by pathnlngy ranging frnm acute or chrnnic rupture tn
nveruse injury nr insertinnal tendinnpathy. Any cif these
El 1016 American Acadenw cif Drthnpaedic Surge-ens
 Chapter 12: Ankle and Foot Injuries and flthcr Disorders

conditions can result in create serious athletic limitation

and loss of playing time.

Acute Rupture
Despite considerable published research, there is little
consensus on the optimal treatment of Achilles tendon
ruptures. The injury is most common in men who are
so—called weekend warrior athletes in their third through
fifth decades of life, but it can affect individuals regardless
of age, sex, or level of athletic participation {including
nonparticipation}.
The mechanism of injury most commonly involves a
sharp dorsiflexion force onto a tensioned tendon, which
typically creates a rupture through an area of preexisting
degenerative change in the watershed area between 2 cm
and 6 cm from its insertion.”5 The diagnosis of acute rup-
ture was missed in 24% of patients, many of whom were
elderly or had a high body mass indexfli'fi 1ii'iii'ith a careful
history and physical examination findings including an
abnormal Thompson test, decreased resting tension, and a
palpable gap within the tendon, the diagnosis can reliably
he made without the need for more sophisticated studies”?
{Figure 1?]. Ultrasound and MRI can be useful in patients
who have ambiguous examination findings, a chronic
rupture, or a need for objective continuation of the injury.
The treatment of acute rupture of the Achilles tendon
is controversial. A meta~analysis found a significant de— Figure 1'.-' Photograph shows an Achilles tendon rupture
with a palpable gap (arrow) and loss of resting
crease in the rerupture rate after surgical repair of the tEi'ISlfli'i.
Achilles tendon, whether open or pcrcutaneous {4.4%
compared with 1fl.6% after nonsurgical treatment}.‘-35
The rate of complications was higher after open surgery Q Video 22.6: Hagluncl Deformity. Achilles
than after nonsurgical treatment {2?% versus 5%}. Peru Problems. Johannes J. Wiegerincit, MSc,
cutaneous fixation had a lower risk of infection than PhD; Peter de Leeuw, MD; and C. Niel:
open repair {relative risk = 9.32} but carried a 1.1% risk van Dijk, MD {3 min}
of sural nerve injury. No solid conclusions about func-
tional outcomes could be reached because of the studies”
varied scoring tools, inconsistent definitions, and incom- Dveruse Injuries
plete data acquisition, all of which highlighted the need flverusc injuries related to the Achilles tendon are com-
for greater standardisation in future studies!“ A secr mon and include tendinosis, paratenonitis, superficial and
ond meta-analysis found similar rerupture rates among retrocalcaneal bu rsitis, and insertional Achilles tendinop-
patients treated nonsurgically using functional bracing athy. Achilles tendinosis is a noninflammatory condition 1.4,:
and early range-of-motion exercises and patients treated that involves intratendinous degeneration and atrophy, FT.
:5
surgically”? A Swedish study that compared surgical initially is asymptomatic, and results from repetitive mi- m
in
tn
treatment with nonsurgical treatment using functional crotrauma or aging. Pain may represent partial tearing in 3
El.
bracing also reported similar rerupture rates but found an area of degenerative tendon and warrants evaluation
a significant improvement in single heel rise test and calf and initiation of nonsurgical management consisting of E
circumference in surgically treated patients.““1 Nonsur- rest, the use of a small heel lift or Achilles tendon heel pad,
gical treatment with innnediate weight hearing, which correction of hindfoot misalignment, physical therapy,
improves the patient‘s quality of life during the healing and correction of training errors. Ultrasound and MRI
process, and dynamic rehabilitation can be recommended can he used to evaluate the extent of tendon involvement.
without concern for increasing the risk of rerupture or Eccentric training was found to be effective in reducing
functional outcome deficits?"- pain in male patients but may be significantly less effective

Eb Ifllti American Academy of Urthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Sectinn 3:1Enee and Leg
Figure 13 MRI shnws insertinnal Achilles tendinnpathy.
in wnmenJ“ Surgical management invnlves debridement
nf diseased tissue thrnugh a medial nr lateral apprnach,
althnugh the central tendnn-splitting apprnach has gained
favnr as a mere direct access tn the pathnlngy. Invnlve-
meut nf mnre than SUSS nf the tendnn nr advanced patient
age necessitated augmentatinn with a fleanr hallucis lnn~
gus tendnn transfer, which led tn significant imprnvement
in Achilles tendnn functinn, physical functinn, and pain
in patients whn were nlder than 44 years and relatively
inactive.”
Pa ratennuitis is an in flammatinn nf the parateunn that
in mnst patients can be successfully treated with the mea-
sures used fnr tendinnsis. Surgery is cnnsidered after 3 tn
6 mnuths nf unsuccessful nnnsurgical treatment. Dpeu
nr endnscnpic débridement and lysis nf adhesinns are the
prncedures nf chnice.
Superficial bursitis nften is assnciated with a pnetern-
lateral bony prnminence at the lateral calcaneal ridge, which
nften is called Haglund deformity and may be mistaken fur
DI
insertinnal Achilles tendinupathy.144 Retrncalcaneal bursitis
cu
._I is characterised by tenderness bnth medially and laterally
T:
I:
in
anterinr tn the Achilles insertinn but nnt directly at the
ca
III-1 bnne-teudnn interface. Bnth fnrms nf bursitis can nccur
I:
at iu assnciatinn with insertinnal Achilles tendinupathy but
are separate entities that can be treated nnnsurgically with
H
rest, shne wear mndificatinn, HSAIDs, physical therapy,
and activity mndificatinn. In snme patients, immnbilisatinn
in a shnrt leg cast nr endnscnpic surgical excisinn may be
necessary. A systematic review fnund that patients were
mnre satisfied after endnscnpic excisinn nf the retrncalca—
neal bursa than after an npen prncedure.WT
flrfltnpaedic Knnwledge Update: Spnrts Medicine 5
Figure 19 Ph c-tugraph shows the central Achilles tendnn-
splitting surgical apprnach.
lnsertiunal Achilles Tendinnpamy
Insertinnal Achilles tendinupathy appears as pain at the
bnne-tendnn junctinn and is cnmmnn in men age 35 tn 45
years whn are recreatinnal runners as well as elderly wnm-
en, thnse whn are nverweight, sedentary nr have multiple
medical cnmnrbidities. Nnnsurgical management shnuld
be attempted but nfteu is unsuccessful. Radingraphs may
shnw calcificatinn at the Achilles tendnn insertinn nr a
pnsternsuperinr calcaneal prnminence. MRI is valuable
fnr evaluating the extent nf diseased tendnn and allnws
the success nf nnnsurgical treatment tn be predicted {Fig-
ure 131.1“ ES'WT is mnre beneficial than nther nnnsurgical
treatments and shnuld be used befnre surgical treatment
is cnnsidered."”*”3 Surgical treatment usually is success~
ful, althnugh nn single methnd nr apprnach appears tn
be mnre beneficial than nthers.143 Hnwever, the central
tendnn—splitting apprnach has gained pnpularity because
nf its direct apprnach tn the area nf pathnlngy {Figure 19}.
Sum merryr
Injuries and disnrders nf the inert and anlrle are cnm-
mnn amnng athletes and active individuals. Althnugh
bnth lateral and medial ankle sprains are mnst cnmmnn,
nther subtle injuries will ntten nccur. These can nften
be challenging tn diagunse and treat. Clinicians must be
vigilant and perfnrm a thnrnngh histnry and physical est-
aminatinn. The use nf advanced imaging is nften helpful
in diagnnsis when cnmbined with a thnrnngh clinical
enaminatinn. Many nf these cnnditinns can be treated
nnnnperatively, thnugh surgical management is snmetimes
indicated. 1With the apprnpriate treatments nutlined in
this chapter, gnnd nutcnmes can be achieved.
El 1016 American AcadMy nf Drthnpaedic Surge-ens

Hey Study Points
1' Ankle sprains represent one of the most common
athletic injuries. Good evidence from high-level
studies is available to guide management and treat-
ment decision making.
Dsteoehondral lesions of the ankle respond poorly
to nonsurgical management, and surgical treatment
continues to evolve. The surgical options have dif-
ferent indications.
The causes and locations of ankle impingement are
numerous, and both open and arthroscopic proce-
dures are used.
Plantar fasciitis can be mimicked by calcaneal stress
fracture or tarsal tunnel syndrome.
Anatomic reduction is the most important factor in
achieving a good outcome after a Lisfranc injury.
A high index of suspicion should be maintained to
diagnose a high-risk stress fracture of the foot or
ankle. A prolonged recovery and delayed union or
nonunion are common after these injuries.
Annotated References
1. Fernandez WE, Yard EE, Comstock RD: Epidemiology of
lower extremity injuries among 0.5. high school athletes.
Acad Emerg Med 200?:14{?}:E41-645. Medline DUI
. Waterman BR, Belmont P] Jr, Cameron KL, Deberar-
dino TM, IZirwens ED: Epidemiology of ankle sprain at
the United States Military Academy. Arr: ,l Sports Med
2010;33i4}:?9?—003.Medline DDI
Among military cadets, 614 new ankle sprains were re—
ported during 10,511 person-years {53.4 per 1,000 per-
son-years}. Level of evidence: II.
. Kaplan LD, Jost PW, Honkamp N, Horwig J, West R,
Bradley JP: Incidence and variance of foot and ankle in-
juries in elite college football players. Am I Orthop (Belle
Mead N]; 2011;40{1}:40-44. Medline
A study of 320 intercollegiate football players found that
231 grass} had a history of foot or ankle injury {1.24
injuries per injured player). Lateral ankle sprains were
most common, followed by syndesmosis sprain, MTP
dislocation, and fibula fracture.
. Waterman BR, Dwens ED, Davey S, Eacchilli MA, Bel—
mont P] Jr: The epidemiology of ankle sprains in the Unit-
ed States. I Horse Joint Surg Am 2010;92l’13j:22?9-2234.
Medline DUI
The estimated incidence of ankle sprains was 1.15 per
1,000 person—years in the United States, and the peak
incidence was at age 15 to 15' years. Most ankle sprains
+0 1016 American Academy of Drthopaedie Surgeons
Chapter .12: Ankle and Foot Injuries and Dther Disorders
were in basketball, football, and soccer players. Level of
evidence: II.
Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor
DC: Persistent disability associated with ankle sprains: A
prospective examination of an athletic population. .Foot
Article Int 1990;19l10j:653-600. Medline DUI
Watanabe K, Kitaoka HE, Eerglund L], Zhao ED,
Kaufman KR, An EN: The role of ankle ligaments and
articular geometry in stabilizing the ankle. Cine Biomecb
(Bristol, Avon) 2012:2?{2j:139-195. Medline DDI
The contributions of the lateral ligaments, the deltoid
ligament, and articular geometry in ankle stabilization
were investigated. In the unloaded state, the lateral lig-
aments accounted for T0943 to 80% of anterior stability
and the deltoid ligament accounted for 50% to 30% of
posterior stability. Both ligaments contributed 50% to
00% of rotational stability. In the loaded state, articular
geometry accounted for 100% of translation and 60% of
rotational stability.
Clanton TD, Campbell K], Wilson K}, et al: Qualitative
and quantitative anatomic investigation of the lateral ankle
ligaments for surgical reconstruction procedures. I Bone
joint Sarg Ara: 2014:96l1ljm90. Medline DD]
Anatomic study of the lateral ligaments of the ankle and
subtalar joint found that the ATFL can be found as one to
three bands, with the single band originating an average
13.3 mm above the inferior tip of the lateral malleolus on
the anterior fibular border and attaching along the anterior
border of the talar lateral articular facet an average 1'13
mm superior to the apex of the lateral talar process. The
EFL originates from the fibula an average 5.3 mm ante-
rior to the inferior tip of the lateral malleolus and courses
posteroinferior to insert on the calcaneus an average 16.3
mm from the posterior point of the peroneal tubercle.
Attarian DE, McCrackin H], Devito DP, McElhaney JH,
Garrett 1ll'i’Ejr: A biomechanical study of human lateral
ankle ligaments and autogenous reconstructive grafts. An:
} Sports Med 1935;13l6}:3??—331. Medline DUI
Reed ME, Feibel JB, Dooley BIG, Gina E: Athletic ankle
injuries, in Kibler WE, ed: Drtbopaedic Knowiedge Up-
date: Sports Medicine, ed 4. Rosemont, IL, American
Academy of Orthopaedic Surgeons, 2010, pp 159-214.
This chapter discusses various topics related to athletic
ankle injuries and provides further insight inm manage- Pr'
ment of these conditions. FT.
:5
re
a:
10. Haytmanek CT, Williams ET, James EW, et al: Radio- e:
3
graphic identification of the primary lateral ankle struc- El.
tures. Am1 Sports Med emswsnprs-sr. Medline no: E
An anatomic study quantitatively described the anatomic
attachments sites of the ATFL, |EFL, and PTFL in relation
to reproducible osseous landmarks.
11. Kerkhoffs GM, van den Bekerom M, Elders LA, et al:
Diagnosis, treatment and prevention of ankle sprains:
Drrhopaedic Knowledge Update: Sports Medicine 5
 Sectien 3:1Cnee audLeg
An evidence-based clinical guideline. Br J Spares Med
2fl12;46{11}:354-Efifl.Medline DUI
A literature review previded an evidence-based guideline
fer the preventien, predictien, diagnesis, surgical treat—
ment, and pregnesis ef lateral ankle injury.
11. Kefetelis ND, Kellis E, 1v'iachepeules 5P: Ankle sprain
injuries and risk facters in amateur seccer players during
a 2-year perind. Am J Sperts Med lflfl?;35[3}:453-466.
DUI
13. Petersen W, Rembitzki IV, Keppenburg AG, et al: Treat-
ment ef acute ankle ligament injuries: A systematic re-
view. Arch Urrhep Trauma Serg 2013;133j3}:1129-1141.
Medline DUI
Analysis ef I? randnmized centrelled studies and three
meta—analyses feund that must grade I, II, and III lateral
ankle ligament ruptures can be managed witheut surgery.
A semirigid brace sheuld be used, altheugh grade III in-
juries may benefit frnm shnrt-term immebiliaatieu befere
brace use. Level ef evidence: I.
14. Pihlajamsiki H, Hietaniemi K, Paavela M, Visuri T, Mat-
tila 1v"M: Surgical versus functienal treatment fer acute
ruptures ef the lateral ligament cemplert ef the ankle in
ynung men: A randemiaed centrelled trial. ,1 lines jeirrt
SurgArr: 2U1D;92(14}:136?-23T4. Medline DUI
All .51 active Finnish men with an acute grade III lateral
ligament rupture repertedly returned te previeus activity
level after surgical er functienal nensurgical treatment.
There was ne significant difference in ankle sceres, theugh
the prevalence nf reinjury was higher after functienal
treatment. Level ef evidence: I.
1.5. Takae M, Miyamete W, Matsui K, Sasahara J, Matsushita
T: Functienal treatment after surgical repair fer acute
lateral ligament disruptien ef the ankle in athletes. Am
J Spur-rs Med 1011;40j2}:44?—45 1. Medline DUI
After P3 feet were treated nnnsurgically and 54 were treat-
ed with primary surgical repair fellewed by nensurgical
treatment, 3 nensurgically treated feet {10.3%} had a fair
te peer result, and all surgically treated feet had a gee-d
te excellent result. Level ef evidence: III.
16. van den Bekerem MP, Kerkheffs GM, McCeIlum GA,
Calder JD, van Dijk UN: Management ef acute lateral
ankle ligament injury in the athlete. Knee Sarg Sperts
DI Trauma-rel Arrhresc 2fl13:21{6]:1390-1395. DUI
a:
._I
T:
I:
m
1?. Lamb 5E, Marsh JL, Hutten JL, Na kash R, Ueeke MW:
a: |Eellals-erative Ankle Suppert Trial [CAST Greup}: Me-
III-1
I: chanical suppnrts for acute, severe ankle sprain: A prag-
:c
H matic, multicentre, randnmised centrnlled trial. Lancet
2fl09;3?3{9653]:5?5-531. Medline DUI
A randemised trial ef 534 subjects with severe ankle
sprain shewed that primary eutceme was functien at 3
mnnths with Feet and Ankle Scere {PAS}. Patients whe
received the belew—knee cast had a mere rapid recevery
than these treated with the tubular cempressien bandage.
Urthepaeclie Knewledge Update: Sperts Medicine 5
® ,
13. Haraguchi N, Tega H, Shiba N, Kate F: Avulsieu fracture
ef the lateral ankle ligament cemplmt in severe inversinn
injury: Incidence and clinical eutceme. Am } Spear-ts Med
200?;35i?]:1144-1152.Medline DUI
19. McGuine TA, Ereeks A, Hetsel 5: The effect ef lace-up au-
kle braces en injury rates in high scheel basketball players.
Arr: j Sperts Med 2011;39i9}:134 ill-1343. Medline DUI
After 1,4Ei} high scheel basketball players with ankle
injury were randemly assigned te a lace-up ankle brace
er a centrel greup, lace-up ankle braces were feund te
reduce the incidence but net the severity ef acute ankle
injuries. Level ef evidence: I.
ll}. McGuine TA, Hetael 5, Wilsen J, Ereeks A: The effect
ef lace-up ankle braces en injury rates in high scheel
feetball players. Am }' Sperrs Med 1fl12;4fl{1}l:49-5?.
Medline DUI
After 2,031 high scheel feetball players with ankle inju-
ry were randemly assigned tn a lace-up ankle brace er a
centre] greup, lace—up ankle braces were feund te reduce
the incidence but net the severity ef acute ankle injuries.
Level ef evidence: I.
21. Besien WE, Staple US, Russell 5W: Residual disabili-
ty fellewing acute ankle sprains. I Herve Jere: Snrg Am.
1955;3T:113T—1143.
23. Jacksen DW, Ashley EL, Pewell JW: Ankle sprains in
ynung athletes: Relatinn ef severity and disability. Cffrs
Urrhep Refer Res 19?4;1fl1:1i]1-215.
23. Lentell (3, Has E, Lupe: D, McGuire L, Barrels M, Snyder
F: The centrihutiens ef preprieceptive deficits, muscle
functien, and anatemic laxity te functienal instability ef
the ankle. J Urtfaep Spnrts Pfrys Ther 1995;11:2llfi-215.
DUI
24. Hertel J: Functinnal instability fnlle-wing lateral ankle
sprain. Spnrts Med Zflflflfififi 1:361—3T'1. Medline DUI
25. Clantnn TU, 1lllli'aldrnp NE: Athletic injuries tn the snft
tissues ef the feet and ankle, in Genghlin M], Saltaman
CL, Andersen RE, eds: Mann’s Surgery ef the Feet and
Ankle, ed ELPhiladelphia, PA, Mushy Elsevier, 2fl14, pp
1531-1631
25. Capute AM, Lee JY, Spritzer CE, et al: In vive kinematics
ef the tibietalar jniut after lateral ankle instability. Am
} Sperts Med 10H?;3?{111:2141-2243. Medline DUI
Nine ankles with unilateral ATFL injuries were bieme
chanically studied and cempared as they stepped en a
level surface. A statistically significant increase in internal
retatien, anterinr translatinn, and superinr translatinn nf
the talus was measured in ATFL~deficieM ankles cem-
pared with the intact centralateral centrels.
2?. Maffulli H, Del Euene A, Maffulli {312}, et al: Iselated
anterier talefibular ligament Brestrem repair fer chrenic
lateral ankle instability: 9-year fellnw-up. Am J Sperts
Med 1013:41{4J:8ss-sss. Medline net
El 1016 American AcadMy ef Urthnpaedie Surge-ens

Lung—term uutcnmes were repurted far 33 nf 42 patients
whn underwent Ernstrfim ATFL repair. Twenty-twn pa-
tients {53%} returned tn their preinjury activity level, 5
{16%} were at a luwer activity level but still active, and 10
{26%} abandnned active sperts but were still physically
active. Level nf evidence: IV.
23. 1i'l'iaIdrnp HE III, 1|I'fli'ijdicks CA, Janssun KS, LaPrade
RF, Clantnn TD: Anatomic suture anchnr versus the
Brnstriim technique fur anterinr talc-fibular ligament
repair: a binmechanical cumpariscm. An: ,1 Sparta Med
2fl12;4fl{11}:259fl-2596. Medline DUI
A cadaver smdy cf 24 fresh-fresen ankles revealed sig-
nificantly lnwer strength and stiffness in all three repair
gruupe cumpared with the native, intact ATFL. It was
determined that repairs must be sufficiently prutected tn
avnid premature failure.
23'. Viens Na, 1Wijdicks Ca, Campbell K], Laprade RF, Clan-
tnn TC}: Anterinr talnfibular ligament ruptures: Part 1.
Binmechanical cnmparisnn nf augmented Brnstrfim repair
techniques with the intact anterinr talufibular ligament.
Am J Sparta Med 2fl14;42{2}:4fl5-411. Medline DUI
A cadaver study cf 13 fresh-fruten ankles cnmpared ankles
with an intact fiTFL tn thnse with suture tape augmenta-
tinn nr Ernstrfim repair with suture tape augrnentatinn.
Strength and stiffness were greater after Ernstriim repair
with suture tape augmentatinn in cumparisnn tn the intact
ATFL nr the Ernstriim alnne.
3f}. Clantnn TD. Viens NA, Campbell K], Laprade RF, Wij-
dicks CA: Anterinr talnfibular ligament ruptures. Part 2.
Eiumechanical cemparisnn nf anterinr talnfibular ligament
reccnstructiun using semitendinusus alIc-grafts with the
intact ligament. Am J Sports Med lfl14;41{2}:412-416.
Medline DUI
Mlngraft recnnstructinn nf the ATFL led tcr nn signif-
icant difference in strength ur stiffness cumpared with
the intact ATFL.
31. Eamphell K], Michalski MP, 1Eli'ilscm K], et al: The lig-
ament anatnmy cf the deltnid cc-mplea cf the ankle: A
qualitative and quantitative anatnmical study. J EnneJnfnt
Snrg Arn 1f] 14:96l3}:e62. Medline Dfll
A cadaver anatnmic study detailed the specific cumpunents
cf the deltnid ligament cumpler-t, their prevalence, and their
relatinnships tn nearby anatnmic structures.
32. Attarian DE, McCrackin H], DeVitn DP, McElhaney
JH, Garrett WE Jr: Binmechanical characteristics nf
human ankle ligaments. .a-t Ankle 1935;6{1j:54-53.
Medline DUI
33. Jenng MS, Chni TS, Kim Y], Kim J5, 1Ii’nung KW, Jung TY:
Deltuid ligament in acute ankle injury: MR imaging anal—
ysis. Skeletal Radial 3&14;43{5 }:655- 563. Medline DUI
An MRI study cf 36 patients with acute deltnid injury
detailed patterns nf deltnid injury fur the superficial and
deep deltnid and hnw they related tc- cnncnmitant assn-ci-
ated ankle pathnlngies.
Eb Ifllii American Academy nf Urthnpaedie Surgenns
Chapter 22: Ankle and Feet Injuries and Either Disurders
34. Feminn JE, 1|liaseennn T, Phisitkul P, chigi 1’, Andersen
DD, Amendnla A: Varus external rntatinn stress test fc-r
radingraphic detectinn nf deep deltnid ligament disruptinn
with and withuut syndesmntic disruptinn: A cadaveric
study. FuutAn-ftie int 2fl13;34{21:251 -26fl. Medline DUI
Varus external rntatiun stress was mc-re effective than
valgus external rntatinn stress displacement nf markers
at the medial gutter and cm AP and mnrtise radingraphs
cf the deep deltnid ligament. This finding may imprnve
detection nf assnciated pathnlngy and instability.
33. Heals TC, Crim J, Hickisch F: Deltnid ligament injuries in
athletes: Techniques nf repair and recnnstructiun. Dper
Tech Sports and salnnsmni-ia nnI
Deltnid ligament injuries are a snurce nf valgus and In-
tatiunal ankle instability and uften cccur as a result nf
athletic injury. The anatnmy nf the medial ankle ligament
cnmple}: was reviewed, with emphasis nn pertinent radiu-
lngic findings.
36. Chhabra A, Suhhawnng TK, II'Sarrinun JA: MR imaging
nf deltnid ligament pathnlngic findings and assnciated
impingement syndrumes. Radiogrepbica 2431 fl;3fl{3l:?51-
T61. Medline DUI
MRI technique fur the deltnid ligament was reviewed, with
the nnrmal and ahnnrmal appearances nf its cnmpnnents.
37. Savage-Elliott I, Murawski CD, Smyth NA, Gnland P,
Kennedy JG: The deltnid ligament: An in-depth review
{if anatnmy, functinn, and treatment strategies. Knee
Snrg Sparta Tranmetci Artbruaa 2fl13gllifijfl3lfi—1321
Medliue DUI
The anatnmy and binlngy of the medial ankle ligament
cnmplek and treatment strategies were reviewed.
33. Gnlanr’i P, Vega J, de Leeuw PA, et al: Anatnmy cf the ankle
ligaments: A pictnrial essay. Knee Snrg Sparta Trantnntnf
Artbrnac lfllG;lS{S]:SST—SSS. Medline DC}!
This article is an illustrative review uf ankle ligament
anatnmy. Several annntated phntngraphs and diagrams
nf ankle ligaments in varinus views are presented.
35‘. Williams ET, Ahrherg AB, Gnldsmith MT, et al: Ankle
syndesmnsis: A qualitative and quantitative anatnmic anal-
ysis. Am J Sports Med 1fl15543[11:33-9?. Medline DUI
The anteruinferiur, pusteruinferinr, and intercsseuus ti-
binfibular ligaments were described in relatinn tn nsseuus 1.4.}
landmarks. 5'":
:5
re
40. Williams GIN, Juries MH. Amendnla a: Syndesmutic ankle
en
tn
sprains in athletes. Am J Sparta Med EUDTflSlTlfllFT- 3
El.
110?. Medline DUI
3
41. Clantnn TU, Her CF, Williams ET, et al: Magnetic resu-
nance imaging characterisatinn nf individual ankle syndes-
mnsis structures in asymptnmatic and surgically treated
cnhnrts. Hnee Sam-g Sparta Trenmatni Artist-sac Ellis; Nev
15. [Published nnline ahead nf print] Medline DUI
Drrhnpaedic Knnwledge Update: Spnrts Medicine 3
 seasonasnssanateg
Preeperative 3—Tesla MRI had excellent accuracy in the di-
agnesis ef syndesmetic ligament tears and allowed visuali-
zatien ef relevant individual syndesmesis structures.
Asseciatcd ligament iniuries ceuld be readily identified.
4-1. Sikka RS, Fetaer GE, Sugarman E, et al: Cerrelating
MRI findings with disability in syndesmetic sprains
ef NFL players. Feet Ankle In: 2012:3136 1:3?1-STS.
Mcdlinc DUI
MRI findings censistent with increasing grade ef injury
can helped predict number ef games missed in Natienal
Feetball League players. Level ef evidence: IV.
43. Laver L, Garment MR, McCen key MID, et al: Plasma rich
in grewth facters {PRGF} as a treatment fer high ankle
sprain in elite athletes: A randemised centrel trial. Knee
Snrg Sparta Tranmatel Artistes-r [published enline ahead
ef print June 13, 2014]. Medline DUI
Sixteen elite athletes with an AITFL tear and dynamic
syndesmesis instability were randemly assigned te a PRP
treatment er a centrel greup. The treated patients returned
te play at MILE days cempared with 59.6 days fer these in
the centrel greup, and they had significantly less residual
pain upen return te activity. Level ef evidence: II.
44. Jenes MH, Amendela A: Syndesmesis sprains ef the
ankle: A systematic review. Cffrt Urtfaep Refet Res
ZflflTHSSHSSHfli-US.Mcdlinc DUI
45. Tayler DC, Englehardt DL, Eassctt FH III: Syudes-
mesis sprains ef the ankle: The influence ef heteretep-
ic essificatien. Art: I Sperts Med 1992;.‘Efli21fl46-150.
Mcdline DUI
4-5. Degreet H, Al-Umari AA, El |Ghaaaly SA: Uuteemes ef
suture butten repair ef the distal tibiefibular syndesmesis.
Feet Arr-He fret lflll;32[3]l:25fl—ESS. Medline DUI
Titanium butten fixatien ef the syndesmesis was effective
in maintaining reductien in 1D patients threugheut an
almest 2-year fellew—up peried. Device remeval was mere
cemmen than anticipated. Level ef evidence: IV.
4?. Haqvi GA, Cunningham P, Lynch E, Galvin R, Awan
N: Fixatien ef ankle syndesmetic injuries: lIL'Jemparisen
ef tightrepe fixatien and syndesmetic screw fixatien fer
accuracy ef syndesmetic reductien. Am ] Sperts Med
2fl11;4fl[12}:2323—1335.Medline ee:
S
'U
A study cf 46 patients included 23 whe received tightrepe
fixatien and 23 whe received syndesmesis screw fixatien.
E
I'D
Level ef evidence: II.
Ill
I1!
I:
be:
4-3. Hamid N, Leeffler E], Eraddy W, Kellam JF, Cehen BE,
H
Hesse M]: Uutceme after fixatien ef ankle fractures with
an injury tn the syndesmesis: The effect ef the syndesme-
sis screw. j Berra jeint 5mg Br Zflfl9:91{S}:lflES-1fl?3.
Mcdlinc DUI
The authers present a cnmparative study ef syndesmesis
screws after ankle fracture with asseciated syndesmetic in-
jury. American |[l’vrthepaedic Feet and Ankle Seciety scere
was 33.11}? in the intact screw greup, 91.413 in the hreken
firthepaedic Knewledge Update: Sperts Medicine 5
screw greup, and 85.3!) in the remeved screw greup {P
= {13466}. Ne difference in clinical eutceme ef patients
with intact er remeved syndesmetic screws was feund.
49. Manjee A, Sanders DW, Tiesaer C, MacLeed MD: Func-
tienal and radiegraphic results ef patients with syndesmet-
ic screw fisatien: Implicatiens fer screw remeval. I Gather:
Trauma Efllfl:24(1]:2-E. Medline DUI
A tetal ef T6 patients underwent functienal testing and
radiegraphic review after syndesmesis screw fixatien. Pa-
tients with a fractured, leesened, er remeved screw had a
better functienal eutceme than these with an intact screw.
Level ef evidence: III.
SD. Sung D], Lanei JT, Greth AT, et al: The effect ef syn-
desmesis screw remeval en the reductien ef the distal
tibiefibular ieint: A prespective radiegraphic study. Feet
Andria Int Efl14:35{fil:543 543. Medline DUI
Syndesmesis screw remeval can lead te the spentaneeus
reductien ef a malreduced syndesmesis. Almest Hfl‘ifz- ef
the malreduced ankles were spentaneeusly reduced with
screw remeval. Level ef evidence: IV.
.51. Miller AN, Barei DP, Iaquinte JM, Ledeus WE, Beingcss-
ner DM: Iatregenic syndesmesis malreductien via clamp
and screw placement. ] Urtfrep Trauma EDISflT’iEHflU-
1136. Medline DDI
A cadaver study ef 14 dissected legs with cempletc syndes-
mesis disruptien cencluded intraeperative clamping and
fixatien ceuld cause statistically significant syndesmesis
malreductien.
52. Mitchell ME, Giza E, Sullivan MR: Cartilage transplan-
tatien techniques fer talar cartilage lesiens. ,7 Am Acad
Drtbep Surg 2009:1?[?}:4D?—414. Medlinc
This review article discusses the anatemy ef talar carti-
lage and surgical treatment eptiens. The article fecuses
especially en autelegeus chendrecyte implantatien and
matrix—induced autelegeus chendrecyte implantatien.
53. Easley ME, Latt LD, Santangele JR, Merian-Uenast M,
Nunley ]A II: flsteechendral lesiens ef the talus. I Am.
Acad Gil-thee Serg EUIDflSllOkEIE-ESU. Medline
A review ef management ef ULTs included indicatiens and
centraindicatiens, preeperative evaluatien, arthrescepic
precedurcs ldéhridcment, drilling, micrefracturc, and
hene grafting}. medial and lateral epen appreaches, epen
precedures {esteechendral autegraft transfer, autelegeus
chendrecyte implantatien, structural allegra ft transplan—
tatien}, and cemplicatiens and results.
54. Berndt AL, Harry M: Transchendral fractures {estee—
chendritis dissecans} ef the talus. ] Barre Jefet Sat-erg Am.
1959;40:115-120.
55. Leemer F... Fisher C, Lleyd-Smith R, Sisler J, Ceeney
J: Usteechendral lesiens ef the talus. Am ] Sperts Med
1993:11[IJ:13-19. DUI
fl lfllfi American Academy ef Orthepaedic Surge-ens

SS. Brinberg M, Aglierti P, lEamhardella R, et a1: ICES Carri;
lage Injury Evaluatian Package. Third 1633 Sympasium,
Gateharg, Sweden, April 23, 2011!]. Available at httpa'iIr
www.cartilage.arg.
5?. Hiutertuann B, Regaezaui P, Lampert C, Stute G, Giichter
A: Arthrascapic findings in acute fractures af the ankle.
j’ Eunejainr Snrg Er 2303:32l3}:34§-351. Medliuc DDI
53. Sugiruata K, Takakura T, Ukahashi K, Samara H, Kawate
K, Iwai M: Chandra] injuries af the ankle with recurrent
lateral instability: An arthrascapic study. ] Bane faint
Snrg Arn 2339;91{1}:99-106. Medline DDI
The authars presented a crass-sectianal study af 93 pa-
tients undergaing ankle arthrascapy far recurrent insta-
hility. The relatianship herweeu chandral damage, patient
factars, injury patterns, alignment, and ether variables
was studied.
59. McGahan P], Piuney S]: Current eaucept review: Dstea-
chandral lesiaus af the talus. Paar Ankle i'nr 1310;31{I}:5i}-
131. Medline DUI
The etialagy, clinical presentatian, imaging, and classi-
fieatian af DLTs as well as treatment with hane marraw
stimulatiau, asteachaudral autagrafts, asteachaudral
allagrafts, autalagaus chandracyte implantatiau, and
autageuaus hane grafting were reviewed.
Si}. Stufkens SA, Knapp M, Harisherger M, Lampert C,
Hiutermauu E: Cartilage lesiaus and the develupmeut af
astcaarthritis after internal fixatian af ankle fractures: A
praspective study. J Bane Iain: Snrg Arn 2013;933:331??-
236. Medline DUI
At lung-term fullaw—up af 139 patients wha underwent
surgical treatment af an ankle fracture, initial cartilage
damage seen during arthrascapy was an independent pre—
dictar af pasttraumatic asteaarthritis. Lew] af evidence: I].
SI. Tal JL, Struijs PA, Bassuyt PM, Verhagen RA, van Dijk
CH: Treatment strategies in asteachaudral defects af
the talar dame: A systematic review. Faut Ankfe Int
2003;! 1 [2} : I 1 9-1 2 S. Medlint':
62. Deal PP, lfluttica D], Smith ”WE, Berlet GE: Dsteachundral
lesiaus af the talus: Sire, age, and predictars af autcames.
Fact Ankle Cir'n 2313:13i11:13-34. Medline DUI
The histarical perspective, predictars af autcames, and
uausurgical and surgical treatment aptiaus were presented
far asteachaudral lesiaus af the talus. Lesian size, pres-
ence af edema an MRI, and patient age were discussed as
factars in patient care and autcumes.
SS. Yushimura I, Kauaeawa K, Takeyama A, et a]: Arthruseup-
ic haue marraw stimulatiau techniques fur asteachaudral
lesiaus af the talus: Pregnaetic factars far small lesiaus.
An: I Sparta Med 2313;4ll3}:523-534. Medline DUI
iFifty patients with DLTs smaller than 15!] mm1 underwent
arthrascapic haue marraw stimulatiau. Deep lesiaus and
lesiaus in patients alder than 40 years had inferiar clinical
autcames. Level af evidence: IV.
I3! 2316 American Academy af Drthapaedic Surgeans
Chapter 11: Aulde and Fear Injuries and lEither Disarders
64. Eeugerink M, Struiis PA, Tal JL, vau Diik CN: Treatment
af asteachaudral lesiaus af the talus: A systematic review.
Knee Snrg Sparta Tremnera! Artbrasc 2013:13IZ}:233-
246. Medline DGI
A systematic review uf treatment strategies for DLTs faund
success rates af STS‘J: far asteachaudral autalagaus trans-
plantatian, 35% far bane marraw stimulatiau, P1536 far
autalugaus chandracyte implautatiau, 33% far retragrade
drilling, and 33% far fixatian. Because af its relatively
law cast and marhidity, bane marraw stimulatiau was
identified as the treatment af chaice far primary ULTs.
I55. IElantan TIC}, Jahnsan HS, Matheny LM: Use af cartilage
extracellular matrix and h-aue marraw aspirate cauceu-
trate in treatment uf asteachaudral lesiuns af the talus.
Tech Faat Anieie Snrg 2014;13{4}I:212-223. DDI
Surgical technique and preliminary results were presented
far the use af micrauized cartilage allagraft extracellular
matrix and haue marraw aspirate cauceutrate as a saurce
af meseuchymal stem cells ta augment standard micra-
fracture technique.
66. Daral MN, Bilge D, Eatmae G, et al: Treatment af as-
teachaudral lesiaus cf the talus with micrafracture tech-
nique and pustaperative Hyaluranan injectiun. Knee
Snrg Spar-rs Treamerai Arthrasc 2311;Zfl[?}:1393 4433.
Medline DID]
A praspective randamired study cf 16 patients wha re-
ceived déhridement and micrafracture alaue and 41 pa-
tients wha received déhridemeut and micrafracture as well
as a pastaperativc intra-articular hyaluranan injectian
faund a significant increase fram preaperative ta pastap-
erative scares amaug thase wha received injectiun. Level
af evidence: I.
5?. Guney A, Akar M, Karaman I, Duet M, Guney E: Clin-
ical autcamcs af platelet rich plasma {PRP} as an adjunct
ta micrafracture surgery in asteachaudral lesiaus cf the
talus. Knee Snrg Sparta Trenrnutaf Arthrasc 2314; Nev
33 [published auline ahead af print]. Medline DDI
In a study af 16 patients wha underwent micrafracture
alane and 19 wha underwent micrafracture plus PEP,
thuse whu received PRP had significantly better functiuual
scares. Level af evidence: II.
63. Kim TS, Lee H], IEhai Y], Kim YI, Kah YE: Dues an injec-
tian af a stramal vascular fractian cantaiuing adipasc-dc-
rived meseuchymal stem cells influence the autcames af
marraw stimulatiau in asteachaudral lesiuns af the talus? H
A clinical and magnetic resaua nee imaging study. An: F:
5
} Sparta Med 1314;42{101:2424-1434. Medline ear m
:1:
tu-
MRI af 26 ankles after bane marraw stimulatiau alane :11
D.
and 24 after hane marraw stimulatiau plus stramal vas-
cular fractiuu injectiau cantaiuing meseuchymal stem cells e
revealed significantly better clinical autcamcs in the latter
graup af ankles. Invel af evidence: III.
SS. Chai W], Park EH, Kim 35, Lee JW: Dstcachandral lesian
cf the talus: Is there a critical defect sire far paar aurcamei'
Am J Sparta Med 23 [19:3 Tilfljfl HIM-1933. Medline DflI
Drrhapaedic Knawledge Update: Sparrs Medicine S
 SectiunS:Kneeand1eg
This cahart study af Ilfl ankles eza mined asteachandral
Iesiun size an the talus and clinical autcame fulluwing
arthruscapic marraw stimulatian. Initial defect size was
faund ta he an impartant praguastie factar.
'P'fl. Kwak SK, Kern ES, Ferkel RD, lIl'llian KW, Kasraeian S,
Applcgate GE: Auralagaus chandracyte implantatian
af the ankle: E— ta I'D-year results. Ann ,I Sparta Med
2fl14;42{9}:1156-2164. Medline DUI
At lung-term fallaw-up, 29 uf 32 patients whu under-
went autalagaus ehandracyte implantatian aI the talus
had significant impravement in autcames scares. Lew]
uf evidence: IV.
TI. Yuan HS, Park ‘1’], Lee M, Chai W], Lee JW: Ustea-
chundral autulugaus transplantatian is superiur ta: repeat
arthrasecrpy far the treatment af asteachaudral lesians at
the talus after failed primary arthrascapic treatment. Am
1 Sparta Med 2D14;4l{3]:1396-1903. Medline DUI
After unsuccessful bane marruw stimulatian, 22 patients
underwent asteachandral autulaguus transplantatian and
22. underwent repeat arthraseapy. At a mean Sfl-manth
fulluw-up, results were better in the patients wha under-
went usteachunclral autulugaus transplantatiun. Level uf
evidence: III.
?2. Haleern AM, Russ KA, Smyth NA, et al: Duuhle-plug
autalagaus asteachandral transplantatian shaws equal
functianal autcames campared with single-plug prece-
dures in lesiuns uf the talar dame: A minimum 5-year
clinical fallaw—up. Arn j Sparts Med 2U14;41[3J:1333—
1395. Medline DUI
Faurteen patients with a large ULT treated with dau-
hle-plug autuluguus asteuchundral transplantatiun were
cumpared with 23 patients treated with single-plug au-
talagaus asteachandral transplantatian. Na statistically
significant differences were nuted in uutcumes scures at a
mean BS-manth falluw-up. Level af evidence: III.
T3. Russ KA, Hannun CF, Deyer TW, et al: Functional and
MRI uutcumes after arthrascupic micrufracture fur
treatment af asteachaudral lesiuns at the distal tibial
plafand. J Bane ,Iar'nt Snrg Am 2014;96{2fl}:l?flS-I?15.
Medline DUI
After 31 usteuchundral lesiuns cf the distal tibia were
treated with mierafraeture, patient autcarues were im-
praved hut MRI revealed increased lesian size. Level af
evidence: IV.
E 455. Medline DUI
'U
E ?4. Elias I, Eaikin SM, Schweitzer ME, Besser MP, Marrisan
I'D
Ill
WE, Zuga AC: |[listecz-chandral lesiuns of the distal tibial
I1!
I: plafand: Lacalizatian and marphalagic characteristics
I
H
with an anatamical grid. Paar Ankle Int lflflflfiflifilfild-
529. Medline DUI
Using a nine-zune grid system fur the articular surface uf
the distal tibia, MRI scans item 33 patients were reviewed
and lacatians were assigned far asteachandral lesiuns cf
the distal tihial plafund. Na lucatiun had a preduminant
incidence, and su-called kissing lesiuns were rare. Level
af evidence: II.
Urthnpaeclic Knawledge Update: Sparta Medicine S
7’5. Tal JL, Slim E, van Saest AJ, van Dijk CH: The relatian-
ship cf the kicking actian in succer and anteriur ankle
impingement syndrame: A biumechanical analysis. Arn
I Sparta Med lflfll;30{1}:45-SD. Medline
7’6. Tul IL, van Dijk CH: Etiulugy uf the anteriur ankle im-
pingement syndrame: A descriptive anatamical study. Faat
Ankfe Int Zflfld-tlilfilrd HE 336.
72'7“. Elias I, Zaga AC, Marrisan WE, Besser I'vIP, Schweitzer
.l'v'IE, Raikin SM: Usteuchundral lesiuns uf the talus:
Lucalizatiun and murphulugic data from 414 patients
using a navel anatamical grid scheme. Faat Ankle Int
Zflfl?;23{2]:154-161.Medline DUI
7S. Kim SH, Ha KI, Ahn JH: Tram track lesian af the talar
dame. Arifhrue.-:-clli'r_1.I 1999;15{2}:1fl3-206. DUI
?9. van Dijk EN, Verhagen RA, Tal JL: Arthrascapy far
pruhlems after ankle fracture. I Bane juirrt Srrrg Br
199?;?9{2}:13fl—134.Medline DUI
SD. van Dijk CN, Tul JL, Verheyen CC: A pruspective study uf
pragnastic Iactars cancerning the autcame at arthrasaapic
surgery far anteriar ankle impingement. Arn I Spares Med
199?;25i6}:?3?—?45.Medline DUI
31. Parma A, Euda R, 1|:iannini F, et a1: Arthrascapic treat-
ment af ankle anteriur bany impingement: The lung-term
clinical autcame. Faat Ankle Int 2fi14;35{1}:143-1SS.
Medline DUI
A new classificatian af ankle impingement has lung-term
predictive value far the success uf arthruscupic déhride-
ment. Assaciated pathulugy {including chandral lesiuns],
advanced age, ankle marphalagy, and previaus trauma
were relevant pragnastic factars. Leml af evidence: IV.
32. Walsh SJ, Twaddle EC, Rasenfeldt MP, ale M]: Ar-
thruscupic treatment af anteriur ankle impingement: A
pruspective study cf 46 patients with 5-year fullaw—up.
Arn ] Sparta Med lflld;42{11}:2?12-2?26. Medline DUI
Functianal autcames af 46 patients with arthrascapie
anteriur ankle decampressian remained high at 5-year
fullaw-up despite radiagraphic recurrence cf the lesiuns.
Level af evidence: IV.
B3. Giannini S, Euda R, Masca M, Parma A, Di |lilapriu F: Pus-
teriar ankle impingement. Feat Ankle Int lfllfigfidfiirdfl-
Treatment algarithms far pasteriar saft-tissue and hany
impingement were presented, including warkup and treat-
ment aptians.
34. Hedrick MR, McEryde AM: Pasteriur ankle impingement.
Fuut Ankie Int 1954;IS(1}:2-E. DUI
35. Mauhsine E, Crevaisier I, Leyvraz PF, Akiki A, Dutait
M, Uarafala E: Past~traumatic averlaad ar acute syn-
drume cf the us trigunum: A pussihle cause of pusteriur
ankle impingement. Knee Srrrg Sparts Trenrnatai Arthrasc
lfifl4;12{3}:250-253.Medline DUI
U lfllfi American Academy af Urthupaedic Surge-ans

36. Willits K, Sanneveld H, flmendala PL, Giffin JR, Griffin
5, Fawler P]: Uuteame af pesteriar ankle arthrnscapy far
hindfaat impingement. Arthrascapy 2D flS;24[2]I:196 4102.
Medline DUI
3?. Ldpea 1ivi'aleria V, Seijaa R, Alvarez P, et a1: Endaacapic
repair nf pasterinr ankle impingement syndrame due ta as
triganum in saecer players. Faat Ankle Iat 1015;36{1}:7fl-
P4. Medline DUI
The pesterinr impingement synd tame assnciated with an
as triganum was described. Twenty saccer players un-
derwent pasteriar anltle arthrascapy with exeisian af the
as trigannm. Pain scares significantly decreased 1 manth
after surgery, and patients returned ta preinjury levels 46.9
days after surgery. Level uf evidence: IV.
33. Murawslti CD, Kennedy JG: Anteramedial impingement
in the ankle iaint: Uuteames fallawing arthraseapy. Am
I Sparta Med Zfllflfiflflfllflflfirlflld. Medline DUI
39. Lareau CR, Sawyer GA, 1Wang JH, DiGiavanni CW:
Plantar and medial heel pain: Diagnasis and manage-
ment. ] Am Acad Urtfaap Surg 2014;12ffi}:3?2-330.
Medline DUI
Anatamy, etialag‘fr': treatment aptians, and auteames af
plantar fasciitis were reviewed.
9!}. Danley EU, Maare T, Sferra J, Gaedanavic J, Smith R:
The efficacy af era] nansteraidal anti-inflammatary med-
icatian {NSAID} in the treatment af plantar fasciitis: Pl.
randamieed, praspeetive, placeba-eantralled study. Feat
Pinkie Irtt EflflTtlflil}:ZD-23. Medline DUI
91. Digiavanni BF, Hawaczenslti DA, Malay DP, et al: Pian-
tar fascia-specific stretching exercise impraves autcames
in patients with chranic plantar fasciitis: A praspective
clinical trial with twn-year fallaw—up. }' Bane jat'ut Surg
Am 2Dflfi;33{3l:1??5—1?31. Medline DUI
91. Radfard 1A, Landarf KB, Euchhinder EL, lElaalt C: Ef—
fectiveness af calf muscle stretching far the shart-term
treatment af plantar heel pain: A raudumised trial. EMU
Muscufaskefet Disard lflfl?;fl:36. Medline DUI
93. Hyland MR, Wehher- l[Saffney A, Cahen L, Lichtman PT:
Randamieed cautralled trial af calcaneal taping, sham
taping, and plantar fascia stretching far the shart—term
management af plantar heel pain. I Urtfrap Sparta Phys
Ther aeesastsyssv-svi. Medline ual
94. Crawfard F, Thnmsan C: Interventians far treat-
ing plantar heel pain. Cnchrarve Database Syat Rea
ZUUSflflUDUUUdIE. Medliue
9.5. Lee WC, Wang WY, Hung E, Leung AK: Effectiveness of
adjustable darsiflevtian night splint in camhinatian with
accamrna-dative fact arthasis an plantar fasciitis. J Refrafrff
Res Dev lflll;49[1l]}:lSST-1 SE4. Mctllinc DUI
The use af darsifleatian night splints in canjunctian with
feet arthases far the treatment af chtanic plantar fasciitis
IE! lfllfi American Academy af Urthapaedic Surgeans
Chapter 1.1: Anlde and Fear lniuries and Uther Disardera
is mare effective in relieving heel pain than the use af fnat
artheses alane.
96. 1|Wang C], 1|Wang F5, Tang KD, Weng LI-I, Kn J‘I’: Lang-
term results af eatracarpareal shackwave treatment far
plantar fasciitis. Am ] Sparta Med 2DGfi;34{4}:592-59E.
Medline DUI
9?. Parter MD, Shadhalt B: Intralesianal carticasteraid injec-
tian versus extracnrp-areal shack wave therapy far plan-
tar fasciapathy. Gift: I Spa-rt Med 3005;15{3};119-134,
Medline DUI
9E. Manta RR: Platelet-rich plasma efficacy versus cartica-
steraid injectian treatment for chrnnic severe plantar fas-
ciitis. Pant Ankle fut 2014;35i4}:313-313. Medline DUI
Party patients with plantar fasciitis were randamly as-
signed ta carticasteraid injectian at PEP injectian. These
wha received the PRP iniectian had a mare durable and
effective respanse than thase wha received the steraid
injectian. Level af evidence: I.
99. Landarf KB, Keenan AM, Herbert RD: Effectiveness af
faat arthases ta treat plantar fasciitis: A randamiaed trial.
Arch Intern Med EflflfitlfififllltflflS-ldlfl. Mediiue DUI
100. Eader L, Parlt K, Eu Y, U'Malley M]: Punctianal aut-
came af endascapic plantar fasciatamy. Faat Pinkie Int
2012:33i1}:3?—43.Medline DUI
Patients had rapid impravement in chranic sytnptams with
law marhidity after undergaing endascapic plantar fasci-
ntamy. Lavel nf evidence: IV.
101. Manteaguda M, Maceira E, Garcia-Vina V, Canasa R:
Chrnnic plantar fasciitis: Plantar fascintamy versus gas-
tracnemius recessian. Int Urtfaap 1fl13;3?{9]:1345-1350.
Medlinc DUI
Thirty patients underwent partial plantar fasciatamy, and
3'!) underwent praatimal medial gastracnemius release.
The result was satisfactary in Efl'if. after partial plantar
fasciatamy campared with 95% after preaimal medial gas-
tracnemius release. Patients in the gastracnemius release
graup had much-impraved functianal and pain autcame
scares and fewer camplicatians. Level af evidence: I'v'.
101. Saxena Pt, Fullern E: Plantar fascia ruptures in athletes.
Am I Sparta Med 2904;32{3J:EEE-665. Medline DUI
H
IDS. Nunley JA, 1'v"ertulla C]: Classificatian, investigatian, and
F:
management af midfaat sprains: Lisfranc iniuries in the 5
re
athlete. Am } Sparta Med lflfll;3flifi}:BTI-ETE. Medline re
ru-
3
D.
104. Hear 5, Femina J, Marag ‘1’: Lisfranc jaint displacement
fallawing sequential ligament sectianing. ] Bane faint a
Sarg Am lflfl?:fl9ilfl}:2215u1231. Medline DUI
105. Gallagher SM, Rndriguea NA, Andersen CR, Uran-
herry WM, Panchhhavi VK: Anatamic predispaaitian
ta ligamentaus Lisfranc injury: A matched case-central
study. ] Barre faint Sttrg Am 2013;95illltlfi43-2fl41
Medline DUI
Urthapaedic Knnwledge Update: Sparta Medicme 5
 Sectinndflfneeentlleg
A retrnspective case—central study cf 26 patients with
Iigamentnus Lisfranc injury and 52. cnntrc-l subjects fnund
that the patients with Lisfranc injury had a significantly
smaller ratic: nf seccnd metatarsal length tn fcnt length.
Level nf evidence: III.
106. I-Iaytmanelr CT, Clantnn TC}: Ligamentnus Lisfranc inju-
ries in the athlete. Dper Teck Sperts Med Efl14:32{4j:313-
32f]. DUI
Mechanism nf injury, clinical decisinn making, radiu-
graphic evaluatinn, treatment nptinns, and surgical ap-
prnach were reviewed far liga mentnus Lisfranc injuries.
111?. Henning JA, jnnes CE, Sietsema DL, Enhay DR, An-
dersen JG: Dpen reductinn internal fixatinn versus pri-
mary arthrndesis fnr Lisfranc injuries: A prnspective
randc-mised study. Pent Ankle Int lflDH;3fi{1flj:913-911.
Medline DUI
A prnspective randnmiaed trial nf surgical treatment cp-
tinns fur Lisfranc injuries is presented. Fnrty patients un-
derwent nip-en reductirm and internal fixatinn nr pritnary
arthrndesis. Arth redesis was asseciated with significantly
fewer secnndary surgeries. There was up difference in
SEE-Item Shnrt Fnrm nr Shnrt Fnrm Musculnslreletal Func-
tinnal Assessment scares between cnhnrts.
lflfl. Ly TV, Cnetaee JC: Treatment nf primarily ligamentnus
Lisfra nc jnint injuries: Primary arthrndesis cnmpared with
npen reducrinn and internal fixatinn. A prnspective, ran-
dnmized study. ] Ennejnfnt Snrg Am lflfldflflfljrfi14-51fl.
Medline DUI
1139. Sheibani-Rad S, Cnetzee JC, Giveans MR, DiGinvanni C:
Arthrndesis versus DRIP fc-r Lisfranc fractures. Drrknpe-
rft'cs 2012;35lfi}:e363-e3?3. Medline DD]
A systematic review pertaining tn primary arthrndesis and
npen reductinn and internal fixatinn nf Lisfranc fractures
fcund that bcth prncedures prnvided equivalent satisfac-
tnry results, althnugh clinical nutcnmes may be slightly
better after primary arthrndesis.
111]. Marsland D, Bell-ruff SM, Snlan MC: Binmechanical
analysis nf endnbuttnn versus screw fiJ-ratinn after Lis-
franc ligament cnmples. sectiening. Feet Ankle Snrg
2fl13;19j4}:EET-2?2.Medline DUI
In a cadaver study, 24 fresh-frnaen feet were assigned tn
titanium butt-n cI-r screw iii-ratinn and subsequently were
lnaded tn 343 H and subjected tn 1l],IIDlI cycles. After
f initial leading, Li] tnm cf diastasis was nbserved in the
'U
E buttnn grnup cnmpared with nn diastasis in the screw
I'D
I11
grnup. After cyclic Inading, diastasis in the buttnn grnup
all
I: decreased tn IL? mm, and the screw grnup was unchanged.
I
H effect nf fifth metatarsal Juries and diaphyseal stress
111. lflenrge E, Harris AH, DragnnjL, Hunt K]: Incidence and
tislr factnrs fnr turf tne injuries in intercnllegiate fnntball:
Data frnm the Natinnal |lillnllegiate Athletic Assnciatinn
injury surveillance system. Punt Ankfe Int 2014;35{21:1113-
11.5. Medline DUI
Drthnpaedic Knnwledge Update: Spnrts Medicine 5
Turf tee is a cnmmnn fnntball injury that usually affects
skill-pnsitinn players. Apprnpriate acute and lung-term
management is required. Level bf evidence: IV.
111. Clantnn TU, Butler JE, Eggerl: A: Injuries tn fl1e metatarsa-
phalangeal jnints in athletes. Fun: Ankr'e 1936;?[3]:161-
1T6. Mcdlinc DUI
1131- Crain JM, Phancau JP, Stidham K: MR. imaging cf turf
tee. Megn Reece Imaging Clin N Am 2DGS;16{1}:53-Ii}3,
vi. Medline DUI
114. Waldrnp NE III, Eirlrer CA, 1|liii'ijdiclrs EA, Laprade RF,
Clantcrn TD: Radingraphic evaluatinn nf plantar plate
injury: An in virus binmechanical study. Feet Ankle Int
2313;34j3}:4fl3—4fl3.Medline DUI
Histnrical evaluatinn cf turf tc-c injury has been qualita-
live. This study prnvided quantifiable data an the severity
nf plantar plate injuries, which may prnvide guidance tn
physicians. Three millimeters nf difference in excursic-n
frnm the intact state indicated a three-ligament injury.
115. lIEnhen BE: Hallur-r sesame-id disnrders. Feet Ankle Elise
Eflfl9;14{1}:flI-lfl4.Merlline DUI
This review article {if hallux sesamnid disnrders nutlined
treatment nf several sesamnid pathnlngiee, including acute
fractures, stress fractures, nnnuninns, estennecresis, and
chnndrnmalacia.
116. Bichara DA, Henn RF III, Thendnre GH: Sesamnid-
ectnmy fnr hallus: sesamnid fractures. Pent Ankfe Int
1012;33j9}:?fl4-?fl6.Medline nnI
Sesamnid resectinn is a gnnd nptitm after unsuccessful
nnnsurgical treatment. Twenty-twn cf 24 patients returned
tn full activity at a mean 11.6 weeks after surgery. Hallus
valgus nccurred in nne patient. Pain levels significantly
improved as patients returned tn full activity. Level c-f
evidence: IV.
11?. Maquirriain ], Ghisi JP: The incidence and distributien
nf stress fractures in elite tennis players. H:- j Spnrts Meal
EDI] fi;4l}{5 1:454 455', discussinn 455'. Medline DUI
113. Haeding CC, Spindler KP, Amendnla A: Management
nf trnublesnme stress fractures. Instr Currrse Leer
lflfl4;53:455-469. Mcdline
119. Lawrence 5], Butte M]: jnnes’ fractures and related
fractures cf the prnsrimal fifth metatarsal. Pent Ankle
1993:14j6}:353-365.Medline D-EIII
Ill]. lIEarreira D5, Sandilands SM: Radiegraphic factnrs and
fractures cm participatinn in the NFL. Punt Ankfe Int
2D13;34[4}:513-521. Mcdline DUI
A study cf the effect cf prnirimal fifth metatarsal frac-
tures an the number nf games played, numhm nf games
started, and number nf years played in the Natinnal at-
ball League fcund nu statistically significant differences
D lfllfi American Academy nf Urthnpaedic Surge-nne

between players with a fracture and those in the control
group. Level of evidence: 1'11.
111. Chuckpaiwong E, Queen RM, Easley ME, Nunley JA:
Distinguishing Jones and proximal diaphyseal frac-
tures of the fifth metatarsal. ln Urtlrop Relut Res
lflflfl;466{fl}:1SEE-19?fl.Medline DUI
122. Torg J'S, Balduini FC, Eellto RR, Pavlov H, Peff TC, Das
M: Fractures of the base of the fifth metatarsal distal to
the tuberosity: ISlassification and guidelines for non-surv
gical and surgical management. J Bone Joint Sttrg Ant
1934:66llififlfl-214. Medline
123. Uchenjele G, Ho E, Switaj PJ, Fuchs D, Goyal N, Kadaltia
AR: Radiographic study of the fifth metatarsal for opti‘
mal intramedulla ry screw fixation of Jones fracture. Foot
Anltle Int 2015;36{3}:293-3fl1. Medline DUI
In a retrospective review, 119 patients underwent three-di-
mensional CT of the foot tn determine measurements of
the fifth metatarsal.
124. Lee KT, Park TU, Young KW, Kim JS, Kim JR: The plan-
tar gap: Another prognostic factor for fifth metatarsal
stress fracture. Am J Sports Med 2011:39i1fl}:22fl6-2211.
Medline DUI
In T5 patients with fifth metatarsal stress fracture treated
with tension-band wiring, factors such as the plantar gap
may help guide treatment, especially in patients at high
risk for nonunion. Level of evidence: III.
12.5. Mallee TH, Wee] H, van Dijlt CH, van Tulder MW,
Kerkhoffs GM, Lin CW: Surgical versus conservative
treatment for high-risk stress fractures of the lower leg
{anterior tibial corteit, navicular and fifth metatarsal base}:
A systematic review. BrJ Sports Med 1015;49{63:3Tfl -376.
Medline DUI
A systematic review of the literature pertaining to three
stress fractures of the lower extremity included eight
studies {246 fractures} on proximal fifth metatarsal stress
fracture. Pooled results produced a weighted mean time
to return to sport of 13.3 weeks after surgical treatment
and 19.2 weeks after nonsurgical treatment. For navicular
stress fracture, eight studies {Elli} fractures} had a weighted
mean time to return to sport of 16.4 weeks after surgical
treatment and 21.? weeks after nonsurgical treatment.
Because of the low-quality evidence and high risk of bias,
recommendations for standard of care could not he made.
Level of evidence: 11".
126. Fishman FG, Adams SB, Easley ME, blunley JA II: Vase
cularited pedicle hone grafting for nonunions of the
tarsal navicular. Foot Ankle Int 2012:33i9]:?34-?39.
Medline DUI
The limited blood supply of the navicular and difficulty
in treating nonunion or osteonecrosis led to a technique
using vascularieed bone graft from the cuboid, second
cuneiform, or third cuneiform to aid navicular healing.
In seven patients with a mean 41] -month radiographic fol-
low-up, no cystic change or collapse was noted, although
ID EDIE American Academy of Drthopaedic Surgeons
Chapter 1.1:An1de and Foot Iniuries and Uther Disorders
dorsal fragmentation or esostosis at the graft site occurred
in four patients. Level of evidence: IV.
11?. McCormick JJ, Bray EB, Davis WH, Cohen BE, Jones
CP III, Anderson RE: Clinical and computed tomogra-
phy evaluation of surgical outcomes in tarsal navicular
stress fractures. Am J Sports Med ED11;39{S}:1?41-1?4S.
Medline DUI
Healing and bony union of navicular stress fractures
were evaluated with CT in 10 patients an average 42.4
months after surgery. Eight had bony union, of whom
6 had residual lucency of 1 to 2 mm, although it proved
clinically insignificant. Both patients with nonunion had
a complete, displaced fracture on preoperative imaging.
Level of evidence: IV.
123. Khan KM, Fuller PJ, Brukner PD, Kearney C, Hurry
HE: Uutcome of conservative and surgical management
of navicular stress fracture in athletes: Eighty~sis cases
proven with computerized tomography. Am J Sports Med
1991;2fll6}:65?—SSS.MedIine DUI
129. Torg JS, Moyer J, |Graughan JP, Boden BP: Management
of tarsal navicular stress fractures: conservative versus
surgical treatment: A meta—analysis. Am J Sports Merl
2fl10;33{5 1:1fl4S-1fl53. Medline DUI
A meta-a nalysis included 313 tarsal navicular stress frac-
tures from 13 different reports. No statistically significant
difference was noted in terms of successful outcome and
time to return to sport between non-weight-bearing non-
surgical management and surgical fixation. Nonsurgical
management with weight hearing was statistically inferior
to non-weight—bearing management.
130. Moher D, Liberati A, Tetalaff J, Altman DG; PRISMA
Group: Preferred reporting items for systematic reviews
and meta-analyses: The PRISMA statement. Int J Surg
2010;3[5]:33E—34I.Medline DUI
A review and guidelines statement for conducting ethical
and highwquality systematic reviews is presented. The ar-
ticle specifically reviews the history of UUURUM and its
subsequent evolution to PRISMA.
131. IGross CE, Nunley JA: Medial-sided stress fractures: Me-
dial malleolus and navicular stress fractures. Uper Tesla
Sports Med 2fl14:22{4}:256—3fl4. DUI
This article reviews the diagnosis and treatment of medi-
al-sided stress fractures of the foot and ankle, as well as
specific surgical techniques. lt‘
Fl
5
m
m
132. Caesar BC, McCollum GA, Elliot R, Williams A, Calder ru-
JD: Stress fractures of the tibia and medial malleolus. Foot 3
D.
Ankle Clln lfllSflSlZIflSS-SSS. Medline DUI
The incidence, pathophysiology, clinical presentation, di-
S
agnosis, and treatment options for stress fractures of the
medial malleolus and tibia were reviewed.
133. Steinbronn DJ, Bennett GL, Kay DE: The use of magnetic
resonance imaging in the diagnosis of stress fractures of
the foot and ankle: Four case reports. Foot Ankle Int
1994;15[2}:3[l-33.Medline DUI
Urtbopaedic Knowledge Update: Sports Medicine 5
 seasonssnseanstsg
134. Lempainen L, Liimatainen E, Heikkilsi J, et al: Medial
mallenlar stress fracture in athletes: Diagnusis and up-
erative treatment. Strand ] 3mg 1fl11;101{4}:261-264.
Medline DUI
In a retrnspective review nf medial mallenlar stress frac—
ture in If] patients, 5 patients initially were managed with
pain-free limited weight bearing, thnugh all .5 pruceeded tn
surgical fixatinn after nu radiugraphic signs cf healing 4 tn
6 mnnths after diagnnsis. Five patients underwent surgical
fixaticn because uf small diastasis an MRI nr lung-stand-
ing symptcms. In all 10 patients, nn fracture was visible
an initial plain radiugraphs althuugh subsequent MRI
revealed the fracture and discnntinuity cf the cnrteir. All
1|]| fractures were clinically healed 3 [D 4 mnnths after
surgery. Level uf evidence: IV.
135. Maffulli H, Lungn UG, Maffulli GD, Rabitti C, Khan-
na A, Denarc V: Marked pathulngical changes prmri-
mal and distal tn the site nf rupture in acute Achilles
tendtm ruptures. Knee 5mg Sparts Tranmatnf AHA-rust:
2fl11,19[4}:6fifl—63?.Medline DUI
Micruscupic analysis cf the histupathulugic features c-f
tendun tissue samples frnm 29 patients with an Achilles
tendun rupture and 11 central subjects when had died c-f
cardiuvascular causes fuund that patients with a rupture
had prufnund histupathulngic changes th rnughuut the ten—
dnn and the central su bjects had little pathnlngic change.
136. Raikin 5M, Garras DH, Krapchev PU: Achilles tendnn
injuries in a United States pnpulatiun. .Fnert Ankle Int
2fl13;34{4}:4?5-43i}.Medline DUI
A retruspective review nf 436 patients with Achilles tend-an
rupture fuund that 215 ruptures {63%} were the result cf
spurts activity. The most cummunly invnlved spurt was
basketball. Injuries in patients nlder than .55 years and
patients with a high hudy mass index were mere likely tn
nccur in nunspnrts activities, and the diagnnsis was more
likely tn be initially unrecngnised. Level nf evidence: II.
13?. Garras DIN, Rail-:in 5M, Bhat SE, Taweel H, Karanjia H:
MRI is unnecessary fur diagntising acute Achilles tendnn
ruptures: Clinical diagnnstic criteria. Gift: flrthup Relat
Res 2012;4TfllfllfllfiS-filfi. Medline DUI
A retruspective cnmparisen nf Eli patients with a surgically
c-anfirmed acute Achilles tendnn rupture cm ME] and 66
patients withuut a prenperative MRI fc-uncl that three
clinical findings {an abnurmal Thumpsun test, decreased
resting tension, and palpable defect) were present in all
E
'U
patients and were Illll'ifi sensitive. MRI was less sensitive
and was read as inconclusive in twu patients. Level nf
E
I'D evidence: II.
Ill
I1!
I:
he: 133. Juries I'vIP, Khan R], Carey Smith RL: Surgical interven-
H
tinns fur treating acute achilles tendnn rupture: Key find-
ings frnm a recent Cnchrane review. J Bone faint Surg Am
2011;94f11}:e33.Med|ine um
A Iflirtehrane review cf 14 studies ccmpared surgical and
nunsurgical treatment nf acute Achilles tendnn rupture.
The results supp-titted surgical treatment, althuugh it was
assnciated with mere infecticrns than nensurgical treat-
ment. The risk was reduced with percutaneuus techniques.
® firthnpaedic Knnwledge Update: Spurn: Medicine 5
135'. Sure-ceann A, Sidhwa F, Aarahi 5, Kaufman A, Glase-
brnclr. M: Surgical versus nunsurgical treatment of acute
Achilles tendon rupture: A meta-analysis cf randnmize-d
trials. ,7 Bane Irvin: Snug Am 2012;94[231:21 35-2143.
Medline DflI
A meta-a nalysis cf 1!} smdies cumparing surgical and nun-
surgical treatment {if acute Achilles tendnn rupture found
that functiunal rehabilitatiun with early range-uf—mutic-n
exercises decreased the risk nf rerupture tn cle-se te- that
uf surgery, with fewer cumplicatinns. Level of evidence: I.
1413'. Eergkvist D, Astrtim I,]nsefssnn PD, Dahlherg LE: Acute
Achilles tendcn rupture: A questinnnaire fullnw-up nf 415i?r
patients. I Butte faint 3mg Ant 2011,94[13}:1229-1133.
Medline DUI
A recurds review cf 43? patients with an acute Achilles
tendc-n rupture fuund that the rerupture rate was 3% after
surgical treatment cumpared with 6.6% after functic-nal
nunsurgical treatment. Level nf evidence: III.
141. Barfnd KW, Benclte J, Lauridsen HE, Ban 1, Ebsltcv L, Tru-
elsen A: Hnnnperative dynamic treatment nf acute Achilles
tendnn rupture: The influence uf early weight-bearing
crn clinical nutcc-me. A blinded, randumizecl cnntrulled
trial. _,I Barre Joint Surg Am lflI4;96{13}:I49?-15f13.
Medline DflI
Patients received nensurgical functic-nal treatment fer
acute Achilles tendtm rupture based nn full weight bearing
{29 patients} ur nun—weight hearing [2? patients}. There
were nu hetween~grunp heel~rise test nr mean scare differ-
ences. The patients when were weight bearing had a better
health-related quality nf life. Level cf evidence: I.
142. Enable-ch K, Schreibmueller L, Kraemer R, Jag-Ddsinslti
M, Vugt PM, Redeker J: lBender and eccentric training
in Achilles mid-pnrtinn tendinnpathy. Knee Sutg Spur-ts
Tranmatul Arthtnsc lfllfl;13{5}:E4S-555. Medline DUI
In 53 patients whu underwent eccentric training fc-r
treatment nf midpc-rticrn Achilles tendinnpathy, men with
symptums had significantly better reductinn in pain and
imprnvement in scares than wc-men with symptnms at
11-week fnllcrw-up. Level nf evidence: III.
143. Schun LC, Shcrres JL, Fart: FD, 1|lift-ta AM, Camire LM,
Guytcun GP: Flexnr hallucis Icrngus tendctn transfer in
treatment nf Achilles tendinusis. j Bane faint Sat-g Am
2013;95l1]:54-60.Medline DUI
A study cf 46 sedentary patients {average age, 54 years}
whn underwent Hester hallucis lungus tendun transfer fur
treatment uf insertic-nal nr midsubstance Achilles tendinc-
sis fnund significant imprnvement in Achilles tendnn func-
titm, physical functinn, and pain intensityr at 24-mnnth
fnllciw-up. Level of evidence: IV.
144. van Dijk EN, van Sterlcenbnrg MN, Wiegerinclt JI, Karis-
snn _|, Maffulli N: Terminulugy fur Achilles tendc-n re—
lated disnrders. Knee Sarg Spain‘s Tranmatcf Arthrnsc
2fl11;19{5}:335-fl41. Medline DID]
Inctmsistencies in terminulugy used fur Achilles tendtm
pathnlngy were nutlined. The preferred terminals-g}.T and
fl 211115 American Academy nf Urthnpaedic Surge-ans

classificatiens ef Achilles tenden and related diserders
were presented.
145. Wiegerinclt JI, Eel: AC1, van Dijlt CN: Surgical treat-
ment ef chrenic retrecalcaneal bursitis. Arthrescepy
2012;23{2}:233-293.Medline DUI
A systematic review [if surgical treatment uf chrnnic
retrecalcaneal bursitis reperted en 54‘? precedures in
461 patients. Patient satisfactien and centplicatien rates
favered endescepic surgery ever epen surgery. Level ef
evidence: IV.
145. Nichelsun CW, Berlet GE, Lee TH: Predictien ef the
success ef neneperative treatment ef insertienal Achilles
tmdinesis based en MRI. Feet rink is Int 200?;23f4}:412-
42?. Medline DUI
14?. Mashhad H, Simen JV: The effectiveness ef extracerper
real sheclt wave therapy en chrenic Achilles tendinupathy:
A systematic review. Feet Ankle Int 2fl13;34[1]:33-41.
Medline
A repert ef feur randemired centrelled studies cencluded
there was satisfactery evidence fer the effectiveness ef
lew-energy ESWT at a minimum 3-menth fullew-up. fl.
cemhinatien ef ESWT and eccentric leading had superier
results. Level ef evidence: I.
143. Wiegerinclt JI, Kerkheffs GM, van Sterltenhurg MN, Sier-
evelt IN, van Dijk EN: Treatment fer insertienal Achilles
tendinupathy: A systematic review. Knee Surg Sperts Tren-
eretef Arthresc 2013:21f6}:1345—1355. Medline DUI
IE! 2fllfi American Academy ef flrthepaedic Surgeens
Chapter 1.2: Amide and Feet lniuries and lEither Diserders
A systematic review ef surgical and nensutgical treattnent
ef insertienal Achilles tendinepathy reperted en 451 pre-
cedures in 433 patients. Patient satisfactien was high in all
surgical studies, ESWT appeared effective in nencalcific
insertienal tendinepathy, and fleer-level eccentric exercis-
es had higher patient satisfactien than full range-ef-metien
eccentric exercises. Level ef evidence: III.
Vida-e References
22.1: Ferltel RD, Stuart KI}: Antefegens Chmndrecyte Ine-
pi'errtesien [videe excerpt]. Van Huys, CPL, 2fl11.
22.2.: Glaaehrunlt l'vl: Cunventienal Treatment - Dehridement
Abrasien Micrefracture Drilling [videe excerpt]. Halifax, Neva
Scetia, 2011.
12.3: Hangedy L: BA TS Precedere [videe excerpt]. Budapest,
Hungary, 1011.
22.4: Cectsee JG: Aeterier Ankle fmpingemeet [videe ex-
cerpt]. Edina, MN, 2011.
22.5: Wiegerinck 11, de Leeuw PA, van Dijk EN: Pesterier
Arnhfe Arthrescepy - fmpingemerst Us Trigennm FHL Tene-
synerritis [videe excerpt]. Amsterdam, Netherlands, 2D11.
22.6: Wiegerinclt JI, de Leeuw PA, van Dijlt CN: Hegfrrrtd
Defermity, Achilles Prefrfems. [videe excerpt]. Amsterdam,
Netherlands, 2011.
H
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Drthepeedic Knewledge Update: Sperrs Mediums 5
Rehabilitation '

a. ECTIDN EDITURS
Chapter 23
Current Concepts 1n
Rehabilitation of Rotator Cuff
Pathology: Nonsurgical and
Postoperative Considerations
Todd S. Ellenbecl-ter, DPT, MS, SCS, DCS. |CECE George I. Davies, M D, DPT, h-‘IEd, PT, SCS, ATC. LAT, CSCS, PES, F151 PTA
Abstract
Rehabilitation of the patient with rotator cuff pathology
requires a comprehensive physical examination and
evidence-based rehabilitation focusing on restoring
normal joint motion, scapular stabilization, and ro-
tator cuff strength. Many patients with rotator cuff
tendinitis, impingement, and partial- and full-thickness
tears can return to full activity by means of a complete
rehabilitation program. Patients who ultimately undergo
rotator cuff repair benefit from early range of motion
and progression of rehabilitation exercises to treat both
range of motion and strength deficiencies.
Keywords: shoulder: rotator cuff; rehabilitation
Introduction
Shoulder pain and conditions comprise one of the more
common musculoskeletal problems that occur and can
affect 16% to 11% of the population.1 Rotator cuff pap
thology can comprise up to Efl‘h’s of all shoulder condi-
tions. Although several mechanisms have been reported
to produce rotator cuff injury, one of the more common-
ly described mechanisms is shoulder impingement, or
compression.
Dr. Eilenbecker or an immediate family member serves as
an unpaid consuitant to Them-Band Hygenic. Neither Dr.
Davies nor any immediate family member has received
anything of value from or has stock or stock options held
in a commercial‘ company or institution reiateri directiy or
indirectiy to the subject of this chapter.
@ lflld American Academy of Drthopaedic Surgeons
uoneuucjeuau :1;
Several types of shoulder impingement have been de-
fined in the literature, including primary, secondary, and
internal impingement syndromes. The history, mechanism
of injury, subjective comments by the patient, examina-
tion, and imaging studies all are used to identify the spe-
cific condition, and most important, the causative factors
of the impingement.2 Primary impingement usually results
from three major causes: encroachment of the rotator cuff
in the subacromial space because of swelling or scarring
of the pain-generating structures, acromial morphologies
{type II or type III acromion], or a selective hypomobility
of noncontractile tissues such as the capsule, capsular
ligaments, and fascia] tissue. Secondary impingement
usually results from microinstahility of the glenohumeral
joint, often because of acquired ligamentous laxity, in-
adequate dynamic muscular stabilixation, and scapular
dysfunction.J Internal impingement is commonly involved
in overhead athletes or when the arm is used in an ab-
ducted, externally rotated, and horizontally extended
position.‘ In addition to the listed conditions that can
cause impingement, most patients will also have neuro-
muscular dynamic stability deficits of the scapulothoracic
and glenohumeral musculature.
Nonsurgical Treatment
1"i'Ili'hc-n treating patients with subacromial impingement
syndrome, a multimodal approach is usually performed
that includes, but is not limited to, physical therapy mo-
dalities, postural exercises, stretching for tight contractile
musculotendinous units, mobilization for tight noncon~
tractile tissue, taping techniques, movement reedueation
of the entire kinematic chain, and strengthening of the
entire kinematic chain including legs, core, scapulotho-
racic, and glenohumeral links. This includes rotator cuff,
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
scapular, and total arm strengthening, neuromuscular
dynamic stabilization exercises, and advanced functional
specificity exercises:l Clinicians have an ethical obligation
to do everything appropriate to help the patient recover
and return to activity. However, because of this multi—
modal approach and the potential interaction of various
interventions, it is not clear which are most effective and
which may be unnecessary. Because no high—level evidence
indicates the best practice pattern during the early phases
of rehabilitation, many of the aforementioned treatment
interventions that customize specific interventions to the
patient and the cause of the problem can be applied.
The section of this chapter discussing nonsurgical
E
treatment primarily focuses on the application of ther—
.E
4.! apeutic exercises including neuromuscular dynamic
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stability and outcomes related to treating patients with
I15 neuromuscular dynamic stability deficits of the scapu—
.E
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lothoracic andfor rotator cuff muscles. These also have
exceptional application for postoperative rotator cuff re-
E
habilitation. Numerous studies,‘"" systematic reviews,”‘”‘
and meta-analyses'i'i13 demonstrate the effectiveness of
exercise for patients with subscromial impingement syn-
drome. Most of these studies demonstrated decreased
pain, increased strength, improved movement patterns,
and improved functional outcomes in patients following
therapeutic exercise for shoulder impingement. Authors
of a 20 Ellil study performed a systematic review of 12,423
articles and identified only 11 that had good methodol-
ogy.” Exercise strongly decreased the patients’ symp—
toms and led to significant improvements in functional
measures. However, one conclusion of the analysis was
the lack of consensus on an ideal treatment program for
patients with rotator cuff disease. A EDI 1 meta-analysis
demonstrated the effectiveness of therapeutic exercises
on patients with shoulder dysfunction.” Another men
ta—analysis of the effectiveness of therapeutic exercises
for treatment of painful shoulder conditions evaluated
19 articles, 1? of which had a rating of 6 or better on the
PEDro scale.” Therapeutic exercise had a greater positive
effect on pain and function than all other interventions;
however, subsequent research is necessary for translation
to clinical practice.
Therapeutic exercises are usually performed as a com-
bination of isolated and multiple-joint exercises. Most
clinicians think that multiple-joint exercises must be per—
formed because they are functional to improve perfor-
mance. However, other studies have demonstrated that
isolated rotator cuff exercises carry over to improving
functional movements such as throwing and serving.”11
A group of healthy, uninjured subjects in a training
study performed isolated shoulder rehabilitation exer—
cises for each muscle group in the shoulder complex.ll
flrfltopaodie Knowledge Update: Sports Medicine 5
After training, functional test outcomes increased during
both a closed kinetic chain {weight hearing} test and an
open kinetic chain {throwing} test. This study found that
subjects who never performed functional multiple-joint
movement activity during training demonstrated im—
provements in these functional outcome measurements.
One conclusion from these studies is that performing
isolated shoulder exercises without multiple—joint exercis-
es can still improve multiple-joint functional movement
activities.
Exercise to Treat Rotator Cuff Pathology
The current review of literature supports the use of ex—
ercise to treat rotator cuff pathology. A therapeutic ex-
ercise program usually progresses through four stages:
{1} muscle activatioul'motor learningl'motor control, {2}
muscle strengtheningfpowerfendurance, {3] neuromus-
cular dynamic stability exercises, and {4} functional
specificity exercises. Despite the forthcoming focus on
rotator cuff and scapular exercise training, total-body
training, including the legs and core muscles, should be
performed and is recommended during a comprehensive
rehabilitation program. Many training techniques can be
used for these areas, but these are beyond the scope of this
chapter. The authors of this chapter recommend working
each link in the kinematic chain first to establish a good
foundation with each muscle group and add the advanced
neuromuscular dynamic stability and functional exercises
after establishing the r"basics.”
Scapulnthnracic Exercises
The following scapulothoracic exercises are supported
by electromyographic [EMS] research and involve move-
ment patterns appropriate for patients with rotator cuff
pathology.”15
Scapular Plane Elevation
Scapular plane elevation {scaption with the thumb point-
ing up} creates a functional strengthening of the force
couple with the upper trapezius, lower trapezius, and
serratus anterior. In most patients with shoulder dys-
function, the upper trapezius is hypertonic and does not
need isolated strengthening. Consequently, this exercise
activates both the upper trapezius in the scapula and
the glenohumeral muscles. The patient moves through
the range of motion {RUM} appropriate to his or her
particular shoulder condition [typically limited to less
than 9B” of elevation to minimize the effects of sub-
acromial contact}. Alternating arm motions to prevent
compensation and recruit core stabilisation are also rec-
ommended“ {Figure l}.
El 1016 American AcadMy of Unhopaedic Surgeons
 lIIZhapter 13: Current Concepts in Rehabilitation of Rotator Eufi Padlologj': Nonsurgical and Postoperative Considerations
Figure 1 Photograph demonstrates scapular plane
elevation in the "thumb up" position using
weights.
Press DownfUp
Mauv muscle groups are recruited, but the lower trape—
aius muscles and scapular depressors are substantiallv
activated {Figure I].
Push-Up With Plus Position and Protraction
The push-up with the plus position is designed to recruit
the serratus anterior muscle using the “plus” position,
which encourages maximal scapular protraction. If a
“hug motion" is used, such as in the dynamic hug ext
ercisefi" patients are recommended to have their palms
face each other {thumbs pointed to the ceiling} to prevent
internal rotation at the end of the plus maneuver. If the
hands internally rotate, it causes the greater tuberositv
to compress the pain generators in the subacromial space
and can iatrogenicallv result in problems or continue
aggravating the condition (Figures 3 and 4).
IE! lfllii American Academy of flrthopaedic Surgeons
uvsvnuavuas :1:-
Figure 2 Photograph demonstrates press-down exercise.
Figure El Photog ra ph demonstrates the pu shop with the
plus position exercise.
Rowing Motions and Scapular Retraction
The rowing motions activate the middle and lower trape-
aius muscles as well as the rhomboids. Scapular retraction
exercises such as the robbery {Figure 5 l and lawnmower
exercises {Figure 6} use retraction to activate the mus-
clesfifl‘i i'ltdditionallv,r exercises with elastic resistance
such as external rotation with retraction” {Figure T")
combine the movements of external rotation with scap-
ular retraction, and EMG research has shown the lower
Drtbopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
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Figure 4 A and B. Photographs demonstrate dynamic hug using an elastic band.
trapezius is recruited at a 3.3‘fold greater rate than the
upper trapezius, forming a favorable lower trapezius—
to-upper trapezius ratio. This ratio is important when
reviewing EMG research of scapular stabilisation exer-
cises because many exercise movement patterns produce
abnormally high upper trapezius muscle activity, which
is unwanted and can result in abnormal motor patterns
and recruitment strategies.“ A lflll study demonstrated
that scapular exercises using a lower resistance level {Borg
scale 3 versus Borg scale 3) produce higher lower trape—
zius—to—upper trapezius ratios, which are beneficial for
the rehabilitation of shoulder pathology.“
filenohumeral Exercises for the Rotator Cuff
Internal and External Rotation
Glenohumeral exercises include internal and external
rotation exercises starting at 30° abductionflfl“ forward
flexion into scaptionflfl" diagonal movement, also called
the 3flf3flflfl position {Figures 8 and 9}, and progressing
the patient to the 90:90 position in the scapular plane {Fig-
ure 10}, if appropriatefilall The 3flf3flf3fl position is the
initial starting position for the rotator cuff strengthening
firthnpaedic Knowledge Update: Sports Medicine 5
exercises for several reasons. Using 3H“ of abduction pre-
vents the wringing-out effect on the rotator cuff, speeds
the healing process by means of increased blood flow
to increase the oxygen and nutrients to the tendon, and
decreases the strain on the rotator cuff tendon.3"~35 Using
3E1“ of scapular plane elevation stress shields the ammo-
inferior capsule and prestretches the posterior shoulder
muscles, which increases their length-tension ratio to
improve power.M In the 3080130 position, a bolster is
placed under the arm for the aforementioned reasons, but
also for research-based reasons. Placing a bolster under
the arm and adducting the muscles to hold the bolster
in place creates a synergistic overflow {cocontractionif
irradiation} to the posterior muscle groupsxud" These
are the weakest muscles in the shoulder complex, and
using the bolster enhances the muscles’ ability to generate
more power. Moreover, using the bolster and adducting
the arm with 15 N of force increased the subacromial
space in all arm positions: 3i)“, 6H”, 9i)“, 120“, and 150“
of abductionfifls” Because this area of the shoulder is the
most vulnerable to impingement, this technique can help
minimize subacromial contact stress in this area.
fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 13: Current lEtuuaepts in Rehabilitaliun uf Retatur Cuff Pathulegj': Hullsurgieal anid Pastuperafive Cuneitlerafiuns

lube Exercises
Prune herizental abductien {Figure 11}, prune extensien
{Figure 12}, and prune external rcntaticrn with 90" Df ab—
ducticnn [Figure 13], ccnn‘u'nunljrr referred tn as Jebe exercis-
es, have been studied extensivelyF since their intreduetinn
in 1.932.” Extensive EMS and research analysis have
been performed c-n these movement patterns {exercises},
the exact pnsitien hi the extremity {thumb peinted eutif
in and su furth}, and their inherent activatitin levels bf the
rc-tatcir cuff and surrciunding musculaturefiL‘I'“ These
exercises celleedvelv repnrt high levels ef EMG aetivatinn
in the retatur cuff including the supraspinatus while de—
creasing the level cif activatinn ef the surrounding delteid
and upper trapezius t minimize fll' quiet cumpensaticln.

ueueuuqeuaa :1:-
Additicunallv, a lbw-lead, high-repetiticm format is used
and recummended te decrease large muscle recruitment
during humeral rcitatic-n anch'ur rc-tater cuff exercises.”

Additienal Cencepts ef Exercise for Retater Cuff

Pathelugy
The ll] upper extremity,r exercises described fer rehabil-
itatinn exercises ef the shnulder enmplex should be per-
farmed using the fulluwing guidelines tn establish the
fuundaticm bv wurlcing each link in the kinematic chain.
h; J
The American Enllege ef Sperts Medicine and ethers“
previde guidelines for designing exercise pregra ms based
Figure 5 Fhetegraph clemnnstrates rubbery exercise.
cm mere than Tflflr references. The American |Crsllege ef

a
Figure ti A and B, Phciteg raphs clemenstrate lavvn mevver exercise using an elastic band.

IE! lfllfi American Academyr ef flrthepaeclic Surgeens Drthepeedic Knuwledge Update: Sperts Medichie 5 ®
 Seeticin 4: Rehabilitation

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Figure }' A and B, Phntctgraphs demenstrate external retaticm with retractien using an elastic band.

Figure B i-tegraph demonstrates standing external

retaticm using an elastic band with a tbwel rclll Figure 9 F'hntcrg raph demnnstrates sidelying external
placed under the arm. ratatien with a hand held weight while lying en
the left side.

Sperts Medicine and anthers“? recpmmend training 3 tn

4 days per week with a day at rest and reccwerjr between
resistance training wnrkeuts. Patients whe are untrained
shbnld perfc-rm ene set c-f exercises; patients when are
trained sheuld perfcrrm three sets tn bptimiae gains in
tetal werlr, peak terqne, and average pnwer.“
Ten repetitiens per set is the eptimnm number tn in—
crease strength in the beginning bf an exercise pregram. As
the exercise pregram pregresses, the specificityr bf 1Irctlume
at training {the specific needs and functienal demands cf
the patient} determines the number pf repetitiens. The
retatcrr cuff muscles are prednminantl},r fast-twitch muscle
fibers; therefnre, it is impertant tn exercise the muscles
when apprepriate based en clinical cenditiens. Te recruit
the fast-twitch fibers, bne must exercise at least 50% at

firthnpaedic Knewledge Update: Sparta Medicine 5 fl lflld American Academy at Cirrhepaedic Surge-ens
 Chapter 13: Current Concepts in Rehahflitafiun crf Retater Cufi Pamelugy: Hensurgieal and Pastuperafive Censiclerafiens

:5
Figure 11 Phetegraph demenstrates prc-ne herizc-ntal
Phategraph demenstrates external retaticln abducticsn with a handheld weight.

uvevauavuas :s-
with Bu“ ef alscluctic-n in the scapular plane
using an elastic band.

Figure 12 Phatagraphs demenstrate prene extensictn with a handheld weight.

the maximal veliticmal centracticm er repetitien maxi—

mum.” The resistance sheuld be established at 60% re
BITE;- ef the subject’s ace-repetitian maximal centractien,
allewing the subject ta cemplete the exercises threugh full
range at matic-n {RUM} witheut deviating frem cc-rrect
technique. The UMHI-Resistauce Exercise Scale can he
used as a guideline fer the patientsii'r“ {Figure 14}. The
patients sheuld use a superset farmer in which the agenist
muscle is trained fuller-wed immediately by the antagenist
muscle. Supersets were used to impreve muscle balance,
save time in the clinic, and previcle the muscle with re- Figure 13 Photograph clemenstrates prune external
cevery time ta achieve efficiency ef werkuuts. retaticrn with 9d“ at abductien with a hand—
After the basic exercises are performed to establish a held weight.
selid foundaticm, the advanced neurumuscular dynamic
stability and functienal exercises are perfermed. Numer— limited studies demtmstrate the effectiveness ef the pre-
eus descriptive articles exist in the literature; hewever, grams in a pruspective, systematic manner. Based an

IE! lfllfi American Academy at flrthepaedic Surgeens Drthepaedic Knuwledge Update: Sperrs Medichse 5
 Sectien 4: Rehabiflmfiuu

s n
[ill '7’
[I it
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II 1“

'1 s hard
W 3 II Semavhet
2 Sanewhat hard
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1's: a Elli)? systematic review, limited high-level evidence
supperts the effectiveness ef sente ef these advanced ' d.__._'

interventiens in rehabilitatien with patients.51 Plyemet-

ric exercises have been indicated in threwing athletes
te increase threwing velecity and beth cencentric and
eccentric strength;53 A recent EMG study“ quantified
the muscular activity ef plyemetric sheulder exercises
perfernted in 90" ef abductien that are cetnntenly used
in high-level rehabilitatien pregrams.” Finally, the use
ef isekinetic test results and training in sheulder reha-
bilitatien is supperted in the literature. An extensive
review en this tepic eutlined evidence-based training
paradigms, pepulatien-specific descriptive data, and ere
ercise pregressiens.55
Festeperative Cements
A 2012 research study cempared the increase in reta-
ter cuff repairs perferrned between 1995 and lflflfi and
identified natienal trends, including the increased num-
ber ef tetal retater cuff repairs as well as these that are
perfernted arthrescepicaliy (a EDD‘ih increase frem 1995
re Eflflfil.“ Pesteperative rehabilitatien cencepts {Figures
15 and 16} used by the anthers ef this chapter fellevving
arthrescepic retater cuff repair are listed in Table 1.
RUM Cencepts
Initial pestsurgical rehabilitatien fecuses en RUM te
prevent capsular adltesien while pretecting the surgically
repaired tissues. Seme pestsurgical pretecels have specific
ROM limitatiens that are applied during the first 6 weeks
ef rehabilitatien. Several basic science studies previde a
ratienale fer the safe applicatien ef glenehurneral jeint
Figure 15 Fhetegreph demenstrates the stemach rub
exercise.
RUM, specifically eutlining the nieventent‘s jeint excur-
siens and capsular lengthening that previde safe inherent
mnsiens in the repaired tenden. A 1001 cadaver medel ef
repaired 1 a l—crn supraspinatus tears studied the effects
ef humeral retatien RUM en the tensien in the supra-
spinatus in 30“ cf elevatien in the cerenal, scapular, and
sagittal pla nes.” lIEentpared with tensien in a pesitien ef
neutral retatien, external retatien ef 3D“ and till“ actually
resulted in decreased tensien within the supraspinatus
rnusculetendineus unit. In centrast, 3D" and 60" ef in—
ternal retatien resulted in increased tensien within the
supraspinatus tenden. Because mest patients are placed
in pesitiens ef internal retatien feiiewing surgery during
the immebilizatien peried, intents] sheulder retatien is
perferrned despite the increased tensien. In additien, the
tensile lead in the repaired supraspinatus tenden was
cempared in the cerenal, scapular, and sagittal planes
during humeral retatien simulatien. Substantially higher
leading was present in the supraspinatus tenden during
humeral retatien in the sagittal plane cempared with
beth the frental and scapular planes. Therefere, early
passive ROM sheuld be perfernted in the directiens ef

firthepaedic Knewledge Update: Sperts Medicine 5 fl lfllfi American Academy ef Urthepaedic Surge-ens
 lIIZhapter 13: {Jul-rent Enncepts in Rehabilitatinn nf Rntatnr Cuff Pathnlngy: Nunsurgical and Pnstnperafive Cnnsiderafinns
Figure 1E Phntngraph demnnstrates the sewing exercise.
bnth external and internal humeral rntatinn using the
scapular plane pnsitinn tn minimize tensile leading in
the repaired tendnn.
The effects nf passive mntinn nn tensile leading nf the
supraspinatus tendnn were alsn studied in lflflfi.“ Nn sub-
stantial increases in strain were fnund during the mnve-
ment nf crnss-arm adductinn in either the supraspinatus
nr infraspinatus tendnns at till“ nf elevatinn. Hnwever,
internal rntatinn perfnrmcd at 3C!“ and 60" nf elevatinn
placed increased tensinn in the inferinrmnst pnrtinn nf the
infraspinatus tendnn nver the resting nr neutral pnsitinn.
This study demnnstrated the impnrtance nf lcnnwing the
degree nf tendnn invnlvement and repair because pesteri-
nrly based rntatnr cuff repairs {thnse invnlving the infra-
spinatus and teres minnr} can be subjected tn increased
tensile lnads if early internal rntatinn is applied during
pnstnperative rehabilitatinn. Cnmmunicatinn between the
surgenn and treating therapist is nf vital impnrtance tn
ensure that nptima] RUM is perfnrmed fnllnwing repair.
Passive Versus Active—Assisted RUM
The prngressinn frnm passive RUM applicatinns tn ac—
tive-assisted and active RUM is impnrtant in the early
IE! Ellie? American Academy nf Urthnpaedic Snrgenns
stages nf rehabilitatinn fnllnwing arthrnscnpic rntatnr
cuff repair. Snme disagreement amnng clinicians exists
regarding the amnunt nf muscular activatinn nccurring
during activities cnmmnnly used fnr rehabilitatinn. A
1993 study clearly delineated the degree nf muscular ac-
tivatinn nf the supraspinatus during supine assisted RUM
and seated elevatinn with the use nf a pulley.” Althnugh
bnth activities prnduce lnw levels nf inherent muscular
activatinn in the supraspinatus, the upright pulley activity
prnduces substantially mnre muscular activity than the
supine activities. The delay in upright pulley nr active-as-
sisted elevatinn exercises is present in several prnminent
rehabilitatinn prntncnls that inherently use nnly passive
RUM in the initial 6—week perind fnllnwing surgery.Efl Tn
truly minimise muscle activatinn, RUM pcrfnrmed by
uvsexuqvuas :v
a physical therapist with the patient supine is indicated
based en the results nf the 1993 study.”
The levels nf muscular activatinn during the IUndman
pendulum exercise have been quantified in a study that
shnws minimal levels nf muscular activatinn in the rnta-
tnr cuff musculature.“ Hnwever, the exercise cannnt he
cnnsidered passive because the musculature is truly acti-
vated, especially in individuals with shnulder pathnlngy.
In additinn, althnugh many therapists dn nnt recnmmend
bnlding a weight in the hand during pendulum exercises tn
avnid pntential anterinr tra nslatinn, activity in the rntatnr
cuff musculature was nnt changed between performing
the pendulum exercise with nr withnut a handheld weight.
A mnre recent study measured supraspinatus and in—
fraspinatus EMG activity in patients perfnrming a series
nf early rehabilitatinn exercises fnllnwing subacrnmial
decnmpressinn and distal clavicular resectinn.f1 These
exercises included therapist-assisted external rntatinn and
elevatinn perfnrmed in the supine pnsitinn, patient-assist-
ed external rntatinn and elevatinn perfnrmed in the supine
pnsitinn, as well as pulleys, table flexinn, and scapular
retractinn exercises. EMU activity during these early re-
habilitatinn exercises was cnmpared with baseline levels
[standing at rest} in the infraspinatus and supraspinatus
muscles. The findings shnwed nn difference between ther-
apist-assisted external rntatinn and elevatinn and baseline
activity in the supraspinatus and infraspinatus. Pendulum
exercises were alsn nnt different frnm baseline EMG levels
in thnse muscles. This study suppnrted therapist-assisted
external rntatinn and elevatinn fnr patients fnllnwing
shnulder surgery because the level nf muscular activity
inherent in these maneuvers facilitates early jnint mutinn
and mnbilixatinn withnut mu sculntendinnus unit activa-
tinn abnve baseline {standing pnsture} levels.
Rehabilitatinn in the first 2 tn 4 weeks fnllnwing rn-
tatnr cuff repair typically cnnsists nf truly passive and
several minimally active nr active-assisted exercises fnr the
Urthnpnedic Knnwledge Update: Spnrts Medicine 5
 Section 4: Rehabilitation

-—
Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair of a Medium-Size Tear
General Guidelines
Progression of resistance exercise and ROM depends on patient tolerance.
Resistance exercise should not he performed with specific shoulder joint pain or pain over the incision site.
A sling is provided for support as needed with daily activities and to wear at night. The patient should be
weaned from the sling as tolerated and under the direction of the referring surgeon.
Early home exercises given to the patient following surgery should include stomach rubs {Figure 15}. sawing
{Figure 15}, and distal gripping activity.
Progression to assisted Hfllvl against gravity and duration of sling use is determined by the size of the rotator
cuff tear and the quality of the tissue and fixation.

i: Postoperative Weeks 1 and 1

.E
4.!
I'll
Early postoperative Rfllvl to patient tolerance during the first 4 to 6 weelcs
:
E Flexion
I'fl
.: Scapular and coronal plane abduction
fill
a:
1's: IHIER with 9D“ to 45" abduction as tolerated
Mobilization of the glenohumeral joint and scapulothoracicjoint. Passive stretching of elbow. forearm. and
wrist to terminal ranges.
Side-lying scapular protractionlretraction resistance to encourage early serratus anterior and lower trapezius
activation and endurance.
Home exercise instruction:
Postoperative and active-assisted HUM exercises with T-har, pullfiyfi. or opposite-arm assistance in sUpine
position using HUM to patient tolerance.
Weight-bearing {closed chain} Codman exercise over a ball or countertoprtable
Therapeutic putty for grip strength maintenance

Postoperative Week 3
Continue above-shoulder ROM and add isometric strength program (IRIEH in neutral} to patient tolerance.
Begin active scapular strengthening exercises and continue side-lying manual scapular stabilization exercise:
Scapular retraction
Scapular retraction with depression
Begin submaximal rhythmic stabilization using the balance point position {9W to 1'30" elevation} in supine
position to initiate dynamic stabilization.
Ell = external rotation. In = intee rotation. HUM = range of motion.

rotator cuff such as active-assisted elevation and pendu-
lum exercises. The balance point position [9'3“ of shoulder
elevation in the scapular plane} in the supine position is
also used: the patient is queued to perform small active
motions of flexionfextension from the El)“ starting posi-
tion to recruit rotator cuff and scapular muscular activity.
These exercises, coupled with early scapular stabilization
via manual resistance techniques emphasizing direct hand
contact on the scapula to bypass force application to
the rotator cuff and optimize trapezius, rhomboid, and
serratus anterior muscular activation, are recommended.
Early scapular stabilization exercises have also been
advocated using EMG quantification of low-level closed
chain exercise such as weight shifting on a rocker
boardfiiri‘3 The low levels {a 10%} of activation of the rota-
tor cuff ancl scapular musculature during application were
highlighted as well as several exercises such as robbery
and the low row, which produce low to moderate levels
of scapular stabilizer activation while not placing the
shoulder with a repaired rotator cuff in harmful positions.

firthopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons
 lIIZhapter 13: {Jul-rent Concepts in Rehabilitation of Rotator Cufi Padlology: Nonsurgieal and Postoperative Considerations

Table 1 rrr —
Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair of a Medium-Size Tear
Postoperative Weeks 5 and E
Initiate isometric and isotonic resistance exercise focusing on the following movements:
Standing IRIEP. isometric step-outs with elastic resistance
Sidelying EH
Prone extension
Prone horizontal abduction [range limited to 45'; 3 weeks postoperative}
Side-lying flexion to SD“
A. low-resistancei'high-repetition {for example, 30 repetitions} format is recommended initially using no
resistance {such as the weight of the arm}.
Progression to full postoperative and assisted RDM in all planes including ER and IR in neutral adduction,

uarlesrqeuaa :1:-
progressing from the 91]“ abducted position used initially postoperatively.
EH oscillation [resisted ER with a towel roll under axilla and a body blade or flexion bar}
Home exercise program for strengthening the rotator cuff and scapular musculature with isotonic weights
andfor elastic tubing.

Postoperative Week 111

Begin closed chain step-ups and quadruped rhythmic stabilization exercise.
Initiate upper extremity plyometric chest passes and functional two-hand rotation tennis groundstroke or golf
swing simulation using small exercise ball progressing to light medicine ball as tolerated.

Postoperative Week 12
Initiation of submaximal isokinetic exercise for IHrER in the modified neutral position.
Criterion for progression to isokinetic exercise:
Patient has IRrER REM greater than that used during the isokinetic exercise.
Patient can complete isotonic exercise program pain—free with a 2- to 3-lb weight or medium resistance
surgical tubing or elastic band.
Progression to 90" abducted rotational training in patients returning to overhead work or sport.
Prone EH
Standing EHIIH with Sfi‘ abduction in the scapular plane
Statue of Liberty {El-l oscillation in the SDISD position}
Reevaluation of strength with isometric IHIEH strength [at sidE}. goniometric HUM {active and passive ROM],
and functional outcome measures

Postoperative Week 15
Progression to maximal isokinetics in IHrEH and isokinetic test results to assess strength in modified base
SWEDISH position. Formal documentation of assisted RUM, postoperative REM, and shoulder rating scales.
Begin interval return programs if following criteria have been met:
IHIEH strength at minimum of 35% of contralateral extremity
t'lfl ratio is 50% or higher
Pain-free RUM
Negative impingement and instability signs during clinical examination
Preparation for discharge from formal physical therapy to home program phase
EH - external rotation. In - internal rotation. HUM - range of motion.

IE! Eillfi American Academy of flrthopaedic Surgeons Drtbopaedic Knowledge Update: Sports Medicine S
 Section 4: Rehabilitation
Resistance Exercise
The progression to resistance exercise for strengthening
the rotator cuff and scapular musculature typically occurs
in an interval of approximately 6 weeks following sur-
gery. The time for initiation of resistance exercise varies
substantially'i'l“ and is based on several factors including,
but not limited to, tear size, tear type, tendon retraction,
tissue quality, fatty infiltration, concomitant surgical pro-
cedures, patient health status, and age. Communication
between the referring surgeon and physical therapist is
critical to ensure information is shared regarding fixation
limitations, tissue challenges, andfor other concomitant
i:
relative factors that would limit the progression of posts
.E
4.! surgical rehabilitation.
The clinical application of resistance exercise during
I'll
:
E
I'fl this critical stage of rehabilitation should be guided by
.i:
ll
o: both the literature detailing the level of muscular activity
1's: within the individual muscles of the rotator cuff and scap-
ular stabilizers and the patient’s demonstrated exercise
toleranee.31~“~3?~‘"~”~54 The application of low resistance
levels used in a repetitive format are recommended both
for safety and relative protection of the repaired tissues
as well as to improve local muscular endurance. Multiple
sets of 15 to 20 repetitions have been recommended and
described in several training studies to improve muscu—
lar strength in the rotator cuff and scapular stabilizing
musculature.”EH Exercise patterns that use shorter lever
arms and maintain the glcnohumcral joint in positions less
than 9d“ of elevation and anterior to the coronal plane
of the body {such as the scapular plane} are theorized to
reduce the risks of both compressive irritation and capsu-
lar loadingfattenoation.“ In addition, early focus on the
rotator cuff and scapular stabilizers without emphasis on
larger, primary muscles such as the deltoid, pectorals, and
upper trapezius are recommended to minimize joint shear
and inappropriate arthrolcincmatics as well as optimizing
externali'internal rotation muscle balance.”
fine specific exercise that has been described extensively
in the literature is the empty can exercise: scapular plane
elevation with an internally rotated {thumb pointed down}
arm position. Although EMG studies have shown high
levels of supraspinatus activation during the empty can
exercise,“~m*“ the combined movements of elevation and
internal rotation have produced clinically disappointing
results in practical application as well as common patterns
of substitution and improper biomechanical execution.
A 2'306 study quantified these compensations objectively
and showed increases in scapular internal rotation and
anterior tilting when comparing the empty can and full can
[scapular plane elevation with external rotation) exercises
using motion analysis.41 Movement patterns characterized
firthopaedic Knowledge Update: Sports Medich'ie 5
by scapular internal rotation and anterior tilt theoretically
decrease the subacromial space and could compromise the
ability to perform repetitive movement patterns required
to improve strength during shoulder rehabilitation.
Progression to Functional Activities
The patient evaluation used to determine return to func-
tional and recreational activities requires reexamination
of clinical test results, objective determination of RUM
and muscular strength, and the ability to simulate func-
tional movement patterns without symptoms or unwant-
ed compensatory movement deviations. Progression to
advanced strengthening exercises, including isolcinetic
training, emphasizes the movement of internal and exter-
nal rotation, which prepares the patient for the increased
loading and faster angular joint movements inherent in
most functional activities.-"5 The contralateral extremity
is used as the baseline for most patients and allows a
meaningful comparison of postsurgical ROM and mus—
cular strength. Although the goal is a full return of both
passive and active RDM as well as muscular strength
and endurance, these indices cannot always be measured
during the initial length of many rehabilitation programs.
Formal rehabilitation should restore 35% to MW: of co-
tational strength compared with that of the contralateral
uninjured extremity, as well as muscular balance repre-
sented via an externali'internal rotation strength ratio of
at least 60% {65% to 735% is the preferred ratio}, before
recommending the patient return to functional activities
such as upper extremity sports and aggressive activities
of daily living. In addition, clinical impingement and
instability signs should also be eliminated before higher
level activities can be recommended.
Short-term follow-up of patients for 12 weeks follow-
ing both mini-openfij and arthroscopic“1 rotator cuff re-
pair shows the return of almost full active and passive
ROM, with deficits in muscular strength ranging from
1G% to EME- in internal and extemal rotation compared
with the uninjured extremity. Greater deficits following
both mini-open and arthroscopic rotator cuff repair have
been reported in the posterior rotator cuff {external rota-
tor musclcsj despite emphasis placed on these structures
during postsurgical rehabilitation.
Early lv‘ersus Delayed Hfll‘v'l: Effect on Dutcome
Early versus delayed RUM is likely one of the areas
of greatest controversy and variation in rehabilitation
following rotator cuff repair. Given the increase in the
numbers of arthroscopic rotator cuff repairs being per—
formed, rehabilitation professionals and surgeons have
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 13: Current Ueneepts in Rehabilitaliee ef Retater {Sufi Pamelegy: Heesurgieal and Pusteperative Censideratiens
been investigating this particular issue fer seme time. A
systematic review in 2009” feund insufficient evidence te
previde an evidence—based cenclusien er recemmendatien
regarding immebilisatien versus early passive RUM fer
retater cuff repair rehabilitation.“
Five randemised centrelled trials {RCTs} have been
published cemparing early passive RUM te sling imme-
bilisatien fellewing arthrescepic retater cuff repair?“-Til
PL meta—analysis identified the impertant findings frem
these RCTs fer clinical applicatien.” Advecates ef early
passive RUM fellewing surgery cite the must cemmen
cemplicatien fellewing arthrescepic retater cuff repair
{pesteperative stiffness} as the primary ratienale fer early
mebilisatien and mevement;fulfil eppenents cite the high
incidence ef re-tearff-HE' The meta-analysis” shews that
early pesteperative passive RUM results in substantial
increases in sheulder flexien at 3, 6. and 12 menths after
surgery cempared with immebilisatien. External retatien
RUM alse increased acress the early passive RUM greups;
hewever, this increase was enly significant at 3 menths
after surgery. Perhaps mest impertant, early passive RUM
did net result in increased retater cuff re-tear rates at a
minimum fellew—up ef 1 year. The studies included in this
analysis excluded massive retater cuff tears. A Hill study
alse excluded retracted tears and these that extended
heyend a single tenden.“
These results indicate that early passive RUM is net
a risk facter fer increased re-tear rates fellewing arthre-
scepic retater cuff repairs. The early metien perfermed
in these studies included pendulum exercises and manual
passive RUM perfermed by a physical therapist. A 2fl13
study shewed that therapist-assisted passive RUM dees
net preduce EMG activity in the supraspinatus and infra-
spinatus abeve baseline levels {pestural standing at rest}.fl
This finding, ceupled with the results ef increased RUM
in elevatien and external retatien in the meta-analysis.”
supperts the use ef early passive RUM fellewing retater
cuff repair.
A 2-311 study applied a medified early RUM pretecel
in “F9 patients with identified risk facters fer stiffness
fellewing arthrescepic retater cuff repair.“I These risk
facters included calcific tendinitis. partial articular supra-
spinatus tenden avulsien lesiens, cencemitant superier
labrum anterier te pesterier repairs, preeperative adhe-
sive capsulitis, and singleutenden retater cuff repairs. The
pretecel included patient—directed RUM with a polyvinyl
chleride bar as well as the use ef table slides perfermed
in a seated pesitien next te a table tep. Ne patient ex—
perienced any pesteperative stiffness with the medified
treatment pretecel fellewing retater cuff repair, and an
early metien pretecel is advecated fer patients fellewing
retater cuff repair.
IE! lfllfi American Academy ef Urthepaeclic Snrgeens
It is imperta nt te review the current cencepts and evidence
regarding key elements ef rehabilitatien fer retater cuff
pathelegy. The benefits and indicatiens fer RUM and
retater cuff and scapular strengthening ferm the primary
fecus ef rehabilitatien efferts presently recemmended
and supperted in the current literature. Further research
is always needed and is indeed ferthceming regarding
greater delineatien ef the specific parameters and char-
acteristics ef exercise interventiens as well as additienal
randemised clinical trials te develep eptimal pretecels fer
rehabilitatien ef the patient with retater cuff pathelegy.
Hey Study Feints
usssaussuaa:s
I Retater cuff rehabilitatien invelvcs specific appli-
catien ef Exercise interventiuns that activate the
retater cuff and scapular musculature at high levels
witheut placing the cuff in pesitiens er mevement
patterns that premete impingement er instability.
I It is imperative that beth nensurgical and pest-
eperative retater cuff rehabilitatien begin with a
key feundatien ef scapular stabilisatien exercises.
1iWeakness er dykinesis ef the scapula is a cemmen
clinical finding in patients with retater cuff diser-
ders, and early rehabilitatien and emphasis en the
serratus anterier and lewer trapezius ferce ceuple
is recem mended.
e Pesteperative retater cuff rehabilitatien begins with
early passive range ef metien te pretect the repair
while preventing the develepment ef pesteperative
stiffness, fellewed by scapular stabilizatien exercise
and finally retater cuff strengthening te restere full
active metien, muscular strength, and endurance.
shaneHsHEHflsefenences
1. Picavet HS, Scheuten J5: Musculeskeletal pain in
the Netherlands: Prevalences, censequences and risk
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3. Jebe PW, Kvitne RS, Giangarra CE: Sheulder pain in the
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This study supports the use of exercise and manual ther-
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4.! evidence: IV.
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:
E 15. Grant H], Arthur A, Pichora DR: Evaluation of inter-
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sual analog scale pain ratings showed that arthroscopic
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impingement.
1D. McClure PW, Eialker J, Neff bl, Williams G, Karduna A:
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This review of 11 RCTs focused on the effect of exercise
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the studies showed that exercise had a substantial effect
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and increasing strength.
14. Desmeules F, care CH, FnEntont P: Therapeutic exer-
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vEntions for shoulder pain. Cochrane Database Syst Rev
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Manual therapy did not provide an additional benefit
scientifically to exercise in patients with rotator cuff pa-
thology. Level of evidence: 1a.
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exercise in shoulder rehabilitation concluded that exer—
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the improvement of function in patients with shoulder
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fects of Theraband and lightweight dumbbell training on
D 211115 American Academy of Orthopaedic Surgeons
 Chapter 13: Current fleecepts in Rehabilitalien ef Retatur Cuff Patbelegy: Nunsurgical and Pustuperalive Censiderafieus
sheulder retstieu terque and serve perfertuance in cellege
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scapular centre] in early phases ef sheulder rehabilitatien.
Am I Seer-rs Med 2fl03;36i9i:l?89-l?93. Medline DUI
26. Will: KE, Yenchalc A], Attige CA, findtews jE: The Ad-
vanced Threwets Ten Exercise Pregram: :5: new exercise
series fer enhanced dynamic sheulder central in the ever-
head threwing athlete. Phys Sperrsmed 2011:39i4i:9fl-9?.
Medline DUI
This cemmentaty included advanced sheulder exercises
fecusing en bilateral upper extremity perfermance and
use ef a physie hall te impreve sheulder activatien and
previde a training stimulus te ptegtessively impteve sheul-
der strength and endurance. The exercises previded can
be incerperated inte advanced rehabilitatien pregrams
fer patients with sheulder pathelegy. Level ef evidence: V.
3?. Decker M], Hintermeister RA, Faber K], Hawkins R]:
Settatus anterier muscle activity during selected rehabil-
itatien exercises. Am I Sperts Med 1999;1Ti6}:?34-?91.
Medline
23. Tsuruilce M, Ellenbeclter TS: Setratus anterier and lew-
er trapezius muscle activities during multi-jeint isetenic
scapular exercises and isemetric centractiens. ] ms: Tree:
2015;50{2}:199-21fl.Medline DUI
This study previded EMG analysis ef several key scap-
ular exercises used in rehabilitatien ef sheulder patients
including a quadrupecl arm elevatien, rehhery, and lawn-
mewet exercises. The interactiens ef exercise intensity
with external leading and muscle activatien ef the serratus
anterier and lewer trapezius are previded in this clinically
applicable study. Level ef evidence: lIEtess-sectienal lab-
eratery study.
29. McCabe RA, Dtishime KP, McHugh MP, Nichelas 5]:
Surface electremygtaphic analysis ef the lewer trapezius
muscle during exercises perfermed helew ninety degrees
ef sheulder elevatien in healthy subjects. N Am I Sperts
Phys Ther lfifl?;2(1):34-43. Medline
ID EDIE American Academy ef Drthepaeclic Surgeens
30. Ellenbeclter TS, Ceels A: Rehabilitatien ef sheulder im-
pingement syndreme and retater cuff injuries: An evi-
dence-based review. Br J Sperts Medr 2D1fl:44{5):319-321
Medline DUI
This paper reviews evidence fer the treatment ef retater
cuff pathelegy. Detailed reviews ef therapeutic exercise,
manual therapy including retater cuff strengthening, and
scapular stabilisatien are previded. Exercises that premete
activatien ef the lewer trapezius and serratus anterier in
additien te retater cuff activatien are recem mended and
summarized. Level ef evidence: V.
31. Andersen CH, Zebis MK, Saervell C, et al: Scapular
muscle activity ftem selected strengthening exercises per-
fermed at lew and high intensities. I Strength Cend Res
2011;26f9]:24fl3-2415.Medline eel
This study analyzed EMG activity between the upper
usesuuavues :1:-
and lewer trapezius musculature under Berg scale 3 and
E cenditiens. Increased lewer trapeeius activatien and
reduced upper traperius activatien was feund with lewer
intensity exercises fer scapular stabilisatien {Berg scale 3}
cempared with higher intensity exercise. This study has
impertant clinical applicatien fer therapists designing
eptimal ptegrams fer patients with sheulder pathelegy.
Level ef evidence: Centrelled laheratery study.
32.. Reineld MM, Will: KE, Fleisig GS, et a1: Electremye-
graphic analysis ef the retater cuff and delteid mus-
culature during cemmen sheulder external retatien
exercises. J Drthep Sperts Phys Ther 2DM;34{?}:335—354.
Medline DDI
33. Hintenneister RA, Lange 5W, Schultheis JM, Bey M],
Hawkins R]: Electtemyegtaphic activity and applied lead
during sheulder rehabilitatien exercises using elastic re-
sistance. Am I Sperts Med 1 993;26{2J:210-220. Medline
34. Rathbun JB, Macnah I: The micrevascular pattern ef the
retater cuff. ,i Bese Jeinr Surg Br 19?fl;52[3}:54fl-553.
Medline
35. Biberthaler P, 1liiii'iedemann E, Nerlich a, et al: Micrecir-
culatien asseciated with degenerative retater cuff lesiens.
In vive assessment with erthegenal pelarixatieu spectral
imaging during arth rescepy ef the sheulder. ] Herve jer'ut
Surg Am Eff-[13:35 -fi{3}:4?5 "430. Medline
36. Saha AK: The classic. Mechanism ef sheulder mevements
and a plea fer the recegnitien ef “zete pesitien" ef glene-
humeral jeint. Cffrr Urtfsep Ref-st Res 1933;1T3:3-1fl.
Medline
3?. Reineld MM, Macrina LC, Will: KE, et al: Electremye-
graphic analysis ef the suptaspinatus and delteid muscles
during 3 cemmen tehabilitatien exercises. I Ash-f Tfflffl
Zflfl?;42{4}:464a469. Medline
33. Ilflraichen H, Hinterwimmer E, ven Eisenhart-Rethe R,
1|lifegl T, Englmeier KH, Eclcstein F: Effect ef abducting and
adducting muscle activity en glenehumeral translatien,
scapular kinematics and suhacremial space width in vive.
J Biemeef: 2005;33H}:T55-T6fl. Medline DIDI
Drthepeedic Knewledge Update: Sperrs Medicine 5
 Sectien 4: Rehabilillutiuu
3.9. Hinterwimmer 5, Men Eisenhart-Rethe R, Siebert M, et
al: Influence ef adducting and abducting muscle furces
en the subacremial space width. Med Sci Sperts Eaters
Eflfl3;35{11k2f155-2fl59.Medline DUI
4|]. Jebe PW, Meynes DR: Delineatien ef diagnestic criteria
and a rebabilitatien pregram fer retater cuff injuries. An:
I Sperts Med 1932:1fl{51:336-339. Medline DUI
41. Tewnsend I-I,]ehe FW, Pink M, Perry]: Electremyegraph-
ic analysis ef the glenehumeral muscles during a baseball
rebabilitatien pregram. Ant ] Sperts Med 1991,11 9f3]:164-
EFL Mfidllnc DUI
41. Thigpen CA, Padua DA, Mergan bl, Kreps E, Karas
EU: Scapular kinematics during supraspinatus rehabil-
i: itatien exercise: fl cemparisen ef full-can versus emp-
.E
4.!
ty-can techniques. Ant ] Sperts Med 1DDE;34{4}:644»551.
:
I'll
Medline DUI
E This systematic review identi fied 2U RCTs that supperted
I'fl
.: 43. Takeda Y, Kasbiwaguchi S, Ende K, Matsuura T, Sasa T:
all
u: The mest effective exercise fer strengthening the supraspi-
I'd narus muscle: Evaluatien by magnetic resena nce imaging.
Am I Sperts Med lflfl1;3l}{3}l:3?4-331. Medline
44. Balla ntyne ET, U‘Hare S], PaschallJL, et al: Electremye-
graphic activity ef selected sheulder muscles in cemmenly
used therapeutic exercises. Phys Ther- 1 993;?3{1fl]:663-
EFT, discussien GIFT-632. Medline
45. Alpert 5W, Pink MM, Jebe PW, McMahen P], Mathiya-
kem W: Electremyegraphic analysis ef delteid and retater
cuff functien under varying leads and speeds. }' Shenfder
Efbew Snrg lflfl U;9I{I}:4?—53. Medline DUI
4E. Bitter HL, Clisby EF, Jenes MA, Magarey ME, Jaber—
aadeh 5, Sandew M]: Relative centributiens ef infra-
spinatus and delteid during external retatien in healthy
sheulders. I Shenfder Efbew Snrg EDDT;IE{S}:d-563.
Medliue DUI
47-". llilarrell T], Abernethy P], Legan PA, Barber M, McEniery
MT: Resistance training frequency: Strength and myesin
heavy chain respenses te twe and three heuts per week.
Eur 1 App! Pbysfef Uccup Pbysfef 1993;?3l3}:2?fl-2TS.
Medline DUI
43. Durrall C, Hermsen D, Demutb C: Systemic review ef sin-
gle-set versus multiple-set resistance— training randemiaed
centrelled trials: Irnplicatiens fer reha bilitatien. Crit Rev
Plays Refrebff Med Efl06;13f2}:IDT-IIE. DUI
49. Levering RM, Russ DW: Fiber type cempesitien ef cadav-
eric human retater cuff muscles. I Urtfaep Sperts Phys
Ther lflfl3;33{11}:ET4-6flfl. Medline DUI
5t}. Celade JC, Garcia-Masse H, Triplett TN, Flandes J, Eur-
reani 5, Tella V: Eencurrent validatien ef the UMI‘ILresis-
tauce exercise scale ef perceived exertien with Theta-band
resistance bands. I Strengtil'lI [Tend Res 1fl11;16{11]:3fl13-
Sill-4. Medline DUI
Urthepaedic Knewledge Update: Sperta Medichie S
This study validated using the DMNI—Resistance Exer-
cise Scale te ebjectively evaluate exercise intensity using
a visual scale. This allews clinicians te accurately under-
stand the exercise intensity free: the patient fer eptimal
resistance exercise pregressien and strength develepment.
51. Eelade JC, lI'.'.iarcia-I'vfasse K, Triplett NT, et al: Censtruct
and cencurrent validatien ef a new resistance intensity
scale fer exercise with theta-bandlfil elastic bands. I Sperts
Sci Med 2014513I41:?53-?66. Medline
This study fecused en the use ef elastic resistance using
a validated pregressien ef celer-based elastic bands and
cencemitant exercise intensity.
52. Zech A, Hubscher M, Vegt L, Bearer W, Hansel F,
Pfeifer K: Neuremuscular training fer rebabilitatien ef
spurts injuries: A systematic review. Med Sci Sperts Exerc
lflfl9:41{10}:1331-134I.Medline DUI
the use ef balance training and preprieceptive training
te impreve neuremuscular centre] in patients with er-
thepaedic injuries. This study supperts the current use
ef preprieceptive exercise interventiens and prevides key
ebjective evidence fer its inclusien in rebabilitatien pre-
grams. Level ef evidence: Systematic review.
53. Carter RB, Kaminski TW, Deuex AT Jr, Knight CA,
Richards JG: Effects ef high velume upper extremity
plyemetric training en threwing velecity and functienal
strength raties ef the sheulder retaters in cellegiate base-
ball players. ] Strength Cend Res lOfl?;21(1}:2fl3—115.
Medline DUI
S4. Ellenb-edcer TS, Sueyesbi T, Baille D5: Muscular activatien
during plyemetric exercises in 9D” ef glenehumeral jeint
abductien. Sperts Heuftf: EDIS;?{1}:?5-TR Medline DUI
This study analyzed the EMU results ef [we plyemetric ex-
ercises perfermed in 913" cf glenehumeral feiut abductien,
which had high activatien levels ef the infraspinatus, lewer
trapezius, and serratus anterier. [LS- and l-kg exercise
leads were used. These exercises are recemmended fer
clinical use te increase retater cuff and scapular strength.
Leml ef evidence: |I'.'.‘entrelln.=:d laberatery study.
.55. Ellenhecker T5, Davies (3]: The applicatien ef isekinet-
ics in testing and rebabilitatien ef the sheulder cemplex.
j Athf Train Iflfll};35{3}:33fl—SSD. Medline DUI
56. Celvin AC, Egereva N, Harrisen Ali, Meskewits A, Fla-
tew EL: Hatienal trends in retater cuff repair. I Benejetnt
Snrg Ant Eflllgfl‘llfikllilfl.
This study analysed the number ef retater cuff repairs
between 1996 and lflllfi. A 141% increase was feund in
the number ef retater cuff repairs and a 600% increase
in the repairs perfermed arthrescepically were reperted.
5?. Hata keyama 't', Itei E, Urayama M, Pradban RL, Sate If:
Effect ef superier capsule and ceracehumeral ligament
release en strain in the repaired retater cuff tenden. A
cadaveric study. An: I Sperts Med lflfll;29{5}:633-64ll.
Medliue
D lflld American Academy ef Urrhepaedic Surge-ens
 Chapter 13: Current Concepts in Rehabilitation of Rotator Cuff Padaology: Nonsurgical and Postoperative Considerations
SS. Mural-ti T, Aoki M, Uchiyama E, Murakami G, Miyamoto
S: The effect of arm position on stretching of the supra-
spinatus, infraspinatus, and posterior portion of deltoid
muscles: .f'i. cadaveric study. Clin Biomeeb (Bristol, Arron)
lflfld;11{5}:4?4-4Sfl.Medline nor
59. McCann PD, 1illfootten ME, Kadaba MP, Bigliani LU: A
kinematic and electromyographic study of shoulder reha-
bilitation exercises. Cltn Grtbop Rer'nt Res 1993:ESS:ITS-
133. Medline
Si}. Koo SS, Parsley BK, Eurkhart SS, Schoolfield JD: Reduc-
tion of postoperative stiffness after arthroscopic rota-
tor cuff repair: Results of a customized physical therapy
regimen based on risk factors for stiffness. Arthroscopy
2fl11;2?{2}:ISS-ISD.Medline DUI
This case series studied 152 patients {152} who underwent
rotator cuff repair; T9 were at high risk for stiffness. Pa-
tients in this subgroup were given a table slide exercise in
addition to a standardised rehabilitation program. The
patients in this group did not develop stiffness and the
authors recommend this exercise for patients who are at
risk for stiffness following rotator cuff repair.
ISL Ellsworth Ah, Mulla ney M, Tyler TF, McHugh M, Hichv
olas S: Electromyography of selected shoulder musculature
during un-weighted and weighted pendulum exercises. N
Ant ,1 Sports Phys Ther Iflflti;1{2}:?S-TS. Medline
62. Murphy CH, McDermott W], Petersen RH, johnson SE,
Baxter SA: Electromyographic analysis of the rotator cuff
in postoperative shoulder patients during passive rehabil-
itation exercises. ] Shoulder Elbow Strrg 1fl13;12(1}:1i}1-
lfl'F. Medline DUI
This study examined 14 passive shoulder rehabilitation
exercises and compared them with baseline activity in
the shoulder 4 days following shoulder surgery using fine
wire electrodes. Exercises such as therapist-assisted supine
ROM and external rotation, pendulum exercises, and
isometric internal rotation created supraspinatus activity
level similar tn baseline. Actual levels were nut reported
but were measured relative to baseline activity. This infor-
mation provides key evidence for clinicians on early muscle
activation during passive exercises used following rotator
cuff repair. Level of evidence: EMG laboratory study.
63. Hibler WE, Livingston E, Bruce E: Current concepts in
shoulder rehabilitation, in Advances in Upsratr‘ee Ortho-
paedics .St Louis, Mushy, 1995, pp 249-293 vol 3.
I54. Wilk FEE, hrrigo C: lIL'Iurrent concepts in the rehabilita-
tion of the athletic shoulder. J Drtfrop Sports Phys Timer
1993;13(1i:3SS-3?S.Medline DUI
SS. Ellenbecker TS, Elmore E, Bailie D5: Descriptive report
of shoulder range of motion and rotational strength :5 and
12 weeks following rotator cuff repair using a mini—open
deltoid splitting technique. ] Urtirop Sports Phys Ther
20G6;36{Si:326-335.Medline DUI
66. Moncrief sa, Lau JD, Gale JR, Scott Sn: Effect of rota-
tor cuff exercise on humeral rotation torque in healthy
IE! Eillti American Academy of firthopaedic Surgeons
individuals. I Strength Bond Res lflfilflfitlflelvflfl.
Medline
6?. 1|Wang CH, McClure P, Pratt HE, Hobilini R: Stretching
and strengthening exercises: Their effect on three-di-
mensional scapular kinematics. Arch Plays Med Rehabil'
1999;BD[3}:913-919.Medli11e DUI
63. IEiannakopoulos K, Beneka A, Malliou P, Godolias G:
Isolated vs. complex exercise in strengthening the rotator
cuff muscle group. J Strength Cond Res lflfldflflilhfld-
143. Medline
65'. Lee SH, An RN: Dynamic glenobumeral stability provided
by three heads of the deltoid muscle. Clin Urthop Relat
Res 1Dfl1;4flfl:4fl—4?. Medline DUI
Ft}. Malanga GA, Jenp TN, Growney ES, Pin KN: EMG analy-
uneasiness-vs :r-
sis of shoulder positioning in testing and strengthening the
supraspinatus. Med Sci Sports Exere 1996;23lfil:fifil-664.
Medline DUI
3’1. Kelly ET, Kadrmas WR, Speer HP: The manual muscle
examination for rotator cuff strength. Pin electroluyo-
graphic investigation. Ant I Sports Med 1996;14iSlt531-
SSS. Medline DUI
"Tit. . Ellenbecker TS, Fischer DJ, Eeman D: Glenohumeral joint
range of motion, rotational isokinetie strength, and func-
tional self-report measures following All-Arthroscopic
rotator cuff repair.[flbstract]. } Urtbop Sports Phys Ther
2i] fltifi sueass.
T3. Baumgarten RM, Vidal AF, Wright REF: Rotator cuff
repair rehabilitation. A level I and II systematic review.
Sports Health ZflflftflillfllS-ISD. Medline DUI
This systematic review of rotator cuff repair rehabilitation
studies noted a paucity of evidence identified in high-level
studies. The use of continuous passive motion was not
supported by the literature by one study included in this
review. Level of evidence: I.
“F4. Arndt J, Clavert P, Mielcarek P, Eouchaib J, Meyer N,
Kempf JF; French Society for Shoulder Sc Elbow {SUFEC}:
Immediate passive motion versus immobilization after en-
doscopic supra spinatus tendon repair: A prospective ran-
domised study. Urtlrop Trnrrrnrttol Srrrg Res lflllflfllfi,
Suppl}:5131-5133.Medline DUI
This study analysed the effects of immediate passive RUM
following rotator cuff repair with complete immobilise-
tion for 6 weeks following surgery. Improved functional
results were found in the early passive RUM group without
decreases in healing. This study supports early passive
RUM following rotator cuff repair. Level of evidence: I.
3’5. Cuff D], Pupello DR: Prospective randomized study of
arthroscopic rotator cuff repair using an early versus de-
layed postoperative physical therapy protocol. }' Shorrfder
Effiote' Sttt‘g 2G13;21{11]:145fl-14SS. Medline DUI
This prospective, randomized controlled trial stud-
ied S3 patients who either started physical therapy on
Unbopaedic Knowledge Update: Sports Medicine S
 Sectinn 4: Rehabilillatitln
pnstnperative day 2 at were immnbilited and had RUM
initiated after *5 weeks. Nu significant difference was re-
pnrted between grnups in RUM, re-tear rates, and patient
satisfactinn at 1 year. Level nf evidence: 1.
5'6. Kim vs, Chung sw, Kim yr, D}: JH, Park 1, cs: JH: Is
early passive metinn exercise necessary after arthrnscnpic
rntatnr cuff repair? AmJSpni-ts Med lflll:40{4}:315-321.
Medline DUI
In this study, 1135 patients underwent arthrnscnpic rntatnr
cuff repair [excluding large and massive tears} and were
randnmised intn either an early RUM grnup with mntinn
three In four times per day while wearing an immnbiliaer,
nr iutc: a delayed mntinn grnup with up mntinn far 4 tn
5 weeks. RUM and VHS pain ratings were cnmpared at
1-year fnllnw-up and several either intervals and nu sub-
:: stantial differences were fnund between the twn grnups.
.E Early passive pcrstnpcrative RUM did nut prcducc greater
4.!
I'll
:I: RUM but alsn did net increase re-tear rates.
E In this review nf 345 patients whn underwent rntatnr cuff
I'fl
.: T1 Lee BIG, Che- NS, Rhee TE: Effect nf twn rehabilitatinn
fill
a: prntncnls cm range nf mntinn and healing rates after
if
arthrnscnpic rntatnr cuff repair: Aggressive versus limit-
ed early passive exercises. Arthrnscnpy 2012;23i1}:34—42.
Medline DD]
In this study, 64 patients were assigned tn either an ag-
gressive early mntinn and unlimited self-stretching grnup
nr a limited passive exercise grnup fnllnwing arthrnscnpic
rntatnr cu ff repair. Patients in the early mntinn grnup
shnwecl an early increase in shnulder ROM nver the limited
passive mntinn grnup. bin substantial difference was fnuncl
in RUM at 1—year fullnw up. He substantial difference in
restear rates was fnuncl berween the twc- grnups.
T3. KeenerJD, Galata Ll'vI, Stabbs—Eucchi G, Patten R, Ya-
maguchi K: Reha bilitatinn fnllnwing arthrnscnpic rntatnr
cuff repair: A prnspecn've randcrmized trial nf immnhiliaa-
tinn campared with early mntinn. } Enuefnint Snag Am
2fl14:9fifIJ:II'19. Medline DflI
In this study, 122 patients ynunger than 65 years under-
went arthrnscnpic rntatnr cuff repair and either underwent
a traditinnal rehabilitatinn prngram with early passive
ROM at were immnbilised far 6 weeks with us mntinn.
Nu lung-term differences were fnund in functinnal return,
REM, and strength between grnups and ma difference in
rntatnr cuff healing was seen between the two grnups.
Level nf evidence: I.
firthnpaedic Knnwledge Update: Spnrts Medicine 5
?9. Eibnh JCS, Garrigues GE: Early passive mntinn versus
immnbilizatinn after arthrnscnpic rntatcrr cuff repair. Ar-
throscnpy 2fl14;3fl{3}:99‘F—Iflfl5. Medline III-[III
This meta—analysis identified five RCTs nf early passive
REM fullnwing arthrnscnpic retatnr cuff repair. Imprnved
flexinn ROM was mated at 3 mnuths, E mnnths, and 12
months pnstnperatively. External rntatinn was nnly identi-
fied as superinr with early mntinn at 3 months. He differ-
ence was nnted in re—tear rates between early and delayed
passive RUM. Level nf evidence: II.
3f}. Brislin K], Field LI}, Eavnie FH III: Cnmplicatinns
after arthrnscnpic rntatnr cuff repair. Arthrnscnpy
lflfl?,23{11:114-113.Medline nca
31. Namdari S, Green Ft: Range nf mntinn limitatinn after rt:-
tatc-r cuff repair. I Shnafder tnw Sarg 2fl10;19{l}:19fl-
296. Medline DUI
repair, mean active fnrward flexinn was 90%, external
rntatinn was E3253, and internal rntatinu was 30% nf the
cnntralateral side at 3—mnnth fullnw-up. Patients with
restricted prenperative RUM were mnre likely tn have
limited RUM pnstnperative that was significant. |fil'nly 3
nf 4? patients whn had stiffness at 1 year required cap—
sular release.
32. Galatt LI'vI, Ball CM, cfey 5.5L, Middletnn WEI, Tamas
guchi K: The nutcnme and repair integrity nf cnmplete-
Iy arthrcrscnpically repaired large and massive rntatnr
cuff tears. j Base faint Snrg An: lflfl4:EE—A(2}:119—214.
Medline
33. Tashjian RE, Hnllins AM, Kim HM, et al: Factnrs affect—
ing healing rates after arthrnscnpic dnuble-rnw rntatnr
cuff repair. Am I Sparta Mad EflIfl;33{IZ}:2435-2442.
Medline [ll-DI
In this study, 49 shnuldcrs with full-thick ness rcrtatnr cuff
tears underwent arthrnscnpic dnu ble-rnw repair and were
evaluated fur tend-an healing at a minimum fi-mcmth ful-
lnw—np: at ultrasnnngraphic evaluatitm, 51% nf tendnns
were healed, tiF'if- nf single—tenders tears she-wed cnmplete
healing, and 36% nf multiple-tendnn tears shnwed healing.
Increased age and [anger fnllnw-up time were significant
factnrs fer healing Iimitatinns in this study.
fl lfllfi American Academy nf Urthnpaedic Surge-nus
Chapter 24
Nonsurgical and Postoperative
Rehabilitation for Injuries of
the Overhead Athlete’s Elbow
Iiievin E. Willi. PT. DPT. FAPTa Todd R. Hooks. PT. ATE. {DC-5. 5C5. NREMT—l. CECE. CMTPT. FAADMPT
Abstract
fiverhead athletes are subject to injuries at the elbow
joint as a result of high levels of forces imparted onto
the elbow during the throwing motion. Injuries can
be acute to the point of tissue failure, or chronic as a
result of repetitive overuse. It is imperative that the
restoration of elbow function is achieved to allow the
elbow to return to its prior level of function. Systematic
and progressive rehabilitation programs can help avoid
overstressing healing tissues. The treatment programs
are designed to restore full motion, muscular strength,
and endurance, and restore neuromuscular control.
Multiphased rehabilitation programs are designed to
restore function in the overhead athlete’s elbow and
include both nonsurgical and specific postoperative
pathologies of the overhead athlete.
Keywords: overhead athlete: ulnar collateral
ligament: elbow: rehabilitation
or. Will: or an immediate family member serves as a paid
consultant to LiteCure Medical. intelliSlrin, and Zetrfla;
serves as an unpaid consultant to Alter-‘3: has received
research or institutional support from lntelllsizin; and has
received nonincome support {such as equipment orservices},
commercially derived honoraria. or other non-research-
related funding {such as paid travel} from Educational
Grant, Bauerfeind. and ERMl. Neither lvh'. Hooks nor any
immediate family member has received anything of value
from or has steel: or steel: options held in a commercial
company or institution related directly or indirectly to the
subject of this chapter.
fl acne American Academy of Drrhopaedic Surgeons
uvsomqvuas :v
introduction
Elbow injuries are common in the overhead athlete
because of the repetitive nature of overhead sporting
activities. Elbow injuries have been reported to repre-
sent approximately 22% to 25% of all injuries in Ma-
jor League Baseball.“ The elbow extends at more than
23flflils during overhead throwing, which produces a
medial shear force of 300 H and a compressive force of
9th] H} These fumes impart a valgus stress of E4 I'll-mi
during the acceleration phase of throwing, which exceeds
the ultimate tensile strength of the ulnar collateral liga-
ment (UCL).
Throughout the throwing motion, several forces con-
verge at the elbow.3 During the acceleration phase of
throwing, valgus stresses at the elbow create tension
across the medial elbow, whereas compression forces are
applied to the lateral aspect of the elbow during this phase
of throwing.3 During the acceleration and deceleration
phases of throwing, the posterior compartment is subject
to valgus extension overload as a result of tensile, com-
pressive, and torsional forces that can cause osteophyte
formation, stress fractures of the olecranon, or physeal
injury.”
The rehabilitation program described in this chapter
uses a multiphased approach focused on returning the
athlete to the prior level of function via a systematic pro-
cess. This program is divided into four phases that are
designed to follow a gradual progression of exercises and
stresses applied methodically to restore strength, dynamic
stability, and neuromuscular control. The key to a success-
ful and effective treatment program is the identification
of each athlete’s causative factors, facilitating the design
of a specific treatment program to address these factors.
Guidelines for rehabilitation following elbow injury {Ta-
ble 1} and elbow arthroscopy {Table 2} are presented.
The postoperative rehabilitation programs for specific
pathologies and for surgical intervention also are included.
Drthopaeclic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation

-—
Nonsurgical Rehabilitation Program for
as.“ .-.......-.—..s..;. _
Nonsurgical Rehabilitation Program for
Elbow Injuries Elbow Injuries
I. Acute Phase {Week 1] Weeks 4-5
Goals: To improve motion, diminish pain and 1. Continue daily strengthening exercises, endurance
inflammation, retard muscle atrophy drills. and flexibility exercises.
Exercises 2. Continue Thrower's Ten Program.
1. Stretches for wrist, elbow, and shoulderjoint 3. Progress plyometric drills.
2. Strengthening exercises; isometrics for wrist, 4. Emphasize maintenance program based on
elbow. and shoulder musculature pathology.
3. Pain and inflammation control: cryotherapy. HUGS. 5. Progress swinging drills [for example. hitting}.
ultrasound. and whirlpool W
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4.!
II. Intermediate Phase [Weeks 1-4) 1. Initiate interval sport program as determined by
I'll
:
E Goals: To normalize motion; improve muscular physician.
I'fl
strength, power, and endurance 2. Begin Phase I program.
.:
II
o: Week 2 IV. Heturn-to—Activity Phase [Weeks 5-9}
1's:
1. Initiate isotonic strengthening for wrist and elbow Return to play depends on the athlete's condition
muscles. and progress: physician determines when it is safe.
2. Initiate exercise tubing exercises for shoulder. 1. Continue strengthening program and Thrower's
3. Continue using cryotherapy and other pain-control Ten Program.
modalities. 2. Continue flexibility program.
M1 3. Progress functional drills to unrestricted play.
1. Initiate rhythmic stabilization drills for elbow and HG'v'S - high-voltage galvanic stimulation, HUM - range of motion.
shoulder joint.
Data from lll'll'ilk ltE. Fleinhold MM. Andrews IR: Heha bllitatlon ofthe
2. Progress isotonic strengthening for entire upper
thrower‘s elbow. Tech Hand Up Extrem Surg remainder-sis.
extremity.
3. Initiate isokinetic strengthening exercises for
elbow flexio nfextension. Nonsurgical Rehabilitation
flecks!
Phase I: Acute Phase
1. Initiate Thrower's Ten Program. The first phase of the elbow rehabilitation program is
2. Emphasize work on eccentric biceps. concentric designed to reduce pain and inflammation, normalize
triceps, and wrist flexor. range of motion {REM} and muscle balance, correct
3. Progress endurance training. postural adaptations, and re-establish baseline dynam-
4. Initiate light plyometric drills. ic joint stability. During this phase, the athlete may be
5. Initiate swinging drills. prescribed NSAIDs andfor local injections. In addition,
lll. Advanced Strengthening Phase [Weeks 4-3} the clinician can use local therapeutic modalities such as
ice, iontophoresis, phonophoresis, and electrical stimu—
Goals: To prepare athlete for return to functional
activities
lation to reduce pain and inflammation. The athlete also
is educated about activity avoidance and activity modi-
Criteria: To progress to advanced phase
fication during throwing, exercise, and other strenuous
1. Full nonpainful HCIM activities. Following the initial acute inflammation phase,
2. hlo pain or tenderness the clinician can use moist heat, a warm whirlpool, and.If
3. Satisfactory isokinetic test or ultrasound to increase local circulation and soft~tissue
4. Satisfactory clinical examination extensibility to increase the pliability of the joint capsule
and musculotendinous tissues.
RUM activities are initiated in the acute phase of treat-
ment to ensure the normalization of motion. All aspects of
elbow mobility should be assessed, but it is common for
the overhead athlete to display a loss of elbow extension

firthopaedic Knowledge Update: Sports lviedich'ie 5 fl lflld American Academy of Orthopaedic Surgeons
 Chapter 24: Nousurgital and Postoperative Rehabilitation for Injuries of die Overhead Athlete’s Elbow

_ —
Postoperative Rehabilitation Protocol
Table 2 (ritiir'rifntievii')
Postoperative Rehabilitation Protocol
for Elbow Arthroscopy for Elbow Arthroscopy
I. Initial Phase {Week 1} Week 3
Goals: Full wrist and elbow REM, swelling and pain Initiate biceps eccentric exercise program.
reduction. retardation of muscle atrophy Initiate shoulder exercise program.
Day of surgery External rotators
Begin gently moving elbow in bulky dressing. Internal rotators
Postoperative days I and 2 Deltoid
Replace bulky dressing with elastic bandages.
Supraspinatus
Immediate postoperative hand, wrist. and elbow Scapulothoracic strengthening
exercises
Ill. Advanced Phase [Weeks 4-H}

ussexlrssvaa :1:-
Puttyigrip strengthening
Goal:_ To prepare athlete for return to functional
Wrist flexor stretches
activities
Wrist exten sor stretches
Criteria to progress to advanced phase
Wrist curls
Full nonpainful ROM
Reverse wrist curls
Absence of pain or tenderness
Neutral wrist curls
Isoltinetic test that fulfills criteria to throw
Pronationr'supination
Satisfactory clinical examination
ARDM elbow extensioniflexion
Weeks at through 6
Postoperative days 3 through ?
Continue maintenance program. emphasizing
PROM elbow extensioniflexion {motion to muscular strength, endurance, flexibility.
tolerance]
Initiate interval throwing program phase
Begin PRE exercises with 1-lb weight.
HUM - range of motion. AHDM = active range of motion. FROM -
Wrist curls passive range of motion, FEE - progressive resistance exercise.

Reverse wrist curls

Neutral wrist curls
Pronationisupination
Broomstick roll-up
II. Intermediate Phase [Weeks 2-4}
Goal: To improve muscular strength and endurance.
normalize joint arth roltine matics
Week 2
RUM exercises {overpressure into extension}
Add biceps curl and triceps extension.
Continue to progress PHE weight and repetitions as
tolerable.
Supraspinatus
Scapulothora cic strengthening
in particular. The authors of a 2flfl6 study evaluated 33
professional baseball players during the preseason and
determined a mean loss of elbow extension of 7'“ and a
mean loss of elbow flexion of 5.5", compared with the
contralateral elbow.‘l5 The elbow is predisposed to flexion
contractures because of the intimate congruency of the
joint articulations, the tightness of the joint capsule, and
the tendency of the anterior capsule to develop adhesions
following injury.”r Furthermore, the brachialis muscle at-
taches to the anterior joint capsule as it crosses the elbow
joint, and injury to the elbow joint can create excessive
scar tissue formation of the brachialis muscle, causing
functional splinting of the elbowf Therefore, ROM ac-
tivities should be performed for all planes of elbow and
wrist motions to prevent the formation of scar tissue
and adhesions by providing nourishment to the articular
cartilage and assisting in the synthesis, alignment, and
organization of collagen tissue-“"91 Restoring full elbow
extension or preinjury REM is the primary goal of early
RGM activities, to minimize the occurrence of elbow
flexion contractures.”r Determining the athlete’s preinjury
ROM helps to guide the clinician in restoring motion. The
athlete also can be queried whether full elbow extension
was present before injury.
Joint mobilization may be performed to minimize the
occurrence of joint contractures and improve joint mou
bility. Grade I and II mobilisations are used initially and

IE! lfllfi American Academy of flrthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
are progressed to grade III and IV mnbiliaatinns during
the later stages of rehabilitation, as symptoms subside.
Grade I and II mobilization techniques also may be used
to neurnmndulate pain by stimulating type I and type II
articular receptors. Posterior glides of the humeroulnar
jnint are performed at end range of joint mobility to assist
in the regaining of full elbow extension {Figure 1}. In
addition, the clinician may perform mobilization for the
radiocapitellar and radinulnar joints.
The aggressiveness of the stretching and mobilization
techniques is determined by the healing constraints of
the involved tissues, the specific pathology or surgery,
and the amount of motion and end feel. If the patient
i:
presents with a reduction in motion and a hard end feel
.E
4.! without pain, aggressive stretching and mobilization tech-
niques may be used. Conversely, a patient who exhibits
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re progressed slowly with gentle stretching. In addition, it
1's:
Figure 1 Photograph shows pnste rinr mobilization of the
ulna to improve elbow extension.
.3“.
Figure 1 Photographs demonstrate the low-load. long duration lLLLDl stretch to increase elbow extension. A. The stretch
is performed using light resistance while the sh oulcler is placed in internal rotation, with the forearm pronated
to minimize compensation and best isolate the stretch on the elbow joint. B, Splinting and bracing using a
commercial device also can be used to create the LLLD stretch and perform elbow extension range of motion as
part of a home exercise program.
@ firthopaedic Knowledge Update: Sports Medicine 5
is beneficial to be aggressive with glennhumeral rehabil-
itation to improve 11t through internal rotation and
external rotation stretching.
Clccasinnally, patients may continue to have difficulty
achieving full elbov.r extension. In such cases, the clinician
can implement a low—load, long duration {LLLD} stretch
to produce deformation nr creep of the collagen tissue,
which results in tissue elongation. Clinically, this stretch
can be performed by having the patient lie supine with
a towel rnll placed under the distal humerus to act as a
cushion and fulcrum. Light resistance exercise tubing is
applied to the patient’s wrist and secured to the table or
to a dumbbell on the ground {Figure 2, A} as the patient is
instructed to relax for the duration of 10 to 15 minutes of
LLLEI treatment. The amount of resistance applied should
be of low magnitude to enable the patient to perform the
stretch for the entire duration without pain or muscle
spasm; this technique should impart a low-load but a
long-duration stretch. Patients are instructed to perform
the LLLD stretches several times per day, equaling at least
ED minutes of total end range time. This type of program
has been referred to as the total end range time program.11
The program has been extremely beneficial for patients
with a stiff elbow. In some patients, it may be beneficial
to use spliuting and bracing to create the LLLD stretch
{Figure 2, B}.
The early phase of rehabilitation also focuses on the
voluntary activation of muscle and the retardation of
muscular atrophy. Pain—free submaximal isnmetrics are
performed initially for the elbow flexors and extensors,
wrist flexnrs and extensors, as well as the forearm pro—
natnrs and supinatnrs. Shoulder isnmetrics also may be
fl ants American Academy of Orthopaedic Surgeons
 Chapter 24: Nousurgiml and Postoperative Rehabilitation for Injuries of line Dyerbead Athlete’s Elbow
performed during this phase, with caution against in-
ternal rotation and external rotation exercises if they
are painful. Alternating rhythmic stabilization drills for
shoulder flexion, extension, horizontal abduction, and
adduction as well as shoulder internal rotation and ex-
ternal rotation are performed. Elbow flexion, extension,
supination, and pronation also are performed to begin
reestablishing proprioception and neuromuscular con-
trol of the upper extremity. Furthermore, the patient’s
shoulder joint RUM may be addressed during this phase
using a stretching program to improve internal rotation
and horizontal adduction.
Phase II: lntennediate Phase
Phase II is initiated when the patient has achieved full
RUM, experiences minimal pain and tenderness, and has
a good HIS} score with manual muscle testing of the elbow
flexor and extensor musculature. The goals of this phase
of treatment are to progress the strengthening program,
maintain normal physiologic flexibility, mobility, and
RUM of the elbow, and enhance neuromuscular control.
Stretching and ROM exercises of the elbow, shoul-
der, and trunk are progressed throughout this phase of
rehabilitation. Joint mobilization techniques may be pro-
gressed to grades III and IV to apply a stretch to the joint
capsule and improve joint mobility. Flexibility exercises
are continued for the wrist flexors, extensors, pronators,
and supinators, with increased emphasis on improving
elbow extension and forearm pronation flexibility.
Shoulder mobility and flexibility should be assessed,
because it is common for the overhead athlete to lose
internal rotation and horizontal adduction. The loss of in-
ternal rotation commonly is described as a glenohumeral
internal rotation deficit {GIRD}. An 13" loss of internal
rotation in the throwing shoulder has been implicated in
elbow injuries.” GIRD has been attributed to osseous
adaptations, posterior rotator cuff tightness, posterior
capsule tightness, and an anteriorlyr tilted scapulaJI'“ A
proper clinical assessment to differentiate between altered
scapula positioning, posterior capsule tightness, andfor
posterior shoulder tightness is essential for the clinician
to direct the appropriate treatment program. Shoulder
external rotation also should be assessed, because a loss
of motion can result in increased strain on the medial
aspect of the elbow du ring the throwing motion. Shoulder
flexibility exercises in all planes of movement also are
continued during this phase. The clinician may assess for
the total arc of motion and compare the motion to the
contralateral shoulder.
Strengthening exercises are progressed to include iso-
tonic exercises, beginning with concentric activities and
progressing to eccentric activities. Although emphasis is
IE! lfllfi American Academy of flrchopaedic Surgeons
-_
Exercises for the Scapular Musculature
I Seated scapular neuromuscular control with manual
resistance
- Sidelying scapular neuromuscular control with
manual resistance
- Prone horizontal abduction {prone T's} on table or
stability ball
I Prone full can {prone T’s] on table or stability ball
I Prone rowing into external rotation {prone W's} on
table or stability ball
I Prone extensions {prone l's} on table or stability ball
I Seated modified robbery movement for lower
usilealiseuaa :1:-
trapezius
.- Wall circles
.- Corner stretch for pectoralls minor
placed on the entire elbow and forearm musculature, the
clinician should incorporate strengthening exercises for
the glenohumeral and scapulothoracic musculature as
well. The Thrower’s Ten Program,” which is based on
electromyography {EMS} data to ensure the restoration
of muscle balance in the treatment of the overhead ath—
lete, can be used."‘-‘~IT Because the external rotators are
commonly weak, particular focus is placed on this muscle
group by the inclusion of sidelying shoulder external ro-
tation and prone rowing into shoulder external rotation
exercises, because these movements have been shown to
have high EMG activity of the posterior rotator cuff.13
The scapula is critical for optimal arm function, be-
cause it provides the proximal stability needed for effi-
cient distal arm mobility. The importance of the scapular
muscles in facilitating optimal shoulder function has been
well described by numerous authorsflg-‘ED The scapular
retractors, protractors, and depressors are emphasized
because of their commonly noted weakness. Specific exer-
cises (Table 3} have been developed, designed to normalize
the force couples of the scapular musculature and enhance
proprioceptive and kinesthetic awareness to facilitate neu-
romuscular control of the scapulothoracic joint.“
Closed kinetic chain exercises are advanced to include
proprioceptive drills such as table pushuups on a tilt board
or ball (Figure 3}. These drills have been shown to gen-
erate increased upper and middle trapezius and serratus
anterior activity compared with a standard push—up exa
erciser'iI Rhythmic stabilization drills can be performed
by having the athlete place a ha ad on a small ball against
a wall as the clinician performs perturbation drills to the
athlete’s arm {Figure 4}. Additionally, neuromuscular
Drtbopaedic Knowledge Update: Sports Medicine 5
 Seerien 4: Rehabilitation

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Figure 4 F'hetegraph demenstrates dynamic stability
:
.-.-'I_'. .

E
at. 'i' - .'- l
training with the patient's hand placed ente a
I'fl
Figure 3 Fhetegraph depicts a push—up en an unstable ball against a wall. The arm is in the scapular
.: surface with manual rhythmic stabilizatie ns te plane te preyide cemp ressiye ferces inte the
Ill
ac facilitate dynamic stability fer the shoulder and glenehumeral jeint as the clinician preyides
Iii: cere musculature. rhythmic stabilizatlens.

Phase III: Advanced Strengthening Phase

Figure 5 Fheteg ra pb shews manual preprieceptiye
neuremuscular facilitatien using cencehtric
and eccentric resistance with rhythmic
sta bilizatiens.
centrel exercises can be perfermed fer the upper extrem-
ity, including preprieceptiye neuremuscular facilirarien
exercises with rhythmic stabilizatiens and manual resis—
tance drills {Figure 5}.
Phase III is designed te initiate aggressive strengthening
exercises, pregress functienal drills, enhance pewer and
endurance, and impreye neuremuscular centrel re pre-
pare fer a gradual return te spert. Befere advancing re this
phase, the athlete sheuld exhibit full nenpainful RUM,
have ne pain er tenderness, and demenstrate strength that
is Tfl‘i'v‘i. ef that ef the centralateral extremity.
Muscle fatigue has been sbewn re decrease neure-
muscular centrel and diminish preprieceptiye sense.fl
Therefere, the athlete is pregressed with strengthening
activities using the Advanced Threwer’s Ten Exercise
Pregram, which incerperates high—level endurance and
alternating meyement patterns re further challenge neu-
remuscular centrel and restere muscle balance and sym-
metry in the threwing athlete.14 The incerperatien ef
sustained helds challenges the athlete re maintain a set
pesirien while the eppesire extremity perferms iserenic
exercises. Three sets are incerperated inte each exercise,
each fellewing a sequential pregressien that integrates
bilateral iserenic meyemenr and unilateral iserenic mere-
ment with a centralateral sustained held and alternating
iserenici'susrained-held sequencing. The athlete can be
instructed te perferm these exercises en a stability ball
re further challenge the cere. Manual resistance drills
can be added re increase muscle excirarien and premere
endurance. Manual resistance prexided by the clinician is
applied re seared stability ball exercises re augment muscle
excirarien and impreee the endurance ef the sbeulcler and
cere musculature {Figure 6].
Elbew flexjen exercises are pregressed te emphasise

firthepaedic Knewledge Update: Sperrs Medicb'ie 5 fl lfllfi American Academy ef Cirrhepaedic Surge-ens
 Chapter 24: Nousurgioal and Pbsboperative Rehabilitation for Injuries of the Overhead Athlete’s Elbow
Figure ti Photograph demonstrates manual resistance
external rotation using tubing performed on a
stability ball to incorporate proximal and core
stabilization.
eccentric control. The biceps muscle is an important stabi-
lizer during the follow-through phase of overhead throw-
ing, because it eccentrically controls the deceleration of
the elbow and therefore prevents pathologic abutment
of the olecranon within the fossa.” Elbow flexion can
be performed with elastic tubing to emphasis slow— and
fast-speed concentric and eccentric contractions. Manual
resistance can be applied for concentric and eccentric
contractions of the elbow flexors. The triceps are exercised
primarily with a concentric contraction because of the
acceleration {muscle shortening] activity of this muscle
during the acceleration phase of throwing. Aggressive
strengthening exercises with weight machines also are
incorporated during this phase. These exercises most
commonly begin with bench presses, seated rowing, and
front latissirnus dorsi pulldowns.
Neuromuscular control exercises are progressed to in—
clude sidelying external rotation with manual resistance.
Concentric and eccentric external rotation are performed
against the clinician’s resistance, with the addition of
rhythmic stabilization at end range. This manual resis-
tance exercise may be progressed to standing external
rotation with exercise tubing at El" and finally at 90”
{Figure ff}.
Plyometric exercises are initiated to further enhance
dynamic stability and proprioception and to introduce
and gradually increase functional stresses to the shoulder
joint. Enhanced joint position sense and lcinesthesia as
well as decreased time for peak torque generation were
seen following 6 weeks of single-arm plyonietric tosses
performed at 9B“ of shoulder abduction as demonstrated
with isokinetic testing.“ In a comparison of 3 weeks of
IE! lfllii American Academy of flrthopaedic Surgeons
uessalissuaa :s
Figure 3' Fri otog raph depicts external rotation at 911‘ of
abduction using exercise tubing. The clinician
provides rnanual resistance and rhythmlc
sta bilizations.
plyometric exercises with conventional isotonic train-
ing, an increase of shoulder internal rotation power and
throwing distance was reported.“ Plyometric exercises
begin with a rapid prestretch eccentric contraction that
stimulates the muscle spindle, followed by the amortiza-
tion phase, which marks the time between the eccentric
and concentric phase. To allow an effective transfer of
energy and prevent the beneficial neurologic effects of the
prestretch from being dissipated as beat, this phase should
be as short as possible. The athlete is instructed to coor-
dinate the trunk and lower extremity to most efficiently
facilitate the transfer of energy into the upper extremity
during the plyometric drills. A plyometric program has
been described that systematically introduces stresses on
the healing tissues, beginning with two-hand drills such
as the chest pass, side—to—side throws, side throws, and
overhead soccer throws.” fin successful completion of
these two-hand drills, the athlete can progress to one-
haud drills, including standing one-hand throws, wall
dribbles, and plyometric step-and-throw exercises. Spe-
cific plyometric drills for the forearm musculature include
wrist flexion {Figure fl} and extension flips, which are
important components of an elbow rehabilitation pro-
gram that emphasise the forearm and hand musculature.
Muscle fatigue has been shown to diminish pro-
prioceptive sense and alter biomechanics; therefore,
muscle endurance training should be included in any re-
habilitation program for overhead athletes.”r Kinematic
and kinetic motion analysis reported in a 1001 study
showed that shoulder external rotation and ball veloc~
ity declined along with lead knee flexion and shoulder
Drthopoedic Knowledge Update: Sports Medicine 5
 Seeders 4: Rehabilitatinn
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Figure B ttng ra ph sh nws a plyn metric wrist flip using
a E-Ih medicine ball tn strengthen the wrist
flexnrs.
adductinn tnrque after a thrnwer became fatigued.” En-
durance training perfnrnied by the athlete includes wall
dribbles with a medicine ball, prnne ball drnps {Figure 9)
wall arm circles, the upper-bndy cycle, and Advanced
Thrnvver‘s Ten Prngram exercises.
Phase W: Return-tn-Activity Phase
Phase IV nf the rehabilitatinn prngram enables the athlete
tn cnntinue prngressing with activities that allnw a return
tn full cnmpetitinn. This phase includes an interval thrnw-
ing prngram {ITP}. The criteria required tn begin phase
IV nf treatment include the achievement nf full REM, the
absence nf pain nr tenderness, a satisfactnry isnltinetic test
result, and a satisfactnry clinical examinatinn. Isnkinetic
testing is perfnrmed at 13fl°fs and 3fl0‘b's. Data indicate
that the bilateml cnmparisnn at 130% fnr the thrnwing
arm‘s elbnw flexinn is 10% re 2fl% strnnger and the dnm—
inant extensnrs are typically 5% tn 15% strnnger than
these nf the nnnthrnwing arm?
The ITP was develnped tn gradually intrnduce the
quantity, distance, intensity, and types nf thrnws needed
tn facilitate the restnratinn nf nnrmal thrnwing mntinns.
The ITP is divided intn twn phases. Phase I is a lnng—tnss
prngram {Table 4 and Table 5} that is initiated at 45 feet
[15 m} and is prngressed with increased distances and
vnlume nf thrnws. Phase II is a mnund thrnwing prngram
used fnr pitchers. During phase I, the athlete is instructed
tn use a crnw—hnp methnd nf thrnwing, tn incnrpnrate
synchrnniaatinn nf the trunk and lnwer extremities, while
firthnpaedic Knnwledge Update: Spnrrs Medicine 5
Phntngraph shnws an athlete perfnrming a
prnne hall drnp and catch, with the shnulder
in hnriznntal abductinn fnr lncal muscular
endurance.
thrnwing with a slight arc fnr each prescribed distance.
It is necessary tn implement a slight arc {versus thrnwing
en a line} in the lnng-tnss prngram as a way tn regulate
the intensity nf each thrnw and ensure that the athlete
is net thrnwing harder than needed fnr each distance.
During the lnng-tnss prngram, as intensity and distance
increase, the stresses alsn increase en the patient’s medial
elbnw and anterinr shnuldcr jnint. A 2011 study repnrted
that the lnnger thrnwing distances substantially increased
these threes.31 The lnng-tnss prngram is designed tn grad-
ually intrnduce leads and strains and shnuld be cnmpleted
successfully before thrnwing frnm the mnund is allnwed.
Pnsitinn players additinnally can begin a prngressive hit-
ting prngram that begins with swinging a light bat and
prngresses tn hitting nff a tee, snft-tnss hitting, and finally,
batting practice.
Fnllnwing the cnmpletinn nf a lnng-tnss prngram,
pitchers prngress tn phase II nf the thrnwing prngram,
thrnwing nff a mnund [Table 6}. In phase II, the num-
ber nf thrnws, the intensity, and the type nf pitch are
prngressed tn gradually increase stress nn the elbnw and
shnuldcr jnints. Generally, the pitcher begins at 5fl% nf
intensity and gradually prngresses tn T593, 9D%, and
113034;. nver a 4-week tn 6-week perind. Breaking balls
are initiated after the pitcher can thrnw 4|} tn SCI pitches
at least at 30% nf intensity withnut symptnms. During
this phase, pnsitinn players will be prngressed with pnsi-
tinn-specific fielding drills and functinnal drills.
The athlete is instructed tn cnntinue with all previnusly
described exercises and drills tn maintain and imprnve
upper extremity, cnre, and lnwer extremity strength, pnw-
er, and endurance during this phase nf rehabilitatinn.
It is alsn impnrtant tn teach the athlete a year-rnund
cnnditinning prngram, including the perindiaatinn nf
thrnwing and strength-training activities, tn help prevent
nvertraining and thrnwing when pnnrly cnnditinned and
alsn tn prepare for the upcnming seasnn. A 1992 study
fl lfllfi American Academy nf Cirrhnpaedic Surge-ens

_—
Interval Throwing Program for Baseball
Positional Players
45-Feet Phase
Step 1
A} We rm-up throwing
El} 45 feet {25 throws}
C} Rest 5-10 min
Step 2
A} We rm-up throwing
El} 45 feet {25 throws}
C} Rest 5-10 min
D} Warm-up throwing
Eli-Feet Phase
Step 3
A} We rm-up throwing
5} Eli feet [25 throws}
C} Rest 5-11.} min
Step 4
A} We rm-up throwing
5} 55 feet [25 throws}
C} Rest 5-11] min
D} We rm-up throwing
Elli-Feet Phase
Step 5
a} so feet [as throws}
E} Rest 5-10 min
5t 5
ep
A} Warm—up throwing
C} Rest 5—10 min
D} WE rm-IJIJ thrDWIng
1104;531: Phase
Step 1"
A} Werm-up throwing
B} 12f] feet [25 throws}
_ -
C} REF" 5 10 mm
Step 3
A} We rm-up throwing
B} 120 feet [25 throws}
C} Rest 5-10 min
D} Warm-up throwing
showed that a dynamic variable resistance exercise pro-
gram significantly increased throwing velocity.32 Similar—
ly, the throwing velocity in high school baseball players
ID 2fl15 American Academy of flrthopaedic Surgeons
Chapter 24: Nousurgitall and Postoperative Rehabilitation for Injuries of dse Overhead Athlete’s Elbow
D} Warm-up throwing
E} 45 feet {25 throws}
E} 45 feet {25 throws}
F} Rest 5—11] min
G} Warm-up throwing
H} 45 feet (25 throws}
D} Warm-up throwing
E} 60 feet {25 throws}
E} 5D feet {25 throws}
F} Rest 5-10 min
G} Warm-up throwing
H} so feet (25 throws}
E} as feet [as throws}
E} 55 feet [25 throws}
G} We rm—up throwing
H} St} feet (25 th rows}
D} Warm-up throwing
E} 120 feet {25 throws}
E} 120 feet {25 throws}
F} Rest 5-11] min
G} Warm-up throwing
H} 125 feet {25 throws}
Table 4 (titsr'rffntre'rifl
Interval Throwing Program for Baseball
Positional Players
fill-Feet Phase
Step 9
A} Warm -up throwing D} We rm-up throwing
B} 150 feet {25 throws} E} 151] feet {25 throws}
C} Rest 3-5 min
Step 15
A} Warm-up throwing E} 151] feet {25 throws}
B} 151] feet {25 throws} F} Rest 3—5 min
E} Rest 3-5 min E} Warm-up throwing h
D} Warm—up throwing H} 15D feet [25 throws} g,
1Bfl-Feet Phase %
D'
Step 11 ET:
DJ
A} Warm-up throwing D} We rm-up throwing E”
R} 135 feet (25 throws} E} 135 feet (25 throws} 1'
E} Rest 5-5 min
Step 12
A} Warm-up throwing E} 130 feet (25 throws}
B} 130 feet {25 throws} F} Rest 3-5 min
C} Rest 3-5 min E} Warm-up throwing
D} Warm-up throwing H} 15f} feet {25 throws}
Step 15
A} Warm-up throwing G} We rm-up throwing
51 Rest 3-5 "1|" '1 Rest 3-5 "1'"
D} Warm-up throwing J} Warm-up throwing
E} 150 feet {25 throws} R} 15 throws progressing
F} Rest 3-5 min from 120 feet to 5D
feet to so feet
All throws should be on an arc with a crow—hop. Warm—up throws
consist of ll;I to 25 throws at approximately 51: feet. The throwing
program should be performed every other day, 3 times per weelr.I
unless otherwise specified by the physician or rehabilitation
specialist. Each step is performed ___ times before progressing to
the "an it”
Date eda pted from Will: RE, Reinhold MM. Andrews JR:
Rehe bilitation of the thrower‘s elbow. Sports Med Arthrosc Rev
lflfl3;11{1}:?5-95, and Ellenbeclter TS, Willc RE, Reinhold MM.
MurphyI TM, Paine RM: Use of interval return prog re ms for shoulder
rehabilitation. in Ellenbeclter T5: Shoulder Rehebiiita tion: Non-
fiperative Treatment. New vars, av. Thieme, sass. pp 139-155.
was increased using a program that includes a variety of
resistance exercises, including plyometric training and a
Thrower’s Ten training program.”
Drthopaedic Knowledge Update: Sports Medicine 5 a
 Section. 4: Rehabilitation

Table 5 {cr:;nntirrued}
Interval Throwing Program for Baseball Interval Throwing Program for Baseball
Pitchers: Phase I Pitchers: Phase I

45- Feet Phase Flat Throwing

Step 1 Step 9
A} Wa rm-up throwing D} Wa nn-up throwing A} Throw SCI feet [113-15 C} Throw 120 feet {10
B} 45 feet [25 throws} E} 45 feet [25 throws} throws] throws}
E} Rest 3-5 min E} Th row 50 feet [1D D} Throw ED feet [flat
throws} ground} using
Step 2 pitching mechanics
A} We rm-up throwing E} 45 feet [25 throws} {ED-3i} throws}
B} 45 feet [25 throws} F} Rest 3-5 min Step 10
C} Rest 3-5 min I5} Warm-up throwing A} Throw 60 feet (1 [1-15 E} Rest 3—5 min
E
.E
4.!
D} Warm-up throwing H} 45 feet {25 throws} throws} F} Throw 60-99 feet {1i}-
I'll
::
E tin-Feet Phase 5} Th row 50 feet {it} 15 throws}
throws} G} Throw Efl feet [flat
I'D
.: Step 3
I} C} Throw 120 feet iii}| ground} using
ac A} We rm-up throwing D} We rm-up throwing throws} pitching mechanics
if
E} El} feet {25 th rows} E} 6i} feet {25 throws} D} Th row 5i} feet {flat {2t} throws}
C} Rest 3-5 min ground} using
pitching mechanics
Step 4
{20-30 throws}
A} Wa rm-up throwing E} 6i} feet [25 throws}
Throwing program should be performed every}I other day. with
5} 5i} feet {25 throws} F} Rest 3-5 min one day of rest between stepsr unless otherwise specified by the
C} Rest 3-5 min G} Warm-up throwing physician. Each step is performed 2 times before progressing to the
next Etep.
D} Warm-up throwing H} so feet {25 throws}
Bil-Feet Phase Data from Willt ICE, Reinhold MM, Andrews JR: Rehabilitation of the
thrower's elbow. Tech Hand Up Extra-m Surg 2443:?{4}:15?—215. and
Step 5 Will: RE. Reinhold MM. Andrews .IR: Rehabilitation of the thrower's
elbow. Sports Med Arthrosr: Rev 2Dfl3;11{1}:?5v55.
A} Go feet {1 [I throws} D} 5i} feet {10 throws}
E} 5i} feet {2D throws} E} 9i} feet {2i} throws}
E} Rest 5-5 min Specific Nonsurgital Rehabilitation Guidelines
Step 5
A} so feet {If throws} E} 50 feet {15 throws} UCL Injury}r
E} 5i} feet {15 throws} F} Rest 3-5 min Nonsurgical treatment is attempted for partial tears and
C} Rest 5—5 min E} El} feet {1 throws} sprains of the UCL, although surgical reconstruction
D} iii} feet (3’ throws} H} 51'} feet {13 throws} may be warranted for complete tears or if nonsurgical
tau-Feet Phase
treatment is unsuccessful. A nonsurgical rehabilitation
program is outlined in Table 1 Initially, a brace can be
Step ?
used to restrict RUM and prevent valgus stresses from
A} 60 feet (5-? th rows} E} 60 feet (5-? throws} limiting movement so additional adverse stresses on the
B} 91] feet (5-? throws} F} 90 feet {S-ir' throws} UCL can be avoided. RUM nsnallv is permitted, although
C} 124 feet [15 throws} G} 120 feet {15 throws} in a nonpainful are of motion, typicallv from 1D” to 1m} “',
D} Rest 3-5 min
to allow inflarmnation to subside and collagen tissue to
Step 3 align. Isometric exercises are performed for the shoulder,
A} 56 feet {5 throws} E} 60 feet [5 throws} elbow, and wrist to prevent muscular atrophy. Ice and
5} 5|} feet iii] throws} F} 50 feet {it} throws} anti—inflammatory medications are prescribed to con-
C} 120 feet [15 throws} G} 12D feet {15 throws} trol pain and inflammation. Elbow flexion and extension
D} Rest 5-5 min RUM is increased gradually,F by 5” to 1D“ per week during
the second phase of rehabilitation or as tolerated, with
full RUM achieved bv at least 3 to 4 weeks. The clini-
cian should ensure the restoration of full shoulder RUM
by incorporating manual stretches, RUM exercises, and

Drthopaedic Knowledge Update: Sports Medicine 5 D lflld American Academy of Orthopaedic Surgeons
 |Chapter 24: Hensurgital and lbstepetafive Rehabilitatien fer Injuries ef the Dyerhead Athlete’s Elbew

-_
Interval Threwing Program: Phase II,
mebilisatien techniques. Altheugh all aspects ef sheul-
tier Rfllvi sheuld he addressed, glenehumeral internal
retatien sheuld be emphasized, because a less ef internal
Threwing f the Meund retatien RUM has been implemented in elbew injuries}1
Stage I: Fastball: lilnlyl Rhythmic stabilizatien exercise: are initiated as tel-
erated in the acute stage: ef rehabilitatien te develep
Step 1: Interval threwing
dynamic stabilisatien and neuremuseular centre] ef
15 threw: eff meund at 50%”
the upper extremity. A: dynamic stability is advanced,
Step 2: Interval threwing isetenic exercises are incerperated fer the entire upper
30 threw: eff meund at 50% extremity. The flexer carpi ulnaris and flexer digiternm
Step 3: Interval threwing superficialis everlay the UCL; therefere, strengthening
45 threw: eff meund at 50% exercises fer these muscle: can assist the UCL in resist-
Step 4: Interval threwing ing valgus stresses at the elbew.“ In additien, pesterier
50 threw: eff meund at 50% retater cuff and scapular strengthening exercises are per

uvuemqsvaa :-
Step 5: Interval threvving fermed te restere preximal stabilisatien. The advanced
10 threw: eff meund at 50% strengthening phase usually is initiated at 5 te 1' weeks af-
Step 5: 45 threw: eff meund at 50% ter injury, with valgus leading menitered threugheut the
50 threw: eff meund at 15% rehabilitatien pregram. An interval return-te-threwing
Step 1: 30 threw: eff meund at 50%
pregram is initiated after the athlete regains full metien,
45 threw: eff meund at 15% adequate strength, and dynamic stability ef the elbew.
The athlete is allewed te return te cempetitien fellewing
Step 5: 10 threw: eff meund at 50%
the asymptematic cempletien ef the interval spert pre-
55 threw: eff meund at 15%
gram. If symptems recur during the interval threwing
Stage II: Fastball: tilnlyr pregram, they typically present when threwing at lenger
Step 9: 50 threw: eff meund at 15% distances er with greater intensity er during threwing
15 threw: in batting practice frem the meund. If symptems persist, the athlete is reas-
Step 10: 50-50 threw: eff meund at 15% sessed and surgical interventien is censidered.
SD threw: in batting practice
Step 11: 45-50 threw: eff meund at 5% Medial Epicendyl'rtis and Flexer—Prenater Tendinitis
45 threw: in batting practice Medial epicendylitis eccurs because ef changes within
Stage III the musculetendineus flexer—prenater unit, character-
ized by micrescepic er macrescepic tearing within the
Step 12: 30 threw: eff meund at 15% warm-up
15 threw: eff meund at 50%; begin breaking balls
flexer carpi radialis er prenater teres near the erigin en
45-50 threw: in batting practice {fastball enly] the medial epicendyle. lDyerhead threwers whe exhibit
flexer-prenater tendinitis alse may have UCL pathelegy
Step 13: 30 threw: eff meund at 15%
that create: this secendary pathelegy due te the underly-
30 breaking balls at 15%
ing increased laxity. Furthermere, it may be beneficial te
50 threw: in batting practice
determine the number ef episedes and the chrenicity ef
Step 14: 30 threw: eff meund at 15% medial epicendylar symptems. Patients with lung histeries
50-90 threw: in batting practice [gradually increase
breaking balls] ef medial epicendylitis may exhibit a chrenic degeneratien
knewn as tendinesis er tendinepathy, net true tendinitis.
Step 15: Simulated game; pregress by 15 threw: per
werlteut (pitch ceunt} The treatment ef tendinepathy is based en a careful
examinatien te determine the exact pathelegy present.
All direwing eff the meund sheuld he dene in the presence ef the
pitching ceach er spert hiemethanist te stress preper th revving
Uften, patients in whem tendinitis has been diagnesed
mechanics. Use speed gun te aid in effert centrel. enly later discever that the tenden had undergene a de-
' Fer steps 1 thrnugh 5, use the interval threwing at 110 feet {35.5 m}
generative precess referred te as tendinesis.35-3“ The dif-
phase as a warm-up. ferential diagnesis ef tendinesis may be made using MRI,
ultrasenegraphy, er tissue biepsy.
" Percentage ef effert.
The treatment ef tendinitis typically fecuses en reduc-
Data frem near M, Willi ItE: Heneperat'rve treatment efthe elbew in ing inflammatien and pain. This geal is accemplished
threvvers. Oper Tech Spares Med 1595:412131-95.
threugh the reductien ef activities, stereid injectiens, an-
ti—inflammatery medicatiens, cryetherapy, ientepheresis,

ID 2015 American Academy ef flrthepaedic Surgeens Drthepeedic Knewledge Update: Sperts Medichse S
 Section 4: Rehabilitation

——
Nonsurgical Treatment Following Ulnar Collateral ligament Sprains of the Elbow
Immediate Motion Phase lnterrnediate Phase Advanced Phase Heturn-to-Activity Phase
Weeks {1 through 2 Weeks 3 through 6 Weeks 6 through 12 Weeks 12 through 14
NA NA Criteria to progress: Criteria to progress to
Full RUM, no pain or return to throwing:
tenderness, no increase Full nonpainful RUM,
in laxity. strength #5 of no increase in laxity.
elbow flexio niextension fulfillment of isokinetic
test criteria, successful
clinical examination
Goals: To increase HUM, Goals: To increase ROM, Goals: To increase Goals: Maintain strength,
promote healing of improve strength and strength, power and power, and endurance
c UCL, retard muscular endurance, reduce endurance: improve gains. Maintain REM
.E
4.! atrophy, reduce pain pain and inflammation, neuromuscular control; and flexibility.
I'll
:: and inflammation promote stability initiate high-speed
E exercise drills
I'fl
.:
flil RUM: Brace (optional) ROM: lGradually increase HUM: Progress to full Maintain full elbow REM
ac
if
for nonpainful RUM motion III" to 135‘I elbow HUM and elbow and forearm
{Eat-ED“), AARDM, increase 11] per week muscle flexibility
PROM elbow and wrist
{nonpainful ROM 1
Exercises: Isometrics Exercises: Initiate Exercises: Initiate exercise Exercises: Initiate interval
for wrist and elbow isotonic exercises: tubing, shoulder throwing, continue
musculature: shoulder wrist curls, wrist program: Thrower's Thrower's Ten Program.
strengthening {no EH: extensions, pronationiIr Ten program. biceps! continue plyometrics
strengthening} supination, bicepslr triceps program,
triceps; dumbbells: supinationl'pronation,
glenohumeral ER wrist extensionfflexion.
and IR, deltoid, plyometrics, throwing
supraspinatus, drills
rhom boids
Modalities: Ice. Modalities: Ice. Modalities: Moist hot Modalities: Moist hot
compression compression pack pretreatment; ice pack pretreatment; ice
FDSttI'Et'IEI'I'l: posttreatment

HUM = range of motion. UCL = ulnar collateral ligament. AAHDM = active-assisted range of Inotio n. PROM = passive range of motion.
Ell - extemal rotation, IR - internal rotation, HA - not applicable.

Data from Wllk ltE. Reinhold MM. Andrews llt: Rehabllltatlon of the throwe elbow. Sports Med Arthrosc ltev 2flfl3:11i11:?9—95.

light exercise, and stretching. Conversely, the treatment
of tendinosis focuses on increasing the circulation to pro-
mote collagen synthesis and collagen organisation. Such
treatment would include heat, stretching, eccentric exer-
cises, laser therapy, transverse massage, and soft-tissue
mobilisation. These therapies are performed to increase
the circulation and promote tissue healing. Dry needling
has been advocated for this pathology to promote tendon
healing.“
Platelet-rich plasma {PEP} therapy is a promising in-
tervention in which a small sample of the patient’s own
blood is separated and the platelet-rich layer is injected
into the site of injury. The proposed mechanism delivers
humoral mediators and growth factors locally to induce
a healing response. Either advantages of PEP therapy are
that it is minimally invasive, provokes a local response
only, and avoids an inflammatory response. Disadvan-
tages can include the cost of treatment, a laclc of sup—
porting evidence, and increased staff time to withdraw
and centrifuge the blood, and then reinject it into the site
of pathology. Early research on the clinical application
of PEP to promote healing and an adaptive response is
promisingfifldg Substantial benefits of PRP were shown in
patients with chronic lateral epicondylitis.” Basic science
and controlled studies have yet to report the efficacy of
such a treatment.
The nonsurgical approach [Table 3} for the treatment
of epicondylitis {tendinitis andior paratendinitisl focus-
es on diminishing the pain and inflammation and then
gradually improving muscular strength. The primary

flrdsopaedic Knowledge Update: Sports Medich'le 5 fl lflld American Academy of Orthopaedic Surgeons
 |Chapter 24: Nonsozgieal and Pbstuperative Rehabilitation for Injuries of tile Overhead Athlete’s Elbow

—_
Epicondylitis Rehabilitation Protocol
Phase I: Acute Phase
Goals: To reduce inflammation.
promote tissue healing. retard
muscular atrophy
Therapies and exercises:
Cryotherapy
Whirlpool
Stretching to increase flexibility:
wrist extensionrflexion. elbow
extensioniflexion. forearm
Phase II: Suhacute Phase
Goals: To improve flexibility.
increase muscular strength»Ir
endurance. increase functional
activities. promote return to
function
Exercises:
Emphasize concentricfeccentric
strengthening
Concentrate on involved muscle
group
1ii'v'rist extensioni'flexion
Phase III: Chronic Phase
Goals: To improve muscular
strength and endurance.
maintaini'enha nce flexibility.
gradually return to sport and
high—level activities
Exercises:
Continue strengthening exercises
I{emphasize eccentrici‘concentricl
Continue to emphasize deficiencies
in shoulder and elbow strength
Continue flexibility exercises

uyuexuaeuas :1:-
supinationipronation Forearm pronationfsupination Gradually decrease use of
Isometrics: wrist extensioniflexion. Elbow flexioni'extension counterforce brace
elbow extensioniflexion. forearm Initiate shoulder strengthening {if Use cryotherapy as needed
su pinationipro nation deficiencies are noted} Gradually return to sport activity
High-voltage galvanic stimulation Continue flexibility exercises Modify equipment {grip size. string
Phonophoresis May use counterforce brace tension. playing surface}
Friction massage Continue using cryotherapy after Emphasize maintenance program
lontophoresis {with anti- exerciseffunction
inflammatory drug. eg. Gradually return to stressful
dexa met hason e] activities
Avoidance of painful movements Gradually reinitiate formerly
lea. gripping} painful movements
Data from Will: HE. Macrina LC: Rehabilitation for elbow instability: Emphasis on the throwing athlete. in Sklrven TM. Cisterman AL Fedorczylt J.
Arnadio PC: Rehabiiitation of the Hand and Upper Extremity-r. Philadelphia. PA. Elsevier. 2U“. PP 1143-1155.

goals of rehabilitation are to control the applied loads
and create an environment for healing. The initial treat-
ment consists of warm whirlpool baths, iontophoresis,
stretching exercises, and light strengthening exercises to
stimulate a repair response. Therapeutic modalities often
are used by rehabilitation specialists to reduce inflamma-
tion and promote healing. Very limited evidence supports
using these modalities in isolation. Common modalities
can include massage. cold laser therapy, iontophoresis,
ultrasound, nitric oxide, and extracorporeal shock wave
therapy. When used in combination with exercise or with
other modalities, however, studies have shown improved
tissue quality and ontcomes.“‘5"“1 Conversely, patients with
tendinosis are treated with transverse friction massage,
forceful stretching, a focus on eccentric strengthening
with gradually progressing loads, and warm modalities
to promote tendon regeneration.
After the patient’s symptoms have subsided, an ag—
gressive stretching and strengthening program featuring
high loads and low repetitions that emphasizes eccentric
contractions is initiated. 1Wrist flexion and extension activ—
ities should be performed, initially with the elbow flexed
30° to 45". A gradual progression through plyometric
and throwing activities precedes the initiation of the ITP.
Ulnar Heuropathy
Ulnar nerve changes can result from tensile forces, com-
pressive forces, or nerve instability. Ulnar neuropathy
occurs in three stages."'3 The first stage is characterized
by an acute onset of radicular symptoms. During the
second stage, a recurrence of symptoms occurs as the
athlete attempts to return to competition. The third stage
is distinguished by persistent motor weakness and sensory
changes. If the athlete presents in the third stage of injury,
nonsurgical management may not be effective.
A leading mechanism for tensile force on the ulnar
nerve is valgus stress. This mechanism may be coupled
with an external rotation supination stress overload mech-
anism. The traction forces are magnified further when
underlying valgus instability from UCL injury is present.
Ulnar neuropathy is often a secondary pathology of UCL
insufficiency. Compression of the ulnar nerve is often
due to hypertrophy of the surrounding soft tissues or the
presence of scar tissue. The nerve also may be trapped

IE! lfllfi American Academy of Cirrhopaedic Surgeons Urthopoedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
between the two heads of the flexor carpi ulna ris. Repet-
itive flexion and extension of the elbow with an unstable
nerve can irritate or inflame the nerve. Additionally, the
nerve may subluxate or rest on the medial epicondyle,
rendering it vulnerable to direct trauma.
The nonsurgical treatment of ulnar neuropathy focuses
on reducing ulnar nerve irritation, enhancing dynamic
medial joint stability, and returning the athlete to com-
petition gradually. Using a night splint with the elbow
flexed to 45“ can help to restrict movement and prevent
ulnar nerve irritation. HSAIDs can be prescribed as well
as an iontophoresis dispensable patch and cryotherapy.
Throwing athletes are instructed to discontinue throwing
c
activities for at least 4 weeks, depending on the severity
.E
4.! and chronicity of symptoms. They will be progressed
through the immediate motion and intermediate phases
I'll
:
E
I'fl over 4 to 5 weeks, with emphasis on eccentric and dy—
.:
fill
or namic stabilization drills. Plyometric exercises are used
1's: to facilitate further dynamic stabilization of the medial
elbow. The athlete is allowed to begin an ITP when full
pain-free RDM and muscle performance are achieved
without neurologic symptoms.
flsteochondritis Dissecans
Dsteochondritis dissecaus (0CD) of the elbow eau de-
velop as a result of the valgus strain on the elbow joint,
which produces not only medial tension but also a lateral
compressive force.“ This is observed as the capitellum
of the humerus is compressed against the radial head.
Patients often report lateral elbow pain on palpation and
valgus stress. Classification of the pathologic progress
sion of DIED has been described in three stages.“ Stage I
describes patients without evidence of subchondral dis-
placement or fracture, whereas stage II refers to lesions
showing evidence of subchondral detachment or articular
cartilage fracture. Stage III lesions involve detached os-
teochondral fragments, resulting in intra—articular loose
bodies. Nonsurgical treatment is attempted for stage 1
patients only and consists of relative rest and immobili-
zation until elbow symptoms have resolved.
Honsurgical treatment includes 3 to 6 weeks of im-
mobilization at 90" of elbow flexion. RUM activities for
the shoulder, elbow, and wrist are performed three to
four times a day. As symptoms resolve, a strengthening
program is initiated with isometric exercises. Isotonic ex~
ercises are added after approximately 1 week of isometric
exercise. Aggressive high-speed, eccentric, and plyometric
exercises are included progressively to prepare the athlete
for the start of an ITP.
If nonsurgical treatment fails or evidence of loose
bodies exists, surgical intervention, including arthro—
scopic abrading and drilling of the lesion with fixation
firthnpaedie Knowledge Update: Sports Mediehie 5
or removal of the loose bodies, is indicated.” Long-term
follow-up studies regarding the outcome of patients un-
dergoing surgery to drill or reattach the lesions have not
reported favorable results, suggesting that prevention
and early detection of symptoms may be the best form
of treatment.“
IJttle Lesguer's Elhow
During the arm~cocking and acceleration phases of throw-
ing, the medial epicondyle physis is subject to repetitive
tensile and valgus forces that can lead to a spectrum of
injuries to the medial epicondylar apophysis, ranging from
microtrauma to the physis to fracture and displacement of
the medial epicondyle through the apophysis. Pain in the
medial elbow is common is adolescent throwers. These
forces can result in microtraumatic injury to the physis,
with potential fragmentation, hypertrophy, separation
of the epiphysis, or avulsion of the medial epicondyle.
In the absence of an avulsion, a nonsurgical rehabilita-
tion program similar to that used for the UCL is initiated.
Initial emphasis is placed on the reduction of pain and
inflammation and the restoration of motion and strength.
Strengthening exercises are performed in a gradual fash—
ion. First, isometrics are performed, then, light isotonic
strengthening exercises are initiated. Young throwing ath-
letes often exhibit poor core and scapular control, along
with weakness of the shoulder musculature, therefore,
core, leg, and shoulder strengthening are emphasized.
In addition, stretching exercises are performed to nor—
malize shoulder REM, especially into internal rotation
and horizontal adduction. No heavy lifting is permitted
for 12 to 14 weeks. An ITIJ is initiated as tolerated when
symptoms subside.
In the presence of a nondisplaced or minimally dis-
placed avulsion, a brief period of immobilization for ap-
proximately 7’ days is encouraged, followed by a gradual
progression of RUM, flexibility, and strength. An ITP usu—
ally is allowed at week 6 to B. If the av ulsion is displaced,
open reduction and internal fixation may he required.
Specific Postoperative Rehabilitation Guidelines
LICL Reconstruction
Su rgica] reconstruction of the UCL attempts to restore the
stabilizing functions of the anterior bundle of the UCL.”
Several types of surgical procedures are available to re-
construct the UCLJM‘W The modified Jobe procedure
can be used, in which the palmaris longus or gracilis graft
source is obtained and passed in a figure-of-S pattern
through drill holes in the sublime tubercle of the ulna
and the medial epicondyle.” A subcutaneous ulnar nerve
transposition is performed at the time of reconstruction.
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 24: Nonsurgiml and Postoperative Rehabilitation for Injuries of die Overhead Aflflete’s Elbow
-_
Postoperative Rehabilitation Protocol
Following Ulnar Collateral Ligament
Reconstruction Using Antogenous Palmaris
Longus Graft {Accelerated RUM]
Immediate Postoperative Phase {ti-3 Weeks}
Goals: To protect healing tissue. reduce pain and
inflammation, retard muscular atrophy, protect
graft site to allow healing
Week 'i
Brace: Posterior splint at BB“ elbow flexion
ROM: Wrist ABDM extensioniflexion immediately
after surgery
Elbow: Postoperative compression dressing 5-? days
1llla‘rist {graft site) compression dressing 1-1131 days as
needed
Exercises: Gripping exercises, wrist ROM, shoulder
isometrics {no shoulder ER}, biceps isometrics
Cryotherapy to elbow joint and to graft site at wrist
Week 2
Brace: Elbow BUM 15‘-1l]5° or as tolerated
Motion to tolerance
Exercises: Continue all exercises listed above
Elbow BUM in brace Elf-105'
Initiate elbow extension isometrics
Continue wrist ROM exercises
Initiate light scar mobilization over distal incision
{strait}
Cryotherapy: Continue ice to elbow and graft site
Week 3
Brace: Elbow HUM 5"1'10“ to 115°l'120“, motion to
tolerance
Exercises: Continue all exercises listed above
Elbow BUM in brace
Initiate ABUM wrist and elbow [No resistance]
Initiate light wrist flexion stretching
Initiate ABDM shoulder
Full can
Lateral raises
ERIIR tubing
Elbow flexio nfextension
Initiate light scapular strengthening exercises
May incorporate bicycle for lower extremity strength,
endurance
IE! tots American Academy of flrthopaedic Surgeons
Table '3 {contoured}
Postoperative Rehabilitation Protocol
Following Ulnar Collateral Ligament
Reconstruction Using Antogenous Palmaris
Longus Graft [Accelerated RUM}
Inten-necllate Phase [Weeks ill-1}
Goals: Gradual increase to full ROM, promote healing
of repaired tissue, regain and improve muscular
strength, restore full function of graft site
Week If
Brace: Elbow BUM Elf-135", motion to tolerance
Exercises: Begin light resistance exercises for arm
{1 lb]: wrist curls, extension. pronation, supination:
massacres-as a
elbow extensionfflexion
Progress shoulder program emphasize rotator cuff
and scapular strengthening
Initiate shoulder strengthening with light dumbbells
Week 5
REM: Elbow BGM {if-135’
Discontinue brace
Maintain full ROM
Continue all exercises; progress all shoulder and
upper extremity exercises {progress weight 1 lb}
Week 6
ABGIM: {if-145“ without brace or full HUM
Exercises: Initiate Thrower's Ten Program, progress
elbow strengthening exercises, initiate shoulder Eli
strengthening, progress shoulder program
Week 3’
Progress Th rower‘s Ten Program (prog ress weig hts}
Initiate PNF diagonal patterns {light}
Advanced Strengthening Phase [Week B44]
Goals: To increase strength, power, endurance;
maintain full elbow REM; gradually initiate
sporting activities
Week 3
Exercises: Initiate eccentric elbow flexioniextension,
continue isotonic program: forearm and wrist,
continue shoulder program (Thrower's Ten
Program}, manual resistance diagonal patterns,
initiate plyometric exercise program (two-hand
plyometrics close to body only), chest pass, side
throw close to body, continue stretching calf and
hamstrings
Week id
Exercises: Continue all exercises listed above:
program plyometrics to two-hand drills away from
body: side-to-side throws, soccer throws, side
throws
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
Table 9 {continued}
Postoperative Rehabilitation Protocol
Following Ulnar Collateral Ligament
Reconstruction Using Autogenous Palmaris
Longus Graft [Accelerated RflM}
Weeks 12-14
Continue all exercises: initiate isotonic machines
strengthening exercises {if desired}: bench press
{seated}. lat pull down; initiate golf. swimming;
initiate interval hitting program
lteturn-to Activity Phase {Weeks 14-31]
Goals: Continue to increase strength. power.
r: endurance of upper extremity musculature;
.E
4.!
gradually return to sport activities
I'll
:I: Week 14
E
I'fl
Exercises: lContinue strengthening program;
.:
fill
a: emphasize elbow and wrist strengthening and
1's: flexibility exercises: maintain full elbow RUM:
initiate one-hand plyometric throwing [stationary
throws); initiate one-hand wall dribble; initiate
one-hand baseball throws into wall
Week 16
Exercises: Initiate interval throwing program
{phase I. long-toss program]; continue Thrower's
Ten Program and plyometrics; continue stretching
before and after throwing
Weeks 22-24
Exercises: Progress to phase II throwing (after phase I
successfully completed].
Weeks 313-3.?
Exercises: Gradually progress to competitive
throwingl'sports.
HUM = range of motion, AHDM = active range of motion, Elil I
external rotation. IF. = internal rotation. PHF = proprioceptive
neuromustular facilitation.
Data from Willl'. ltE, Arrigo EA. Andrews .llll. Azar FM: Fleha bilitation
following elbow surgery in the throwing athlete. Dper Tech Sports
Med mementos-132.
The rehabilitation program in current use following
UCL reconstruction is outlined in Table 9. The athlete‘s
arm is placed in a posterior splint with the elbow immo-
bilized at 9H“ of flexion for the first T days postoperatively
to allow early healing of the UCL graft and fascial slings
involved in the nerve transposition. The patient is allowed
to perform wrist ROM and gripping and submaximal
isometrics for the wrist and elbow. The patient is pro—
gressed from the posterior splint to a hinged elbow ROM
brace to protect the healing tissues from valgus stresses
that can be detrimental. The brace is discontinued at the
beginning of week 5.
firthopaedic Knowledge Update: Sports Medicine 5
Passive RUM activities are initiated immediately to
reduce pain and slowly stress the healing tissues. Initially,
the focus of the rehabilitation is on obtaining full elbow
extension while gradually progressing flexion. Elbow
extension is encouraged early, to at least 15‘“, but full ex-
tension is allowed if the patient can comfortably achieve
it as long as no discomfort is present. a recent study
demonstrated that passive ROM of the elbow produced
3% or less strain in both bands of the reconstructed liga—
ment and approximately 1% strain for the anterior band
of the UCL.“ Therefore, it has been determined that in
the immediate postoperative period, full elbow extension
is safe and does not place excessive stress on the healing
graft. Conversely, elbow flexion to 100“ is allowed and
should be progressed at about 10” per week until full
RDM is achieved by 4 to 6 weeks postoperatively.
Isometric exercises are progressed to include light resis-
tance isotonic exercises at week 4 and the full Thrower’s
Ten Program by week 6. Progressive resistance exercises
are incorporated at week 3 to 9. Again, focus is placed
on developing dynamic stabilization of the medial elbow.
Because of the anatomic orientation of the flexor carpi
ulnaris and the flexor digitorum superficialis overlying
the UCL, isotonic and stabilization activities for these
muscles can assist the UCL in stabilizing valgus stress
at the medial elbow.“ Thus, concentric and eccentric
strengthening of these muscles is performed.
Aggressive exercises involving eccentric and plyometric
contractions are included in the advanced phase, usual-
ly weeks 11 through 16. The Advanced Thrower‘s Ten
Exercise Program is initiated at week 12 after surgery.
Two-hand plyometric drills are performed at week 12,
and one-hand drills are executed at week 14. An ITP is
allowed at postoperative week 15. Progression to throw‘
ing from a mound may occur within 4 to 6 weeks follow-
ing the initiation of an ITP, and a return to competitive
throwing may cormnence at approximately 9 months
following surgery.
a Edit) study reported the outcomes of UCL recon-
struction of the elbow in T43 athletes during a 2—year
minimum follow-up.“ The authors stated that UCL recon-
struction with subcutaneous ulnar nerve transposition was
found to be effective in correcting valgus elbow instability
in the overhead athlete and that the procedure allowed
most athletes {fl 3%, 616 patients} to return to the previous
or a higher level of competition in less than 1 year. Major
complications were noted in only 4% {30 patients].
Ulnar Herve Transposition
An ulnar nerve transposition can be performed in a subcu-
taneous fashion using fascial slings. The clinician should
use caution to avoid overstressing the soft-tissue structures
fl lflld American Academy of Orthopaedic Surgeons
 |Chapter 24: Nonsnrgieal and Pbstpperative Rehabilitation for Injuries of tile Overhead Aflflete’s Elbow

Postoperative Rehabilitation Following Ulnar Nerve Transposition

Phase W:
Phase I: Immediate Phase III: Advanced Heturn-to-Activlty
Postoperative Phase Phase II: lntennediate Phase Strengthening Phase Phase
Week 0-2 Weeks 3-? Weeks 3-12 Weeks 12-16
Goals: To allow soft— Goals: To restore full pain—free Goals: To increase Goal: To gradually
tissue healing of REM; improve strength. power, strength, power, return to sporting
relocated nerve, endurance of upper-extremity endurance; activities
reduce pain and musculature: graduallyr increase gradually initiate
inflammation, functional demands sporting activities
retard muscular
atrophy
Week 1 Week 3 Week 8 Wee-It 12

uvsvxllssuas :v
Posterior splint at Discontinue posterior splint; progress Initiate eccentric Return to competitive
9G“ elbow flexion elbow REM and emphasize full exercise program; throwing; continue
with wrist free extension; initiate flexibility begin plyometric Thrower's Ten
for motion (sling exercise for wrist extensionl'flexion, exercise drills; program
for comfort}; forearm supinationl‘pronation, continue shoulder
compression and elbow extensionl'flexion; and elbow
dressing; exercises initiate strengthening exercises for strengthening and
such as gripping wrist extensionfflexion, forearm flexibility exercises;
exercises, wrist supinationr'pronation, elbow initiate interval
HUM, shoulder extensorsrflexors, and a shoulder throwing program
isometrics program
Week 2 Week 6 NA NA
Remove posterior Continue all exercises listed above;
splint for exercise initiate light sports activities
and bathing;
progress elbow
HUM {PRGM 15"
420“}; initiate
elbow and wrist
isometrics; continue
shoulder isometrics
HDM - range of motion, PROM - passive range of motion, HA - not applicable.

involved in relocating the nerve while soft—tissue healing
occurs.“ The rehabilitation guidelines following an ulnar
nerve transposition are outlined in Table 10. A posterior
splint at 90° of elbow flexion is used for the first post—
operative weelc to prevent excessive extension RUM and
tension on the nerve. The splint is discontinued at the
beginning of week 2, and light RUM activities are initiat-
ed. Full RUM usually is restored by weeks 3 to 4. |Gentle
isotonic strengthening is begun during week 3 to 4 and
progressed to the full Thrower’s Ten Program by 4 to 6
weeks after surgery. Aggressive strengthening, including
eccentric training, the Advanced Thrower’s Ten Exercise
Program, and plyometric training, is incorporated at week,
3 and an [TP is begun at week 3 to 9 if all previously
outlined criteria are met. A return to competition usually
occurs between weeks 12 and 16 postoperatively.
Posterior Dlecranon Dsteophyte Excision
Surgical excision of posterior olecranon osteophytes is
performed arthroscopically using an osteotome or mo-
torised burr. Approximately 5 to ll] mm of the olecranon
tip is removed, and a motorised burr is used to contour
the coronoicl, olecranon tip, and fossa to prevent further
impingement during extreme flexion and extension.fl
The rehabilitation program following arthroscopic
posterior olecranon osteophyte excision is slightly more
conservative in restoring full elbow extension secondary
to postsurgical pain. RUM is progressed within the pa-
tient‘s tolerance, but by 1|] days after surgery, the patient
should exhibit at least 15“ to 10591 If!” of RUM, and 5“-
10” to 115* by day 14. Full ROM ll)” to 145“} typically is
restored by day 20 to 25 after surgery. The rate of RUM
progression most often is limited by osseous pain and

IE! Elllli American Academy of flrthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
synovial joint inflammation, usually located at the top
of the olecrauon.
The strengthening program is similar to the previously
discussed progression. Isometric exercises are performed
for the first 10 to 14 days, and isotonic strengthening is
performed from weeks 2 to I5. During the first 2 weeks fol—
lowing surgery, forceful triceps contractions can produce
posterior elbow pain; therefore, the clinician should avoid
initiating or reducing the force produced by the triceps
muscle. The full Thrower’s Ten Program is initiated by
week 6. An ITP is included by week lfl to week 12. Em-
phasis again is placed on eccentric control of the elbow
flexors and dynamic stabilisation of the medial elbow.
c
The outcomes of elbow surgery in T2 professional based
.E
4.! ball players have been reported.” Elf these athletes, 4?
exhibited a posterior olecranon osteophyte, and 13 of the
I'll
:
E
I'fl athletes who underwent an isolated olecranon excision
.c
fill
a: later required a UCL reconstruction.” These findings
1's: suggest that subtle medial instability can accelerate os-
teophyte formation.
The elbow joint is a common site of injury in athletes,
especially in the overhead athlete, because of the repet-
itive forces occurring at the elbow that create repetitive
microtraumatic injuries. |Conversely, in athletes playing
in collision spurts such as football, wrestling, soccer,
and gymnastics, elbow injury often results from mace
rotraumatic forces to the elbow, leading to fractures,
dislocations, and ligamentous injuries. Rehabilitation of
the elbow, whether after injury or surgery, must follow a
progressive and sequential order to ensure that the healing
tissues are not overstressed. The rehabilitation program
should limit immobilization and achieve full ROM ear-
ly, especially elbow-ar extension RCM. Furthermore, the
rehabilitation program should restore strength and neu—
romuscular control progressively and should incorporate
sport-specific activities gradually to successfully return
the athlete to his or her previous level of competition as
quickly and safely as possible. Additionally, the rehabili-
tation of the elbow must include the entire kinetic chain
[the scapula, shoulder, hand, corei'hips, and legs} to ensure
the athlete’s return to high-level sports participation.
Clrthopaedic Knowledge Update: Sports Medicine S
Hie-y Study Points
- Multiphased rehabilitation programs allow individ-
ualised progression of the athlete as determined by
successful completion of each phase.
II A complete and thorough evaluation allows the re-
habilitation specialist to properly design an effective
treatment program for each athlete.
I The rehabilitation programs are designed to gradu-
ally introduce functional forces and stresses through
functional and sport—specific drills to prepare for a
return to prior level of function.
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C lfllfi American Academy of Orthopaedic Surgeons
 Chapter 24: Noosorgiml and Ibstoperafive Rehabilitation for Injuries of the Overhead Athlete’s Elbow
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players with no history of shoulder, elbow, or cervical
injuries and measure passive glenohumeral internal and
external rotation, elbow flexion and extension, and fore—
arm pronation and supination. The authors reported a
significant difference between players with UCL injury
versus control patients for dominant arm internal rotation,
internal rotation deficit, and total RUM. The authors
concluded that pathologic glenohumeral internal rotation
deficit can be associated with elbow valgus instability.
Level of evidence: Ill.
13. Crockett HC, IGross LB, Wilk FEE, et al: Dsseous ad—
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lflfl2530{1}:20-16. Medliue
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Elhotu Sstrgr lflllglfljS]:TflS-TIS. Medliuc DCII
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{PCT} using a lfl-MI-Is transducer to determine the cor-
relation with glenohumeral internal rotation, external
rotation, and scapular upward rotation. The authors re-
ported that PCT was greater on the dominant shoulder
than on the nondominant shoulder. A negative correlation
was noted between PCT and internal rotation. A positive
correlation was found between PCT and external rota—
tion and between PCT and scapular upward rotation at
ED”, 9S”, and 120” of glenohumeral abduction. Level of
evidence: III.
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hilitutitre Exercises for the Shoulder and Elliott! ,od 6'.
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IE! lfllfi American Academy of Cirrhopaedlc Surgeons
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134. Medline D01
1?. Townsend H, Jobe PW, Pink M, Perry J: Electromyograph—
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2T2. Medliue DUI
13. Reinold MM, Will: KE, Fleisig '35, et al: Electromyo-
graphic analysis of the rotator cuff and deltoid mus-
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exercises. J C'lrthojilI Sports Phys Ther 20M;34{T}:SSS-394.
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19. Kibler WE: The role of the scapula in athletic shoulder
function. Am J" Sports Med 199 SflfijljfllS-SST. Modliue
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Andrews JR, Wilk HE, eds: The Athlete’s Shoulder .Hew
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1992;1:33T—36fl.
22.. Tucker WS, Armstrong CW, Gribble PA, Timmons MK,
Yeasting RA: Scapular muscle activity in overhead ath-
letes with symptoms of secondary shoulder impingement
during closed chain exercises. Arch Phys Med Rehabil
2fl10;91{4}:55D-556.Medline DUI
Using EMG data, this controlled laboratory study was
performed to compare the scapular muscle activation pat—
terns in 15 overhead athletes having symptoms of shoulder
impingement with the patterns of 15 overhead athletes
with no shoulder pathology. The authors noted altered
muscle activation of the middle trapesius, and the serratus
anterior and upper trapesius had similar muscle activation.
23. Carpenter JE, Blaster RB, Pellizzon GIG: The effects
of muscle fatigue on shoulder joint position sense. Am
J Sports Med tsssuststosssss. Medline
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vanced Throwers Ten Exercise Program: A new exercise
series for enhanced dynamic shoulder control in the over-
head throwing athlete. Phys Sportsmed 2011:39l4}:9fl-9 1
Mcdliuc DUI
The authors describe the Advanced Thrower’s Ten Exer-
cise Program.
IS. Andrews JR, Jobe FW: 1|slalgus extension overload in the
pitching elbow, in Andrews JR, Zarins E, Carson WE, eds:
Injuries to the Throwing Arm .Philadelphis, Saunders,
lass, pp ass-ass.
16. Swanilt EA, Lephart SM, Swanik CE, Lephart SP, Stone
DA, Pu PH: The effects of shoulder plyometric training
on proprioception and selected muscle performance char-
acteristics. J Shoulder Elbow Surg 2fl02:11{6}:5?9-SSS.
Mcdliuc DUI
Drthopaedic Knowledge Update: Sports Medichie S
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plynmet‘ric training nu the shnulder internal rntaturs. Phys
Tat-r isssnsisnssa
13. 1iiiiilk HE. Vuight ML. Keirns MA. Gambetta V. Andrews
JR. Dillman CJ: Stretch—shnrtening drills fur the upper
extremities: Thenry and clinical applicatien. j Drtbnp
Spurts Phys Titer 1993:1315 1:225-239. Medline DUI
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nf arm dnminance tn shnulder prnprinceptinn. J Drtfrnp
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c pitchers. Am J Spurts Med Eflfll;Z9{Z}fl3T-l42. Medliue
.E
4.!
31. Fleisig GB. Belt B. Fertenbaugh D. 1iiii'ilk BEE. Andrews JR:
I'll
:I:
E
Einmechanical cnmparisnn c-f baseball pitching and lung-
tnss: Implicatinns for training and rehabilitatinn. J Drtbnp
I'fl
.c
fill
n: Spurts Phys Ther 2fl11;41{5}|:29fi-3fl3. Mcdlinc DID]
if
This kinematic and kinetic analysis examined the differ-
ences between pitching frnm a mnund and lnng-tnss pitch-
ing in 1'? healthy cullege pitchers. The results indicated that
hurianntal flat thrnws prncluced binmechanical patterns
similar tn pitching. whereas maximum-distance thrnws
had increased tnrques cnmpared with mnund pitching.
32. Wursden MJ. Greenfield l3. Jnhansnn M. Litaelmau L.
Mundrane M. Dnnatelli RA: Effects nf strength training
un thrcwiug velucity and shuulder muscle perfermance
in teenage baseball players. I Drifter: Spurts Phys Ther
1992;15i5}:223-223.Medliue DUI
33. Escamilla RF. Innne M. deMahy M5. et al: Cemparisnn
uf three baseball-specific 6-week training prngrams nu
threwing velucity in high schccl baseball players. ] Strength
Cured Res ZBIEQEWMTET-ITBI. Medline DIDI
The authc-rs cnmpared thrnwing velncity fullnwing
a 6-week training prngram in 63 high schnnl baseball
players. The subjects were divided intn three training
grcups {the Th mwer’s Ten. Keiser Pneumatic [Kciser]. and
Plynmetric} and a centre] grnup. |Ccimplared with pretest
thrnwing velncity values. pusttest velncity values were
significantly greater in the Thruwer's Ten grcup {1.3%}.
the Keiset Pneumatic {1.3%}. and the Plynmetric {23%}
grnups than in the cuntrnl gruup. with ma significant dif-
ference in the cnntrnl gruup. Level crf evidence: II.
34. Davidsnn PA. Pink M. Perry J. ae PW: Functinnal anat-
nmy cf the flexur prnnatur muscle grnup in relatinn tn the
medial cullateral ligament cf the elbew. Am ] Spurts Med
1995;23il}:145-25i}. Medline DD]
35. Kraushaar B3. Nirschl RP: Tendinnsis nf the elbnw (ten-
nis elbnw]. Clinical features and findings nf histnlngical.
immunnhistuchemical. and electrnn micruscnpy studies.
I Bnne Jnint Sang Am 199 9:31i2}:239-2?B. Medline
Drthnpaedic Knnwledge Update: Spnrts Medich'ie 3
36. Hirsch] BF. Ashman E5: Tennis elbcw tendinnsis {epicen-
dylitis}. Instr Cnnrse Leet 2U D4:53:53 3-593. Medline
3?. Suresh 5P. Ali KB. Jenes H. Ccnnell DA: Medial epicen-
dylitis: Is ultrasnund guided autulnguus bin-Dd injectinn an
effective treatment? Br] Spnrts Med anssssnnssssss.
discussinn 939. Merliine DDI
33. de Mus M. van der Windt AE. Jahr H. et a1: Can plate-
let-rich plasma enhance tendcn repairi' A cell culture study.
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39. Mishra A. Pavelkn T: Treannent cf chrnnic elbnw tendi-
nnsis with buffered platelet-rich plasma. Am J Spurts Med
1906;34f11}:1??4-1??3.Medline D'DI
4f]. Gum 5L. Reddy GK. Stehnn-Bittel L. Euwemeka C5: Cum-
binetl ultrasuund. electrical sti mulatic-n. and laser prnmc-te
cuilagen synthesis with mnderate changes in tendnn bin-
mechanics. Am J Phys Med Rebufaif 199?;Tfii4iflflfl-29E.
Medline DUI
41. Reddy GK. lGum 5. Stehnn-Bittel L. Enwemeka C5: Ein-
chemistry and biuruechanics of healing tendcn: Part II.
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ulatinn. Med Sci Sparts Exerc 1993;3flifih'3'94-Bflfl.
Medliue DD]
42. Sterginulas A. Sterginula M. Aarskng R. aes-Martius
RA. Bjnrdal jM: Effects uf luw—level laser therapy and
eccentric exercises in the treannent cf recreatinnal ath-
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lflflfl;3£{5}:331-33?.Medline Dfll
43. Alley RM. Pappas AM: Acute and performance related
injuries cf the elbnw. in Pappas AM. ed: Upper Extremity
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1995. pp 339-364.
44. Andrews JR. 1i'ii'hitesicle JA: lIamnn elbow prnblems in
the athlete. J Drtisnp Spurts Phys Ther 1993;19ffiitll39-
195. Medliue DD]
45. MurreyT BF: Dstenchnudritis Dessicans. in DeLee JC. Dre:
D. eds: Drtbupeiiie Spurts Meriieine .Philadelphia. Saun—
ders. 1994. pp 903-912.
46. Bauer M. Jnnssnn K.]nsefssnn PC}. Lindéu B: {Listenchnn—
dritis disseca ns nf the elb-nw. A lung-term fnllnw-up study.
Ciia Drthnp Heist Res 1992;234:136-160. Medline
4?. Andrews JR. Jelsma RD. Jnyce ME. Timmerman LA:
Dpeu surgical prncedures fnr iniuries nf the elbnw in
thrcwers. Oper Tech Sparta Med 1 996:4{2J:109—113.DDI
4B. Dines J5. ElAttrache H3. CnnwayJE. Smith W. Ahmad
1'35: Elinical nutcemes cf the DANE TJ technique tn treat
ulnar cullateral ligament insufficiency cf the elbnw. Am
.r Spurts art-e anagssnaynsssesaa. Medliue nnI
49. Enhrbnugh JT. Altchek DW. Hyman]. Williams E] III.
Butts JD: Medial cullateral ligament recnustructinn c-f
D lfllfi American Academy nf Drthnpaedic Surge-ens
 Chapter 24: Nunsurginal and Ibstnpetafive Rehabilitatinu Enr Injuries nE the Dverhead Athlete’s Elbnw
the elbnw using the ducking technique. Ans ,7 Spuril‘s Med
2002;30i4jfi41-543. Medline
5B. Bernas GA, Ruberte Thiele RA, Kinuaman FLA, Hughes
RE, Miller BE, Carpenter JE: Defining safe rehabilitatinn
fnr ulnar enllateral ligament teenusttuetinn nf the elbnw: A
binmeehanieal study. Am] Spurts Med Elli] 9;3?{12}:2392-
24(10. Medline DUI
This enntrnlled labnratnrv stud}r evaluated the strain nu
the UCL in eight eadaver elbnws fnllnwing UCL reenn-
struetinu using a graeilis teudnn graft. Strain was mea-
sured with elbnw passive REM, 22.2 H isnmetrie flexinn
and eatensinn enntraetinn. and 3.34 N -n1 varus and val-
gus tnrque at 91]“ fleetinn. Frnm fl“ tn 50“ flexinn, strain
was less than 3%, and at 90'" fleetinn, strain was 2%. Nn
substantial strain with fnrearn: rutatinn was nnted.
51. Cain EL Jr, Andrews JR, Dugas JR, et al: Gutenme nf
ulnar enllateral ligament reennstruetinn at the elbnw
IE! 2fllfi American Aeadernv nt' flrthnpaedie Surgenna
in 1231 athletes: Results in T43 athletes with minimum
2-vear fnllnw—up. Am I Sports Med 2U]D;3E{12}:242E-
2434. Medline DUI
This retrnspeetive nutenme study repnrted the nutenmes
and the return tn Fla}r in athletes fnllnwing UCL reenn-
struetinn at a minimum at 2-year tellnw-up. {if all ath-
letes, 33% were able tn return tn their previnus level nf
enmpetitinn nr higher. The mean time fnr the initiatinn
nf thrnwing was 4.4 mnuths, and the mean time fur the
return tn full enmpetitinn was 11.6 mnnths. Level nf
evidenee: IV.
52.. Martin 5D. Baumgarten TE: Elbnw injuries in the threw-
ing athlete: Diagnnsis and arthrnsenpie treatment. Utter
"ll"ee.l:lI Spur-ts Med 1996;4{2}:1flfl-1fl3. DUI
53. Andrews JR, Timmerman LA: flutenme nf elbnw sur-
get}; in prufessinnal baseball players. Am} Spnrts Med
uaasuuqeuaa :1:-
1955;23l4}:4fl?—413.Medlitlt: DUI
Drthnpaedie Knuwledge Update: Sperts Medicine 5
®
Chapter 25
Hip Rehabilitation
Heelan Enseld. MS. PT. 0C5. SOS ATE. CSCS Dave Koblrieset. DPT, - . r n
Ashley Young, PT, DPT, CSCS
Abstract
Injuries to the hip joint in athletes have recently gained
increased attention. lntra-articular conditions resulting
from femoroacetabular impingement and hypermobility
have been of particular interest. Because evidence to sup-
port both nonsurgical and postoperative rehabilitation
protocols is relatively limited, intervention should be
based on impairments and functional limitations iden-
tified using structured evaluation. The known charac-
teristics of specific athletes related to hip injuries should
be considered when developing treatment programs.
Future emphasis should be placed on critical appraisal
of nonsurgical treatment, postoperative rehabilitation
protocols, and return-to-play considerations for athletes
with hip injuries.
Keywords: hip: rehabilitation: femoroacetabular
impingement: hypermobility
Introduction
Rehabilitation of hip injuries in the athletic population is
a rapidly growing subject of interest in the field of sports
medicine. Intro-articular pathology such as acetabular
labral tears and associated underlying mechanisms such
as femoroacetabular impingement {PM} and joint by-
permobility have prompted innovations in surgical and
nonsurgical treatment. Nonsurgical and postoperative
rehabilitation for these individuals must consider the
mechanical factors of underlying injury {and associated
surgery when applicable}, the demands of the athlete, and
most current available evidence.
None of the following authors or any immediate famiiy
member has received any-“thingI of vaiue from or has stock or
stock options heici in a commerciai company or institution
reiated directiy or indirectiy to the subject of this chapter:
Dr. Enseiri. Dr. Kohirieser; and Di: Young.
fl lflld American Academy of Drrhopaedic Surgeons
n 1....
Femoroacetabular Impingement
The treatment of symptomatic FM has been debated re-
uvnvuuqvuas :1:-
cently. Although literature reporting generally positive
results for the surgical treatment of PM in athletes is in-
creasing,1 the current lack of definitive evidence justifies a
trial of nonsurgical treatment of this population. Monaur-
gical rehabilitation should focus on activity modification,
treatment of physical impairments, and optimization of
joint functionsm
Reasonable training modifications should be the ini-
tial recommendation when treating symptomatic FM.
Activities that place the hip in a position of impingement
should be minimised. Although impingement can occur
in various positions, combined positions of flexiou, ad-
duction, and internal rotation are commonly associat-
ed with increased symptoms associated with FAI. Deep
squatting, lunging, cycling, and hurdling are examples of
activities that may require modification during rehabili-
tation. Effective training while modifying symptomatic
activities can be difficult for competitive athletes partic-
ipating in sports that require frequent performance of
these activities.
Impaired strength has been noted in individuals with
nonarthritic hip pain, including those with Fit]. Particu-
lar deficits of the abductors and external rotators of the
hip have been noted.“l Uncontrolled pelvic motion in the
frontal and transverse planes can contribute to the pain
associated with FAI.‘ Strengthening exercises should be
advanced to include weight-hearing activities that chal-
lenge the patient to control excessive adduction and inter-
nal rotation of the hip. Exercises that maximize gluteal
recruitment and minimize use of the tensor fascia lata
should be emphasized, including the resisted clam shell
(Figure l}, the resisted sidestep {Figure I], the unilateral
bridge (Figure 3}, and ouadruped hip extension exer-
cises.‘5 Exercises to strengthen the lumbopelvic muscles
should also be considered. Appropriate control can help
to decrease the occurrence of excessive anterior pelvic
tilt associated with impingement secondary to altered
acetabular orientation.1r
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation

Figure 1 Photograph demonstrates the resisted clam

shell ese rcises. The patient abducts and
esternally rotates the hip against resistance.

:
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4.!
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I'fl
.: Figure 3 Photograph demonstrates the unilateral bridge.
Ill
cc The patient lifts the pelvis off the ground using
vii: one leg. Pelvic stabilization is emphasized.

the athlete to move the hip through the ranges of mo-

tion (RflMsl associated with symptomatic impingement.
Treating hip flesror tightness should he a priority. Exces-
sive tightness of this muscle group can he associated with
anterior pelvic tilt. Anterior pelvic tilt has been correlated
with the occurrence of PHI earlier in hip RUMF 1illnl'hen
prescribing stretching activities, clinicians must be cau-
tions to avoid placing the patient in positions associated
with symptomatic impingement.l
Physical therapy techniques should be considered for
patients with FA]. Joint mobilisation may be indicated
when the patientis examination suggests a loss of capsu-
lar mobility. Possible examination findings include loss
of passive RDM, a capsular end-feel with passive RUM
assessment, and a decrease of symptoms with manual dis-
traction of the hip joint. Because FA] can be part of a spec—
trum of changes and a precursor to hip osteoarthritis in
some individuals,3 capsular changes should he considered.
Soft—tissue mobilisation can be useful when the tissue
restricts joint mobility. A loss of motion associated with
an elastic end-feel coupled with an immediate response to
manual treatment of the target tissue indicates soft-tissue
mobilization as a potentially useful intervention.l

Figure 2 Photograph demonstrates the resisted sidestep

exercise. The patient steps laterally with a
resistance band placed around the lower legs.
Patients with symptomatic PM may demonstrate im-
paired hip flexibility and pelvic musculature.3 Flexibility
activities should treat muscle tightness that can cause
Joint Hypermoloility.r
Following a diagnosis of hypermohility or structural
instability of the hip joint, patient education and coun-
scling regarding activity modification is of primary con-
cern to protect andi'or avoid further injury in the region.
It is recommended that the individuals avoid activities

firthopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons

involving uncontrolled, forceful end-range extension
andi'or rotation that can place repetitive strain on the
passive restraints of the hip}
The correction of muscular imbalances of the hip and
lumbopelvie region should be emphasized in athletes with
hypermobility. An individualised program should be
developed to treat impairments identified through eval-
uation. Flexibility exercises should he prescribed with
caution only after end—feels have been assessed and are
to be discouraged in those patients with excessive RUM}
RUM measurements should be recorded and compared
with the contralateral limb. Individuals with rotational
hip REM imbalances demonstrate specific patterns of
strength deficits. Individuals with excessive hip external
rotation ROM have decreased strength of the hip internal
rotators, and those with excessive internal rotation ROM
have decreased strength of the hip external rotators.9 The
development and maintenance of sufficient strength to
limit auditor control excessive hip RUM is essential in the
nonsurgical management of this population.I
Strengthening programs designed for individuals with
hip joint hypermobility should primarily focus on the hip
abductor and external rotator muscle groups because of
their role in controlling lower extremity alignment during
functional activities. These specific muscle groups are
responsible for maintaining a level pelvis and preventing
adduction and internal rotation of the lower extremity
while in single-leg stance.m Decreased hip rotational sta-
bility andfor strength has also been noted in individuals
with symptomatic acetabular labral tears.1
In the presence of joint hypermobility, neu romuscular
re-education including proprioceptive and perturbation
training may be beneficial. Neuromuscular reeducation
has had positive effects with other pathologies of the
lower extremity. Individuals with labral pathology and
compromised hip stability may benefit from the inclusion
of dynamic stabilisation andfor perturbation training
{Figure 4} to increase the efficiency of the surrounding
musculature, which can improve dynamic hip joint con-
trol during functional activities.1
Q "Idea 25.1: Manual Perturbation, Prone
and Quaduped. Keelan Enselci, MS. PT,
DES (1 min}
Postoperative Concerns for Athletes Undergoing
Hip i'iyrthroscopyr
In the patient who has undergone hip arthroscopy, post-
operative goals are similar irrespective of the specific pro—
cedure performed. The main objectives are to reduce both
IE! Ellie American Academy of flrtbopaedic Surgeons
Chapter 25: Hip Rehabilitation
usssaiiqsuaa :1:-
Figure 4 Photograph demonstrates the manual
perturbation exercises. In the prone position.
the patient is instructed to match randomly
directed force applied by the clinician.
the joint and postoperative inflammation quickly while
protecting the repaired structures. Many complications
in rehabilitation are preventable and can be avoided with
deliberate patient education regarding the postoperative re-
habilitation protocol, appropriate level of activity progres-
sion, and early activity modification strategies. Problems
can occur during this period if the patient is not compliant
with the prescribed period of limited weight bearing, par-
ticipates in forceful RUM exercises, andfor is progressed
too rapidly through the rehabilitation protocol."
Procedure-specific considerations should be applied
to the rehabilitation program. Prevention of postopera-
tive joint stiffness andi'or the formation of intra-articular
adhesions should be emphasised immediately after hip
arthroscopy. Circumduction RGM exercises {Figure 5} are
used early in the rehabilitation program. Early applica-
tion of circumduction exercises during the postoperative
period has been associated with a lower rate of revision
procedures.”
Acetabular labrum repair should be protected during
the initial postoperative period by limiting hip flexion,
extension, and external rotation RUM. The specific mo-
tion limitations depend on the location of the repair. Hip
flexion is typically limited to 9d“ to protect posterior
repairs, and hip extension and external rotation are of-
ten limited to neutral to protect anterior labral repairs.
1iiiihen the anterior joint capsule is involved {plication
procedures}, external rotation is often restricted for up
to 4 weeks after surgery. ROM is typically progressed
over the course of '3 months. Fewer precautions are used
if labral débridement is performed."
Drthopoedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
i:
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4.! III- a- -_ I --._-. I —_I . __--
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I'fl I -
.i:
fill
a:
1's: Figure 5 Photograph demonstrates the circumduction
range-of-motion activity. The clinician passively
circumducts the patients hip in midrange to
prevent joint stiffness.
1li'ilfeight-hearing precautions vary depending on the
surgical procedures performed. In less-invasive proce-
dures such as isolated labral débridement, a short pe—
riod of partial weight bearing {1 weeks or less} is often
recommended.” For more involved procedures such as
labral repair, protected weight bearing is maintained for
an extended period. In such cases, patients typically bear
weight as tolerated with an appropriate assistive device
such as axial crutches for approximatelyr 4 weeks.""“
When using crutches, patients should be encouraged to
bear partial weight through the involved lower extremity
while demonstrating a normal heel-to-toe gait pattern.
This decreases the compression forces across the hip joint
and can decrease potential iliopsoas irritation that can
result from a sustained contraction while maintaining a
toe-touch gait pattern."-” Patients should continue to use
crutches or an appropriate assistive device until the abil—
ity to ambulate without deviation can be demonstrated,
even if crutch or device use persists beyond timeframes
stated in postoperative guidelines. Wee hing patients from
crutches who are amhulating with compensatory patterns
can delay recovery by contributing to continued intra-
articular irritation andfor overuse of accessory muscula—
ture around the hip.”~”
Osteoplasty is often performed during hip arthros—
copy to treat FA]. Up to 3fl% of the diameter of the
anterolatetal femoral neck can be resected to treat carn
deformities without decreasing the load—bearing capacity
of the femur.”-"5 Resection of 30% of the femoral neck
firthnpaedic Knowledge Update: Sports Medicine 5
diameter can significantly decrease the amount of energy
required to produce a fracture.” Although rare, femoral
neck fractures can occur following arthroscopic osteoplas-
ty; therefore, weight bearing must be limited after proce-
dures that include osteoplasty. Weight-bearing precautions
specific to these procedures vary, but a period of partial
weight bearing of up to 6 weeks is often recommended.”
When capsular modification procedures are performed
to treat laxity, the rehabilitation program should be ad—
justed to protect the integrity of the repaired tissues. In
these cases, RUM precautions specific to the procedure
are reconunended.” If capsulectomy was performed, often
to visualize a cam lesion in the peripheral compartment,
extension and external rotation RUM is avoided in the
-"II_I early postoperative period. With anterior capsular repair,
avoiding external rotation greater than 20" is often rec-
'-
. 'I-"II' I _. '. l
1‘ FEi’t-I- — '.-.‘EIIJ-_r.l,. ' ommended during the immediate postoperative period.11
Microfracture procedures can be performed in patients
with focal full-thickness cartilage lesions of appropriate
sise.“' The immature marrow clot should be protected
during rehabilitation. Recommendations support extend-
ing the protected or limited weight hearing period to 6 to
3 weeks.“1‘3~13 In conjunction with weight—bearing precau—
tions, continuous passive motion can be recommended
after microfracture to avoid intra-articular adhesions
and scar formation. It is commonly recommended that
continuous passive motion be used 4 hours per day during
the first 1 to 4 weeks, with ROM set between 3C!” and W“.
RUM should be based on patient tolerance and progressed
gradually during this period."~'f
Sport—Specific Rehabilitation Concerns for
Athletes With Hip Injuries
Running
Hip musculature is often involved in various running-
related injuries, including iliotibial band syndrome and
gluteal muscle strain. Previous research has demonstrated
that hip joint moments are greatest during the loading
response phase of running, with the gluteus medius hear—
ing the greatest load, followed by the gluteus minimus,
gluteus maximus, and rectus femon' s9” increasing the step
rate has been shown to increase loading of the hamstring
and gluteal muscles in late swing phase. Conversely, in-
creased step rate has been shown to decrease gluteal and
piriformis muscle loading in stance phase.11 For distance
runners, the effect of step rate on specific muscles during
various phases of gait should be considered.
Soccer
Most severe injuries in soccer players occur in the lower
extremity. Although these injuries are more common in
fl lflld American Academy of Orthopaedic Surgeons

the knee and ankle, elite athletes often report unilateral
or bilateral groin pain. Groin pain affects many differ-
ent aspects of play, including kicking, accelerating, and
changing direction. Athletes with groin pain have been
found to produce notably less torque during hip adduc-
tion tasks than those without groin pain.“ In uninjured
players, a marginal difference exists between isometric
measurements of hip adduction and abduction strength
between the dominant and nondominant sides.fl When
determining return-to-play criteria for soccer players,
a near-identical side-to-side measurement of isometric
hip abduction and adduction strength indicates strength
recovery. In cases of bilateral involvement, a ratio of 1.0
for ipsilateral hip abductors versus adductors may be
considered ideal.
Golf
Most golf injuries occur at the lumbar spine; few occur at
the hip joint. However, because of the close association of
the lu mbar spine and pelvis, issues with hip rotation RflM
are thought to influence spinal injuries. During the swing
of right-handed female golfers, the hip joint primarily ro-
tates in the transverse plane, with the lead leg using 50%
to T594:- of available external rotation during the back-
swing and 34% to ”131% of internal rotation during the
downswing. The lag leg rotates substantially less during
a full swing, creating an asymmetric movement pattern
at the hip.” Because golf is a weight-bearing activity, it
is reconunended that RUM be clinically assessed during
weight bearing, rather than in the traditional positions
of sitting and prone. In addition, when treating hip in—
juries in golfers, obtaining full lead leg internal rotation
through joint or soft tissue-mobilisation techniques must
be emphasised to minimize compensatory RUM through
the lumbar spine.
Ballet
Ballet dancers require an extreme amount of motion at
the hip, which often results in compensatory soft-tissue
laxity. This pronounced amount of flexion, extension,
abduction, and external rotation renders these athletes
more susceptible to labral injuries, femoroacetabular
subluxation, tendinopathies, and muscular imbalances.
lGenerally, dancers exhibit increased external rotation at
hip at the expense of internal rotation RGM.“ External
rotation strength in dancers has not been found to be
greater than in nondancers; however, dancers generate
a substantially greater angle—specific torque at extreme
ranges of external rotation.” Rehabilitation should focus
on establishing external rotation strength, particularly at
the extreme RDMs commonly used by dancers.
IE! lfllfi American Academy of flrthopaeclic Surgeons
Chapter .15: Hip Rehabilitation
Return—to—Play Considerations for Athletes With
Hip Injuries
A relatively small body of literature describes functional
testing and return-to-play considerations for athletes be-
ing treated nonsurgically or postoperatively following
injuries in the hip region. Currently, clinicians must use
the limited available evidence combined with established
functional tests and protocols for other lower extremity
injuries. Variations of deep squat test results have been
described for individuals with FAIR-'5 Hip abductor func-
tion has been correlated to performance on the single-
leg squat and star excursion balance test. However, this
association has only been studied in nonsymptomatic
uvilvaltqsuvs :s-
individuals.” Postoperative return-to-play criteria have
often been adapted from protocols described following
athletic knee injuries.l
Several patient-reported outcome measures have been
validated for the younger, active population with hip inju-
ries. The International Hip flutcome Tool liHUT—dfil has
shown reliability and validity for assessing the quality of
life in young, active patients.” The Hip Outcome Score
has shown reliability and validity in patients undergoing
hip arthroscopy. Additionally, the Hip Dutcome Score
contains a sports subscale.“ Using patient-reported out-
come measures may help the clinician assess perceived
characteristics that affect an athlete’s readiness for return
to sports.
5 u no me ry
Hip and groin pain can become a chronic condition in
athletes, potentially affecting performance and athletic
participation. Recent advances in diagnostic imaging and
improved understanding of pertinent examination find-
ings should result in more rapid and accurate diagnosis of
these pathologies. Many factors need to be considered by
clinicians when implementing guidelines for nonsurgical
management or a specific postoperative rehabilitation
program. To achieve the most effective results and de—
sired outcomes, the rehabilitation program should be
based on the most current literature, individualized to
treat impairments identified during clinical examination,
and modified to consider athlete’s diagnosis, history, and
specific surgical procedure performed. A paucity of evi-
dence exists detailing objective criterion—based progres-
sion through nonsurgical or postoperative rehabilitation.
For this reason, decisions to advance exercise or activity
level should be based on the individual’s ability to demon-
strate correct mechanics and appropriate dynamic con-
trol during functional activities versus advancing solely
on time-based measures. Current evidence provides a
Drrhopaedic Knowledge Update: Sports Medicine 5
 Secfien 4: Rehabilitatien
theeretical feundatien en which re base rehabilitatien;
hewever. future research sheuld fecus en cemparisens
between interventiens andfer pretecels te impreve ef—
fectiveness ef carc.
Key Study Peints
I Treatment techniques applicable tn athletes with
symptematic FAI and hyperme bility ef the hip jnint
must be identified.
It The apprepriate pesteperative treatment pregres-
sien te athletes undergeing hip arthrescepy sheuld
be applied.
' Spert—specific facters affect rehabilitatien ef athletes
c
with hip injuries.
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4.!
I'll
: cruitment. Level ef evidence: III.
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all
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1's:
Annetated References
l. Tranc-vich M]. Salsler M]. Ensclti KR. Wright 1|If]: A re-
view ef femereacetabular impingement and hip arthres-
cepy in the athlete. Phys Spertsmed ID14;41{1}:T5-31
Medline DUI
This clinical review expleres recent evidence en the eval-
uatien. recegnitien. and treatment ef FAI. and discusses
nensurgical management, pesteperative rehabilitatien.
and treatment in the pediatric and master athlete pepu—
latiens. Level ef evidence: V.
1. Enselti It. Harris—Hayes M. White DM. et a1; Drthepaedic
Sectien ef the American Physical Therapy Asseciatien:
Nenarthritic hip jnint pain. I Urrhep Sperts Phys Ther
2fl14;44{6}:A1-A31.Medline DUI
These guidelines develnped by the Urthepaedic Sectien
ef the American Physical Therapy Asseciatien describe
evidence-based physical therapy practice fer treatment ef
nnnarthritic hip pain. Level ef evidence: I.
3. Yasbelt PM. Uvanessian V. Martin RL. Fultuda TY:
Hensurgical treatment ef acetabnlar labrum tears: A case
series. ] Urthep Sperrs Phys Ther 2011:41i5 1:346—353.
Medline DUI
This case series describes a nensurgical pregram fer these
with clinical evidence ef an acetabnlar labrum tear and
fen nd all patients demenstratcd decreased pain. functienal
imprevement. and cerrectien ef muscular imbalances.
Level ef evidence: IV.
4. Harris-Hayes M. Mueller M]. Sahrmann EA. et al: Perseus
with chrenic hip jnint pain exhibit reduced hip muscle
strength. I Urthep Sperts Phys Ther 2fl14;44{11}:39fl—
393. Medline DUI
This centrelled laberatery cress-sectieual study assess-
ing hip abductien and retater strength characteristics in
Urthepaedic Knewledge Update: Sperts Medicine 5
individuals with chrenic hip pain and centre] patients
feund substantial differences exist between experimental
and centrel greups. Level ef evidence: III.
Austin AB. Senna RB. Meyer JL. Pewers CM: Identi-
ficatien ef abnermal hip mntinn asseciated with ac-
etabular labral pathelegy. J Uri-“hep Sperss Phys Ther
Zflfl3;33{9}:553-565.Medline DUI
Selltewits DM. Benecls G]. Pewers CM: 1i'ii'hich exercises
target the gluteal muscles while minimizing activatien
ef the tenser fascia lata? Electremyegraphic assessment
using fine—wire electredcs. ] Urshep Sperrs Phys Ther
2013:43i2]:54-64.Medline DUI
This centrelled laberatery study used electremyegraphic
data tn determine gluteal muscle activity during selected
exercises and identified specific exercises that recruit the
gluteal muscles while minimising tenser fascia lata re-
Ress JR. Nepple J]. Philippen M]. Kelly ET. Larsen EM.
Hedi A: Effect ef changes in pelvic tilt en range ef me-
tieu te impingement and radiegraphic parameters ef ac—
etabnlar merphelegic characteristics. Am J Sperts Med
2D14;41[1fi}:24fl2-24i}9.Medline DUI
This centrelled laberatery study examining the effect ef
changes in pelvic tilt en terminal hip RUM and measure-
ments ef acetabnlar vetsien feund dynamic changes in
pelvic tilt substantially influence the functienal erientatien
ef the acetabulum. Level ef evidence: III.
Hedi A. Lynch EB. Sibilslty Enselman ER. et al: Elevatien
in circulating biemarlters ef cartilage damage and inflam-
matien in athletes with femereacetabular impingement.
Am I Sperts Med 2fl13:41(11}:2535-2590. Medlilte DUI
This centrelled laberatery study measured biemarlters ef
cartilage degradatinn and inflammatien in athletes with
FAI cemparcd with centrel patients and feund the results
were substantially higher in the experimental greup. Level
ef evidence: III.
Cibull-ta MT. Strube M]. Meier D. et al: Symmetrical
and asymmetrical hip retatien and its relatienship te hip
retater muscle strength. Clix Eiemech {Batiste-l. Ayers}
2Dlfl:25[ll:55-62.Medline DUI
10. Lectun DT. Ireland ML. 1ilii’illsc-n JD. Ballantyne ET.
Davis IM: ISure stability measures as risk facters fer
lewer extremity injury in athletes. Med Sci Sperrs Exerc
lflfl4:36{fil:926-934.Medline DUI
This study examined strength measurements in subjects
with symmetrical and asymmetrical hip retatien RUM
and fennd that strength values depended en the pnsi-
tien that the hip retater muscle is tested and the type nf
hip retatien symmetry er asymmetry present. Level ef
evidence: III.
11. Spencer—Gardner L. Eischen ll. Levy BA. Sierra R].
Engasser WM. Krych A]: A cempreheusive five-phase
rehabilitatien pregramme after hip arthrescepy fer
D lfllfi American Academy ef Urrhepaedic Surge-ens

fcmereacetabular impingement. Knee Satrg Sperts Trans
metei A-rtbresc 1014;22t4}:343-359. Medline Dfll
This case series describes a nensurgical pregram fer pa—
tients with clinical evidence ef an acetabular labrum tear
that emphasizes hip and lumbnpelvic stabilizatinn, cnrrec-
tien ef hip muscle imbalances, biemechanical centre], and
spert-speeific functienal pregressien. Level ef evidence: IV.
12. TN'illinten 5C, Briggs KK, Philippen M]: Intra—articular
adhesiens fellewing hip arthreseepy: A risk facter analy-
sis. Knee Sarg Sperts Trnnmetni drtbresc 2014;21{4}:322-
325. Medline DUI
This case series was cenducted te evaluate the pessible risk
facters fer adhesiens after hip arthrescepy and feund ad-
hesiens fellewing hip arthrnscepy were reduced with mud-
ificatien nf rehabilitatinn pretecels. Level ef evidence: IV.
13. Enseki KR, Kahlrieser D: Rehabilitatinn fellnwing hip
arthrescepy: An evelving precess. int j Sperts Phys Ther
2D14;9{fil:755-TT3. Medline
14. Edelstein J, Ranawat A, Enseki KR, “fun It], Draevitch P:
Pest-eperative guidelines fellewing hip arthrescepy. Curr
Rea Mnsctdeskeiet Med 2fl12;5[1l:15-23. Medline DUI
This clinical cc-mmentary details a multiphase reha-
bilitatien pretecel fellewing hip arthrescepy. Level ef
evidence: V.
15. Ayeni (JR, Eedi a, Lerich DIG, Kelly ET: Femeral neck
fracture after arthreseepie management ef femereaeetab-
nlar impingement: A case repert. I Bette Infnt Surg Am
lfll];93{9l:e4?.Mcdline net
The authers reperted a case descriptien ef a patient experi-
encing fracture ef the femeral neck fellewing arthrescepic
esteeplasty for PAL Level nf evidence: V.
16. Mardenes RM, Genaalea C, IEheu Q, Zebita M, Kaufman
KR, Trnusdale RT: Surgical treatment {if femnreacetab-
ular impingement: Evaluatien ef the effect ef the size ef
the resectien. f Bette. jeinct Sing Am lflfl5;3?{2}:2?3-279.
Medline DUI
1?. Haughem ED, Ericksen B], Rybalke D, Hellman M,
Nhe 5]: Arthrescnpic acetabnlar micrnfracture with the
use ef flexible drills: A technique guide. Artbresc Teri:
2014;3{4]:e459-e463.Medline DUI
The anthers reperted a technical descriptien ef an ar-
threscepic micrnfracture technique fer the hip using a
flexible micrnfracture drill. Level nf evidence: V.
13. Ten YM, Kecher M5: Chendral lesicrns nf the hip: Mi-
crefracture and chendreplasty. Sparta Med Attbtesc
EDIG;IS[EI:E3-39. Medline DUI
This clinical cemmentary describes chendral injuries that
eccur in the hip jerint and arthrnscepic precedures tn treat
such patbnlngy. Level nf evidence: V.
IE! lfllfi American Academy ef flrrhepaedic Surgeens
Chapter 25: Hip Rehabilitatinn
19. Enseki KR, Martin EL, Draevitch P, Kelly ET, Philippen
M], Schenker ML: The hip jeint: Arthrescepic precedures
and pesteperative rehabilitatien. ] Drtitep Sperts Phys
Timer lflfl6;36{?}:516-525. Medline DUI
20. Schache flG, Blanch PD, Darn TW, Brawn NA, Resemend
D, Pandy MG: Effect ef running speed en lewer limb jeint
kinetics. Med Sci Sperts Exevc 2m 1;43i?}:116fi-12?1.
Medline DUI
This centrelled laberatery study evaluated the effect ef
running speed en lewer limb kinetics and feund hip eit-
tenser and knee fleser muscles during terminal swing
demenstrated the mest dramatic increase in bieruechanical
lead when running speed pregressed reward sprinting.
Level crf evidence: III.
21. Lenhart R, Thelen D, Heiderscheit B: Hip muscle leads
during running at varieus step rates. ,i Ortbep Sperts Phys
usswqu-‘is :1:-
Titer Efl14;44{101:?tifi~??4. ALA-4. Medline DUI
This cress-sectienal centrelled Study characterising hip
muscle ferces and pc-wers during running and hew these
measurements change with step—rate demenstrated in-
creasing step rate and increased hamstring and gluteal
muscle leading in late swing, but decreased leading ef
gluteal muscles and pirifnrmis during stance-phase. Level
ef evidence: III.
11. Therbnrg K, Serner A, Petersen], Madsen TM, Magnus-
sen P, Hiilmich P: Hip adductien and abductien strength
prefiles in elite seccer players: Implicatieus fer clinical
evaluatinn cf hip adductnr muscle recnvery after injury.
slaw } Spetts Med lflllgfifliljflll—IZE. Medline DUI
This cress-sectienal study cemparing isemetric hip ad-
ductieu and abductieu strength between deminant and
nendnminant sides demenstrated that a cemparisnn
between nendeminant and deminant isnmetric hip ad-
ductien strength and ipsilateral hip adductieniabductien
strength ratie sheuld be used as a guideline fer seeeer
players with grein pain. Level nf evidence: III.
23. Gulgin H, Armstcnng C, Gribble P: 1lil'eight-hearing hip
retatien range {if mntinn in female gelfers. M Art: ] Sperts
Phys Ther Zfllfl;5{2}:55—52. Medline
This centrelled laberatery study measuring weight hear-
ing hip retatien RUM in female gelfers cempared with
actual hip retatien RUM eccnrring during a full swing
demenstrated that weight-bearing ROM limits were net
exceeded during swing, but the lead hip demenstrated
decreased weight-hearing internal retatien. Level nf
evidence: III.
24-. Weber AE, Bedi A, Tiber LM, Zalta I, Larsnn CM: The
hyperfleatible hip: Managing hip pain in the dancer and
gymnast. Sperts Health: A Maitidiscipiinnry Appreech.
2fl14;flpril23 [Epnb ahead ef print].
25. Gupta A, Ferniheugh E, Bailey G, Bembeck P, |liIIlarke A,
aper D: fin evaluatien c-f differences in hip eicternal re-
tatien strength and range ef metien between female danc-
ers and nee-dancers. Br I Sperts Med 2Dfl4;3fll[ti1:??E-i'33.
Medline DUI
Drthepeedic Knewledge Update: Sperts Medicine 5
 Sectinn 4: Rehabilitatiun

25. Kivlan ER, Martin RL: Functinnal performance testing This study describes the dcvelnpment nf a self-administered
DI the hip in athletes: A systematic review fur reliability evaluative tun] tn measure healtharelated quality nf life in
and validity. Int }' Spnn‘s Phys Tire-r 2012:?{4l:4fl2—412. ynnng, active patients with hip disnrders that resulted in
Medline the develnpment nf a new quality-nf-life patient-repnrted
c-utcnme measure, the Sid-item Internatinnal Hip |Clutcnme
This systematic review examining perfnrmanee tests fur Tn-nl {iHflT—SS}. Level nf evidence: IIa.
the ynunger active pnpulatic-n with hip pathnlngy found
the use nf functinnal perfnrmance tests in the assessment
at hip dysfunctinn has nnt been well established in the 23. Martin RL, Philippnn M]: Evidence nf reliability and
current literature. Le:tel nf evidence: lIb. respnnsiveness fur the hip nutcnme scure. Arrlrruscflpy
lflflfl;24{6}:fi?fi-EEZ.Mcdlitlc DUI
2?. Mnhtadi HG, Griffin DR, Pedetsen ME, et al. Multicenter
Arthrnscepy (If the Hip Dutcnmes Research Netwurk: The
develnpment and validatinn of a self-administered quality- Videe Reference
nf—life nutcnme measure fnr ynung, active patients with
symptnmatic hip disease: the Internatinnal Hip |[Tuner-me 15.1: Enselti K: Viden. Manual Perturbatinm PWHE and Quad-
Tupi (MDT-33}. Arthrnsenpy 2fi12;23{511:59'5 -505. raped. Pittsburgh, PA, 2-315.
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flrdtnpaedie Knnwledge Update: Sparta Medicine 5 El ll] 16 American Aeadem~y nf Drthnpaedie Surge-ans
Chapter 26
Current Rehabilitation Concepts
Following Anterior Cruciate
nament Reconstructlon
Penny Lauren Goldberg, PT, DP'I', ATE Giorgio Zeppieri Jr, PT, SE, EGGS
’I‘erese L. |lilhmielewslti. PT. PhD. 5C5
Abstract
Injuries to the anterior cruciate ligament {ACL} are
common in sports. Patients usually are recommended to
undergo ACL reconstruction to regain the knee stability
that is necessary for resuming preinjury sports participa-
tion. Recent evidence indicates that REL reconstruction
outcomes include a low return—to—sport rate, a high
incidence of second ACL injury, and the development
of posttraumatic knee osteoarthritis, however; ACL
reconstruction outcomes can be improved with a com-
prehensive preoperative and postoperative rehabilitation
program that addresses knee impairments, patient ex-
pectations, psychosocial factors, and movement pattern
deviations. Deciding when to allow a patient to return
to sports participation or other high-dams or] activities
is challengng and should be judicious, based on the
results of a battery of objective tests.
Keywords: anterior cruciate ligament:
rehahllltation; return to sports
Introduction
Knee ligament injuries are common musculoskeletal in-
juries that often occur during sports participation. The
anterior cruciate ligament (ACLI is the knee ligament
with the highest prevalence of injury.1 ACL injury usually
None of the foiiowiny authors or any immediate famiiy
member has received anything of vaiue from or has stock or
stock options heici in a commerciai company or institution
reiateci ti‘inactiyr or indirectly to the subject of this chapter:
Dr. Goiciberg. Ms zeppieri, Eh: Jones, and Dr. Chmieiewski.
@ lfllfi American Academy of Drthnpaedic Surgeons
Debi Iones, ' II
uoneuuqeqau :11
results in knee instability that leads to reduced knee func-
tion and a lower activity level. Most patients require ACL
reconstruction to regain knee stability and resume sports
or other high-demand activities} Consequently, ACL rc-
construction rehabilitation receives substantial attention
in clinical and research settings.
It is not surprising that most patients who undergo
ACL reconstruction expect to return to sports partici-
pation? flnly approximately 60% of affected patients
actually return to preinjury sports participation after ACL
reconstructiond-5 Moreover, within 2 years after ACL
reconstruction, as many as sea sustain a second ACL
injury to either the surgical or nonsurgical knee, with a
slightly higher risk to the nonsurgical knee.“ Within 1U
years after ACL reconstruction, up to 30% show signs
of posttraumatic knee osteoarthritis,” which can reduce
knee function progressively. Clinicians should be mindful
of these outcomes and should seek ways to improve ACL
reconstruction rehabilitation to enhance returnutousport
(RTE) rates, guard against a second injury, and protect
long-term joint health.
Patients undergoing ACL reconstruction ideally should
undergo a brief period of rehabilitation before surgery and
more extensive rehabilitation after surgery. Postsurgical
ACL reconstruction rehabilitation can be divided broadly
into early rehabilitation and late rehabilitation. Early
rehabilitation focuses on resolving knee impairments and
reintroducing low-level functional activity, whereas late
rehabilitation focuses on preparing and transitioning the
patient back to high-demand activity, including sports
participation. Although general agreement about this
approach to ACL reconstruction rehabilitation exists,
consensus has not been reached on when to initiate cer-
tain exercises—especially those that impart high loads
to the graft or knee articular surfaces—or what criteria
to use when progressing patients between rehabilitation
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
phases or back to sports participation.Em In addition,
altered psychosocial factors"=” and movement patterns13
have been identified after ACL reconstruction, which
can negatively influence rehabilitation outcomes. These
impairments are not addressed routinely in most ACL
reconstruction rehabilitation protocols.
This chapter describes the current concepts in ACL
reconstruction rehabilitation. Although the focus is ACL
reconstruction rehabilitation, many of the concepts are
applicable to the rehabilitation of other knee ligament
injuries.
Preoperative Rehabilitation
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4.! A primary goal of preoperative rehabilitation is to resolve
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knee impairments to the greatest extent possible. Acute
I15 knee impairments resulting from ACL injury, including
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pain, effusion, quadriceps inhibition, and loss of motion,
should be addressed because they can contribute to the
E
development of postoperative knee arth rofi brosis.“ Quad—
riceps weakness occurs in almost all patients after ACL
injury, likely because of effusion and pain.” Quadriceps
muscle inhibition is common after ACL injury and can
contribute to quadriceps weakness.1 High-intensity neu~
romuscular electrical stimulation can be used to reduce
quadriceps muscle inhibition and increase strength.”*“'
Additional exercises to improve quadriceps activation
include the quad set and straight leg misc. Patients usually
adopt an antalgic gait after injury and benefit from gait
training to reestablish knee extension and symmetric
weight hearing.
A subject not addressed routinely in preoperative rehae
bilitation that could influence postoperative outcomes is
patient expectations. Patients should be educated about
the course of ACL reconstruction rehabilitation and need
to be engaged in a discussion about their expectations of
postoperative outcomes to prevent postoperative dissat-
isfaction?“ Practitioners should establish baseline expec-
tations for rehabilitation milestones, create RTE criteria,
and provide direction to prevent unrealistic patient ex-
pectations.” Practitioners also should be aware that the
conventional criteria used to determine success following
ACL reconstruction, such as knee laxity or functional
testing, may fail to capture the patient's definition of
a successful rehabilitation outcome. Excellent clinical
and functional outcomes do not always equate to patient
satisfaction.”~18 Recent evidence has shown that patient
expectations following ACL reconstruction are higher in
younger, highly active patients without a history of previ-
ous knee su rgeryf‘ however, the influence of these factors
on expectations may be unique to the individual and
case.” Patient education aimed at managing expectations
flrrhopaedic Knowledge Update: Sports Medicine 5
is necessary, because failure to address expectations early
in rehabilitation can lead to dissatisfaction and increased
health care utilization and cost."
Patients often have an elevated fear of reinjury follow-
ing ACL injury,” and fear of reinjury is a key reason for
not returning to sports participation after ACL recon-
struction.m Fear of reinjury is high immediately after
ACL injury but tends to decline substantially in the first
month after MIL reconstruction and throughout early
rehabilitation,“ at the same time as knee impairments
are improving. However, psychologic disturbances can
follow a “U“ pattern, in which disturbances are high
immediately after ACL injury, improve through early
rehabilitation, and increase again on FlTS.12 Preliminary
work in this area suggests that the level of a patient’s
fear of reinjury immediately after ACL injury does not
affect RTE." During the preoperative period, however, it
might be beneficial to assess the level of a patient’s fear of
reinjury. If a high fear of reinjury is present, the patient
could be engaged in a discussion about the underlying
reasons for the fear to begin reducing the anxiety about
reinjury.“ The Tampa Scale for Kinesiophobia is a ques-
tionnaire that could be used to assess levels of a patient's
fear of reinjury.l4 A recent survey showed that Sfl‘iis of
physicians discuss the fear of reinjury with their patients;
this type of discussion could be done more regularly.H
Early Postoperative Rehabilitation
Immediate Postoperative Phase
The goals of the immediate postoperative phase are to
reduce knee effusion and pain, increase knee range of
motion {RGM}, obtain good quadriceps contraction, im-
prove proprioception, and normalize gait. Weight bearing
should begin immediately after surgery to restore prop—
er gait sequencing. Patients should be transitioned from
protected weight bearing with assistive devices to weight
bearing without assistive devices when they can achieve
full knee extension and can effectively control pain. The
immediate postoperative phase continues to focus on
resolving acute knee impairments, because surgery reac-
tivates the inflammatory process.
Reducing postoperative knee effusion following ACL
reconstruction is imperative because persistent effusion
has been shown to negatively affect intra—articular struc-
tures, inhibit quadriceps contraction, interfere with the
recovery of knee RUM, disrupt gait mechanics, and pro-
long rehabilitation.”*2‘5 A failure to reduce knee effusion
can lead to patellofemoral pain, increased postoperative
pain, posttraumatic osteoarthritis, and an increased risk
of arthrofibrosis.”=”‘13 Strategies to reduce knee effusion
include the use of compression wraps, limb elevation,
El 1016 American AcadMy of Drrhnpaedic Surgeons
 Chapter 26: Current Rehabilitatinn Enncepts Fnllnwing finterinr Cruciate Ligament Recnnstructinn
mndalities such as cryntherapy and high-vnltage electrical
stintulatinn, and knee RUM exercises."
Initiating knee RUM exercises and restnring knee
RUM in the immediate pnstnperative phase nf rehabil-
itatinn are essential. Delaying knee mntinn can cause
cnmplicatinns, including articular cartilage degradatinn,
arthrnfibrnsis, impedance nf graft remndeling, capsular
cnntractures, patellnfemnral pain, gait dysfunctinn, and
scar tissue fnrmatinn in the intercnndylar nntch.”-1*‘~3“13“
Achieving knee extensinn that is symmetric tn the cnn-
tralateral knee is critical because extensinn deficit is a
pntential risk factnr fer the develnpment nf nstenarthritis
and knee stiffness.” Therefnre, rehabilitatinn shnuld be
directed first tnward the achievement nf symmetric full
knee extensinn tn the cnntralateral side, fnllnwed by full
knee flexinn.if Heel slides nr active assisted RDM exer-
cises pcrfnrmed while seated in a chair nr nn the edge
nf a bed can he used tn imprnve extensinn and flexinn
RUM. If a patient has difficulty regaining full knee ex-
tensinn, passive interventions that use lnw—lnad lnng—du—
ratinn stretching can be implemented, such as heel prnps
{Figure 1} and prnne hangs. Patellar mnbilieatinn in the
superinr directinn can assist the recnvery nf knee exten-
sinn by facilitating quadriceps activatinn and preventing
infrapatellar fat pad cnntracture.”~15 Seft-tissue mnbiliaa-
tinns shnuld be pcrfnrmed alnng the incisinn and pnrtal
sites tn minimise the risk nf adhesinns, which can cause
pain and interfere with knee RGM and patellar mnbility.
Reestablishing prnprinceptinn is essential fnllnwing
ACL recnnstructinn tn assist in muscle activatinn, dy—
namic jnint stability, the reductinn nf inint fnrces, and
the relearning nf mnvement patterns.” Initially, weight
shifts can be used tn prnvide snmatnsensnry input and
prnmnte weight bearing nn the surgical limb. Weight
shifts can be prngressed tn single-leg standing with 5“ tn
3D" nf knee flexinn.
Intermediate Pnsteperative Phase
Befnre beginning the intermediate pnstnperative phase,
the patient shnuld have achieved full-extensinn RGM,
nearly full-flexinn RUM, a nnrmaliced gait pattern, and
minimal tn nn effusinn, with nn jnint line nr patellnfemr
nral painJfli' The gnals nf this phase are tn resnlve any
remaining acute knee impairments, increase muscle
strength and endurance, restnre neurnmuscular cnntrnl,
and nnrmalize mnvement patterns in lnw—demand func-
tinnal activities. A factnr that cnuld delay progress during
this phase is persistent knee effusinn, which can limit knee
RUM and inhibit quadriceps cnntractinn. Functinnal
activities shnuld be prngressed tn gradually increase the
lnad nn the knee. In additinn, the graft type will deter—
mine exercise prngressinn sn that the lnad nn the healing
Eb Ifllii American Academy nf Urthnpaedic Surgenns
Figure 1 Phctegraph shews a heel prep exercise.
perfnrmed tn restnre full knee extensinn in the
preoperative and eariy pnstnperative phase of
rehabilitatinn.
unglflulqeqeu :1;-
tissue is increased gradually.
Quadriceps strengthening is impnrtant during this
phase, but it must nnt cnmprnmise the integrity nf the
graft. After the patient can elicit a visible quadriceps cnu-
tractinn and perfnrm a straight leg raise withnut an ex-
tensinn lag, exercises tn increase quadriceps strength and
endurance can be implemented. Seated knee extensinn is
an np-en kinetic chain exercise that isnlates the quadriceps
muscle; it shnuld he pcrfnrmed frnm 9i)“ tn 4D” nf knee
flexinn tn minimize anterinr tibial translatinn in ranges
that can be harmful tn the healing graft?“31 |E'Innversely,
clnsed kinetic chain multijnint exercises shnuld be per-
fnrmed in the range nf fl“ tn iii)“ nf knee flexinn. Exam-
ples nf clnsed kinetic chain exercises include the leg press
(Figure 2}, squats, lunges, and fnrward nr lateral steprups.
Strengthening exercises shnuld incnrpnrate cnuceutric
and eccentric training cf the lnwer extremity. Studies
have shnwn that patients whn include eccentric training
have mnre quadriceps strength and perfnrm hetter nn
hnpping tasks than thnse whn trained with traditinnal
exercise alnnesl1 High—intensity neurnmuscular electrical
stimulatinn may he cnntinued in the intermediate phase if
the patient cnntinues tn have difficulty prnducing a quad-
riceps cnntractinn, has marked weakness, nr experiences
pain during npen nr clnsed kinetic chain exercises.
aement pattern deviatinns during clnsed kinetic
chain exercise nr nther functinnal activities are cnmrnnn
after ACL recnnstructinn. ICine pntential deviatinn is re-
duced weight bearing cm the surgical side, which may
result frnm quadriceps weakness and cnuld he addressed
with strengthening exercises. Hnwever, many patients
cnntinue tn reduce weight bearing an the surgical side
even after acquiring sufficient quadriceps strength. In
such cases, patients may benefit frnm instructinn frnm
the rehabilitatinn specialist and feedback frnm a fnrce
measuring device {such as a fnrce plate nr scale}, nrirrnr,
nr viden.
Drthnpaedic Knnwledge Update: Sperrs Medicine .5
 Section ii: Rehabilitation
- I iiii
Figure 2 Photograph shows a shuttle leg press exercise,
which may be used for early controlled flexion
E range of motion and closed chain concentric
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4.! and eccentric exercise during the intermediate
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phase of rehabilitation. The shuttle is also
:5 useful for initiating jumping in a gravity
I15 eliminated position.
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It is widely accepted that abnormal femoral motion has
the potential to directly affect tibiofemoral ioint mechan-
ics and specifically the soft-tissue restraints that connect
the distal femur to the tibia.3'3 Another potential move-
ment pattern deviation is media] deviation of the knee in
the frontal plane secondary to hip adduction and internal
rotation, resulting from hip muscle weakness. This devia—
tion is addressed best with strengthening exercises such as
resisted clam shells, side stepping with elastic resistance,
the unilateral bridge, and quadruped hip extension with
knee flexion.“ This movement pattern, often referred to
as dynamic knee valgus, has been associated with ALL
injury” and may continue to be present even after ACL
reconstruction if not addressed.liar If sufficient hip strength
is present, this medial deviation in the frontal plane may
be a learned movement pattern that requires instruction
and feedback.
A final consideration for the intermediate phase is
trunk control and core stabilization, because reduced core
proprioception has been linked to knee injuries.“ Most
high-level activities require core stabilization and trunk
control to maintain the body’s center of mass within the
base of support in response to unexpected perturbations,
so that potentially injurious forces are minimized. Poten-
tial beneficial exercises include bridges, planks, crunches,
and double—leg and single—leg dead lifts. Perturbation
training using stable and unstable surfaces {Video 26.1)
as well as training anticipatory strategies [Video 26.2} and
reactive balance strategies {Video 26.3} should be incor—
porated to enhance proprioception and neuromuscular
control of the lower extremity [Figure 3}.
flrdtopaeciic Knowledge Update: Sports Medicine 5
@' Video 26.1: Perturbation Training for Neu-
romuscular Control and Dynamic Stability.
Penny Goldberg, PTr DPT, ATE {0.13 min}
aI Video 25.2: Anticipatory Strategies to
Enhance Neuromuscular Control and
Proprioception. Penny Goldberg, PT, DPT.
ATE {H.1S min]
Video 25.3: Reactive Strategies to En-
a' hance Heuromuscular Control and
Proprioception. Penny Goldberg, FT, DPT.
ATE {dJT min}
Tasks that train anticipatory strategies include stepping
onto unstable surfaces or moving the other extremity
outside of the base of support. Reactive strategies can
be taught using catching tasks with weighted balls; the
patient must react to the ball and stabilize after the catch.
Completion of the intermediate phase is marked by
full, pain-free lcnee ROM, adequate quadriceps and
hamstring strength, good proprioception and balance,
and minimal pain or effusion during activities of daily
living.”~15-19 The quadriceps index, a ratio between the
strength of the involved side to that of the uninvolved
side, is an important predictor of performance, empha-
sizing the role quadriceps strength plays in function and
performance.“ Quadriceps strength can be measured
using an isokinetic or hand—held dynamometer or by
isometric strength testing or one-repetition maximum
testing. 1ii'alues ranging from 65% to 90% have been re-
ported as adequate to begin higherrlevel rehabilitation
activities-”JEJFJT-HH
Late Postoperative Rehabilitation
The goal of the late phase of AC1. reconstruction rehabil-
itation is to initiate high—demand activities in preparation
for RTS.”~"5~1” A combination of in-line running, agility,
and sport-specific exercises are implemented progres-
sively to appropriately challenge the patient‘s strength
and endurance. Increasing levels of intensity should be
used to ensure that the patient is physically fit enough to
return to full, unrestricted participation in sports. Proper
movement patterns are emphasized during these activities,
and neuromuscular training should play a major role in
late—phase rehabilitation to reinforce appropriate muscle
firing patterns and a suitable reaction to external forces,
which contribute to proper joint biomechanics and possi-
bly help prevent knee osteoarthritis” and reduce the risk
of reinjnry."'1 Strengthening and flexibility exercises are
El 2016 American AcadMy of Cirrhopaedic Surgeons
 Chapter 215: Current Rehabilitatinn Euncepts Fullevving Anterier Cruciate Ligament Recunstructiuu
Figure 3 Phetegraph depicts unstable surface training in
a single-leg stance tc- enhance neuremuscular
centrel ef the lewer extremity. Adding
pertu rbatiens er thruwing and catching tasks
can be used tn increase the difficulty utthe
drill.
centinued and move tn a maintenance er heme exercise
prugram as impairments resnlve.
Straight-plane running fur 4 tn ti weeks shuuld be
perfnrmed befure the intruductinn uf lateral muvements
intn the rehabilitation prngrarn tn allcnv the patient an
build unilateral strength and farce generation thruugh
the dynamic nature cf running.” Activities that puse a
high risk bf ACL iniury include landing a jumpy41 sidestep—
ping, and cutting maneuvers.“3 Duuble-leg crr single-leg
landing tasks and ladder er cane drills sheuld be incur-
perated during this phase {Figures 4 and 5}. The chesen
activities shuuld mimic the muvements must likely tu be
El Ifllli American Academy ef flrfliupaedjc Surgecus
3”."
:
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5
Figure 4 Fhetngraph shuvvs a ladder drill, which can be
used te incerperate lateral rnevements and
ready the patient fer a return te spurt during
the late phase at rehabilitation.
enccruntered by each individual athlete. Mevement pat-
terns shbuld be assessed cuntinually fur the presence bf
dynamic valgus, weight-bearing asymmetries,“ and de-
creased knee flexiun tn minimise the risk at ACL injury.“5
If weakness in the hip and quadriceps muscles has been
addressed earlier in the early phase at rehabilitatiun, these
mevernent pattern deviatieus are less likely te be present.
Altheugh the specific criteria fur the return te spurt—spe-
cific activities vary, the prctnculs generally use a cumbiua-
tie-n cf the quadriceps strength index, RUM, knee laxity,
episudes bf instability, pain, effusicrn, and self—reperting bf
functicn tn determine the achievement uf each milestune
Drthupaedic Knewledge Update: Spurts Medicine 5
 Sectien 4: Rehabilitatien

te indicate readiness fer the neat milestene.“ Cemmen a 65% te 90%”“5353139 return ef quadriceps strength
criteria used te assess readiness te begin running include cempared with the healthy limb, full RUM, and minimal
pain and effusien. Additienally, patients may benefit from
an understanding ef the sereness rules {Table 1] se that
they may self—manage during transitien frem a supervised
te an unsupervised pregressien.”
The pregressien ef activities sheuld advance frem deu-
ble—limb activities te single-limb activities. Tasks that
challenge presimal centre] ef the lewer extremity sheuld
remain a fecus ef the pregram {Figure 6}. Altheugh criti-
cal fer identifying limb and weight-bearing asymmetries,
success in bilateral tasks alene has been shewn te be inad-
equate in identifying ether underlying unilateral deficits
E
{such as strength, endurance, preprie-ceptien} even when
.E
4.! activities are biased tnward the affected limb.” Plyemetric
exercise te develep neuremuscular ceerdinatien during
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I15 the esplesive elements ef running and athletic activities

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sheuld be included in the rehabilitatien pregram. Surface
electremyegraphy te the gluteus masimus and medius as
E

well as the medial and lateral hamstrings ef the deminant

Figure 5 Phetegraph clernenstrates a cutting drill. These
drills, heth tewa rd and away frem the invelved
side, sheuld lee emphasized during the late
phase ef rehabilitatien.
limb has been used te evaluate the activatien ef these
muscles during cemmen plyemetric exercises.“ Single-leg
and deuble—leg sagittal plane hurdle heps censistently
preduced mere muscle activity in the hamstrings and
gluteal muscles, whereas jumping while retating the bedy
13f!“ during the flight phase preduced the least activad
tien ef these muscles. This suggests that when selecting
plyemetrie exercise, the practitiener sheuld cheese these
perfermed in the sagittal plane, because they may effec-
tively reduce lead re the ESL and prevent dynamic knee
valgus than these perfermed in the frental plane.
A cembinatien ef visual, verbal, and tactile feedback
may be beneficial when respending te athletes regard-
ing gait deviatiens, limb asymmetries, and abnermal

Sereness Rules

Eriterien Action
Sereness during warm—up that 2 days eff, drep dewn 1 level
centinues
Sereness during warm-up that Stay at level that led te sereness
gees away
Sereness during warm-up that 2 days eff, clrep clewn 1 level
gees away but redeveleps
during the sessien
Soren ess the day after lifting 1 day eff, de net advance pregrarn tn the nest level
{net muscle sereness]
He seren ess Advance 1 level per week er as instructed by health care prefessienal
Hepre-ducecl with perrnissien frern Fees M. Decker T, Snyder-Machler L, Arte M]: Upper extremity weight-training rneelificatiens fer the injured
athlete: A clinical perspective. Am J Spnrts Med 19535613535.

flrdtepaedic Knewledge Update: Sperts Medicine 5 El 1016 American Academ1r ef Drthepaedie Surge-ens
 Chapter 26: Current Rehabilitatien Concepts Fellewing Anterier Cruciate Ligammt Ilecunstructiun
Pheteqraph shuws a deuble-leg wall jump,
which is an example et an early plyemetric
exercise. These exercises can he used te identify
weight—bearing and limb asymmetries ea rly in
the late phase uf reha hilitati en.
Eb Ifllii American Academy ef flrfltepaedic Surgeuns
mevement patterns cempared with the healthy limb.“
Pregrams that target individual biemechanical cerrec-
tiens have preved te be efficient in changing mevement
patterns,“ petentially leading te impreved pesteperative
eutcemes. The incerperatien ef mirrers, videe feedback,
er ferce plates in additien te verbal cueing after visual as-
sessment may impreve perfermance. Multiple stable and
unstable surfaces, which replicate spert—specific demands,
sheuld he used in jumping and landing tasks. Additien-
ally, exercises that include anticipated and unanticipated
mevements will prepare the athlete te accept the varieus
ferces mest likely te be enceuntered during spurts par-
ticipatien. Depending en surgical pretecel timelines, an
athlete sheuld cemplete agility and jump training fer a
ueglflulqeqeu :1;-
peried ef several weeks te several menths te ensure that
adequate strength, endurance, and neuremuscnlar centrel
are achieved befere the initiatien ef RTE testing.
Ne single test can be performed te determine the read-
iness fer RTS. Instead, a battery ef tests sheuld he used
te create a cemplete picture ef the athlete‘s strength and
functienal status.” Functienal perfermance tests such
as hep tests can identify limb asymmetries. The mest
cemmen hep tests are the single hep fer distance, the
cressever hep fer distance, the triple hep fer distance, and
the d-meter timed hep.1'5+”+3“ The limb symmetry index
is cemmenly used te determine when muscle strength
and hep perfermance are nermal. Generally, hep testing
is included in the RTS testing, but it has been suggested
that specific criteria In be achieved befere initiating hep
testing include full RDM, a quadriceps index greater
than were, and ne pain with single-leg hepping.” Simi-
larly, a wide variety ef criteria are used te determine if a
patient is ready te begin the RTS pregressien (Table 2}.
The mest cemmen criteria are full, pain-free HUME-“~15”
3fl% te 9fl% en the quadriceps index,5'*""15*"-""+‘“5 and limb
symmetry index sceres ef 30% re 90% ef the uninvelved
Sidfl_16,19,39
At the time ef RTS, the effect ef quadriceps strength
asymmetry en functienal perfermance and self—repert-
ed functien after ACL recenstrnctien has been estab-
lished.’T Mere quadriceps weakness is asseciated with
lewer self-reported knee functien and peerer perfermance
in all functienal testing. Additienally, a quadriceps index
scere less than 35% negatively affected functien, whereas
patients with a quadriceps index scere ef 9fl% er greater
perfermed in a manner similar te uninjured individuals.3T
Fer many athletes, rehabilitatien will end with RTE,
but clinicians may cheese te centinue te meniter the
patient after full RTS has eccnrred. Issues ef strength er
hiemechanics that were net reselved cempletely during
the late phase ef rehabilitatien can centinue te be ad-
dressed beth during and after RTS. Additienally, the
Drthupaedic Knewledge Update: Spurts Medicine .5
 Section 0: Rehabilitation

-—
Return-to-Sport Criteria From Published Protocols
Authors and Criteria
Tsar

van Grinsven et I Full range of motion

3' {201 “l" I Hop tests a 35% of centralateral side
I Hamstrings and quadriceps strength a 95% of centralateral side
I Hamstringsi'quadriceps ratio -c 15% compared with contralateral side
I No increased pain or swelling with sport-specific activities
Adams et al I a 12 wk postoperative
(20123“ I a 90% on quadriceps index
I a 90% on all hep tests
E I a 90% on Knee |iZlutcon'ie Survey Activities of Daily Living Scale
.E
4.! I a 90% on global rating score of knee function
I'll
.1:
:5 I'vlanske et al I Full pain-free range of motion
I15
.E
(2012)“ I No patellofemoral irritation
El
fl'.’
E
I 90% quadriceps and hamstring strength
I Sufficient proprioception
I Physician clearance for advanced activities
Wilk et al I Satisfactory clinical examination
{2013315 I Symmetric pain-free range of motion
I Quadriceps bilateral comparison a 90%
I Quadriceps torque-body weight ratio a 65%
I Hamstrings-quadriceps ratio a- 66% fer males, :4- ?5% for females
I Acceleration rate at 0.2 s 30% of quadriceps peak torque
I ltT-2000 test within 2.5 mm of centralateral leg
I Functional hop test a 95% of contralateral side
Kyritsis and I No pain or swelling
Egg-FEW I lsokinetic test at 50%. 1300‘s, and 30005 :- 10% deficit in quadriceps and hamstrings
I lsokinetic test at 50"l's hamstringrquadriceps ratio [ii—0.9
I Student
I Limb symmetry index a- 90%
I Knee Injury and Osteoarthritis Dutcome Score :- 90 on each subscale
I Patient-Specific Functional Scale score of 9—10 for each reported activity
I [in-field Sports-Specific Rehabilitation fully completed

athlete may demonstrate higher levels of kinesiophobia
and may benefit from continued training to develop ap-
propriate levels of confidence.
5 u re ma ry
ACL reconstruction rehabilitation continually evolves
and currently is being scrutinised for ways to improve
RTS rates, reduce second ACL injury rates, and minimise
the development of posttraumatic knee osteoarthritis.
ACL reconstruction rehabilitation protocols commonly
address acute knee impairments (pain, effusion, less of
motion and quadriceps weakness}, which is important
because these knee impairments can adversely affect ACL
reconstruction outcomes. Clinicians should cautiously
progress patients from early to late rehabilitation in the
presence of persistent knee impairments because progres-
sion too quickly mayr impede RTS and contribute to the
early development of posttraumatic knee osteoarthritis.
Awareness has increased about how altered psychosocial
factors can prevent RTS and altered movement patterns
can increase the risk for a second ACL injury. Recogni-
tion of key psychosocial factors and movement pattern
alterations as well as potential assessment methods and
interventions is important. Even though standardized
clinical guidelines for ACL reconstruction rehabilitation
are not available, the concepts presented provide guidance
during the decision-making process.

flrrhepaedic Knowledge Update: Sports Medicine 5 El 10115 American AcadMy of Cirrhopaedie Surgeons
 Chapter ES: Current Rehabilitation Concepts Following Anterior Cruciate Ligament Reconstruction
Key Study Points
1' RTE rate, the second ACI. injury rate, and the in-
cidence of posttraumatic knee osteoarthritis are
important ACL reconstruction rehabilitation out-
comes that require improvement.
Knee impairments (effusion, pain, loss of RCM,
and quad riceps weakness] can negatively affect ACL
reconstruction rcha bilitation outcomes and are the
focus of early rehabilitation.
Movement patterns should be assessed for common
deviations, particularly in late rehabilitation, when
sport-specific tasks imparting high forces to the
lower extremity are introduced.
Psychosocial factors {such as patient expectations,
the fear of reinjury, and self-efficacy} should he
monitored throughout ACL reconstruction reha-
bilitation because they can negatively affect ACL
reconstruction rehabilitation outcomes.
Annotated References
1. Nicolini AP, de Carvalho RT, Matsnda RIM, aum JF,
Cohen M: Common injuries in athletes"I knee: Experience
of a specialised center. Acts flrtop Bros lfll4:11{3}:12?—
131. Medline DCII
In this cross-sectional comparison of common knee inju-
ries in various sports, it was determined that ACL injuries
were most common in football, basketball, and volleyball
players. Level of evidence: IV.
. Hurd W], Axe M], Enyder-Mackler LA: 1fl—year prospec-
tive trial of a patient management algorithm and screen-
ing examination for highly active individuals with ACL
injury: Part II. Determinants of dynamic knee stability.
Arr: } Sports Med someones—5s. Medline D01
This cohort study [diagnosis] found that neither knee laxi-
ty nor quadriceps strength differed in potential copers and
noncopers. Additionally, quadriceps strength influenced
hop test performance more than activity level or knee
laxity. Level of evidence: I.
. Feucht M], Cotic M, Eaier T, et a1: Patient expectations
of primary and revision anterior cruciate ligament recon-
struction. Knee Snrg Sports Trenrrsntof Arrhrosc 2014.
[Epub ahead of print] Medline DUI
This prospective study demonstrated that younger pa-
tients, patients without a history of knee surgery, and
highly active patients have high expectations for RTE fol-
lowing ACL reconstruction. Irvel of evidence: IV.
. Ardern CL, Taylor HF, Feller JA, Webster KE: Fifty-five
per cent return to competitive sport following anterior
cruciate ligament reconstruction surgery: An updated
Ci Ifllti American Academy of Crthopaedic Surgeons
systematic review and meta-a nalysis including aspects of
physical functioning and contextual factors. Br I Sports
Med 2014;43f21}:1543-1SS£. Medliue DUI
This update of a previous systematic review discusses
RTS rates following ACL reconstruction surgery. Level
of evidence: III.
McCullough KA, Phelps KD, Spindler KP, et aI.Re—
turn to High School and College Level Football Fol-
lowing ACL Reconstruction: A MDDN Cohort
Studylfl]2;4fl{11}:2523-1519.
This article is a retrospective analysis of RTE rates, self-re-
port performance and reasons for RTS, and risk factors for
not returning to the same level of play in football players.
Level of evidence: III.
Kamath CV, Murphy T, Creighton RA, Thfiradia N, Taft
uoglflulqeqeu :1;-
TN, Epang JT: Anterior cruciate ligament injury, return
to play, and reiniury in the elite collegiate athlete: Anal-
ysis of an NCAA Division I Cohort. An: ] Sports Med
2D14;41{T}:1638-1643. Medline DUI
This case series of athletes undergoing ACL reconstruction
before or during collegiate competition presents data on
graft survivorship, reoperation rates, and career length.
Leml of evidence: IV.
Paterno M‘v', Rauh M], Schmitt LC, Ford KR, Hewett TE:
Incidence of second ACL injuries 2 years after primary
ACL reconstruction and return to sport. An: I Sports Med
1fl14541{?}:ISSF—IS?3.Medline DC’II
This cohort study to determine the incidence of repeat ACL
injury following ACL reconstruction and RTS showed
that, following ACL reconstruction and RTE, patiEnts
have a higher risk of suffering a second ACL injury than
those with healthy knees. Level of evidence: II.
fiiestad RE, Holrn I, Anne AK, et a]: Knee function and
prevalence of knee osteoarthritis after anterior cruciate
ligament reconstruction: A prospective study with 1|) to
15 years of follow-up. Am J Sports Med 101 fl;33{11}:22fl1-
1210. Medline DC]
This prospective cohort examination of long-term changes
in knee function after ACL reconstruction and ACL recon-
struction with concomitant injuries found a significantly
higher prevalence of osteoarthritis in those who had un-
dergone ACL reconstruction with concomitant injuries.
Level of evidence: II.
Barber-Westin SD, Noyes FR: Factors used to determine re—
turn to unrestricted sports activities after anterior cruciate
ligament reconstruction. Arthroscopy 2 fl11;2?{12]:1697—
1TDS. Medline DCII
This article is a systematic review of published criteria
to explore the factors used to determine when to allow
athletes to return to unrestricted sports activities after
ACL reconstruction.
10. Thomee R, Kaplan Y, Kvist J, et a]: Muscle strength and
hop performance criteria prior to return to sports after
Cirrhopaedic Knowledge Update: Sports Medicine S
 Sectian 4: Rehabilitatian
ACL recanstructian. Knee Stirrg Sparta Trerrrrtatal Ar-
tbrasc 2G11;19{11]:1T93-1305. Medline DUI
This article uses relevant literature ta present recammen-
datians far new muscle strength and hap perfarmance
criteria m be used far RTE decisians fallawing ACL re-
canstructian. Level at evidence: IV.
11. Ardern CL, Taylar NF, Feller JA, Whitehead T5, Web-
ster KE: Psychalagical respanses matter in returning ta
preinjuty level at apart after antetiar cruciate ligament re-
canstructian surgery. Am 1' Sparta Med 2fl13;41{?1:154fl-
1553. Medline DUI
In this case-cantralled study explaring whether psycha-
lagic factars predicted RTS at 11 manths after ACL re-
canstructian, several psychalagic factars were independent
E
cantributars ta RTE. Level af evidence: III.
.E
4.!
I'll
.1: 11. Cauppan 5, Racette EA, [{lein 5E, Ha rris—Hayes I'vI: 1ii'ari—
:5
ables assaciated with return ta spart fallawing anteriar
I15
.E cruciate ligament recanstructian: A systematic review. Hr
El
fl'.’ 1 Sparta Med lfll4;43{5}:356—354. Medline DUI
E
The authars present a systematic review aF the variables
prapased ta be assaciated with RTE fallawing AEL te-
canstructian, including RI‘IEE impairments, functian, and
psychalagical status. Level at evidence: IV.
13. Risberg MA, Merl: IvI, Jenssen HR, Halm I: Design and
implementatian af a neuramuscular training pragram fal-
lawing anteriar cruciate ligament recanstructian. ,i' Urtirap
Sparts Phys Ther lflfllfllfllltfilfl-ESI. Medline DUI
14. van Urinsven S, van Cingel RE, Halla C], van Lana C]:
Evidence-based rehabilitatian fallawing anteriar cruciate
ligament recanstructian. Knee Surg Sparta Tranrnatal
Artbraac amusements-1144. Medline net
This systematic review creates an evidence—based pastap-
etative rehabilitatian pratacal far ACL recanstructian.
15. Manslce RC, Ptahaslta D, Lucas E: Recent advances fali
lawing antetiat cruciate ligament recansttuctian: reha-
bilitatian perspectives : lI'Zritical reviews in rehabilitatian
medicine. Curr Ree Musculasleeiet Med 2011;5{1}:59-?1.
Medline DUI
The authars af this critical review discuss variaus phases
at rehabilitatian, using the current research an the early
rerurn af passive matian, early weight bearing, bracing,
ltinetic chain exercises, neuramuscular electrical stimu-
latian, and accelerated rehabilitatian.
15. Adams D, Lagerstedt DS, Hunter—Giardana A, Arte M],
Snyder—M ackler L: Current cancepts far anteriar cruciate
ligament recanstructian: A criterian-based rehabilitatian
pragressian. I Urtirap Sparta Phys Tiber 2012;42{?}:6fl1-
614. Medline DUI
This article presents an updated pastaperative rehabil-
itatian guideline far ACL recanstructian, including the
timelines and criteria far variaus milestanes thraughaut
the rehabilitatian pracess ta reflect the mast current avail-
able research. Level af evidence: ‘9’.
Urthapaedie Knawledge Update: Sparta Medicine 5
@ ,
1?. Bialaslty JE, Eishap MD, |Eleland JA: Individual expecta-
tian: An avetlaaked, but pertinent, factar in the treatment
at individuals experiencing musculaslteletal pain. Phys
Tirer 2010:90i9}:1345-l 355. Medline DUI
This clinical perspective paper describes the rale af ea-
pectatians in clinical autcames in individuals with mus-
culaslceletal pain.
IE. Becker R, Daring C, Deneclce A, Brass l'vI: Expectatian,
satisfactian and clinical autcame af patients after tatal
knee arthraplasty. Knee Serg Sparta Treemetai Arrbrasc
2011:19i9}:1433-I441.Medline DUI
This praspective study determined that patient satisfactian
carrelates with Knee Saciety Scare, Western Untaria 8c
McIvIaster Universities Usteaatthtitis Index, and Shart
Farm-36 Health Survey autcames in a patient's status after
tatal ltnee arthraplasty. Level af evidence: II.
15‘. Hartigan EH, Lynch AD, Lagerstedt D5, |Ehmielews-
hi TL, Snyder-Mackler L: Kinesiaphabia after anteriar
cruciate ligament rupture and recanstructian: Hancap-
ers versus patential capers. _i Urtisap Sparta Phys Ther
2013;43i11j:321-332.Medline DUI
This secanda ry analysis, langirudinal cahart study ea-
amining ltinesiaphabia in nancapers and patential capers
befare and after ACL reeanstructian faund that preaper—
ative kinesiaphabia was high in nancapets and patential
capers and that nancapers had greater reductians in fear
after surgery.
2t}. Ardern CL, Webster KE, Taylar NF, Feller JA: Return
ta apart fallawing anteriar cruciate ligament recanstruc-
tian surgery: A systematic review and meta-analysis at
the state at play. Br ] Sparta Med 2011:45{?]:596-Efl6.
Medline DUI
This article is a systematic review af pastaperative RTE
autcames after ACL recanstructian.
21. Chmielewslti TL, Eeppieri (3 Jr, Lents TA, et al: Langitu-
dinal changes in psychasacial Iactats and their assaciatian
with knee pain and functian after anteriar cruciate lig-
ament recanstruetian. Phys Ther 2011:91i9]:1355-1366.
Medline DUI
This praspective, langituclinal, abservatianal campares the
changes in psychasacial factars and their assaciatiaus with
knee pain and functian fallawing AEL recanstructian. All
factars changed acrass a 12-week periad and early scares
were nat predictive af pain ar functian.
22. l'v'Iarrey MA, Stuart M], Smith AM, Wiese-Ejarnstal DM:
A langitudinal examinatian af athletes’ ematianal and
cagnitive respanses ta anteriar cruciate ligament injury.
Elie: I Spa-rt Med 1999:9{2}:63-69. Medline DUI
13. Nichalas MIC, lI'fiearge SE: Psychalagically infarmed in-
terventians far law back pain: An update far physical
therapists. Phys Tirer 2fl11;91{5}:?65-?Tfi. Medline DUI
This article discusses the applicatian af empirically
based psychalagical principles and clinical reasaning ta
assist physical therapists in managing the psychalagical
El ll] 16 American AcadMy at Unhapaedie Surge-ans
 Chapter 25: lll'.h:rrent Rehabilitation Concepts Felltrwing Aurel-int- Grudate Ligament Eeennstnletieu
ebstacles that arise with activity-based interventiens in
patients with lew back pain.
24. Weby 5E. Reach HE. Urmstea M. 1|Illln"atsen P]: Psychemet-
ric preperties ef the TSll: A shertened versien ef the
Tampa Scale fer Kinesinphnbia. Pair: EU [15:1 1?{1-E}:13T—
144-. Medline DGI
2.5. Mann B]. Grana WA. Indelicatn PA. D’Neill DP. Genrge
52: A survey ef sperts medicine physicians regarding psy-
chelegical issues in patient-athletes. Arr: I Sperts Med
2DG?;35{12}:214fl-2141Medline DUI
26. Saks T: Principles ef pesteperative anterier cruciate liga-
ment rehabilitatien. Werfdj Drtfrep 2fl14:5{4}:45fl-459.
Medline DUI
This article is a review ef pesteperative brace use. early
ROM. electrical stimulatien. preprieceptien. and epen
chain and clesed chain strengthening in REL recenstruc-
tien rehabilitatien.
2?. Shelbnurne KD. Urch SE. Gray T. Freeman H: Less nf
nnrmal knee mntien after anterier cruciate ligament
recenstructien is asseciated with radiegrsphic arthritic
changes after surgery. Arr: J Sperts Mad 2fl12:4fl{1}:1fl8-
113. Medline DUI
This prespective cnhnrt study feund that rsdiegraphic es-
teea rthritis is lewer in patients whe achieve nermal ROM
regs rdless ef meniscsl cenditien at 5-year fellew'up after
ACL recenstructien.. Level ef evidence: III.
2-3. Shelbeurne KD. Freeman H. Grsy T: Dsteesrthritis after
anterier cruciate ligament recenstructinn: The imp-ertance
ef regaining and maintaining full range ef metien. Sperts
Heeftb 2fl12;4{1]:?'9 -35. Medline DUI
This literature review discusses the ssseciatien between
ROM and nsteearthritis fellnwing ACL recenstructien.
29. Wilk ICE. Macrina LC. |Cain EL. Dugas JR. Andrews
JR: Recent advances in the rehabilitatien ef anterier
cruciate ligament injuries. 1 Urtbep Sparta Phys Ther
2D12:42{3):153-1?1.Medline DUI
This evidence-based cemmentary describes an accelerat-
ed rehabilitatinn pregram fellnwing ACL recnnstrnctien
with additienal censideratiens fer special pepulatiens.
including female athletes and patients with cencemitsnt
knee injuries.
Si}. Shelbeurne FED. Gray T: Minimum 10-year results after
anterier cruciate ligament recenstructinn: Hnw the less
ef nermal knee metien cempennds ether facters related
tn the develepment ef esteearthritis after surgery. Ara:
I Sperts Med lflfl9:3?{3]:4?1-4Bi}. Medline DUI
This prespective cehert study examining RUM lnsses
feund that patients with a less ef knee extensinn cf 3'”
ta 5“ including hyperextensien had lewer subjective and
ebjective Intematienal Knee Decumentatien Gemmittee
sceres at Ill-year fellnw-up frem ACL recenstructien.
Level ef evidence: ll.
IE! Elllti American Academy ef flrthepaecllc Surgeens
31. Escamilla RF. Macleed TD. Iill-fill: HE. Faules L. Andrews
JR: Anterier cruciate ligament strain and tensile ferces
fer weight-bearing and nen-weight-besring exercises: A
guide tn exercise selectien. f Drthep Sperts Phys Ther
1012:42l3]:203-220.Medline DD]
This article is a descriptive laberatery investigatien ef
the tensile and strain ferces te the AGL during several
cemmen weight-bearing and nen-weight-bearing reha-
bilitatinn exercises. It includes a review ef similar studies
and makes recemmendatiens fer the clinical utility ef
the findings.
32. Gerber JP. Marcus EL. Dibble LE. Greis FE. Burks RT.
LaStaye PC: Effects nf early pregressive eccentric exer-
cise en muscle size and functien after anterier cruciate
ligament recenstructien: a 1-year fellew-up study ef a
randemised clinical trial. Plays The:- lflflfltflfllljfil-SE.
Medline DUI
uvsvauavuvs :v
This article presents 1-year fellnw-up data re a rsndnm-
iced clinical trial that investigated the effect ef early
eccentric resistance training after AGL recenstructien.
Eccentric exercise led tn increased quadriceps and glute-
us maximus velume as well as quadriceps strength and
hepping distance.
33. Pewers CM: The influence ef abnermal hip mechanics
en knee injury: A biemechanical perspective. J Drtfrep
Sperts Phys Thar lfllt};4fl{2}:42-5 1. Medline DDI
This clinical cnmmentary focuses primarily en the peren-
tially detrimental effects that altered hip biemechanics
preduce at the knee jeint. Level ef evidence: V.
34. Selkewitr DM. Eeneck G]. Pewers CM: Which exercises
target the gluteal muscles while minimising activatien
ef the tenant fascia lata? Electrnmyegraphic assessment
using fine-wire electredes. } Drtbep Sperts Phys Ther
2013;43l2]:54-64.Medline DUI
This centrelled laberatery study used a repeated-mea-
sures design tn determine which exercises activate gluteal
muscles while simultanenusly minimizing tenser fascia
lata {TFLJ activity. Five exercises scered greater than er
equal te 50 en the gluteal-te-TFL index. a ratie ef gluteal
activity tn TFL activatien.
35. Hewett TE. Myer GD. Ferd KR. et s1: Eiemechanicsl
measures ef neuremuscular central and valgus leading
cf the knee predict anterier cruciate ligament injury risk
in female athletes: A prespective study. Arr: I Sperts Med
2fl05;33{4}:492-501.Medline DGI
36. Easels]: ET. Hewett TE. Reeves NF. Geldberg B. Chele-
wicki J: The effects ef cnre preprieceptinn en knee injury:
A prespective biemechanical—epidemielegical study. Am
I Sperts Med lflfl?;35l[3}l:363-3?3. Medlitte DID]
3?. Schmitt LG. Paterne MM. Hewett TE: The impact ef
quadriceps femeris strength asymmetry en functienal
perfermance at return te spnrt fellewing anterier cruci-
ate ligament recenstructien. I Grtbep Sperts Phys Ther
2011:42i9}:?5[l—?59. Medline DD!
Grthepaedic Knewledge Update: Sperrs Medicine 5
 Sectinn 4: Rehabilillntinn
This article is a cress-sectienal examinatieu cf the ef-
fect ef quadriceps asymmetry en RTS using self-reperted
functiun and functienal perfermance iellewing BEL re-
censtructinn. These with weaker quadriceps had reduced
functien, whereas these with better strength perfermed
similarly te uninjured individuals.
33. Kyritsis F, Witvreuw E: Return te spurt after anterier cru-
ciate ligament recunstructien: A literature review. I Nee
Pirysietirer 2014;4{1b1—fi. DD]
This literature review examines RTE criteria fellewing
ACL recenstructien.
3.9. Munre AG, Herringten LC: Betweenvsessien reliability
nf feur hnp tests and the agility T-test. ] Strength Cend
Res 2fl11:25{5]:l4?fl—l47?. Medline DUI
i: This article is an evaluatien cf the reliability and learning
.E effects nf hnp tests and agility tests used after ACL recnn«
4.!
structien. Participants achieved greater than er equal te
I'll
r:
E
fifl‘ii: symmetry en hep tests, leading re a recemmendatinn
that this thresheld be used in RTE decisien making.
I'fl
.:
fill
a:
Iii 4D. lEulvener AG, Schache AG, TIni'iceneine B, et al: Are
knee biemechanics different in these with and witheut
patellefemetal esteearthritis after anterier cruciate lig-
ament recenstructieni Arthritis Care Res (Hebeizen)
2fl14:6fi{1flj:1556—15?fl. Medline DUI
This article is a cruss-secrienal investigatiun ei knee ru-
tatienal angles during running and walking after REL
recenstructiun in subjects with and witheut patelleiemeral
nsteearthritis. Less internal knee rntatien was fuund in
subjects with patelleiemeral esteeartbritis and valgus
alignment.
41. Paterne MV, Schmitt LC, Ferd KR, et al: Binmechauical
measures during landing and pestural stability predict
secend anterier cruciate ligament injury after anterier
cruciate ligament recunstructien and return te spert. Am
1 Sparta Med 2B1fl;BB{1B}:IBEB-19?B. Medline DDI
This pres ctive cehert study nf Id'iree—dimensinnal bieme—
chanical acters assuciated with ACL graft failure reperted
that altered neurumuscular centrel nf the hip and knee
predicted secenda ry injury after primary ACL recenstruc-
tinn. Level nf evidence: II.
42. Ferretti A, Fapandrea P, Centeduca F, Mariam PF: Knee
ligament injuries in velleyball players. Ant 1 Sparta Med
1992;2fli2}:2fi3-2fl7.Medline DUI
43. CechraneJL, Lleyd DG, Euttfield PL, Seward H, McGivern
J: Characteristics ef anterier cruciate ligament injuries in
Australian feetball. I Sci Med Spert lflfl?;1fl{2]:96-ili}4.
Mcdline DUI
Gardinier E5, Di Stasi 5, Hana] Bi, Buchanan T5, Sny—
der-Mackler L: Knee centact fnrce asymmetries in patients
whe failed return—te—spurt readiness criteria 6 mentbs af—
ter anterier cruciate ligament recenstructien. Ann I Spur-ts
Med2fl14;42{12}:291?-2925.Medline net
This descriptive 1a beratery study at centact ferce symme-
tries in patients whe underwent RTE readiness testing 5
mentbs after AEL recenstructien reported that patients in
Drthupaedic Knewledge Update: Sperts Medicine 5
whum testing failed demunstrated significant and mean-
ingful centact ferce asymmetries.
45. Myer GD, Ferd KR, Khnury J, Succep P, Hewett TE: De-
velu ment and validatien ef a clinic—based predictien reel
tn i entify female athletes at high risk fer anterier cruciate
ligament injury. Arn j Sperts Med 2010;33i1fl]:2ii25-2033.
Medliue DDI
This article is a cressasectienal cehert study ef the clinical
predicters ef increased knee abductiun mement during
landing tasks. Increased valgus, knee flexinn RUM, bndy
mass, tibia length, and uadric s-tu—hamsttings ratie
cnrrelated with increasefl knee Eductien mement in a
female pepulatien. Level ef evidence: II.
4d. Myer GD, Schmitt LC, Brent JL, et a1: Utilisatien ef med-
ified NFL cnmbine testing In identify functienal deficits in
athletes felluwing AEL recunstructiun. J Drtnep Sparta
Phys Tirer 2B11;41{E}:3??—337. Medline DDI
This case—centrelled study nf mndified Natinnal Feetball
League I[Iem bine drills attempted te determine whether bi-
lateral tasks adequately identified unilateral deficits when
biased teward the invelved side. The mudified tests failed
tn identify deficits feund with hep testing.
4?. Struminger AH, Lewek MD, I{Ente- S, Hibberd E, Black-
burn JT: Eemparisen ef gluteal and hamstring activatien
during five cnmmnnly used plyemetric exercises. Ciirt Bin-
rnecir (Bristei, Arlen} 2013;23[?J:?33-?39. Mcdliue DUI
This descriptive laberatery study used electremyegraphy
tn investigate gluteal and hamstring muscle activity during
cemmen plyemetric exercises. 5a ittal lane plyemetric
exercises prnduced greater levels e muscliis activatien than
these in the fruntal plane.
43. Barrett D5: Preprieceptiun and functien after anterier cru-
ciate recenstructinn. ] Bene feint Surg Br 1991;?3i5 j:333 -
33?. Medliue
45'. Pappas E, Nightingale E], Simic M, Ferd KR, Hewett
TE, Myer GD: De exercises used in injury preventinn
pregrammes mediiy cutting task biemechanicsi' A sys-
tematic review with meta-analysis. Br I Sperts Med
2015:49{IDI:E?3—63i}.Medline DOI
This article is a systematic review ef the effect ef injury
preventinn pregrams en hinmechanical changes during
cutting tasks. injury preventinn pregrams have the paten-
tial tn impreve binmechauics during cutting tasks, particu-
larly when they target technique currectinn in pustpubertal
female athletes.
Video References
26.1: Geldberg P: Videu. Perinbaiiun Training fur Nearernns-
cniar Centrei and Dynanric Stabiiity. Gainesville, FL, 2015.
26.2: Geldberg P: 1|iiidee. Anticipatery Strategies te
Enhance Nenrnrnnscuflar Centrei and Preprieceptien. lGaines-
ville, FL, 2fl15.
26.3: I|.'.3‘reldberg P. Videe. Reactive Strategies te Entrance Hen-
renniecniar Centrei andl Proprieceptien. Gainesville, FL, 2015.
D 2fllfi American Academy ei Drthepaedic Surge-ens
Chapter 27
Patellofemoral Pain Syndrome:
Current Concepts in Rehabilitation
Mark V. Patcrno. PT. PhD. MBA. 5C5. ATC Ielfery A. Taylor—Haas. PT. DPT. DES. CECE
Patellofemoral pain is the most prevalent condition
involving the knee that is referred to physical therapy,
and it results from a diverse range of pathomechanics
and pathoanatomic lesions. Despite the conditions prev-
alence, only limited evidence concerning the etiology,
risk factors, and optimal management of this condition
exists in the literature. An evidence-based approach
for the evaluation and nonsurgical management of
patcllofemoral pain is suggested. The interventions are
classified by proximal factors related to the hip and
trunk, local factors specific to the knee joint, and distal
factors focused on the distal shank and foot. Successful
management is rooted in the detection of underlying
impairments and functional limitations found during
a thorough evaluation and in the appropriate applica-
tion of interventions designed to target individually
identified deficits.
Keywords: rehabilitation: patellofemoral pain
syndrome: proximal factors: local factors: distal
factors
Introduction
Patellofemoral pain syndrome {PFPS} is the most preva-
lent disorder involving the knee‘ and is the second most
Dr. Paterno or an immediate family member serves as a
board member. ownec officer. or committee member
of Pediatric and Adolescent Research in Sports Medicine
and serves as a consultant for flJL'l Global. Neither Dr. Tay-
lor-Haas nor any immediate family member has received
anything of value from or has stock or stock options held
in a commercial company or institution related directly or
indirectly to the subject of this chapter.
fl lflld American Academy of Drrhopaedic Surgeons
common musculoskeletal symptom presenting to physical
therapists.‘ Despite this high prevalence, the etiology of
uvsvauqvuaa :1:-
and risk factors for developing PFPS remain unclea r,2 and
a variety of theories about its etiology and rehabilitation
exist. The most common etiologic theories describe al-
terations andlor impairments in anatomic morphology3
and dynamic neuromuscular function" Rehabilitative
and etiologic investigations have focused on three areas
of dynamic neuromuscular function and their associated
effect on PF PS: the proximal area at the trunk and pelvis,
the distal area at the foot and ankle, and the local area at
the quadriceps and the patellofemoral joint {PFj} itself.
Before implementing a course of rehabilitation for a
patient with PFPS, it is critical to complete an accurate
and thorough history and physical evaluation to deter-
mine the underlying mechanism. The identification of
specific impairments and dysfunctions associated with
the patient’s reports of pain should drive the treatment
planning and specific interventions. The authors of a
lflflfl study linked intrinsic risk factors to the develop-
ment of IJ'FPS.5 They outlined local factors—including a
reduction in quadriceps flexibility, altered neuromuscular
coordination between the vastus medialis oblique {VIVID}
and the vastus lateralis, decreased quadriceps strength,
and patellar hypermobility—to the development of PFPS.
More recently, other authors examining multimodal fac-
tors have identified the interaction of local and proximal
variables such as hip rotation weakness as being related
to the presence of PFli'Ei.‘E Another study relates more
distal factors such as foot mechanics to PFPSF This lack
of consensus underscores the theory that no single mech~
anism for the development of PFPS exists. Therefore, a
thorough evaluation of the potential underlying factors
that may contribute to the development of PFPS must be
undertaken by the physical therapist before developing
an evidence—based intervention program. Specific inter-
ventions exist to address the proximal, local, and distal
factors that may contribute to PFPS. An ideal rehabilita-
tion program should incorporate components of each of
these areas, as deemed necessary by the initial evaluation.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
Proximal Interventions
Df all the etiologic and rehabilitative theories, none has
received more recent attention than that focusing on the
proximal factors that may contribute to the development
of PFPS. A 21303 study theorized that biomechanical de—
viations of the femur into excessive adduction andl'or
internal rotation might result in a relative lateralization
of the patella with respect to the trochlear groove.4 These
abnormal mechanics were believed to result in increased
infrapatellar compression, pain, and dysfunction.4 A 2010
study provided preliminary theoretical support when re-
porting that, compared with an uninjured cohort, adult
i:
females with PFPS demonstrate greater femoral inter
.E
4.! nal rotation during the closed chain single-leg squatfi'
Accordingly, enhancing strength andfor neuromuscular
I'll
:I:
E
I'fl activation to the muscles of the pelvic girdle may have
.:
Ill
o: a clinically relevant role.‘ Dver the past decade, many
1's: studies have advocated assessing the role of hip muscle
strength, hip neuromuscular activation, and dynamic
lower extremity biomechanics on PFPS."5'~” Emerging
research highlights the contribution of dynamic ttunk
mechanics to altered PF] stress."
Recent prospective research has been conducted on the
risk factors that contribute to PFPS. In a military popula-
tion performing a jump landing task, prospective risk fac—
tors for the development of PFPS included decreased knee
flexion angle, decreased vertical ground-reaction force,
and increased hip internal rotation angle? In adolescent
girls, a large knee abduction moment incurred during a
drop vertical jump task was linked prospectively with
the later development of PFPS.” In adult female runners,
greater hip adduction, but not hip internal rotation, has
been linked prospectively with the development of PFP'EL"3
This finding agrees, in part, with several cross-sectional
studies that have identified excessive hip adduction and!
or hip internal rotation in women with I’FPS compared
with age- and sex-matched controls.“'1'5 These altered
mechanics are not reported consistently in male run-
ners,” indicating the differing role that sex may play in
the development and treatment of PFPS in adults. Recent
evidence suggests that, compared with women with PFPS,
men with I’FPS squat and run with less hip adduction and
increased knee adduction or varus.” Further prospective
studies in males are needed to delineate the relative risk
of proximal biomechanical abnormalities on the devel—
opment of PFPS.
Reductions in hip strength have been cited consistently
in adolescent girls and women with PFPS, compared with
age- and sex-matched controls'i" In a systematic review
of five cross-sectional studies, the authors of a 2-1] I]? study
summarised strong evidence suggesting that females with
firthnpaedic Knowledge Update: Sports Medicine 5
PFPS have weaker hip external rotators, hip abductors,
and hip extensors than controls.” Moderate evidence
indicates that females with PFPS have weaker hip internal
rotators and hip flexors compared with controls, whereas
no evidence indicates differences in hip adductor strength
between cohorts.” In two separate cross—sectional stud—
ies, male and female runners with PFPS demonstrated
increased hip adduction and hip internal rotation range
of motion, compared with controls, and these deficits
correlated with endurance deficits to the hip abductor and
hip extensor musculature, respectively?” Future longi-
tudinal work is needed to validate a casual relationship
between these variables.
Rehabilitation efforts that focus on hip abductor and
hip external rotator strength have resulted in positive
outcomes, including short-term reductions in pain and
improvements in function, in patients with PFPS.‘”1” A
recent randomized contmlled trial demonstrated that,
compared with quadriceps strengthening alone, postero-
lateral hip strengthening resulted in superior outcomes in
terms of pain reduction and functional improvement?l
Although it is theorized that improvements in hip muscle
strength may reduce stress on the PF] through kinematic
alterations to the hip joint and the knee joint in the frontal
and transverse planes,‘1 several authors have found no
changes in hip and knee kinematics after implementing a
variety of hip-strengthening protocols.m*13 Thus, further
investigations are required to understand the association
between hip muscle strengthening, hip and knee kinemat-
ics, pain, and functional outcomes.
Recent investigations have focused on the association
between PFPS, alterations in hip neuromuscular activa-
tion, and lower extremity kinematics. Compared with
control subjects, adults with PFPS demonstrate a delayed
and shorter duration of gluteus medius muscle activation
during stair negotiation? Furthermore, preliminary ev-
idence indicates that gluteus medius activity is delayed
and of shorter duration during running, whereas gluteus
maximus activity is increased during stair descent in those
with PFPS.” In women with PFPS, increased hip adduc—
tion and hip internal rotation excursion were correlated
with later onset in the gluteus medius and gluteus maxi-
mus, respectively.“ Because of the cross-sectional nature
of the studies, however, cause and effect cannot be es-
tablished, and further prospective studies are warranted.
Dynamic trunk mechanics may influence stress on
the PF]. a 1014 study demonstrated that, in a cohort of
healthy adult male runners, increased sagittal-plane trunk
flexion was associated with reduced peak PF] stress.11
In a cohort of adolescent girls with PFPS, a reduction
in sagittal—plane trunk flexion during a single—leg squat
was one of several variables—along with altered hip and
fl lfllfi American Academy of Orthopaedic Surgeons
 |Chapter 17: Patellnfemnral Pain Syndrnme: Current Ennnepts in Rehabilitatinn
A
Figure 1 Ph ntngraphs demn ristrate early-stage interventinns tn address impaired hip strength. A, A hip abductinn straight
leg raise is shnvvn. B, Lateral side step ping with band resistance facilitates gluteus medius muscle activity. C.
Quadru ped hip extensinn is shnwri with the knee straight.
knee kinematics—differentiating injured frnm uninjured
patients.” Frnm a kinetics standpnint, increasing trunk
flexinn reduces the external flexnr mnment acting npnn
the PF] and therefore may reduce the internal knee exten-
snr mnment. The net effect is a reductinn in cnmpressive
fnrces acting upnn the PF]. Altered dynamic trunk me-
chanics in the frnntal plane alsn may influence mntinn
and thus stress tn the PF]. Cnmpared with cnntrnls, men
and wnmen with PFPS demnnstrate increased ipsilateral
trunk lean and cnntralateral pelvic drnp.“ An increased
ipsilateral trunk lean may result in an increased external
knee abductinn mnment acting upnn the PF], which, in
turn, may result in altered frnntal-plane knee pnsitinning
and thus stress tn the PF].”12l'-~m Therefnre, rehabilitative
effnrts centered nn altering the abnnrmal frnntal-plane
and sagittal-plane trunk mechanics in patients presenting
with PFP‘S may have a clinically relevant rnle.
A rchabilitatinn plan nf care designed tn target prnx-
imal impairments nften will fncus nn hip strength and
muscle activatinn and can be staged intn early interven-
tinns and return-tn-fuuctinn interventinns. Early inter-
ventinns fncus nn imprnving gluteal muscle recruitment
while limiting pain reprnductinn, whereas return-tn-ftmc-
tinn interventinns fncus primarily nu clnsed- chain neurn-
muscular reeducatinn that targets the specific mnvement
dysfunctinns and participatinn limitatinns unique tn the
patient.
Early interventinns tn address impaired hip strength
may be staged intn exercises that gradually prngress the
neurnmuscular activatinn nf the gluteal musculature frnm
lnw tn high. Exercises in the lnw categnry, which recruit
less than nr equal tn 40% nf the muscle’s maximal vnlun-
tary isnmetric cnntractinn {MVIC}, frequently begin with
nnn—weight-bearing npen kinetic chain activities such as
ID ants American Academy nf flrthnpaedic Snrgenna
uailEiiiisELi-as :1:-
side-lying leg lifts {Figure l, A} and side-lying hip exter-
nal rntatinn with band resistance.31 These fnundatinnal
exercises target the isnlated hip muscle weakness nften
seen in patients with PFPS. Other early-stage interven-
tinn nptinns tn activate the gluteal musculature while
minimizing activatinn nf the tensnr fascia latae include
sidestepping with bands {Figure 1. El. single-leg bridging,
and quadruped hip extensinn with the knee straight and
bend"1 {Figure 1, Cl.
Interventinns in the intermediate stage nf therapy
encnmpass npen kinematic chain and clnsed kinematic
chain interventinns designed tn increase gluteal and trunk
muscle recruitment and tn address altered neurnmuscular
mnvement patterns. l[lpen kinetic chain interventinns with
mnderate gluteal recruitment {40% tn 60% nf MVIC}
include alternating arm and leg {fnr the gluteus maximus]|
elevatinn in quadruped and single-leg bridges}3 {fer the
gluwus medius, Figure 2, A}. Clnsed kinetic chain inter-
ventinns with similar gluteal recruitment levels include
a variety nf lunges and step-ups nntn a bnx, including a
retrn step up.“ Interventinus targeted tn imprnve trunk
muscle recruitment and stability include a mix nf ex-
ercises nn stable surfaces such as anterinn’frnnt planks
(Figure 2. B} and side planks [Figure 2, Cl and exercises
that intrnduce instability such as these cnndncted using
a therapeutic ball.
Returnutnuactivity interventinns are designed tn max-
imally recruit and strengthen the prnximal musculature
and tn nnrmalice faulty mnvement patterns tn prepare
fnr the return tn activity. Strengthening exercises that
maximally recruit the gluteal musculature {greater than
60% cf MVIC} include resisted lateral sidestepping, sin-
gle—limb deadlifts {Figure 3. A], and single—limb siquatsi'l
{Figure 3, E}.
Drtbnpaedic Knnwledge Update: Spnrts Medicine 5
 Secticm 4: Rehabilitation

i:
.E
4.!
I'll
:
E
I'fl
.:
Ill
ac
Iii:

p fine - E
Figure 2 Phntugraphs shuw interventions frnm the intermediate stage at rehabilitaticin, including single-leg bridging {A}, a
prene plank ta). a side plank {C}. single-leg step down fecusing qn quadriceps fe meris recruitment in}, and single-
leg step down facusing an gluteus maximus recruitment {E}.

[n additinn tn strengthening, nptimiaing the technique

and muscle activaticm are critical. Medifieatiqns to tech-
nique can result in a mare targeted apprpach tn certain in—
terventicms. For example, a single-leg step dawn can incus
mere an quadriceps recruitment {Figure l, B} if executed
with a mare erect pasture. Cnnversely, if executed with
an increase in hip and trunk flexicm, additicmal gluteal
muscle recruitment is required ta successfully accnmplish
the task {Figure 2, E}. Mndificatiuns tn the technique can
influence the desired nutenme nf an interventinn. Finally,
prc-ximal muscle recruitment is necessary tn nptimally
align the lawer extremity during dynamic movement.
Friar research has identified hip adductien mement as a
potential risk factcrr far the develc-pment pf PFP in yuung
athletes.11 Interventinns that target neurnmuscular re-
cruitment during dynamic tasks may facilitate aptimal
muscle activity and, ultimately, mere nprnial movement
patterns in this pnpnlatinn.
aal Interventians
aal interventipus, specific tn the knee jeint, lnng have
been advecated in the rehabilitatian pf patients with PFPS.
This philesnph},r was driven by the theary that PFPS was
rented in deficits in lncal facturs, such as patellar tracking,
limited muscle flexibility, er altered balance pf quadri-
ceps muscle functinn."‘+1'5 These lacal cantributing factnrs
cuuld he the result cf pathnanatnmic c-r structural factprs,
such as patellar apprehensinn, tibial tuhercle deviaticms,
patellar alta, the presence pf patellc-femnral articular
cartilage injury, and ahnnrmal trachlea mnrphnlngyfi‘i-fl
In additian, hie-mechanical and neuramuscular factars
related tn the quadriceps femnris muscle such as VMU
respnnse time and the rural crass-sectional area of the
quadriceps have been linked tn eutcemes in this papa-
laticin.“ A 2005 study described a clinical classificatipn
scheme fucused rm lacal facts-rs that guided treatment

firthnpaedic awledge Update: Sparta Medichte 5 fl lfllfi American Academy at Urthnpaedic Surge-ans
 |L'Ihapter 17: Patellofemoral Pain Syndrome: Current Conoepts in Rehabilitation
A
Figure 3 Photographs depict interventions from the retu rn-to-activity stage of rehabilitation. including single-leg
deadlifting {A} and single-leg squatting {B}.
based on malalignment and muscular dysfunction, in-
clusive of strength deficits, neuromuscular dysfunction,
and flexibility deficits.” These muscular deficits provide
a template for addressing local modifiable impairments
in patients with PFPS.
A primary modifiable local impairment often associ—
ated with PFPS is altered quadriceps femoris function.
Reduction in quadriceps femoris strength limits the knee‘s
ability to provide dynamic stability to the PF]. Coupled
with potential pathoanatomie factors, this reduction in
strength may result in pain, instability, or loss of func-
tion. Interventions to target isolated quadriceps femoris
weakness can use closed kinetic chain activities such as
those described previously. Although these activities may
successfully strengthen the lower kinetic chain, they may
fail to address isolated weaknesses if compensatory pat-
terns of movement develop. As a result, if the presence
of isolated quadriceps weakness is appreciated at the
evaluation, open kinetic chain quadriceps strengthening
may be indicated. This intervention must be approached
with caution, however, because open kinetic chain knee
extension has the potential to increase shear forces on
the PF]. Recent research has identified safe ranges of
motion in which to execute this task.” Specifically, the
authors recommend a range of extension from 9G“ to 45".
Conversely, a closed kinetic chain squat is safest when
performed from full extension to 45° of knee flexion.
Ifii'ther local interventions have been reported in the
literature with varying efficacy. Deficits in quadriceps,
IE! lfllfi American Academy of flrthopaedic Surgeons
uvsvauqsuas :v
hamstring, and gastrocnemius-soleus complex flexibility
have been identified in patients with PFPS‘”; however,
the efficacy of targeted interventions to address these
impairments has not been reported. Patellar taping to
improve alignment and muscle activation also has been
reported in the literature as a way to reduce PFPS and
increase self-reported function in a period of less than 1
year.'~‘"*41 Interestingly, a systematic review performed in
2003 showed that limited evidence in lower quality stud-
ies supported using patellar bracing as an effective means
to manage PFPS. In summary, local interventions having
the strongest evidence to improve short-t outcomes in
patients with PF P5 are focused on therapeutic exercises.“II
Distal Interventions
Abnormalities in distal lower extremity biomechanics
may be related to PFPS.‘ During dynamic activity, the
foot and ankle provide the initial shock absorption and
affect the proximal lower extremity motion. Because of
the tight articulation of the talus within the distal tibi-
al~fi bular joint, pronation at the foot and ankle is coupled
proximally with tibial internal rotation and knee internal
rotation.43 Thus, a theoretical construct exists, in which
abnormalities in arch structure and dynamic function
may lead to abnormal mechanics, stress, and ultimately
pain and dysfunction at the PF .‘i-‘i‘
Evidence supporting this theoretical construct is mixed,
with several authors finding no differences in pronation
Drthopaedie Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
excursion between subjects with PFPS and uninjured
cohorts during walkingfi'” and running.”~”-4‘""'5 |E’Ithers
have found increases in pronatiou variables in walkersfi‘”
A recent investigation using an altered definition of ex-
cessive pronatiou found that runners with PFPS used
more of their available rear foot range of motion than
did controls.” Additional prospective investigations are
warranted to appreciate the association between altered
distal lower extremity mechanics and the risk for PFPS.
Many clinicians assess foot posture as a static measure
in an attempt to infer dynamic motion. Limited evidence
links reduced medial longitudinal arch height and in-
creased dynamic foot pronation in asymptomatic adults
c
during walking”~51 and runningdlifl1 Limited evidence
.E
4.! also links reduced medial longitudinal arch height and
I'll
:I:
E increased dynamic foot pronatiou in adults with PFPS.”
I'fl Because of the nature of the cross—sectional study design,
.i:
ll
o: caution must be used in interpreting the results. Prospec-
1's: tive findings are needed to better establish a cause-and-ef—
fect relationship between static arch height, dynamic foot
pronatiou, and the risk of incurring PFPS. In a prospective
study of novice recreational adult runners, no association
was found between static arch structure and the future
development of PFPSF Additional prospective studies in
subjects of different ages and activity levels are warranted
to better understand the relationship between static arch
structure and the risk of developing PFPS.
Because of the coupling between foot pronatiou and
internal rotation of the tibia and knee, clinicians often
prescribe over-the-counter {OTC} or custom foot orthoses
in an attempt to modify distal biomechanics that may afd
fect PF] stress and dynamic function. The biomechanical
evidence of the effect of OTC or custom foot orthoses
on walking and running biomechanics is mixed. Several
authors, using a heterogeneous approach to foot orthoses
fabrication, have found no effect in healthy runners of
a custom foot orthosis on such biomechanical variables
as rearfoot eversion pronation,53'55 tibial internal rota-
tionfif-ff or knee kinematics.”r Others have found that
custom foot orthoses do significantly reduce pronatiou—re—
lated variables at the rearfoot,5f'~53 tibia,53~5*~59 and knee,
however?!Eu Differences in study results may be explained
partially by heterogeneity in study design, subject popu-
lations, and outcome variable selection.
Biomechanics aside, individuals provided orthotic de-
vices as part of a treatment program for PFPS frequently
report reductions in pain'“453 and improvement in the
quality of life.‘52 Limited evidence suggests that, com—
pared with a flat insert, CITE foot orthoses reduce knee
internal rotation and improve the short-term quality of
life in individuals with PFPS.“ Furthermore, limited ev—
idence suggests that a combination of physical therapy
firthupaedic Knowledge Update: Sports Medicine 5
{PT} and an GTC foot orthosis is better at reducing pain
and improving quality of life than an GTE: foot orthosis
alonefl'“ Compared with individuals receiving only PT,
those receiving PT combined with an GTE foot orthosis
have mixed outcomes, with some reports detailing im-
proved subject outcomes‘” and others finding no differ—
ence."1 Further ra ndomiaed controlled trials are needed to
better understand the added value, if any, of foot orthoses
in enhancing patient outcomes.
Although rehabilitation frequently has focused on im-
proving dynamic lower extremity alignment by enhancing
hip and quadriceps muscle strength and neuromuscular
activation, emerging evidence suggests that gait retraining
may play a role in modifying stress to the PF]. In runners,
two key areas have been studied: step rate manipulation
and visual gait retraining.
An increased stride length in runners results in in-
creased PF] stress.“ An increased step rate has an inverse
relationship with stride length“ and PF] forcesfi"f The
proposed mechanisms for reductions in PP] stress may
include alterations to hip kinematics,“ knee kinematics,”
hip neuromuscular activation,“ and the external ground
reaction force vector acting upon the PFJF6 Additional
studies with long-term follow-up in injured patients are
warranted to better understand the role that step rate
manipulation may have on the improvement of functional
outcomes in runners with PFPS.
Although step rate manipulation seeks to alter stride
length as a means of influencing key kinematic and kinet-
ic variables associated with PFPS, visual gait retraining
primarily focuses on the alteration of frontal plane kinee
matic variables at the knee, pelvis, and trunk. Limited
evidence suggests that real-time visual gait retraining us-
ing a computer?fl or a mirror?1 alters pelvic kinematicsfr'jf‘r1
hip kinematicsjl'i-T1 loading rate variables,” and external
knee momentsf‘and leads to short-term improvements
in painf'flfTI and functiond’f’f”1 The effect of running visual
gait retraining on an untrained task of single-leg squat
mechanics is mixed, with one study reporting a significant
alteration in squat mecha nics“ and another finding no sig—
nificant effectf“ Limitations in these studies include their
retrospective nature, homogenous subject populations,
and short-term follow-up periods. Further randomised
controlled trials with long-term follow-up are warranted
to better understand the role that visual gait retraining
may have on the reduction of pain and the improvement
of function in subjects with PFPS.
5 u m m a ry
Despite the current high prevalence of PFPS, optimal
nonsurgical management has yet to be outlined in the
fl lfllfi American Academy of Orthopaedic Surgeons
 |L'lhapter ET: Patellofemoral Pain Syndrome: Current Concepts in Rehabilitation
literature. Success in rehabilitation is dependent on a thor-
ough history and physical examination to identify the
underlying mechanism. After the syndrome is identified,
the development of a targeted intervention program ad-
dressing appropriate proximal, local, and distal factors is
necessary to ensure the best outcome in this population.
Key Study Points
1* Successful conservative management of PFPS is
dependent on a thorough history and physical
examination.
I Following identification of the unique mechanism
underlying an individual's PFPS, it is imperative
to apply targeted proximal, local, and distal intern
ventions as appropriate to meet the patient’s needs.
it A targeted plan of care is often unique to the spe-
cific impairments and functional limitations of each
patient.
Annotated References
1. Davis IS, Powers CM: Patellofemoral pain syndrome:
Proximal, distal, and local factors, an international
retreat, April 3llul'viay 2, EDGE}, Fells Point, Baltimore,
MD. I Orteop Sports Phys Tire-r 2010;4fli3}:A1-fi.15.
Medline DDI
This article is a summary statement of the EDD? Pa-
tellofemoral Pain Retreat. Level of evidence: V.
2.. Wilson T, Carter H, Thomas '3: Pl. mnlticenter, sin-
gle-masked study of medial, neutral, and lateral patellar
taping in individuals with patellofemoral pain syndrome.
1 IIlIIrti'Iop Sports Phys Titer 20G3;33{Sl:43?—443, discus-
sion 444-443. Medline DUI
3. McConnell J: The management ofchondromalacia patellae:
A long term solution. dust I Pirysiotber 1936;32i4]:215-
123. Medline DUI
4. Powers CM: The influence of altered lower-extremity ki-
nematics on patellofemoral joint dysfunction: .5: theoretical
perspective. I Drthop Sports Phys Tires- Efl fl3;33{11j:639-
546. Medline DUI
S. Witvrouw E, Lysens Il, Bellemans J, Cambier D, Vander-
straeten G: Intrinsic risk factors for the development of
anterior knee pain in an athletic population. A. two-year
prospective study. Arts jl Sports Med 2000;2«Ej4jt43fl 439.
Medline
IS. Lankhorst HE, Eierma-Zeinstra SM, van Middelkoop M:
Factors associated with patellofemoral pain syndrome: Ill.
systematic review. Br 1 Sports Med 1013;4?{4j:193—206.
Medline DUI
IE! lfllfi American Academy of flrthopaedlc Surgeons
This review systematically summarized factors associated
with PFPS. Factors noted were a larger Q-angle, sulcus
angle, and patellar tilt angle; less hip abduction strength;
a lower knee extension peak torque; and less hip external
rotation strength in PFPS patients than in controls. Level
of evidence: In.
Thijs ‘1', De Clercq D, Roosen P, 1it'lliitvrouw E: Gait'related
intrinsic risk factors for patellofemoral pain in novice rec-
reational runners. Br I Sports Med lflflfiflljfikfilfifi 4'31.
Medline DUI
Sousa RE, Draper CE, Fredericson M, Powers CM:
Femur rotation and patellofemoral joint kinematics:
A weight-bearing magnetic resonance imaging analy-
sis. ] Drtirop Sports Phys Titer lllll};4l}{5]:27?-ZSS.
Medline DUI
usllvslliseuas :1:-
Altered PF] kinematics in females with patellofemoral pain
appear to be related to excessive medial femoral rotation,
as opposed to lateral patella rotation. Control of femoral
rotation may be important in restoring normal PF] kine-
matics. Level of evidence: IV.
Boling ME, Padua DA, Marshall SW, Guskiewica K, Pync
S, Beurler A: a prospective investigation of hiomechanical
risk factors for patellofemoral pain syndrome: The Joint
Undertaking to Monitor and Prevent REL Injury {I UMP-
ACL} cohort. rim _j' Sports Med Zflfl9;3?[llj:EIflS-EIIE.
Medline DUI
This study suggested risk factors for the development of
PFPS included decreased knee flexion angle, decreased
vertical ground—reaction force, and increased hip internal
rotation angle during the jump-landing task. In addition,
decreased quadriceps and hamstring strength, increased
hip external rotator strength, and increased navicular drop
were risk factors for the development of patellofemoral
pain syndrome. Level of evidence: III.
Ill. Earl JE, Hoch AZ: A proximal strengthening program
improves pain, function, and biomechanics in women
with patellofemoral pain syndrome. Arr: ,7 Sports Med
2011;39i1}:lS4-163.Medline DUI
In this study, hip~focused and corewfocused rehabilitation
improved symptoms and patient-reported outcomes in
female patients with PFP. Level of evidence: IV.
11. Teng HL, Powers CM: Sagittal plane trunk posture influ-
ences patellofemoral joint stress during running. } Clrtbop
Sports Phys Tirer 2fl14;44{1l}}:?35-?92. Medline DUI
This study suggests that increased forward trunk lean may
be a strategy to reduce PP] stress. Level of evidence: IV.
12. Myer GD, Ford KR, Di Stasi SL, Foss ED, Micheli L],
Hewett TE: High knee abduction moments are common
risk factors for patellofemoral pain {PFP} and anterior
cruciate ligament (ACLI injury in girls: Is PFP itself a
predictor for subsequent HCL injury?I Br I Sports Med
lfl15;49[2j:llS-122.Medline DUI
This study suggests that in girls age 13.3 years and older
than 16.1 years, greater than 15 Nm and greater than 25
Drthopaedic Knowledge Update: Sports Medicine S
 Seeders 4: Rehabilitatian
Nm af knee abductian laad during landing, respectively,
are assaciated with a greater likelihaad af the develapmllt
af PFP. Level af evidence: III.
13. Naehren E, Hamill], Davis I: Praspective evidence far a
hip etialagy in patellafemaral pain. Med Sci Sparta Exerc
2fl13g4illiHIEfl-1134.Medlinc DUI
This study shawed that adult female runners in wham PFP
develaped exhibited significantly greater hip adductian.
Ha differences were faund far the hip internal ratatiau
angle at rearfa-at evetsian. Level af evidence: III.
14. Hakagawa TH, Mariya ET, i'viaciel CD, Serriia AF:
Frantal plane biamechanics in males and females with
and withaut patellafemaral pain. Med Sci Sparta Eater-c
2fl11;44{9]:1T4?-1?SS.Medline DUI
c
.E
4.!
In this study, females presented with altered frantal plane
I'll
a: biamechanics, which may predispase them ta knee inju—
E ry. Individuals with FFPS shawed frantal-plane biame-
I'fl
.c chanics that cauld increase the lateral PF] stress. Level
fill
a: af evidence: I‘lv'.
1's:
15. Haehren B, Pahl ME, Sanchez Z, lEunningham T, Latter-
ma nn C: Praximal and distal kinematics in female runners
with patellafemaral pain. Ciir: Biamecir (Hristai, nears)
lflilflfl-‘llflfifi-STI.Medline DUI
In this study, greater hip adductian, hip internal ratatian,
and shank internal ratatian were seen in female runners
with PFP. Less cantralateral trunk lean in the PFP graup
alsa was nated. Level af evidence: W.
IE. 1iiii'illsc-n JD, Petrawits 1, Butler E], Kernasek TW: Male
and female gluteal muscle activity and lawer extremity
kinematics during running. Cfirr :li‘iarrrecilaI fiiristaf, Heart}
Eliilflilifilflfljl-IDST. Mcdlinc DUI
This study she-wed that females run with a greater peak
gluteus maximus activatian level and a greater average
activatian level than da males. Female runners alsa dis-
played greater hip adductian and knee abductian angles
at initial cantact, greater hip adductian at peak vertical
graund-reactian farce, and less knee internal ratatian ex-
cursian than did males. Level af evidence: IV.
1?. 1Willy KW, Mans] KT, 1|illli'itvrauw EE, Davis IS: Are
mechanics different between male and female run-
ners with patellafemaral painiI Med Sci Sparta Exerc
2fl11;44{11}l:2165-21?1.Medline DUI
In this study, males with PFP ran and squatted in greater
peak knee adductian and demanstrated greater peak knee
external adductian mament campared with healthy male
cantrals. Males with PFP ran and squatted with less peak
hip adductian and greater peak knee adductian than did
females with PFP. Level af evidence: I‘v’.
13. Cichanawski HR, Schmitt J5, Jahnsan R], Niernuth PE:
Hip strength in callegiate female athletes with patella-
femaral pain. Mari Sci Sparta Exerc lfifl?:39{3h123?-
1131. Medline DUI
Urthapaedic Knawledge Update: Sparta Medicine S
19. Prins MR, van der 1ilii'urff P: Females with patellafemaral
pain syndrame have weak hip muscles: A systematic re-
view. r'iust] Pbysfatfaer lflfl9;55|[1]:9-15. Medline DUI
This systematic review suggests that females with PFPS
demanstrate decreased abductian, external ratatiau,
and extensinn strength in the affected limb campared ta
healthy cantrals. Level af evidence: II.
ll]. Santa RE, Pawers CM: Differences in hip kinematics,
muscle strength, and muscle activatian between subjects
with and withaut patellafemaral pain. ] Uriirap Sparta
Phys Tirer Zflfl9:39i1]:IE-19. Medline DUI
This study suggested that females with PFP presented with
greater hip internal ratatian and decreased hip abductian
and extensian tarque praductian campared with central
subjects withaut PFPS. Greater gluteus maximus recruit-
ment was present in patients with PFPS during running
and step dawn tasks. Level af evidence: I‘v".
11. Sauna RB, Pawers CM: Predictars af hip internal ratatiau
during running: An evaluatian af hip strength and femaral
structure in wc-men with and withaut patellafemaral pain.
Arr: I Sparta Med 2009;3Tl3):5?9-531 Medline DUI
Patients with PFP had less hip internal ratatiau, reduced
hip muscle strength, and greater femaral inclinatian
campared with cantral patients. Isatanic hip extensian
endurance predicted hip internal ratatiau matian. Level
af evidence: IV.
22. Dierks Tn, Manal KT, Hamill], Davis I: Lawer extremity
kinematics in runners with patellafemaral pain during a
pralanged run. Med Sci Sparta Exerc 2fl11;43{4}:693 #00.
Medline DUI
In this study, the PFP graup displayed less averall matian
than did cantrals. Three distinct PFP subgranps were
nated: a knee valgus graup, a hip abductian graup, and a
hip and knee transverse plane graup. Level af evidence: IV.
23. Ferber R, Kendall Kl], Farr L: Changes in knee biame—
chanics after a hip-abductar strengthening prataccl far
runners with patellafemaral pain syndrame. I riff-f Train
2011;46{2}:142-149.Medline nai
This research shawed that hip abductar muscle strength—
ening was effective in increasing muscle strength and re-
ducing pain and impraving knee kinematics in individuals
with PFPS. Level af evidence: IV.
24. Khayambashi K, Fallah A, I'viavahedi a, Bagwell J, Pawers
C: Pasteralateral hip muscle strengthening versus quadri—
ceps strengthening far patellafemaral pain: A. camparative
cantral trial. Arch Phys Med Refrebii 2014:95i5}:90{i-90?.
Medline DUI
In this study, autcames in the pasteralateral hip exercise
graup were superiar ta these in the quadriceps exercise
grnnp. The superiar autcames abtained in the pastera-
lateral hip exercise graup were maintained far 6 mantbs
after interventian. Level af evidence: III.
25. Bartan C], Lack S, I'vialliaras P, Marrissey D: Glutcal
muscle activity and patellafemaral pain syndrame: A
D lfllfi American Academy af Cirrhapaedic Surge-ans
 |[Chapter 17: Patellefememl Pain Syndreme: Current Eeueepts in Rehabilitation
systematic review. Br I Sparta Med lflldfiTI-Hflfllllil.
Medline DUI
This study presented current evidence indicating that gluv
teus medius activity is delayed and af shatter duratian
during stair negatiatian in patients with PFPS. In additian,
limited evidence indicates that gluteus medius activity is
delayed and ef shatter duratien during running and glu-
teus maximus activity is increased during stair descent.
Level ef evidence: I.
26. Willsan JD, Kernarek TW, Arndt RL, Reanichek DA,
Scett Straker J: lGluteal muscle activatieu during run-
ning in females with and witheut patellefemeral pain
syndrame. Clin Hiamecfr (Bristal, Apart) lflllflfilflflifi-
T411}. Medline DUI
In this study, females with PFP demenstrated delayed and
sherter gluteus medius activatieu than females witheut
knee pain during running. The magnitude and timing af
gluteus maximus activatieu was net different between
greups. Greater hip adductien and internal retatien excur-
sien were cerrelated with later sunset in the gluteus medius
and gluteus maximus, respectively. Level ef evidence: IV.
2?. Scattene Silva R, Serraa FV: Sex differences in trunk,
pelvis, hip and knee kinematics and eccentric hip
terque in adelescents. Elie Bic-mach {Bria-tel. Arrest}
lfll‘ltlfllftltlflfid-IDERMedline DUI
In this study, adelescent females presented with greater hip
adductian, hip external ratatian, and knee abductian and
smaller trunk flexian during the single-leg squat than did
males. Additienally, adelescent females shewed smaller
isakinetic eccentric hip tarque narmaliaed by bady mass
in all planes than did males. Level af evidence: IV.
28. Nakagawa TH, Mariya ET, Maciel CI}, Serriia FV: Trunk,
pelvis, hip, and knee kinematics, hip strength, and glue
teal muscle activatieu during a single-leg squat in males
and females with and witheut patellefemeral pain syn-
drame. ] Urtfrap Sparta Phys Thar 2fl12;42{6}:491-501.
Medline DDI
In this study, individuals with PFPS had greater ipsilateral
trunk lean, centralateral pelvic drep, hip adductien, and
knee abductian when performing a single-leg squat than
did cantrals. Individuals with PFPS alsa had 13% less hip
ahductien and 17% less hip external retatien strength.
Cempared with female cantrels, females with PFPS had
mare hip internal ratatian and less muscle activatieu af
the gluteus medius during the single—leg squat. Level ef
evidence: IV.
29. Fewers CM, Ward 5R, Fredericsen M, IGuillet M, Shelleck
FG: Patellefemeral kinematics during weight-hearing and
nan-weight-bearing knee extensian in persans with lateral
subluxatien ef the patella: A preliminary study. I Drthep
Sparta Pbya Thar 2003;33{11}:E??-635. Medline DUI
31}. Myer GD, Ferd FIR, Earher Fess KL}, et al: The inci-
dence and patential pathemechanics ef patellefemeral
pain in female athletes. Cfirt Hfamecf: (Br-fatal, Ayers)
lfllfl;15{?}:?flfl-?fl?.Medline net
IE! lfllfi American Academy ef flrthepaedic Snrgeens
The anthers praspectively evaluated measures ef frau-
tal-plane knee leading during landing te determine their
relatianship tn the develepment ef PFP. The new PFP
greup demenstrated increased knee ahductien mement
at initial centact en the mast symptematic limb and max-
imum knee ahductien mement en the least symptematic
litnb at the asymptematic limb relative te the matched
central limbs. Level af evidence: III.
31. Distefana L], Blackburn jT, Marshall SW, Padua DA:
Gluteal muscle activatieu during cemmen therapeutic
exercises. I Grahep Sparta Pbya Titer 2Dfl9;39{?}:532v54fl.
Medline DGI
This study describes the relative gluteal muscle activatieu
during several cemmen therapeutic exercises. Side-lying
hip ahductien resulted in the greatest gluteus medius ac-
tivity while single limb squatting and single-limb dead-
lifting led ta the greatest gluteus maximus activity. Level
usuaauaeuvs :1:-
ef evidence: IV.
31. Selkewita DM, Beneck G], Pawers CM: Which exercises
target the gluteal muscles while minimizing activatieu
ef the tenser fascia lata? Electreniyegraphic assessment
using fine-wire electredes. j firth-up Sparta Phys Ther
2013;43l2}:54—E4.Medline DUI
This study shewed that the clamshell, side step, unilateral
bridge, and bath quadruped hip extensien exercises weuld
appear ta be the mast apprepriate ta preferentially activate
the gluteal muscles while minimizing tenser fascia latae
activatieu. Level ef evidence: IV.
33. Ekstrem RA, Denatelli RA, Carp KC: Electremyegraph—
ic analysis ef care trunk, hip, and thigh muscles during
9 rehabilitatian exercises. I Drtfrap Sparta Phys Ther
Zflfl?;3?{12}:?54—?62.Medline DID]
34. Ayette NW, Stetts DIM, Keenan I}, |lflreenway EH: Electra-
myagraphical analysis af selected lewer extremity muscles
during 5 unilateral weight-hearing exercises. j Drtfrep
Sparta Phys Ther EUDT;3?{1}:4E-55. Medline DDI
35. Werner S: Anterier knee pain: tin update ef physi-
cal therapy. Knee Surg Sparta Trunmatal Arthrasc
2014;22{10}:2235-1294.Medline DUI
This clinical cammentary prevides a general update an
phsycial therapy management ef anterier knee pain. Level
af evidence: V.
36. Lack 5, Earten C, Vicenaine B, Merrissey D: Dutcenie
predicters fer censervative patellefemaral pain manage-
ment: A systematic review and meta—analysis. Sparta Med
2014;44{IZJ:1?03-1?16.Medline DDT
This systematic review and meta-analysis seught ta
evaluate the efficacy ef preximal rehabilitatian af PFP,
campare variaus rehabilitatian pratacels and identify
hiemechanical mechanisms te aptimiae preximal reha—
hilitatien. The review suggests preximal rehabilitatien
af PFPF shauld be included in censervative management.
Level ef evidence: II.
Drthepeedic Knewledge Update: Sparta Medicine 5
 Sectinn 4: Rehabililutinn
3?. 1iiii’itvrciuw E, Urnssley R, Davis I, McUcnnell J, Pcwers
|IBM: The 3rd Internatinnal Patellnfemnral Research Re-
treat: An internatinnal expert cnnsensus meeting tn im-
prcve the scientific understanding and clinical management
cf patellnfemcral pain. lirjr Spcrts Med 2014:4SIS}:4IIS.
Medline DUI
The authors discussed the cnnsensus statement Item the E‘-rd
Internaticnal Patellufemnral Research Retreat, which at-
tempts tn summarize current trends and research pricrities
in the area pf patellnfemc-ral pain. Level nf evidence: V.
33. 1ilii'itvri':rm.v E, Werner S, Mikkelsen C, TIv'an Tiggelen D,
1lullanden Eerghe L, Gernlli G: Clinical classificatinn nf
patellnfemnral pain syndrnme: Guidelines fnr nnn—nper—
ative treatment. Knee Sssrg Sports Traumatcf Arthrnse
2fl05;13{2i:112-13fl.Medline DUI
E 43. Rudrigues P, Chang H, TenErnek T, Hamill J: Medially
.E
4.!
I'll
39. Pcwers UM, Hc RY, IEben ‘1'], Scuaa RE, Farrekhi S:
:: Patellnfemnral jnint stress during weight-bearing and nnn-
E
I'fl
weight-bearing quadriceps exercises. ,f Urtfsnp Spnrts Phys
.i: Ther 2014:44I5lfilfl—321 Mcdline DUI
fill
a:
1's: This study suggests that, re minimise PF] stress while
perfnrming quadriceps exercises, the squat exercise shnuld
be perfnrmed frnm 4.5“ tn fl“ crf knee flexinn and the
knee-extensinn-with-variable-resistance exercise shnuld
be perfnrmed frem Si!“ te- 45” cf knee flexinn. Level cf
evidence: IV.
4|]. Piva SR, Uncdnite Eh, Childs JD: Strength amend the
hip and flexibility nf snf't tissues in individuals with and
withuut patellcfemeral pain syndrcrmc. ] Urtbcp Spurts
Phys Ther 2005:35Illlfl93-Efll. Medline DUI
41. 1ifiniitvrnuw E, Callaghan M], Stefanik J], et al: Patellnfcm—
nral pain: CUHSEI'ISIJS statement frnm the 3rd Internatinnal
Patellnfemnral Pain Research Retreat held in Vancnuver,
Sepmmber 2013. Br ,i' Sports Med 2fl14;43{6}:411—414.
Medline DUI
A cnnsensus statement frnm the 2013 Patellcfemnral Pain
Retreat is discussed. Level nf evidence: V.
42. Warden SJ, Hinman RS, 1i'iiatsnn MA jr, hvin RU, Bialn-
cerknwski .f'LE, Crnssley KM: Patellar taping and bracing
fer the treatment cf chrc-nic knee pain: A systematic review
and meta-analysis. Arthritis Rheum lflflflgSSIII:?S-SS.
Medline DUI
43. McClay I, Manal R: A cnmparisnn nf three-dimensinnal
Inwer extremity kinematics during running between ex-
cessive prenatcrs and ncrmals. Elia Bicmeelr fBrfstcf.
Avert) ISBS;'13{3]:ISS-EUS. Medline DUI
Tiberic D: The effect of excessive subta lar juint prenaticn
cn patellcfemc-ral mechanics: A thecretical mcdel. ] Ur-
tfmp Spnrts Phys Titer 193T;9{4}I:16il-165. Medline DUI
4S. iers CM, Chen PT, Reischl SF, Perry J: Ccmparisnn
nf fnnt prc-natinn and Inwer extremity rntatinn in persnns
with and witbcut patellufemcral pain. Fc-ct Ankle Int
2Dfll:23[?l:634-S4fl. Medline
Urthnpaedic Kncwledge Update: Sperts Medicine S
46. Hetsrnni I, Finestcne A, Milgrc-m C, et al: A prcspective
binmecha nical study Uf the assnciatinn between fnnt pru-
natinn and the incidence nf anterinr knee pain amnng
military recruits. 1 Rune joint Surg Br Zflfl6:33i?}:9i}5-
EDS. Medline DUI
4?. Rndrigues P, TenE-rnck T, Hamill]: Runners with anterinr
knee pain use a greater percentage cf their available pre-
natinn range nf mntinn. f Appf Hints-tech EDI 3429l1i=141‘
146. Medlinc
In this study, nc- differences in traditinnal prunaticn vari-
ables were ncted berween healthy and injured runners. In
cnntrast, injured runners used significantly mnre nf their
available range nf mntinn than did healthy runners. Level
cf evidence: IV.
pasted insnles ccnsistently influence fnnt prenatinn in
runners with and withnut anterinr knee pain. Gait Pnstnre
1013:3?(4}:52IS-531.Medline DUI
In this study, insules, an average, reduced peak eversicn,
peak eversicn velccity, and eversic-n range crf mntinn. Al-
thnugh insnles reduced eversitm variables, hnwever, they
had small influences cm the transverse-plane kinematics
cf the tibia er knee. Level nf evidence: IV.
49. Eartnn G], Levinger P, Crnssley KM, Webster RE, Men:
HE: Relaticnships between the Fact Pasture Index and
fact kinematics during gait in individuals with and with-
nut patellnfemnral pain syndrnme. j at Ankle Res
1D11;4:ID. Medline DUI
In individuals with and withnut PFPS, a fair tc mc-derate
asscciaticn was fnund between the feet pasture index and
same parameters nf dynamic fnnt functitm. Incnnsistent
findings between the PFPS grnup and the centre] grnup
indicate that pathclc-gy may playr a rule in the relatinnship
between static fnnt pnsture and dynamic functinn. Level
nf evidence: IV.
SD. Bartnn C], Levinger P, Crnssley RM, Webster RE, Men:
HR: The relatinnship between rearfnnt, tibial and hip
kinematics in individuals with patellcfemnral pain syn-
drums. Clix Siamese {Bristnh .tilflflfl} 2012:2?{?}:702-?fl5.
Medline DUI
In this study, greater peak rearfnnt eversinn was assnci-
atcd with greater peak tibial internal rntatinn in the FFPS
grnup. Greater rearfnc-t eversinn range cf mntinn was
assnciated with greater hip adductinn range nf mntinn in
the PFI’S and centre] grnups and greater peak hip adduc—
ticn in the centre] grnup. Level cf evidence: IV.
51. IvIail TG, Cnrnwall MW: Predictitm cf dynamic fc-nt
pasture during running using the lcngitudinal arch
angle. ] Arr: Pnsffsttr Med tissue lflfl?;9?{2}:1fl2-IDT.
Medline DUI
SE. Franettnvich MM, Mail TG, Russell T, Skardnnn G,
Vicenainc E: The ability tn predict dynamic feet pes—
ture frcm static measurements. ,I Am Pcdietr Med Asses
lflfl?;9?{2}:115-120.Medline DUI
U lflld American Academy cf Urrhtipaedic Surge-ens
 Chapter 17: Patellefememl Pain Syndreme: Currenr Eeucepts in Rehabilitatien
53. Miindermann A, Nigg EM, Humble RN, Stefanyshyn
DJ: Feet erthetics affect lewer extremity kinematics and
kinetics during running. Elia: Biemsch (Bristel', Avert)
2fl33;13{3]:154-262. Medline DUI
54. Staceff A, Reinschrnidt C, Nigg EM, et al: Effects ef feet
ertheses en skeletal metien during running. Clirs Bfemech
(Brisrel, Avert} lflfl0515{1}:54-64. Medline DUI
55. Williams D5 III, McClay Davis I, Eaitch SP: Effect ef
inverted ertheses en lewer-estremity mechanics in runv
ners. Med Sci Sperts Exerc lflflfififlllhlflfifl-fllfifl.
Medline DUI
56. Eslami M, Eegen M, Hinse S, Sadeghi H, Pepev P, Allard
P: Effect ef feet ertheses en magnitude and timing ef rear-
feet and tibial metiens, greund reactien ferce and knee
mement during running. J Sci Med Spert ZflflflflltfihrJ'TB-
ES 4. Medline DUI
The authers reperted feet ertheses ceuld reduce rearfeet
eversien se that this can be asseciated with a reductien
ef knee adductien mement during the first fifl‘l’s stance
phase ef running. These findings imply that medifying
rearfeet and tibial metiens during running ceuld net he
related te a reductien ef the greund reactien ferce. Level
ef evidence: IV.
5?. Beldt AR, 1illfillsen JD, Earries JA, Kernerek TW: Effects
ef medially wedged feel: ertheses en knee and hip jeinl:
running mechanics in females with and witheut patelles
femeral pain syndreme. J Appi Biemech 2fl13:29{1]:63-??.
Medline
In this research, ne significant greup :u: cenditien er calca-
neal angle a cenditien effects were ehserved. The additien
ef medially wedged feet ertheses te standardized running
shees during running had a minirual effect en knee and hip
jeirlt mechanics theught te he asseciated with PEPE symp-
tems. These effects did net appear te depend en injury
status er standing calcaneal pestu re. Level ef evidence: IV.
53. lacLean (1, Davis IIvI, Hamill J: Influence ef a custem
feet erthetic interventien en lewer extremity dynam-
ics in healthy runners. Cfffl Bfemech (Eris-tel, Arlen}
sassgusassasseasmm: eel
55‘. Naweczenski DA, Ceek TM, Saltaman |CL: The effect ef
feet erthetics en three-dimensieual kinematics ef the leg
and rearfeet during running. } Grthep Sperts Phys Ther
1995;21f6]:31?—32?.Medline DUI
El]. Stackheuse CL, Davis Ilvl, Hamill]: Drthetic interventien
in ferefeet and rearfeet strike running patterns. Cffn: fife-
mech {Eristeh risen) lflfl4;19{1}:64-?D. Medline D01
61. Cellins N, IEressley K, Heller E, Darnell R, McPeil T,
Vicenaine E: Feet ertheses and physietherapy in the treat-
ment ef patellefemeral pain synd reme: Eandemised clin-
ical trial. Br I Sperts Med 2Ufl9;43{3}|:159-1?1. Medline
DUI
This raudemiaed centrelled trial investigating the efficacy
ef feet ertheses and physical therapy in patients with PFPS
neted that feet ertheses wEre superier te flat inserts but
IE! lfllii American Academy ef flrthepaedic Snrgeens
similar te physietherapy and de net impreve eutceme
when added te physietherapy. Level ef evidence: II.
61. Jehnsten LE, Gress lT: Effects ef feet ertheses en qual-
ity ef life fer individuals with patellefemeral pain syn-
dreme. I Drthep Sperts Phys Ther- Efl fl4;34{3}:44D-443.
Medline DUI
63. McPeil TG, Vicenaine B, Cernwall MW: Effect ef
feet ertheses centeur en pain perceptien in individu-
als with patellefemeral pain. I Am Pediatr Med Asses
2fl11;101l1]:T-16.Medline DUI
In this study, all participants perceived greater suppert
with centeured ertheses in the heel and arch regiens. All
ef the participants rated cushiening as equivalent, despite
differences in material hardness. In the patellefemeral
pain greup, six individuals reperted a clinically significant
reductien in knee pain as a result ef wearing feet ertheses.
uvuvavavaas :1:-
Level ef evidence: III.
64. Batten (3], Munteanu 5E, IvIeua HE, Eressley Kid: The
efficacy ef feet ertheses in the treatment ef individuals
with patellefemeral pain syndreme: A systematic review.
Sperts Med lfl]fl;4fl{5}:3??—395. Medline III-DI
Limited evidence shews that prefabricated feet ertheses
better reduce the range ef transverse-pla ne knee retatien
and previde greater shert-term imprevements in individ-
uals with PFPS than de flat inserts. Findings alse indicate
that cembiniug physical therapy with prefabricated feet
ertheses may he superier te prefabricated feet ertheses
aleue. Level ef evidence: I.
I55. Eng J}, Pierrynewski MR: Evaluatien ef seft feet erthetics
in the treatment ef patellefemeral pain syndreme. Phys
Ther 1993;?3i1l:62—63, discussien 63—?0. Medline
66. 1|Illll'illsen jIlI, Sharpee R, Mearden 5A, Kernezek TW: Ef-
fects ef step length en patellefemeral jeiut stress in female
runners with and witheut patellefemeral pain. Eli's-s Bie-
mech fBrfstef, Avert} 2&14;25‘{3J:243-14?. Medline DGI
In this study, PF] stress per step increased in the leug
step—length cenditien and decreased in the shert step-
length cenditien. Tetal stress per mile experienced at the
PF] declined with a shert step length despite the greater
number ef steps necessaryr te cever the distance. Level ef
evidence: IV.
6?“. Heiderscheit EC, Chumanev E5, Michalski MP, 1Wille
CM, Ryan ME: Effects ef step rate manipulatien en
juiut mechanics during running. Med Sci Sperts Esters
2011;43i2lflfld-3fl2.Medline net
This study shewed that increased step rate results in an
altered peak hip adductien angle as well as a reductien in
peak hip adductien and internal retatien mements. Level
ef evidence: IV.
153. Leuhart ILL, Thelen DIG, Wille CM, |IEhumanuv E5,
Heiderscheit EC: Increasing running step rate reduc-
es patellefemeral jeint ferces. Med Sci Sperts Eaters
2fl14;45[3l:55T-5i54.Medline DUI
Drthepaedic Knewledge Update: Sperts Medicine 5
 Sectiuu 4: Rehahiflllutiun

In this study, increasing the step rate reduced peak In this studv, a reductiun in hip adductiun and cuntra-
PF] furce. Peak muscle furces were altered as a result uf lateral pelvic drup while running was seen fulluwing gait
the increased step rate, with hip, knee, and ankle extensur retraining. Impruvements in pain and functiun alsu were
fumes and hip abductcr furces all reduced in midstance. seen. Subjects were able tu maintain their impruvements
Level uf evidence: IV. in running mechanics, pain, and functiun at 1-munth
fulluw-up. Level uf evidence: IV.
6.9. Churnanc—v ES, Wills GM, Michalski MP, Heiderscheit
BC: Changes in muscle activatiun patterns when running T1. Willy KW, Schulz JP, Davis IS: Mirrur gait rerraining fur
step rate is increased. Gait Pustrrre ID12;SSI{2}:ESI-235. the treatment uf patellufemural pain in female runners.
Medline DD] Eli's: Bic-mesh (Bristul, Anus} 2012;2?{1fl]:1045-1051.
Medline Dfll
An increase in late swing phase muscle activitv uccurs
when the step rate is increased, suggesting an anticipatnrv This stud}r fuund decreased peaks uf hip adductiun,
preactivatiun fur the fuut-grunnd cuntact. Muscle activi- cuntralateral pelvic drup, and hip abductiun mument
ties dnring the luading respunse were nut reduced as the during running with gait retraining. Skill transfer tu sin-
step rate increased. Level uf evidence: IV. gle-leg squatting and step descent was nuted. Subjects re-
purted impruvements in pain and functiun and maintained
:: I’ll. Nuehren E, Schulz], Davis I: The effect uf real-timc gait them thruughuut the S munths after retraining. Level uf
.E evidence: IV.
4.!
I'll
retraining un hip kinematics, pain and functiun in sub-
: jects with patellufemural pain svndrume. Hr] Spurts Med
E
I'fl
2fl11:45[9]:691-696.Medline DUI
.:
fill
a:
1's:

firthnpaedic Knuwledge Update: Spurn: Medicine 5 fl lfllfi American Academy uf Cirrhupaedic Surge-ans
Chapter 28
Foot and Ankle Rehabilitation
Rany L. Martin, PhD, PT
Manual therapy, taping, and exercise are cnmmnnly
included in a cnmprehensive feet and ankle rehabiliu
tatinn prngram. These interventinns typically are per-
fnrmed tn decrease pain and restnre nnrmal mntinn,
muscle functinn, prnprinceptinn, and binmechanics.
Manual therapy prncedures can have binmechanical,
neurnphysinlngic, and psychnlngic effects. Taping tech-
niques are typically used tn reinfnrce nnrmal prntective
suppnrt structures, imprnve prnprinceptinn, enhance
neurnmuscular activatinn, andlnr alter hinmechanics
whereas exercise typically is directed tnward imprnving
range nf mntinn, recruitment pattern, strength, and!
nr endurance. Eccentric exercise can alsn be used tn
ptnmnte tendnn remndeling. It is impnrtant tn review
the literature related tn the pntential effectiveness nf
manual therapy prncedures, taping techniques, and
exercise in fnnt and ankle rehabilitatinn, and review
specific evidence tn suppnrt the use nf these interventinns
for individuals with heel pain, plantar fasciitis, Achilles
tendinnpathy, and lateral ankle sprain.
Keywords: manual therapy; taping; exercise;
evidence-based practice
IntrndUttic-n
Manual therapy, taping, and exercise are cnmmnnly in-
cluded in cnmprehensive fnnt and ankle rehabilitatinn
prngrams. These interventinns typically decrease pain and
restnre nnrmal mntinn, muscle functinn, prnptinceptinn,
and binmechanics. The pntential effectiveness nf manu-
al therapy prncedutes, taping techniques, and exercise
in fnnt and ankle rchabilitatinn has been reviewed, and
Neither Dr. Martin nnr any immediate family member has
received anything nf value from nr has stuck nr stnclr np-
tinns held in a cnmmerclal company nr lnstitutinn related
directly nr indirectly tn the subject nf this chapter.
fl lflld American Academy nf Drthnpaedic Surgenns
specific evidence nutlined tn suppnrt the use nf there inter-
ventinns fnr individuals with heel pain, plantar fasciitis,
Achilles tendinnpathy, and lateral ankle sprain.
uvnealisvuas :1:-
Manual Therapy
Manual therapy can include jnint and snft—tissue mnbi-
lisatinn techniques. The effects nf these techniques can
he hinmechanical, neurnphysinlngic, and psychnlngic
and have been nutlined in a cnmprehensive mndel.1 A
literature review suppnrted using manual therapy as an
interventinn tn treat lnwer extremity cnnditinnsfi Frnm
a binmechanical perspective, jnint and snft—tissue mn—
biliaatinn techniques thenretically address restrictinns
in capsular, ligamentnus, tendinnus, muscular, andlnr
fa scial structures. Annther pntential binmechanical effect
nf jnint mnbiliaatinn is the realignment nf bnny structures.
Generally pnsitivc binmechanical effects can be assnciatcd
with imprnved range nf mntinn. Snft—tissue mnbilitatinn
can he directed tnward increasing circulatinn, imprnving
vennus and lymphatic flnw, and prnmnting cnllagen red
alignment. The neurnphysinlngic effects [if manual ther-
apy can include altering central pain precessing, muscle
recruitment, and reflex activity patterns, which can result
in imprnved fnrce prnductinn and decreased pain percep-
tinn. The psychnlngic effects nf manual therapy may be
placebn in nature and assnciatcd with “a feeling nf being
helped;n hnwever, these effects shnuld nnt be underesti-
mated and can change an individual‘s pain perceptinn,
stress levels, and nverall emntinnal state.I
Taping techniques can reinfnrce nnrmal prntective sup-
pnrt structures, imprnve prnprinceptinn, enhance neurn~
muscular activatinn, andlnr alter binmechanics. Taping
techniques that cnrrect lnwer extremity kinematics and
muscle activatinn in individuals with abnnrmal prnnatinn
are generally categnriaed as antiprnnatinn. A review nf
the literature shnwed that antiprnnatinn taping can in-
crease medial lnngitudinal arch height, reduce calcane-
al eversinn, reduce tibial internal rntatinn, and reduce
Drthnpaedic Knnwledge Update: Spnrts Medicine 5
 Section 4: Rehabilimtion
tibialis posterior muscle activity.3 The treatment-directed
test uses antipronation taping techniques to guide or-
thotic prescription.‘ Research has disproved many the—
ories5 traditionally used in foot assessment and orthotic
fabricatiou.‘5'E Because clinical examination may not be
able to predict dynamic foot function, clinical findings
may not be as helpful as previously assumed in orthotic
prescription. However, the individualized approach to
orthotic fabrication based on response to taping through
the treatment-directed test has reduced pain and improved
function};
Exercise
r:
.E
4.! Typically, active exercise is directed toward changing the
characteristics of a muscle contraction by improving re-
I'll
:
E
I'fl cruitment pattern, strength, andr'or endurance. Stretching
.r:
fill
a: exercises are typically used to improve range of motion
4a: and flexibility. Because muscles do not work in isolation,
active exercises should target not only muscles in the foot
and ankle but also include proximal muscle groups in
functional activities. Exercises often attempt to correct
abnormal pronation by improving the function of muscles
that support the medial longitudinal arch, particularly the
posterior tibialis. Because hindfoot prouatiou has been
coupled with hip internal rotation,"’ exercises that target
hip musculature can be beneficial. Due study found that
individuals with overuse injuries had strength deficits in
the hip musculature.11 It is also theorized that exercise
should include muscle groups of the lumbopelvic region to
facilitate a stable platform for lower extremity movement.
In addition to exercise being directed toward correcting
abnormal prouatiou and improving functional stability,
exercise also can be directed at tendon remodeling using
an eccentric exercise program. A program developed for
individuals with tendiuopathies consists of progressive
eccentric loading with resistance high enough to cause
moderate but not disabling pain.ll The exact mechanisms
behind the success of eccentric training can involve alter-
ing tendon blood flow, collagen synthesis, and production
of growth factors. A 2013 study suggested that eccentric
exercise that loads the tendon in a lengthened position
can cause “squeezing out" and resolution of abnormal
neovascularity.”l
Evidence—Based Practice
Evidence—based clinical practice guidelines for the or-
thopaedic physical therapy management of individuals
with common foot and ankle-related musculoskeletal
impairments have been published. These guidelines out—
line evidence for the use of manual therapy, taping, and
firthupaedic Knowledge Update: Sports Medicine 5
exercise in individuals with heel painfplantat fasciitis,”
Achilles tendinopathy,” and lateral ankle sprain.”
Plantar Fasciitis
Plantar fasciitis usually presents as a chronic condition
in both nonathletic and athletic populations.” Limited
ankle dorsiflexien range of motion, high body mass index
in nonathletic individuals, running, and work—related
weight-bearing activities under conditions with poor
shock absorption have been identified as risk factors for
the development of plantar fasciitis. Strong evidence in-
dicates that plantar fasciitis can be diagnosed based on
plantarmedial heel pain that is most noticeable with initial
steps following a period of inactivity but also may be
worsened following prolonged weight bearing; the onset
of pain associated with a recent increase in weight—bearing
activity; pain with palpation of the proximal insertion of
the plantar fascia; a positive vvindlass test result; and neg-
ative tarsal tunnel test results.“ The treatment of plantar
fasciitis of the heel is summarized in Table 1 and includes
strong evidence for manual therapy, taping, and exercise.“
Manual Therapy
A 21314 review“ recommended that manual therapy con-
sisting of joint and soft—tissue mobilisation procedures be
used to treat relevant lower extremity joint mobility and
calf flexibility deficits and to decrease pain and improve
function in individuals with heel painfplantar fasciitis.
Level I research studies supported this recommendation.
Authors of a Bill}? study” found that patients who un-
derwent exercise and manual therapy had better function
and global self-reported outcomes at both 4 weeks and 6
months when compared with patients in the group treated
with exercise and iontophoresis. Manual therapy consist-
ed of soft-tissue mobilization directed toward the calf
and plantar fascia and joint mobilisation directed toward
identified range of motion restrictions of the hip, knee,
ankle, and foot. Because limited ankle dorsiflexion is
often identified in those with plantar fa sciitis, anterior to
posterior talar glides {Figure 1} are commonly performed.
Authors of a mu study” found that patients who under-
went the addition of soft-tissue mobilisation techniques
directed at gastrocnemius and soleus myofascial trigger
points had better pain reduction at 4 weeks when com-
pared with patients who underwent self~stretching only.
Taping
The authors of the IBM review also recommended that
clinicians should use antipronation taping for immediate
{up to 3 weeks} pain reduction and improved function for
individuals with plantar fasciitis.“ Systematic reviews have
fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 23: Foot and Anlde Rehabilitation

Table 1

Summary of Evidence in the Treatment of Plantar Fasciitis

Strong Evidence
Treatment Intervention
Manual therapy Lower extremity joint mobilization
Plantar fascia, gastrocnemius, and soleus soft-tissue mobilization
Taping Antipronation technique
Exercise Plantar fascia stretching
Gastrocnemius and soleus stretching
Foot orthoses faver-the-counterrprefahricated or a custom foot orthoses that supports
the medial arch andror provides cushion to the heel region
Night splints

ussvuuqeuas :1:-
Weak Evidence
Treatment Intervention
Physical agents lontophoresis with dexamethasone or acetic acid
Low-level laser
Phonophoresis with ketoprofen gel
[Data from Martin EL, Davenport TEr Fleischl 5F, et al: Heel pain-plantar fasciitis: Revision Ell-14- J flrthop Sports Phys Ther mlmMIHIfiI-AEB.
http:fl|'t:|x.doi.orgflfl.2519!jospt.2fl14.l]303.l

Figure 1 Photograph shows implementation of anterior

to posterior talar glides {arrow} to increase
ankle dorsiflexion range of motion.

Figure 1 Photograph shows an antipronation taping

found antipronation taping to be effective in reducing pain
at 1—week follow-up in subjects with plantar fasciitis.”'1”
An example of antipronation tape is demonstrated in Fig-
ure 2. A level I study not included in these reviews found
therapeutic elastic tape applied to the gastrocnemius and
plantar fascia improved pain scores and reduced plantar
fascia thickness when compared with ultrasound and elec—
trotherapy treatments at 1-week follow-up.“ Additionally,
a level II study found that antipronation taping reduced
pain and improved function over a 3—week period in in—
dividuals with plantar fasciitis.:1
technique.
Exercise
Clinicians should use plantar fascia-specific and gastroe-
nemiusl'soleus stretching to provide short-term (1 week
to 4 months) pain relief for individuals with plantar fas-
ciitis.“ Two systematic reviews concluded that stretching
exercises for the ankle and foot can provide short-term {2
weeks to 4 months} improvementsfinrfl with plantar fas-
cia—specific stretching being more beneficial than Achilles

IE! Eillfi American Academy of flrchopaedic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation

-—
Summary of Evidence in the Treatment of Individuals 1With Achilles Tendinopathy
Strong Evidence
Treatment Intervention
Exercises Eccentric leading of the Achilles tendon
Physical agents Low-level laser
Iontophoresis with dexamethasone
Weak Evidence
Treatment Intervention
Exercise Fla ntar flexor stretching
Foot orthoses Custom semirigid inserts
c
.E Manual therapy Achilles tendon soft-tissue mobilization
4.!
I'll
:I: Expert opinion
E
I'fl Treatment Intervention
.c
Ii
ac Taping Directed toward decreased strain on the Achilles tendon
1's:
{Data from Earcia CH, Marlin itL, Hand: J, Wultich DIE; orthopaedic Section of the American Physical Therapy Association: Achilles pain, st'aess,
and muscle power defldts: Achilles tendinitis. J Urthup Sports Phys Ther 2a1a;4a[s]:a1-A2s. http:iii'dx.dal.orgi1D.2519i]ospt.2fl1u.u3u5.l

stretching.m A study not included in these reviews found
improved self-reported outcome scores when comparing
plantar fascia-specific stretching with shockwave therapy
at 2— and 4-month follow—up.“
Achilles Tendinopathy
Achilles tendinopathy is a common pathology in active
individuals. Intrinsic risk factors associated with Achilles
tendinopathy include abnormal dorsil'lexion range of mo-
tion, abnormal suhtalar joint range of motion, decreased
ankle plantar flexion strength, increased foot pronation,
and abnormal tendon structure.'5 A recent study sug-
gested that high body mass index may also he a risl: fac-
tor for developing Achilles pathology.” A 2.010 review”
found that Achilles tendinopathy can be diagnosed by
the following findings: local tenderness of the Achilles
tendon 2 to 6 cm proximal to its insertion; a positive
a_rc sign where the area of palpated swelling moves with
dorsiflexion and plantar flexion; and a positive Royal
London Hospital Test result where Achilles tenderness in
slight plantar flexion decreases as the ankle dorsii'lexes.
Evidence supporting interventions in the treatment of
Achilles tendinopathy is summarized in Table 2 and in—
clude weal: evidence for manual therapy, expert opinion
for taping, and strong evidence for exercise.
Manual Therapy
For individuals with Achilles tendiuopathy, soft—tissue
mobilization can he used to reduce pain, increase mobility,
and improve function. This recommendation was further
supported by a recent systematic review in Zfllli‘ that
outlined low-level evidence for soft-tissue mobilization in
individuals with Achilles tendinopathy. Due soft—tissue
mobilization technique consisted of gliding a hypomohile
Achilles tendon in conjunction with stretching and mus-
cular contraction.” Although not extensively studied,
joint and soft-tissue mobilization could be justified for
increasing ankle dorsiflexion range of motion.
Taping
Taping can also be used to decrease tendon strain in pa-
tients with Achilles tendinopathy.” According to a sys-
tematic reviewfi" there is low-level evidence to support
antipronation taping. Given that abnormal pronation is
a risk factor for developing Achilles tendinopathy, the use
of antiprnnatinn taping techniques could be justified as
an appropriate intervention. A case study of an individual
with Achilles tendinopathy reported that antipronation
taping reduced symptoms and produced a tenfold increase
in pain-free jogging distance.” IEither taping techniques
include “off-loading" and “equinus-constraint,“ which
decrease strain on the Achilles tendon and limit dor-
siflexion range of motion}? Figure 3 demonstrates the
‘off-lnading' taping technique.
Exercise
Clinicians should implement an eccentric loading pro-
gram to decrease pain and improve function in individ—
uals with Achilles tendinopathy.” This recommendation

flrdinpaedic Knowledge Update: Sports Medicine 5 fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 23: Fuut and Ankle Rehabilitation

was further suppurted in ether literature reviews.“hm
Cine study nut included in these reviews fuund eccen-
tric strengthening was mure effective than cuncentric
strengthening in reducing pain and impruving functiun
in individuals with Achilles tendinupathy.“ Additiunally,
a 5—year fulluw—up study nuted that althuugh lung-term
impruvement in symptums can be expected, mild pain
may persist.3L1
Ankle Sprain
The incidence uf ankle sprain was fuund tu be highest
in yuung, active individuals, especially these whu par-
ticipate in cuurt spurts such as basketball.” The fulluw—
individuals between 2 weeks and 96 munths after initial
injury.“ Individuals with lung-term symptums fulluwing
lateral ankle sprain are cummunly characterised as having
either chrunic mechanical ur functiunal ankle instability.
The treatment uf acute lateral ankle sprain and chrunic
ankle instability is summarised in Tables 3 and 4, respec-
tively. Strung evidence has been fuund fur manual therapy,
weight hea ring with suppurt, and exercise fur thuse with
an acute lateral ankle injury. Muderate and weak evidence
were identified for manual therapy and exercise, respec—
tively, fur thuse with chrunic ankle instability.
Manual Therapy
Clinicians shuuld use manual therapy prucedures such

ueseaiiqsuae :1:-
ing risk facturs have been identified fur an acute lateral as lymphatic drainage, active and passive suft-tissue and
ankle sprain: previuus ankle sprain; nut using external
suppurt; nut pruperly warming up with static stretching
and dynamic muvement before activity; abnurmal ankle
dursifleniun range uf mutiun; and nut participating in
balance and prupriuceptive preventiun prugrams after a
lateral ligament injury. Clinicians shuuld use the clinical
findings uf decreased functiun, ligamentuus laxity, hem-
urrhage, puint tenderness, tutal ankle mutiun, swelling,
and pain tu classify a patient with acute ankle ligament
sprain. Tests tu assess lateral ligament stability have nut
shuwn desirable diagnustic accuracy when perfurmed in
isulatiun. Additiunal research has shuwn medial ankle
juint pain with palpatiun and dursiflesciun at 4 weeks
as the must valuable prugnustic indicaturs uf functiun 4 Figure 3 Phutugraphs shuvvs an Achilles “eff-leading“
munths after injury.” Recurrent lateral ankle sprains are taping technique used tu limit painful
dursifleaiun range uf mutiun.
nut uncumrnun, with reinjury uccurring in 3% tu 34% uf

_—n_-.
Summary uf Evidence in the Treatment uf Acute Lateral Ankle Sprain
Strung Evidence
Treatment Interventlen
Exercise Structured rehabilitatiun prugrain including prugressive active range uf mutiun
and resistance exercises incurpurating weight bearing 1inlith suppurt
Physical agents Cyrutherapy
Moderate Evidence
Treatment lnterventien
Manual therapy Anteriur—tu—pusteriur talar mubilizatiun, lymphatic drainage. active and passive
soft-tissue and juint mubilizatiun prucedures
Weak Evidence

Treatment Intervention
Physical agents Diathermy
[Data frurn Martin EL. Davenpurt TE. Paulseth 5. Wukich Elli. Eudges J.I. Drthupaedic Sectiun American Physical Therapy Assuclatiun: Ankle
stability and muvement cuerdinatiun impairments: Ankle ligament sprains. .l' Drthup Sparta Phys flierzflfiyeflliilmi-Adt}. httpdfdsdui.
urgiifl.2519l]uspt.2il13.fl3fl5.l

IE! Eillii American Academy uf Clrthupaedic Surgeuns Drthupaedic Knuwledge Update: Spurts Medicine 5
®
 Section 4: Rehabilitation

-—
Summary of Evidence in the Treatment of Chronic Ankle Instability
Strong Evidence
Treatment Intervention
Manual therapy Non-weight-bearing and weight-bearing joint mobilization
Weak Evidence
‘I'reatlnent Intervention
Exercise Weight'bearing functionalisports-related exercises and single-limb balance
activities using unstable surfaces
{Data from Martln FlL, Davenport TE. Paulseth 5. Wultlrh tilt, Goclges JJ, Eirthopaecllc Sectlon American Physical Therapy Associatlon: Ankle
stability and movement coordination impairments: Ankle ligament sprains- J firthop Sports Phys Ther 2i]lEl;£lEl[9]:A1-A4u- httpfldxdoi.
orgfluj 519ijospt.2l}13.fl3l15.}
c
.E
4.!

joint mobilization, and anterior-to-posterior talar mobi-

I'll
:
E
I'fl lisation {Figure 1} procedures to reduce swelling, improve
.c
all
o: pain-free ankle and foot mobility, and normalise gait
1's: parameters in individuals with acute lateral ankle sprain.”
According to a level II study, a single session of manual
therapy in the emergency department was associated with
decreased edema and pain in individuals presenting with
acute ankle sprain.“ Soft—tissue mobilisation, joint mobi—
lization, isometric mobilisation, contractl'relax, position-
al release, and lymphatic drainage procedures directed
toward identified impairments are examples of manual
therapy. A separate level II study found individuals with
acute ankle sprains who received pain-free posterior ta-
lar joint mobilisations had better outcomes, achieving
full range of motion and symmetric step length within
the first two to three treatments.” The use of manual .___-'-I. r

therapy was further supported by a recent systematic
review.35 Recent evidence also exists that the addition of
myofascial therapy to thrust and nonthrust manipulation
and exercise can further improve outcomes in those with
acute lateral ankle sprain.“
In individuals with nonacute lateral ankle inju—
ries, clinicians should include nonweight-bearing and
weight-bearing joint mobilisation to improve ankle dorsi-
flexion range of motion, proprioception, and weight—bear—
ing tolerance.” A weight-bearing joint mobilisation that
can he used to improve ankle dorsiflexion is demonstrated
in Figure 4. In addition, a systematic review concluded
that manual therapy techniques improve ankle range of
motion, decrease pain, and improve function for those
with signs and symptoms consistent with a subacute:Ir
chronic lateral ankle sprain.“ A study not included in
that review found that posterior talar mobilisations were
associated with improved measures of function for at least
1 week in individuals with chronic ankle instability?“El
Figure 4 Photograph shows implementation of a
weight-bearing joint mobilization technique-to
improve ankle dorsiflexion range of motion.
Taping
Clinicians should strongly encourage use of external
support and progressive weight bearing on the affected
extremity in patients with acute lateral ankle sprain. The
type of external support {which can include tape} and
gait-assistance device recommended should be based on
the severity of the injury, phase of tissue healing, level of
protection indicated, extent of pain, and patient prefer—
ence. In patients with more severe injuries, immobilization
ranging from semirigid bracing to casting below the knee
may be indicated.15 The authors of a systematic review”
found that using a semirigid ankle support rather than
an elastic wrap was associated with substantially shorter
return to work and sports, as well as decreased reports
of instability. External support from tape was most fre-
quently associated with complications, such as skin it—
ritation. Although some studies have noted a positive

383 firthopaedic Knowledge Update: Sports Medicine 5 fl lfllfi American Academy of Orthopaedic Surgeons

effect of taping and bracing on proprioception, a recent
meta-analysis noted the use of an ankle brace or tape
had no overall effect on proprioceptive acuity in those
with recurrent ankle sprain or functional ankle instabil-
ity.” Conflicting evidence exists that fibular reposition
taping“=‘” and therapeutic elastic tape43*“ can improve
postural control and proprioception.
Exercise
Clinicians should implement a rehabilitation program
that includes therapeutic exercises for patients with acute
lateral ankle sprain, along with active range of motion
and progressive resistance exercises for the ankle and
foot. A study that supports this recommendation found
functional improvement in individuals with a severe ankle
sprain who underwent physical therapy intervention and
conventional medical treatment compared with those
who underwent conventional medical treatment alone.”
For chronic ankle instability, clinicians should include
weight—bearing sport-specific exercises and single—limb
balance activities using unstable surfaces to improve mo-
bility, strength, coordination, and postural control. This
recommendation is supported by a systematic review that
concludes functional exercises and activities, especially
using unstable surfaces, promote improvement in dynamic
postural control.“
Summary
Foot and ankle rehabilitation programs can include
manual therapy, taping, and exercise. Manual therapy
procedures can have biomechanical, neurophysiologic,
and psychologic effects. Taping techniques are typically
used to reinforce normal protective support structures,
improve proprioception, enhance neuromuscular acti-
vation, andfor alter biomechanies: exercise typically is
directed toward improving range of motion, recruitment
pattern, strength, andfor endurance. Eccentric exercise
can also be used to promote tendon remodeling. Strong
evidence supports manual therapy used in individuals
with plantar fasciitis and chronic ankle instability, mod-
erate evidence in those with acute lateral ankle sprain, and
weak evidence in those with Achilles tendinopathy. Strong
evidence exists for taping in those with plantar fasciitis
and expert opinion in those with Achilles tendinopathy.
Strong evidence exists for using exercise in those with
plantar fasciitis, Achilles tendinopathy, and acute lateral
ankle sprain but weak evidence for those with chronic
ankle instability.
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 23: Foot and Ankle Rehabilitation
Hay Study Points
l The potential effectiveness of manual therapy pro-
cedures, taping techniques, and exercise in foot and
ankle rehabilitation is described according to the
current literature.
I There is specific evidence to support the use of man-
ual therapy, taping, and exercise for individuals with
heel painfplantar fasciitis, Achilles tendinopathy,
and lateral ankle sprain.
finnneflxflxxilhefiensnces
uvsvauqvuvs:s
1. Bialosky JE, Bishop MI}, Price DD, Robinson ME, George
52: The mechanisms of manual therapy in the treatment
of musculoskeletal pain: A comprehensive model. Mar:
Thar 2009;14{5}:531-533. Medline DO]
The authors present a model of potential mechanisms for
manual therapy.
1. Erantingbam JW, Bonnefin D, Perle SM, et al: Manip-
ulative therapy for lower extremity conditions: Update
of a literature review. I Manipxlatise Physiol Thar
2fl11;35{2]:11?-166.Medline DUI
This systematic review outlines the evidence for manipula-
tive therapy in the management of various lower extremity
conditions, including plantar fasciitis. Lewl of evidence: II.
3. Franettovich M, Chapman A, Blanch P, Vicenzino B: A
physiological and psychological basis for anti-pronation
taping from a critical review of the literature. Sports Med
20D3533l3}:61?—631.Medline DUI
4. Viceneino E: Foot orthotics in the treatment of lower limb
conditions: A musculoskeletal physiotherapy perspective.
Mar: The? lflfl4;9{4}:135-195. Medline DUI
5. Root M, Drien WP, Weed JH: Normal Arid Abnormal
Farr-scrim: ofthe Foot: Ch'rsicnf Biomechnrrr'cs. Los Angeles,
CA, Clincial Eiomechanics, IQTT, vol 1.
6. Cornwall MW, McPoil TG: Motion of the calcaneus,
navicular, and first metatarsal during the stance phase
of walking. I Am Fodiarr Med Assoc Zflfllflllllfiifi.
Medline DUI
3’. McPoil T, Eornwall MW: Relationship between neutral
subtalar joint position and pattern of rearfoot motion
during walking. Foot Ankle Int 1994;15l3}:141-145.
Mcdline D0]
3. McPoil TG, Cornwall MW: Relationship between three
static angles of the rearfoot and the pattern of rearfoot
motion during walking. I Drtbop Sports Phys Ther
1996;23{E}:3?0-3?5.Medline DUI
Drthopaedic Knowledge Update: Sports lvledichie 5
 Seefien 4: Rehabilillutiun
Meier K, McPeii TG, IClernwall MW, Lyle T: Use ef an-
tiprenatien taping te determine feet ertheses prescrip-
tien: A case series. Res Sperts Med 2fl03:16{4):25?-1T1.
Medline DUI
It}. Seuza TR, Pinte RZ, Trede HG, Kirkweed RN, Fenseca
5T: Temperal ceupiings between rea rfeet-shank cem-
plex and hip jaint during walking. Chi: Emma-ch {Bristeh
Avert) 2D1fl:25[?}:?45-T43. Medline DUI
The study feund evidence te suppert a tempera] ceupling
ef rearfeet prenatien with hip internal retatien and rear-
feet supinatien with hip external retatien during walking.
Level ef evidence: IV.
11. Kulig K, Pepevich JM Jr, Neceti-Dewit LM, Reischl
SF, Kim D: Wemen with pesterier tibial tenden dys-
: functien have diminished ankle and hip muscle perfer-
.E
4.!
I'll
mance. ] firthep Sperts Phys Ther 2D11:41{9}:6E?-694.
: Medline DUI
E
I'fl
.: The anthers feund wemen with pesterier tibial tenden
e:
as dysfunctien had decreased ankle and hip muscle perfer—
1's: mance. Level ef evidence: III.
12. Alfredsen H, Pietilii T,]enssen P, Latentzen R: Heavy-lead
eccentric calf muscle training fer the treatment ef chronic
Achilles tendinesis. Arr: I Sperts Med 1993;16{3}:360-366.
Medline
13. McCreesh KM, Riley 5], Cretty JM: Heevascularity in
patellar tendinepathy and the respense te eccentric train-
ing: A case repert using Pewer Deppler ultraseund. Mar:
Thar ED13;13{E}:Efl2-6fl5. Medline DUI
This case repert describes cemplete reselutien ef abnermal
neevascularity, using ultraseund imaging, after 3 weeks
ef eccentric exercise in a subject with chrenic patellar
tendinepathy. Leml ef evidence: IV.
14. Martin RL, Davenpert TE, Reischl SF, et al: Heel
pain-plantar fasciitis: Revisien 1014. j Urtfrep Sperss
Phys TIE-er lfl14:44{11}:A1-A33. Medline DUI
The anthers summarize the evidence related re the diag-
nesis, examinatien, and interventien fer these with heel
painfpla ntar fasciitis.
15. Garcia CR, Martin RL, Heuck J, Wukich DE: Drthepae-
dic Sectien ef the American Physical Therapy Asseciatien:
Achilles pain, stiffness, and muscle pewer deficits: Achilles
tendinitis. I Drrhap Sperts Phys Ther lfllfl:4fl{9]:A1-A26.
Medline DUI
The anthers summarize the evidence related te the di-
agnesis, examinatien, and interventien fer these with
Achilles tendinepathy.
16. Martin EL, Davenpert TE, Paulseth S, 1|iiiin’ukich DK, Gedg-
es 1L flrthepaedic Sectien American Physical Therapy
Asseciatien: Ankle stability and mevement ceerdinatien
impairments: Ankle ligament sprains. J Urtfrep Spur-ts
Phys Ther 2013;43i9}:A1—A4fl. Medline DUI
@ firthapaedic Knewledge Update: Sperts Medicine 5
The anthers summarise the evidence related tn the diag-
nesis, examinatien, and interventien fer these with acute
and chrenic lateral ankle injuries.
1?. Cleland ]A, AbhettJH, Kidd MU, et al: Manual physical
therapy and exercise versus electrephysical agents and
exercise in the management ef plantar heel pain: A multi'
center randemized clinical trial. I Drthep Sparta Phys
Thar 20fl9;39[3}:5?3-535. Medline Dfll
This study feund patients whe underwent exercise and
manual therapy had better functien and glebal self-re—
perted eutcemes at beth 4 weeks and E menths when
cempared with patients in the greup treated with exercise
and ientepheresis. Level ef evidence: I.
13. Renan-Urdine R, Alhurquerque-Sendin F, de Seuza DP,
Cleland JA, Fernandez-de-Las-Pefias C: Effectiveness ef
myefascial trigger paint manual therapy cembined with
a self-stretching pretecel fer the management ef plantar
heel pain: A randemiaed centrelled trial. I Urthep Sperts
Phys Ther 2e11:41{s}:43—sn. Medline DUI
The authers feund patients whe underwent the additien
ef seft-tissue mebiiieatien techniques directed at gastrec-
nemius and seleus myefascial trigger peints had better
pain reductien at 4 weeks when cempared with patients
whe underwent self-stretching enly. Leml ef evidence: I.
19. van de Water AT, Speksniider CM: Efficacy ef taping fer
the treatment ef plantar fascia-sis: A systematic review ef
centrelled trials. I An: Pediatr Med Asset EDI Deli] Miller-ll-
51. Medline DDI
The authers reviewed centrelled trials and feund limited
evidence indicating the effectiveness ef taping ta reduce
pain in patients with plantar fasciesis.
2f]. Landerf KB, Men: HE: Plantar heel pain and fasciitis.
BM] Cffr: Enid 1003:2flflflfllll. Mediine
31. Tsai CT, Chang TD, Lee JP: Effects ef shert-term treat-
ment with kinesietaping fer plantar fasciitis. I Muscufe-
skeiet Petr: 2U1fl:13:T1-3fl. DUI
This study feund therapeutic elastic tape applied te the
gastrecnemius and plantar fascia impreved pain sceres
and reduced plantar fascia thickness when cempared
with ultraseu nd and electretherapy treatments at 1-week
fellew'up in patients with plantar fasciitis. Level ef
evidence: I.
22. Abd E1 Salam MS, Abd Elhafr TN: Mw-dye taping versus
medial arch suppert in managing pain and pain-related
disability in patients with plantar fasciitis. Feet Article
Spec 2fl11:4{2]l:EE-91. Medline DUI
These anthers femd that antiprenatien taping reduced
pain and impreved functien ever a 3-week peried in pa-
tients with plantar fasciitis. Level ef evidence: II.
23. Sweeting D, Parish E, Heeper L, Chester R: The effective-
ness ef manual stretching in the treatment ef plantar heel
pain: A systematic review. I Feet Article Res 2011:4:19.
Medline DUI
fl lfllfi American Academy ef Cirrhepaedic Surge-ens

This systematic review cencluded the main pain-relieving
benefits ef stretching appear te eccur within the first 2
weeks te 4 menths after the initiatien ef treatment. [cvel
ef evidence: I.
24. Rempe JD, ICacchie A, Weil L Jr, et al: Plantar fascia-
specific stretching versus radial sheck—wave therapy as
initial treatment ef plantar fasciepathy. ] Benefefnt Surg
Am 2fl10;92{15]:2514-3522. Medline DUI
The authers cencluded that manual stretching is mere ef-
fective than sbeck-wave therapy in the treatment ef plantar
fasciepathy. Level ef evidence: I.
2.5. Scett RT, Hyer CF, Granata A: The cerrelatien ef Achil-
les tendinepathy and bedy mass index. Feet Ankle Spec
2013;6[4k233-235.Medline DUI
Statistical analysis was perfermed te demrmine the cer-
relatien between bedy mass index and Achilles tenden
pathelegy. Patients with Achilles tenden pathelegy had
a greater bedy mass index than these witheut. Lewl ef
evidence: II.
25. Rewe V, Hemmings 5, Barren C, Malliaras P, Maffulli
N, Merrissey D: Censervative management ef midpettien
Achilles tendinepathy: A mixed metheds study, integrat-
ing systematic review and clinical reasening. Sperts Med
2012;42{11]:941-961Medline DUI
This systematic review feund case-study evidence te sup-
pert the use ef seft—tissue mebilixatien fer these with
Achilles tendinepathy. Level ef evidence: IV.
1?. Christensen RE: Effectiveness ef specific seft tissue
mebilixatiens fer the management ef Achilles tendine-
sis: Single case study—experimental design. Men Tiler
researches—sienna: eel
23. Smith M, Breeker S, Vicenzine E, McPeil T: Use ef
anti-prenatien taping te assess suitability ef erthetic pre—
scriptien: Ease repert. Aster} Pbysietber lflfidfiflfliflli-
113. Medline DUI
29. Martin RL, Paulseth S, Garcia CR: Taping techniques
fer achilles tendinepathy. Urtfiepaedfc Physicaf Therapy
Practice. lflfl9;2fl:lflfi-1DT.
This clinical cemmentary describes twe taping techniques
that can be used te decrease pain fer patients with Achilles
tendinepathy. Level ef evidence: V.
3f}. Sussmilch-Leitch 5P, Cellins N], Bialecerkewski AE,
Warden SJ, |Cressley KM: Physical therapies fer Achilles
tendinepathy: Systematic review and meta-analysis. J Feet
Ankle Res lfllltiilidfi. Medline DUI
The findings ef this systematic review snpperted the use
ef eccentric exercise as an initial interventien fer patients
with Achilles tendinepathy. Level ef evidence: I.
31. Yu J, Park D, Lee G: Effect ef eccentric strengthening en
pain, muscle strength, endurance, and functienal fitness
facters in male patients with achilles tendinepathy. Am
J Phys Med Refrabfl 2013;92flkfifi-Tfi. Medline DUI
IE! lfllfi American Academy ef Urthepaedic Snrgeens
Chapter 23: Feet and Ankle Rehabilitatien
The authers feund eccentric strengthening te be mere
effective than cencentric strengthening in reducing pain
and impreving functien in patients with Achilles tendi-
nepathy. Level ef evidence: I.
32.. van der Plas A, de Jenge 5, de Ves RJ, et al: A 5-year fel-
lew—up study ef Alfredsen’s heel-drep exercise pregramrne
in chrenic midpertien Achilles tendinepathy. Br J Sperts
Med 2fl12;4fi{3]:214-213. Medline DUI
This study feund a significant increase in VISA-A sceres at
5 years fellewing an interventien that included an eccentric
exercise. The authers neted that although imprevement ef
symptems can be expected with eccentric exercises, mild
pain may remain leng term. Level ef evidence: I.
33. U’Cenner 5R, Eleakley CM, Tully MA, ivIcDeneugh 5M:
Predicting functienal recevery after acute ankle sprain.
UGIJEi-HHELIEH :1:-
PLeS Une 2013;3(3}:e?2114. Mcdline DUI
The authers feund clinical assessment variables at 4 weeks
were the strengest predicters ef recevery, explaining 50%
cf the variance in anltle functien at 4 menths.
34. Eisenhart AW, Gaeta T], 1i’ens DP: Usteepathic manip-
ulative treatment in the emergency department fer pa-
tients with acute ankle iniuries. J Ann Usteepatf: Asses
IUD3;1G3[9}:41T~421. Medline
35. Green T, Refshauge K, Cresbie J, Adams It: A randemired
centrelled trial ef a passive accessery jeint mebilisatien en
acute ankle inversien sprains. Phys Tia-er lflfl1;31(4}:9 34--
994. Mcdlinc
36. Leuden JK, Reiman MP, Sylvain J: The efficacy ef man-
ual jeint mebilisatienfmanipulatien in treatment ef lat-
eral ankle sprains: A systematic review. Br I Sperrs Med
2fl14;43(5}:355-3?fl.Medline DUI
This systematic review feund manual jeint mebiliaatien
diminished pain and increased dersiflexien range ef me-
tien in these with acute ankle sprains and impreved ankle
range ef metien, decreased pain, and impreved functien
in these with subacutei'chrenic lateral ankle sprains. Level
ef evidence: I.
3?. Truyels-Demi nes 5, fialem—l'vlerene J, Abian-Vicen J,
Clela nd JA, Ferndnder-de-Las—Pefias {3: Efficacy ef thrust
and nenthrust manipulatien and exercise with er witheut
the additien ef myefascial therapy fer the management
ef acute inversien ankle sprain: A randemixed clinical
trial. J Urrhep Sperts Phys The-r 2fl13:43{5}:3flD-3fl9.
Medline DUI
These authers feund the additien ef myefascial therapy
te thrust and nenthrust manipulatien and exercise can
further impreve eutcemes in these with acute lateral ankle
sprain. Level ef evidence: I.
3E. Hech IvIC, Andreatta RD, Mullineaux DR, et al: Twe-
week jeint mebilisatien interventien impreves self-
reperted functien, range ef metien, and dynamic balance
in these with chrenic ankle instability. J Urrbep Res
2fl12:3fl{11}:1?f-'B-1304.Medline DUI
Urthepeedic Knewledge Update: Sperrs Medicine 5
 Sectiun 4: Rehabilitatiuu
This study feund pesterier talar mebilizatiens were asseci-
ated with impruved measures ef functien fur at least 1
week in individuals with chrenic ankle instability. Level
uf evidence: II.
39. Kerkheffs GM, Rewe EH, Assendelft W], Kelly ED,
Struijs PA, van Dijk (IN: Intntebilisatien fer acute ankle
sprain. A systematic review. Arch flatbep Trauma San-g
2fl01;111{3}:462-4?1.Medline DUI
4|]. Raymund J, Nichelsen LL, Hiller CE, Refshauge KM:
The effect ef ankle taping er bracing en prepriuceptiun
in functienal ankle instability: A systematic review and
meta-analysis. j Sci Med Spurs 2fl12:15{5 1:336-392.
Medline DUI
The authurs wanted te determine if wearing an ankle
::
.E
brace er taping the ankle, cempared with ac brace er
4.! tape, impreves prupriuceptive acuity in individuals with a
:
I'll
histury uf ankle sprain er functienal ankle instability. The
E tape fer impreving pestural centrel deficits in these with
peeled evidence fuund that using an ankle brace ur ankle
I'fl
.: tape had ne effect en preprieceptive acuity in participants
Ill
ac with recurrent ankle sprain er whu have functienal ankle
1's:
instability.
4]. fiemeeh M, Nurasteb AA, Daneshmandi H, Asadi 11: Im-
mediate effects uf Mulligan’s fibular repesitiening taping
en pestural centrel in athletes with and witheut chrenic
ankle instability. Plays The:- Spert 1fl15:16{2}:135-139.
Medline DUI
This study feu ad that fibular repusitiuning taping signifi-
cantly impreved pestural centrel in athletes with chrenic
ankle instability. Lavel ef evidence: III.
41. 1ilii'heeler T], Basnett CR, Hanish M], et a1: Fibular tap—
ing dees net influence ankle dersifleitien range ef Ine-
tien er balance measures in individuals with chrenic
ankle instability. } Sci. Med Spent lfl]3;16{fi}:433-491.
Medline BID]
The anthers did net find a significant change in ankle
dursiflestien range ef mutiun er dynamic balance when
firthepaedic Knewledge Update: fiperts Medicine 5
cemparing fibular taping te sham taping in patients with
chrenic ankle instability. Level ef evidence: III.
43. Simen J, Garcia W, Decherry EL: The effect ef kinesiu tape
en furce sense in peuple with fu nctiunal ankle instability.
Gift: I Spur-t Med 2fl14;24{4]:239-294. Medline DUI
This study neted that in patients with functienal ankle
instability, prupriuceptive deficits were net impreved im-
mediately after applicatieu uf kinesiu tape, bewever, but
did impruve after wearing the tape fur T2 huurs. Level
ef evidence: III.
44. Shields CA, Needle All, Rese WC, fiwanik CE, Ka-
minski TW: Effect ef elastic taping en pestural centrel
deficits in subiects with healthy ankles, cepers, and indi-
viduals with functienal ankle instability. Puut Ankle Int
1013:34ilfl}:142?-1435.Medline net
The results uf this study did net suppurt the use ef kinesiu
ankle instability. Level uf evidence: III.
45. van Rijn RM, van Heest 1a, van der Wees P, Kees 3W,
Bierma-Zeinstra SM: fieme benefit frem physiutherapy
interventien in the subgreup ef patients with severe an—
kle sprain as determined by the ankle functien scere: A
tandumised trial. dust] Pbysfutfser 2i] fl9;55(1]:IUT-113.
Medline DUI
The anthers feund fu nctiunal imprevement in individuals
with a severe ankle sprain whu underwent physical therapy
interventien and ceuveutienal medical treatment cum-
pared with these whu underwent ceuventieual medical
treatment alene. Level ef evidence: I.
46. Webster Kilt, Gribble PA: Functiunal rehabilitatien inter-
ventiens fer chrenic ankle instability: Pi systematic review.
I Spent Rehahif lfllfl:19{1}:98-114. Medline
This systematic review cuncluded that functienal exercises
and activities prumete imprevement in dynamic pestural
centrel fer these with chrenic ankle instability. Level ef
evidence: II.
fl lflld American Academy ef Cirrhepaedic Surge-ens
Chapter 29
Core Stabilization
Rafael F. Escamilla, PhD, PT, CSCS, FACSM
Muscle recruitment patterns of lumbopelvic-hip mus-
culature, which is commonly referred to as the core,
and loading of the lumbar spine during core exercises
common used during core strengthening programs
are described in the literature. The orthopaedic sur—
geon should be knowledgeable about why the core is
important, what muscles comprise the core and which
ones contribute the most to core stability, the benefits
and risks of core stabilization exercises, biomechanical
differences berween abdominal bellowing {drawing-in
maneuver} and abdominal bracing techniques, tradition-
a] and nontraditional exercises used for core stability,
biomechanica] differences between abdominal exercises
that cause active hip or trunk flexion or control hip or
trunk extension, biomochanical differences between the
crunch and the bent—knee sit-up, and abdominal and
oblique recruitment between the crunch and reverse
crunch.
Keywords: stability: abdominal hollowing;
abdominal bracing; electromyography; EMG; low
back pain
Introduction
It is important for the orthopaedic surgeon to understand
muscle recruitment patterns of lumbopelvic-hip muscula—
ture {commonly referred to as the core} and loading of the
lumbar spine during core exercises commonly used during
core strengthening programs. In addition, the importance
of the core, which core muscles are most important for
core stability, the benefits and risks of traditional and
nontraditional core stabilisation exercises, lumbar spinal
Neither Dr. Escamiiia nor any immediate famiiy member
has received anything of value from or has stock or stock
options heid in a commerciai company orinstitution reiateo'
directiy or indirectiy to the subject of this chapter.
fl lflld American Academy of Drthopaedic Surgeons
loading and injury risk during exercises commonly used to
enhance core stability, and biomechanical differences be-
tween abdominal hollowing and bracing exercises, trunk
flex ion and extension exercises, and crunch and bent-knee
uvsvuusvuva :1:-
sit-up exercises are important concepts to therapists and
other health care or fimess specialists who develop specific
core exercises for rehabilitation or training.
Why is the Core Important?
In functional and athletic events, the core provides prox-
imal stability for distal mobility.' Trunk musculature
helps sta bilise the core by compressing and stiffening the
spine, which is important because the osteoligamentous
lumbar spine buckles under compressive loads of only
9t} N {approximately 20 lb}.I Core muscles act as guy
wires around the human spine to prevent spinal buckling.
In addition, intra-abdominal pressure increases as core
muscles contractfi1 which further increases spinal stiffness
and enhances core stability.‘ll
Core Muscles and Stability
Considerable debate exists regarding which core muscles
are the most important in optimizing core stability {spinal
stabilization]. Some studies suggest that the transversus
abdominis and multifidi muscles are key to enhancing spi-
nal stability,-"~5 but others have questioned the importance
of these muscles as major spine stabilizerssid Therefore,
the effectiveness of the tra nsversus abdominis and multi-
fidi on lumbar stability is not clear. Isolated contractions
from the transversus abdominis have not been demon-
strated during functional higher demand activities that
require all abdominal muscles to become active.“
In healthy individuals without lumbar pathology, the
transversus abdominis contracts before upper extremity
motion irrespective of the direction of the motion.” How-
ever, a 2012 study reported that transversus abdominis
activation is direction-specific and that symmetric, bi-
lateral preactivation of the transversus abdominis does
not normally occur in healthy individuals without lum-
bar pathology during rapid, unilateral arm movements}
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation
This is important because bilaterally, preactivation of the
transversus abdominis theoretically provides lumbar spine
stability in anticipation of perturbations of posture? In
contrast, tta nsversus abdominis activation is substantially
delayed in patients with low back pain with all move-
ments, indicating a motor control deficit that can result in
inefficient muscular stabilization of the spine. However,
select low-intensity exercises such as abdominal hollowing
{drawing in} have been shown to preferentially activate
the transversus abdominis in patients with chronic low
back pain during exercise."J Moreover, evidence exists
that the deep abdominal muscles {transversus abdominis
and internal oblique muscles} can be preferentially trained
i:
in individuals with chronic low back pain using targeted
.E
4.! exercises such as abdominal hollowing."
To optimize core stabilization, numerous muscles, in-
I'll
:I:
E
I'fl cluding smaller, deeper core muscles {such as the trans—
.i:
fill
a: versospinales, transversus abdominis, internal oblique,
1's: and quadratus lumboruml and larger superficial core
muscles (such as the erector spinae, external oblique, and
rectus abdominis}, must be activated in sequence, with
appropriate timing and tension} A 2002 study reported
that no single core muscle can be identified as the most
important for lumbar spine stability, that the relative
contribution of each core muscle to lumbar spine stability
depends on trunk loading direction {spinal instability was
greatest during trunk flexion} and magnitude, and that
no single muscle contributed more than 30% to overall
spine stability.“1 Therefore, lumbar sta biliaation exercises
may be most effective when they involve the entire spinal
musculature and its motor control under various loading
conditions of the spine.”
Benefits and Risks of Core Stabilization Exercises
Core strengthening of the lumbopelvic region can de-
crease the risk of injury to the thoracolumbar spine by en—
hancing spinal stability” and has been shown to decrease
the risk of injury to lower extremities and to enhance
performance;“‘ however, no strong relationship exists
between core stability and performance and the results
are inconclusive”:If Appropriate spinal loading enhances
spinal stability, whereas excessive spinal loading can in-
crease the risk of injury to the lumbar spine.” Therefore,
adequate spinal loading is required to maximise core
stability; excessive loading can cause injury to the lum—
bar spine. For example, lifting extremely heavy weights
during the deadlift exercise has resulted in estimated lum—
bar compression forces between 13,1300 to 36,l}fli} NEW
These extremely high lumbar compression forces, which
result from both the heavy external load being lifted and
the high muscle forces that are generated during heavy
firthupaedic Knowledge Update: Sports Medicine 5
lifting, can result in injury to the lumbar spine."-“
The literature is scarce regarding the effectiveness of
lumbar stabilization exercises on lumbar pathology, and
more research is needed.” Although lumbar stabilisation
exercise programs have been effective in treating individ-
uals with chronic low back pain,m these programs have
not conclusively demonstrated that lumbar stabilisation
programs are more effective in treating individuals with
chronic low back pain compared with a generalized,
less-specific exercise program.”r
Biomechanical Differences Between Abdominal
Hollowinq and Bracing
Abdominal hollowing is often performed supine with
the hips flexed 45° and the lcnees flexed 9i)“ {hook lying
position]; individuals are instructed to take a deep breath
and exhale while pulling their navels up and in toward the
Spine}1 In abdominal bracing, individuals are instructed
to globally activate all abdominal and low baclc muscles
by teasing all core musculature, without drawing in or
pushing out the abdominal cavityfi“
Abdominal hollowing is effective in the preferential
recruitment of the deeper abdominal {transversus ab-
dominis and internal oblique muscles} and lumbar [mul-
tifidi} musclesf‘bbifI A lflflfi study“ demonstrated that
the transversus abdominis and internal oblique contract
bilaterally to form a musculofascial corset that appears
to tighten during abdominal hollowing, enhancing lum~
bar spine stability and decreasing the risk of injury to
the lumbar spine. Transversus abdominis and internal
oblique activity is thought to enhance lumbar stability by
increasing intra-abdominal pressure3 and placing tension
on the thoracolumbar fascia, but the multifidi provides
additional spinal stability by directly controlling lumbar
intersegmental movement.f~“ Moreover, contraction of
the transversus abdominis has been shown to substan—
tially decrease sacroiliac joint laxity to a greater extent
in abdominal hollowing compared with abdominal brac-
ingri-5 These data provide some evidence that abdominal
hollowing can enhance spinal stability and be beneficial
for individuals with select lumbar pathologies.
Using biomechanical models, abdominal hollowing
has been compared with abdominal bracing with respect
to spinal stability and muscle activityFrfL” A 2i] 0? study
reported that abdominal hollowing was not as effective as
abdominal bracing for increasing lumbar spine stability,
reporting that abdominal bracing improved lumbar spine
stability by 32% with only a 15% increase in lumbar
spine compression [higher benefit of lumbar stability with
decreased risk of lumbar injury}.H Moreover, the trans—
versus abdominis alone had little effect on lumbar spine
fl lflld American Academy of Orthopaedic Surgeons

stability. However, when the effects of internal oblique
and intra-abdominal pressure are combined with the ef-
fects of the transversus abdominis, core stability improved
as more core muscles were activated, which occurs during
abdominal bracing.
The authors of a 20D? study investigated the effec—
tiveness of abdominal bollowing and bracing techniques
in controlling spinal mobility and stability against rapid
perturbations and reported that abdominal bracing per—
formed better.” During rapid perturbations, abdominal
bracing actively stabilised the spine and reduced lumbar
spine displacement, whereas abdominal bollowing was
not effective in spinal stabilization. Using these data, it
can be inferred that abdominal bracing is more effec—
tive during functional activities such as lifting, iumping,
pushing, and pressing activities in sports or activities of
daily living. However, core muscle co-contraction during
abdominal bracing substantially increases lumbar com-
pression loads compared with abdominal bollowing,
which can be problematic in those with lumbar pain
and pathology. External oblique and rectus abdominis
activity was substantiallyr greater in abdominal brac-
ing than abdominal bollowing. Moreover, abdominal
bollowing demonstrated a higher spinal compression
loading—to—spine stability {cost-benefit] ratio, which im-
plies that bollowing resulted in higher spinal compression
loads {increased injury risk] with less spinal stability.
During abdominal bollowing, individuals were not able
to activate the deep abdominal muscles in isolation, but
always included substantial activity from both the exter-
nal and internal oblique muscles.”1
The effect of abdominal stabilisation contractions
during abdominal bollowing and bracing on posteroan-
terior spinal stiffness was investigated in a 20GB study;
it was reported that stiffness was substantially greater in
abdominal bracing:115 More work is needed to assess the
long—term effects of abdominal bollowing and bracing on
posteroanterior spinal stiffness in individuals with lumbar
pain and pathologies.
Abdominal hollowing or bracing techniques have been
performed immediately before core-strengthening exer-
cisesFL‘i-‘fl Compared with the curl-up {crunch} without
abdominal bollowing or bracing, the curl-up with abdom-
inal bollowing or bracing resulted in the deep abdominal
muscles {the transversus abdominis and internal oblique}
being recruited earlier than the superficial abdominal
muscles {the rectus abdominis and external oblique}.13
Using ultrasonography, deep abdominal recruitment
patterns were examined during numerous abdominal
exercises (crunch, sit-hack, leg lowering, side plank} and
low back exercises [quadruped opposite arm—and—leg
lift} performed immediately after abdominal bollowing.“
IE! lfllfi American Academy of flrrhopaedic Surgeons
Chapter 15': Core Stabilization
The highest recruitment of the transversus abdominis and
internal oblique muscles occurred during the side plank.
High activity from several important core muscles {the
quadratus lumborum, internal oblique, external oblique}
was reported during the side plank {resulting in enhanced
spinal stability} with moderate spinal compressive load-
ing?” A EGGS study reported high recruitment of the
transversus abdominis and internal oblique muscles and
low compressive spinal loading during the crunch per-
formed after abdominal bollowing,1| which is similar to
the results of a 199? study.” Performing the quadruped
opposite arm—and—leg lift after abdominal bollowing
preferentially recruited the transversus abdominis muscle
with minimal recruitment of the internal oblique muscle,
usssauqeuas :1:-
which provides evidence for its use in the early phases
of motor control exercise programs that emphasize the
firing of the transversus abdominis without concomitant
high recruitment from other abdominal muscles.“ Per-
forming abdominal bollowing before abdominal exercises
is beneficial to improving core muscle recruitment and
spinal stability.
The effects of prone hip extension exercises on hip and
back muscle activity and anterior pelvic tilt performed
with and without abdominal bollowing were investigat-
ed.1T Hip extension performed with abdominal bollowing
resulted in significantly less erector spinae activity l1?%
i 11% versus 49 i 14% maximum voluntary isometric
contraction [MVICD and significantly greater activity
in the gluteus maximus {52% = 15% versus 24% s: 3%
MVIC} and medial hamstring (53% i 10% versus 4'?%
e 14% MVIC} muscles. Moreover, anterior pelvic tilt was
significantly greater without abdominal bollowing {lfl‘ :l:
1“) than with bollowing [3" 2 1"}. Performing abdominal
bollowing with hip extension can be an effective strategy
when the goal is to minimize anterior pelvic tilt, lumbar
motion, and erector spinae activity, and to maximise hip
extensor activity.
Traditional and Nontraditional Exercises for |IEore
stability
Traditional and nontraditional exercises [Figures '1
through E] are used to enhance core stability. Although
these exercises are primarily used to strengthen the ab-
dominal musculature, they also recruit additional core
muscles such as the latissimus dorsi and lumbar paraspi-
ual muscles.
The abdominal musculature helps stabilise the trunk
and unload the lumbar spine,” and is commonly activated
by concentric muscle action during trunk flexion such
as during the bent—knee sit-up {Figure 2, A} or crunch
{Figure 2, B}. During the crunch, the hips remain at a
Drtbopaedie Knowledge Update: Sports .lvlediebie 5
 Section. 4: Rehabilitation

{EMGJ to report core muscle activity during these and

similar exercisesfg'31 Cine study examined core muscle
activity among the crunch, bent-knee sit—up, prone plank
on toes, and side plank on toes” {Table 1}. Several impor-
tant differences were found: {1) upper rectus abdominis
activity was greater in the crunch than in both the prone
and side planks on toes, and greater in the bent-knee
sit-up than in the side plan]: on toes; {1} lower rectus ab-
dominis activity was less in the side plank on toes than in
the remaining three exercises; [3} external oblique activity
was greater in the side plank on toes than in the other
three exercises; {4} latissimus dorsi activity was greater in
the prone plank on toes than in the crunch and bent-knee
sit—up; {5} lurnbar paraspinal activity was greater in the
side plank on toes than in the other three exercises; and {6}
4: Rehabilitation

rest us femoris activity was greater in the bent-knee sit-up

than in the side plank on toes and crunch, and greater in
the prone plank on toes than in the crunch.
During the prone and side planks on toes, similar ac-
tivity in the rectus abdominis and external oblique has
been reported, along with moderate to high activity in the
longissimus thoracis, lumbar multifidi, gluteus medius,
and gluteus maximus during the side plank on toes. 3'1 In
addition, the internal oblique and quadratus lumborum
. .

"I
I ll

I II
'_.
have demonstrated moderate to high activity during the
.' :
.
r
,
I
_. -t'
side plank on toes.31 Therefore, the side plank on toes
-
effectively recruits core muscles that are important for
‘ :’ I . " I.
. J - '
I' . . . II I ' _
V. I I f}
- I. .I .

core stability. However, the lumbar compression force is

II. _ I

. - -.'.
.‘I‘ -'I:..,

relatively high in the side plank on toes,33 which can be

n

' ' "" _';sI--; . -.-

. I _l_'

problematic for individuals with lumbar pathologies. The

. _I .
. .- I

Figure 1 Photographs depict the Terse Track lTerse Traclt prone plank on toes and crunch produce similar amounts
Inc-) {A}. Ab Slide [Skyway lntertrade} {B}. Super
Abdominal Machine {Wayne Connor, Super Ah of activity in the rectus abdominis, internal oblique, and
Machine} {E}. and Ab Heller (Tristar Precincts. external oblique muscles, but the prone plank on toes was
Inc-) {It}. (Reproduced with permission from
Escamilla HF, McTaggart M5, Fricltlas EJ, et al:
more effective than the crunch in recruiting the latissimus
An electremyegra phic analysis of co mmercial dorsi and rectus femoris muscles.
and common abdominal exercises: Implications Abdominal musculature is activated in a different man-
for rehabilitation and training. .f Drift-op Sports
Phys Ther zones 5121:4551} ner during nontraditional core exercises than with the
traditional crunch and bent-knee sit-up. ICine example is
the reverse crunch {performing the traditional crunch in
constant angle and the pelvis does not rotate; during reverse}, which involves flexing the trunk by posteriorly
the bent-knee sit-up, the hips flex and the pelvis rotates rotating the pelvis {Figure 4}. Nontraditional core exercis-
anteriorly. Although the bent-knee sit-up has been effec- es can also involve controlling trunk extension {against an
tive in activating the rectus abdominis and internal and external force such as gravity} using isometric or eccentric
external oblique musculature, the crunch has been rec- muscle contractions, such as when performing the Swiss
ommended instead of the bentvknee situun'J‘ Although ball decline push ~up {Figure 5, D} while keeping a neutral
the abdominal musculature is activated similarly between pelvis and spine.
the crunch and bent-knee sit-up, the relatively high hip The Swiss Ball [Figure 5} or commercial devices or
flexor activity that occurs during the bent—knee sit—up can machines {Figures 1 and I5} can also be used during non-
increase lumbar spine stress.15‘*-1“"3'1 traditional core exercises. Some devices or machines allow
flther traditional abdominal exercises include the prone only uniplanar motion such as trunk flexion; others allow
plank on toes [Figure 3, A} and side plank on toes {Fig— multiplanar motions such as trunk flexion and rotation
ure 3, B}, and several studies have used electromyography or trunk extension and rotation.f9'31~~“ Adding rotational

firthepaedic Knowledge Update: Sports Medicbte 5 fl lflld American Academy of Orthopaedic Surgeons

Photographs depict bent-knee sit-up (A) and the crunch {E}. {Reproduced with permission from Escamilla HF,
McTaggart M5, Fricltlas EJ, et al: An electro myog raphic analysis of com mercial and co mm on abdominal exercises:
Implications for rehabilitation and training. if Drthop Sports Phys Tiber Eflflfi;35[2]:45-5?.}
a ' - éfig '. ,r
if
Figure 3 Photographs depicts the prone plank {A} and
side planlt [B] planlt.
components to trunk flexion can be advantageous in inter—
nal or external oblique recruitment. The crunch combined
with the Ab Roller with rotation results in simultaneous
trunk flexion and rotation. Performing these exercises
with left rotation {the oblique crunch and Ab Roller
oblique] results in greater right external oblique activity
compared with performing the crunch and ab roller with
trunk flexion with no rotation {normal crunch and Ab
Roller crunch] 3" {Table 2}. EMG data on performing
nontraditional abdominal exercises with or without ab"
dominal devices are limitedfii'i‘di'” Core muscle activity
has been quantified while performing abdominal exercises
using commercial machines or devices, such as the Torso
Track {Torso Track Inc}, Power Wheel {Jon H. Hindes,
Lifeline USA}, hanging strap, Super Abdominal Machine,
Ab Revolutioniaer, Ab Slide (Skyway Intertrade}, Ab
IE! lfllfi American Academy of flrthopaeclic Surgeons
Chapter 15": Core Stabilization
uvnvanavuas :1:-
Deer, Ab Shaper, Ab-Flex, Ab-Roller (Tristar Products},
Ab Rocker, Ab 1Fv'ice, and Ab Twister.19'“=34'39 Several ab-
dominal devices do not appear to offer any advantage in
recruiting abdominal musculature compared with the
crunch, reverse crunch, and bent—knee sit—up.11“ Howev-
er, one advantage of the Ab Revolutioniaer is that external
weight can be added, thereby varying exercise intensity.
The reverse crunch flat and Ab Revolutioniaer reverse
crunch are almost identical, only differing in that the for-
mer was performed without using an abdominal device.
In addition, the crunch and Ab Roller, which are also
almost identical, produced similar amounts of abdominal
activity (Table 2}. fine advantage of the Ab Roller is that
the head is supported (Figure 1, D], which may be more
comfortable; therefore, many individuals may prefer it
over the crunch. Exercises performed with abdominal
devices reportedly do not appear to offer any advantage
in recruiting abdominal musculature compared with per-
forming similar exercises without devices.“
Some commercial devices exhibited substantially less
abdominal muscle activity than the traditional crunch,
reverse crunch, and bent—knee sit—up, and substantially
less abdominal activity compared with other commer-
cial abdominal devices studied.31 Moreover, the devices
tend to generate relatively high rectus femoris or lumbar
paraspinal activity, which may be contraindicated in in-
dividuals with lumbar spine pathologies.
Core muscle activity was quantified in 27" traditional
and nontraditional core exercises with and without var-
ious commercial abdominal devices and machines.21ml
Twelve of the exercises are illustrated in Figures 1, 2, 4,
and 6}; ElviG data are shown in Tables 2 and 3. Among
these exercises, upper rectus abdominis activity was high-
est for the Power Wheel roll-out, hanging knee-up with
straps, reverse crunch inclined 3-3”, Ab Slide, Torso Track,
crunch, and Ab Roller; and lowest for the Ab Revolu~
tioniner, reverse crunch, Ab Twister, Ab Rocker, and Ab
Drtbopoedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation

-—
Prone and Side Plank Exercises Compared With Traditional Abdominal |Brunch and Sit-Up Exercises
Exercise Upper Lower Internal External Latissimus Lumbar Rectus
Hectus Hectus oblique Oblique Dorsi Paraspinal Femoris
Abdominis Abdominis
Prone plank 34 :|:15t 4G :10 29 :e 12 4D :I: 21" 113 :e 12 5 :I: 2” 20 :l: 2
on toes
Side plank 25 :I: 15"El 21 :I: 33'“ 23 :I: 12 62 :I: 3? 12 :I: 1D 25 3:15 14 :I: 4"
on toes
lI'lrunch 53 :I: 13 33 :l: 15 33 :I: 13 23 t1?“ 8 :I: 3' 5 :I: 2" E :I: 45"
Bent-knee 4D :I: 13 35 :I: 14 31 :I: 11 36 :I: 14'” E :I: 3" E :I: 2" 23 :I: 12
sit-up
c
.E Average electromyographic {EMGI [:I: 513} activity for each muscle and exercise expressed as a percentage of each muscle's maximum isometric
4.!
I'll volu ntarv contraction. A slgniflca nt difference [P s: noon in Elvlfi activity among abdominal exercises was reported for all muscles.
:I:
E
Pairwise comparisons {P c 11.111]:
I'fl
.c
Ill
o: IISignifica ntly less EMG activity compared with the prone planlt on toes;
1's:
IISIgniiicantlar less EMG activity com pared with the side planl: on toes:

“Significantly less EMG activity compared wlth the crunch:

“Significantly less EMG activity compared with the bent-knee sit-up.

Data from Escamilla llF. Lewis C. Bell D. et al: lCore muscle activation during Swiss hall and traditional abdominal exercises. .i Cirthop Sports
Phys Ther 2D10:4Dl5]:255-21'E. lvledline http:iidx.dol.orgi1fl.2519i]oapt.2fl1fl.3il?3; and Escamilla HF. Lewis E. Pecson A. Imamura fl. Andrews lfl.
Electromyographic comparison among supine. prone and side position exercises with and without a Swiss Ball. Sports Health J; in press.

J"

Figure 4 Photographs depict the hanging knee-ups with straps {A}. reverse crunch ilat (Bi. and reverse crunch incline
3D“ {C}. [He prod uced with permission from Escamilla RF, Eahh E, DeWitt it, at al: Electro mvog raphic analysis
of traditional and nontraditional abdominal exercises: Implications for rehabilitation and training. Phys Ther
2flflE:EE[5]:I555-5?1.}

Doer. Lower rectus ahdominis activity was highest for highest for the Power Wheel pike, Power Wheel knee-up,
the Power 1Fl'ii’l‘reel roll-out, hanging knee-up with straps, hanging knee-up with straps, Ah Slide, and bent-knee sit-
Ah Slide, and Torso Track, and lowest for the rib Twister, up; and lowest for the crunch, Ah Roller, and Ah Doer.
Ah Rocker, and Ah Doer. External oblique activity was Internal oblique activity,F was highest for the Power Wheel

@ firthopaedic Knowledge Update: Sports lvledich'ie 5 fl lfllo American Academy of Orthopaedic Surgeons

Figure 5 Phetegraphs depict the Swiss Ball {SwisshalL Therat’iear} pike {A}, knee—up in}. reII-eut {C}, and decline push-up
{D}. {Repreduced with permissien frem Estamilla RF, Lewis E, Bell U, et al: [ere muscle activatien during Swiss ball
and traditienal ahde minal exercises. J Drthep Sperts Phys Ther 2e1e;aa[s]:2ss-2vs.}
rell-eut, Pewer Wheel pike, Pewer Wheel knee—up, hang—
ing knee-up with straps, reverse crunch inclined 30“, Ah
Slide, Terse Track, bent—knee sit-up, and crunch; and
lewest fer the Ab Heller, Ab Twister, Ab Recker, and
Al:- Deer. Altheugh the traditienal crunch and bent-knee
sit—up are effective in recruiting abdeminal musculature,
abdeminal recruitment was higher in the Fewer Wheel
reil-eut, Pewer Wheel pike, Pewer Wheel knee-up, hang-
ing knee—up with straps, reverse crunch inclined SCI", fab
Slide, and Terse Track.
i'vIang.r exercises perfermetl with cernrnercial abderninal
devices er machines can alse be perfermed using a Swiss
ball, and many studies have quantified cere muscle ac-
tiVit‘j-F during varieus Swiss Ball exercises.”~”-"‘”"9 A 2010
stud}:r quantified cere muscle activitv {Table 4} between
several Swiss Ball exercises {Figure 5 i and the traditienal
crunch and bentuknee sit-supafll {Figure 2}. Rectus abdemu
inis activity was greatest in the Swiss ball rell~eut, Swiss
Ball pike, and crunch, whereas external and internal
eblique activitv was greatest in the Swiss Ball tell—eut,
Swiss Ball pike, and Swiss Bali knee-up. Latissimus dersi
activity.r was greatest in the Swiss Ball pike, Swiss Ball
knee—up, and Swiss Ball decline push-up, whereas rectus
femeris activity was greatest in the Swiss Ball pike, Swiss
IE! lfllfi American Academy ef flrthepaedic Surgeens
Chapter 15': Cere Stabilixafien
F.-
:I:
I'll
:r
w
E
E
ta
1".
U
:I
Bali knee-up, and bent-knee sit—up. Lumbar paraspinal
activityF was relativity law in all exercises. Altheugh rec-
tus abdeminis recruitment is similar ameng the crunch,
bent-knee sit-up, and Swiss Ball exercises, internal and
external ehliqee activities were general],r greater in Swiss
ball exercises than in the crunch and bent—knee sit-up.
Manv abdeminal exercises traditienallv perfermed
en a flat surface can alse be perferrned en a Swiss Ball,
such as the push—up, bench press, and crunch. Several
studies have reperted an increase in abdeminal muscle
activitsr when the push-up is perfermed en an unstable
surface {such as a Swiss Ball} cempared with a stable
surf'ace.““‘-5f"5l Abdeminal muscle activity.r is greater when
a bench press is perfertned en a Swiss hall cempared with
a flat stable surfacefildfl Dther studies have demenstrated
an increase in abdeminal muscle activityr when perferm-
ing the crunch en a Swiss Ball cempared with a flat sur-
face.“'4'5'*"’9 Bridging using an unstable surface (Swiss Ball
and EGSU ball} has alse demenstrated greater abdeniinal
activity.r cempared with bridging en a flat surface.“
Cine studv reperted that cempared with a nenlabile
surface. the use ef a labile surface Swiss Ball enhanced
lumbar multifidus activityr in individuals with chrenic Iew
back pain.” Hewever, anether studv reperted that the
Drthepaedic Knewledge Update: Sperts Medicine 5
 Section 4: Rehabilitation

Abdominal Exercises Performed With Machine Devices Compared

With Traditional Abdominal Crunch and Sit-Up Exercises
Exercise or Upper Lower Internal External Latissimus Lumbar Hectus
Machine Hectus Hectus Dhllque Dbllque Dorsl Parasplnal Femorls
Abdominis Abdominis Muscles
AbSlide 62:26 22:13 53:15 46:16 111:4 3:2 ':'.~:3El
Torso 62:25 22:12 56:14 32:13 111:5 2:2 13:5El
Track
Erunch 51:3 36:3m 41:3 16:11“ 5:1d 2:1 3:1id
{normal}
Crunch 50:15 33:14Elli 46:11 32:22 6:5 5:3 3:2“I
c
.E
4.!
(oblique)
I'll
: Bent-knee 33 :12“ 44: 13"“ 49:21 41 :16 6 : 3‘1 4:2 36 :16
E
I'fl sit-up
.:
Iii
a: Super 42 :1?“ 51} : 26““ 36 :13“ 31 : 21 12 : 6 4:2 2D :15
1's: Abdominal
Machine
Ab Heller 46 :1? 42 :12“ 33 : 3” 13 : 6" 5 : 2‘I 3:2 1 :1d
{crunchJ
Ab Heller 4‘3: 12 36: 164': 25: 11"“ 26:3 6:2‘I 3:2 2:2“
(oblique!
Average electromyographic {EMGI 1,: SD} activity for each Muscle and exercise expressed as a percentage of maximum isometric voluntary
contraction. A significant difference {P c 6.661} In EME activity among abdominal exercises was reported for all muscles.

Pairwise comparisons {P c 6.611:

IIISignifica ntly less EMG activity compared with the Ab Slide {straight and curved};

l’Slpnificantly less EMG activity compared with the Torso Tracit:

ESignificantly less EMG activity compared with the bent-knee sit-up:

iSignificantly less EMG activity compared with the Super Abdominal Machine.

Data from Escamllla HF, Mc'Taggart MS. Frlcltlas EJ, et alt An electromyographic analysis of commerdal and common abdominal exercises:
Implications for rehabilitation and training. J Orthop Sports Phys 11ter2DDE:3612]:45-5‘i. http:iidx.doi.orgi16.251Dijospt.2i166.36.2.45.

Swiss Ball may not provide a potential effect on erector
spiuae activity during Pilates isometric exercises with
similar posture when compared with stable surfaces.“
In addition to being effective in activating abdominal
musculature, the 12 exercises evaluated in this chapter
are also effective in activating the latissimus dorsifl‘i’"
[Tables 1 through 4), which tenses the thoracolnmbar
fascia when it contracts and helps stabilize the trunk.
Moreover, tension in thoracolnmbar fascia resulting from
contractions of the internal oblique (and presumably the
transversus abdominis} muscle can further enhance lum—
bar stability, and most of these exercises produce high
activity in the internal oblique muscle. However, except
for the Power Wheel roll-out, Swiss Ball roll—out, Ab
Slide, and Torso Track, these exercises also exhibited
significant rectus femoris activity {and to a lesser extent
lumbar paraspinal activity}, which can be problematic
for some individuals with low back pathologies because
of the tendency of the hip flexors and lumbar extensors
to accentuate lumbar lordosis, lumbar compression, and
intradiscal pressured” Therefore, the Power Wheel ro1l~
out, Swiss Ball roll-out, Ab Slide, and Torso Track may
be the most effective methods of recruiting abdominal
and latissimus dorsi musculature while minimizing rectus
femoris and lumbar paraspinal activity. During these roll-
out exercises, the latissimus dorsi contract eccentrically
during the initial roll-out phase to control the rate of
shoulder flexion, and concentrically in the return phase
as the shoulders extend. Moreover, although it is logical
to assume that the rectus femoris contracts eccentrically

firthopaedic Knowledge Update: Sports Medicine 5 fl 21316 American Academy of Orthopaedic Surgeons
 Ehapter 15': Core Stabilisation

—_
Power Wheel and Reverse Crunch Exercises Compared With
Traditional Abdominal Crunch and Sit-Up Exercises
Exercise or Upper Lower Internal External Latissimus Lumbar Rectus
Machine flectus Flectus flbllque Dbllque Dorsi Paraspinal Femorls
Abdominis Abdominis Muscles
Power Wheel 15 :I: 26 31 :I: 29 56 :I: 25 54 :I: .2?" 15 :I: W“ 5 :I: 23“” E :I: 4%“
roll-out
Power Wheel 41 :|:11""i"gr 53 :I: 16"” 33 :I: 31 36 :I: 32 2? a: 16 3 :I: 3 26 :I: 11*
pilce
Power Wheel 41 :I: 13"“MEI 45 :I: 12““ 32 :I: 32 El} :1: 3D 25 :I: 12 3 :I: 4 43 1:13
knee-up
Hanging 69 e 21 1'5 3: 16 35 a: 40 1'9 a: 25 21:12 1' e 3 15 e 3“

usseaussuaa :s
lcnee-up with
straps
Reverse crunch 1'? :I: 2? 53 :I: 13*"II 36 :l: 3? 5!} :I: 19"mil 14 a: 3M 3 :t 4 22 :I: 12‘
inclined 30"
Reverse crunch 41 :I: 21.1“"Eli 31} :I: 1333““? 52 :I: 314""HIE 39 :I: 1633‘“ 23 :I: 14 6 e 3”“E 11 :I: 5'1““
flat
Crunch 56 :I: 1?" 43 :I: 13"” 43 a: 16W' 2? a: 16'3”“ 5 :I: 3'3““ 3:1”1'“ 3 :I: 3“"""""'
Bent-knee 39 a: 3““ 33 a: 11““ 49 a: 22W' So :I: 16Mil 6 a: 3m“ 6 a: 3"“ 22 :I: 12‘
sit-up
Average electromyographic lEMGl {:I: 5D] activity for each muscle and exercise expressed as a percentage of maximum isometric voluntary
contraction. A significant difference [P -c 6.13131] in EMG activity among abdominal exercises was reported for all Muscles.

Pairwise comparisons lPe H.111}:

'Signiticantly less EME activity compared with the Power Wheel roll-out;

”Significa ntly less EMG aclivity compared with the Power Wheel pilce;

‘Slgnlfica ntly less EMG activity compared with the Power Wheel knee-up;

dSignifica ntly less EMG activity compared with the hanging knee-up with straps;

'Significantly less EMG activity compared with fine reverse crunch inclined 3x11“;

*Slgnlticantly less ElylE activity compared with the reverse crunch flat;

"Significa ntly less EMG activity compared with the crunch;

“Significa ntly less EMG activity compared with the bent-It nee sit-up.

Data from Escamllla RF. Babb E. DeWitt It. at al: Electromyographic analysis of traditional and nontraditional abdominal exerdses: Implications
for rehabilitation and training. Phys Ther Iii-66:66l5]:656-61'1.

during the initial rollout phase {to control the rate of hip
extension] and concentrically during the return phase {to
cause hip flexion}, rectus femoris activity was low during
these four exercises. This may partially be explained by
the neutral pelvic and spine positions that are maintained
while performing these exercises. It has been reported that
abdominal activity»r tends to increase and rectus femoris
activity tends to decrease when the pelvis is maintained
in neutral or posteriorly tilted positions compared with
an anteriorly tilted position.55 Therefore, the latissimns
dorsi (and upper extremity.r muscles in general] may play
a greater role in both controlling and causing the roll-out
and rollback movements during these exercises than the
hip flexors.
Exercises that recruit the rectus femoris and lumbar
paraspinal muscles may be contraindicated for those with
weak abdominal muscles or lumbar instability. The forces
generated when the hip flexors and lumbar extensors con-
tract cause anterior pelvis rotation and increase the lor-
dotic curve of the lumbar spine, as well as increase L4-L5

ID 21116 American Academy of flrthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Section 4: Rehabilitation

Prone Position Swiss Ball Exercises Compared With Traditional

Supine Position Abdominal Crunch and Sit-Up Exercises
Exercise or Upper Hectus Lower Hectus Internal External Latissimus Lumbar Hectus
Machine Abdominis Abdominis |I‘Jibligue Oblique Dorsi Faraspinal Femorls
Swiss Ball 53 :I: 3G 53 :I: 23 46 :I: 21 45 :I: 13" 12 :I: 5"" 6 :I: 2 8 :I: 5""Ilr
rollout
Swiss Ball 4? 5:13 55 :I: iii 55 :I: 22 34 a 3? 25 a: 11 B :I: 3 24 e S
pike
SwissBall 32:15“ 35:14 41 3:15 54:39 22:13 63:3 23:13
Knee-up
Crunch 53 :I: 19 35 :I: 15 33 :I: 13" 23 :I: 1ir'"-E E :I: 3"-'=-f 5 :I: 2 E :I: 4"“
i: Bent-knee 4D :I: 13" 35 :I: 14 31 :I: 11" 35 114“ E :I: 3"-'=-f E :I: 2 23 :I: 12
.E
Sit-up
4.!
I'll
:I:
E
I'fl
Swiss ball 35 :I: 21]" 3? :I: 15 33 :15" 35 :I: 24"'E 13 :I: 12 6 :I: 2 11] :I: 15"“
.:
Ill
decline
o: pushup
1's:
Average electromyographic {EM-Si is: SD} activity for each muscle and exercise expressed as a percentage of each muscle's maximum isometric
voluntary contraction- A significant difference ii" -c [1-0111] in EMt'i activity among abdominal exercises was reported for all muscles.

Pairwise comparisons [F -c 11.131]:

ISignlflca ntly less EMG activity compared with the Swiss ball roll-out:

h5ii_yr-.iiicantl1_.l- less EMG activity compared with the Swiss ball pike:

"Significantly less EMG activity compared with the Swiss ball kneemp;

"Significantly less EMG activity com pared with the crunch:

IISigniiica ntiy less EMG activity compared with the bent-l: nee sit-up;

'Sign 'rfica nfly less EMG activity compared with the Swiss ball decline push-up.

Data from Escamllla HF, Lewis C, Bell D. et al: Core muscle activation during Swiss ball and traditional abdominal exercises. J Orthop Sports Phys
Ther 2illflt4fllS] :255-21'5. httpxidx.doi.orgi1D.2S1Si]ospt.2fl1il.3fl?3.

compression and intradiscal pressure," when coupled with
weak abdominal musculature, the risk of low back pathol-
ogies increases during these conditions.” Exercises such
as the bent-knee sit- up, Power Wheel pike, Power Wheel
knee-up, reverse crunch inclined 30“, and reverse crunch
flat, which have relatively high rectus femoris or lumbar
paraspinal activity compared with the crunch, Ab Roller,
Ab Slide, Torso Track, and Power Wheel roll-out, may
be contraindicated in individuals with weak abdominal
muscles or lumbar instabilityfiiii'd” Moreover, during ab-
dominal exercises, the EMG magnitude and recruitment
pattern of the psoas and iliacus is similar (within 113%] to
that of the rectus femoris,"5 which implies that the psoas,
iliacus, and rectus femoris may exhibit similar EMG re—
cruitment patterns and magnitudes when performing the
aforementioned abdominal exercises. The psoas muscle,
because of its attachments to the lumbar spine, attempts
to hyperextend the spine as it flexes the hip, and this
action may be detrimental to some individuals with lum-
bar instability. The psoas muscle can also generate lumbar
compression and anterior shear force at L5-51,13=-“' which
can be problematic for those with lumbar disk patholo-
gies. Although muscle force from the lumbar paraspinal
muscles can also increase lumbar spine compression, the
aforementioned abdominal exercises generated relatively
low muscle activity is 10% of MVIC] from the lumbar
paraspinal musclesli'ri‘ {Tables 1 and 2}.
Biomechanical Differences Between Abdominal
Exercises That Cause Active Hip or Trunk Flexion
and Control Hip or Trunk Extension
Some core exercises may be appropriate for some indi-
vid uals but not others. Some core exercises {for example,
the bent—knee sit—up} cause hip and trunk flexion; other
core exercises (for example, the Power Wheel roll-out or

firthopaedic Knowledge Update: Sports Medicine 5 fl 2fllti American Academy of Orthopaedic Surgeons
 Chapter 19': Core Stabilization

Swiss Ball roll-out} control hip and trunk extension. Core

exercises that actively flex the trunk can be problematic
for some individuals with lumbar disk pathologies be—
cause of increased intradiscal pressure and lumbar spine
compression,3+” as well as individuals with osteoporosis
because of the risk of vertebral compression fractures.”
In these individuals, it may be more beneficial to maintain
a neutral pelvis and spine {such as when performing the
Power 1'Il'if'heel or Swiss Ball roll—out} rather than forceful
flexion of the lumbar spine {such as when performing the
bent-knee sit-up]. Lumbar stabilization exercises using a
Swiss Ball have been demonstrated as effective interven—
tional therapy to alleviate chronic low back pain and to
increase bone mineral density.“
£-
Some individuals with facet joint syndrome, spondy- a:
I'D
lolisthesis, and vertebral or intervertebral foramen ste- :r
m
nosis may nut tolerate exercises in which the trunk is E
5

maintained in extension, but may better tolerate trunk re

1".
U
flexion exercises such as the crunch. In these individuals, :I
trunk flexion exercises can decrease facet joint stress and
pain and increase vertebral or intervertebral foramina
openings, decreasing the risk of spinal cord impingement,
nerve root impingement, or facet joint syndrome.
Although rollout exercises (such as the Swiss Ball
roll-out] and reverse crunch—type exercises {such as the
hanging knee—up with straps) are effective in activating
abdominal musculature, the exercises are performed in a
different manner. Du ring rollout exercises, the abdominal
musculature contracts eccentrically or isometrically to
resist gravity and extend the trunk and rotate the pelvis.
During the return motion, the abdominal musculature
contracts concentrically or isometrically. If the pelvis
and spine are stabilized and maintained in a neutral po-
sition throughout the rollout and return movements, the
abdominal musculature primarily contracts isometricalr
1y. A relatively neutral pelvis and spine are maintained
while performing rollout exercises. In contrast, in reverse
crunch—type exercises {such as the hanging knee-up}, the lII -. - ' - 2' :__'I*'1_,,

abdominal musculature initially contracts concentrically s’ , J ,

as the hips flex, the pelvis rotates posteriorly, and the
lumbar spine flexes. As the knees are lowered and the hips
extend, the reverse movements occur, and the abdominal
musculature contracts eccentrically to control the rate of
return to the starting position.
The hanging kneebup with straps, Swiss Ball pike, Pow—
er 1Wheel pike, Swiss Ball knee~np, and Power Wheel
knee-up are all performed similarly by flexing the hips,
posteriorly rotating the pelvis, and flattenn the lumbar
spine, which is basically the reverse action of what occurs
during the bent-knee sit-up, which involves trunk flex-
ion followed by hip flexion {bent—knee sit—up only}.19'3'
Cine limitation to the hanging knee-up with straps is a
I _ jag:— / 'lé/ I“
Figure E Photographs depict the Power Wheel (.Iol'I
H. Hinds Lifeline USA) pilte {A}, ltnee- up {I},
and roll-out {l2}. {Reproduced with permission
from Escamilla HF, Babb E. DeWitt H, et al:
Electro myog raphic analysis of traditional
and nontraditional abdominal exercises:
Implications for rehabilitation and training.
Phys Ther IflflE;EE[5]:EEE-E?1.)
relatively high L4-L5 disk compression that occurs; how-
ever, compression has been shown to be slightly higher in
the bent—knee sit-up}3 Furthermore, EMG from the upper
and lower rectus abdominis and internal and external

IEI lfllfi American Academy of flrrhopaedic Surgeons Drthopaedic Knowledge Update: Sports Medichie 5
 Sectinn 4: Rehabilitatinn
nblique muscles are all substantially greater in the hang-
ing knee-up with straps cnmpared with the bent-knee
sit—up.” Therefnre, the hanging knee—up with straps may
be preferred nver the bent-knee sit-up fnr higher level
individuals whn want tn elicit a greater challenge tn the
ahdnminal musculature; hnwever, neither exercise may be
apprnpriate fnr snme individuals with lumbar pathnlngies
because nf relatively high L4-L5 cnmprcssinn.
11iii'hen the lumbar spine is fnrcefully flexed, which can
necur when using cnmmercial ahdnminal machines such
as the Ab Twister, Ab Rncker, and Ab Dner, the anterinr
fibers nf the intervertebral disk are cnmpressed and the
pnsterinr fibers are in tensinn. In additinn, in extreme
c
lumbar flexinn, intradiscal pressure can increase several
.E
4.! times abnve nnrmal frnm a resting supine pnsitinnd| Al-
thnugh the stresses en the disk may nnt be prnblematic
I'll
:
E
I'fl fnr the nnrmal healthy disk, they can be detrimental tn
.c
cu
n: the degenerative disk nr pathnlngic spine.
if
Binmechanical Differences Between the Crunch
and Bent-Knee- Sit-Up
hint all ahdnminal exercises invnlve the same degree nf
lumbar spine flexinn. Dne study demnnstrated that lum-
bar spine flexinu was nnly 3" during the crunch but ap-
prnximately 30" during the bent-knee sit-up.‘m In additinu,
the bent-knee sit-up has been shnwn tn generate greater
lumbar intradiscal pressure3 and cnmpressinn” cnmpared
with exercises similar tn the crunch, largely because nf
increased lumbar flexinn.” This finding implies that the
crunch may be safer than the bent-knee sit—up fnr snrne
individuals whn need minimize lumbar spinal flexinn nr
cnmpressive fnrces because nf lumbar pathnlngy.”
Althnugh the crunch and bent-knee sit—up are bnth
effective in recruiting ahdnminal musculature {Tables 2
thrnugh 4}, snme differences exist. Several studies have
shnwn that external nblique activity and, tn a lesser ex—
tent, internal nblicjue activity, are substantially greater in
the bent-knee sit-up cnmpared with the crunch.”+39'31~”
Hnwever, upper rectus abdnminis activity has been shnwn
tn be greater in the crunch than in the bent-knee sit-up.19'31
In additinn, rectus femnris and psnas activity have been
repnrted as greater in the bent—knee sit-up than in the
crunch.“'31r” Increased muscle activity frnm the rectus
femnris and psnas can exacerbate lnw back pain in snme
individuals with lnw back pathnlngies.
Abdnminal and Dblicjue Recruitment Between the
Crunch and Reverse Crunch
Perfnrmiug the reverse crunch flat activates the lnwer
abdnminals and external nblique tn a greater extent than
firthnpaedic Knnwledge Update: Spnrrs Ivledich'ie 5
the crunch.“ In cnntrast, several studies repnrted substan-
tially greater upper and lnwcr rectus abdnminis activities
in the crunch than in the reverse crunch flat, and external
and internal nblique activity was nnt substantially differ-
ent between the exercisesfii-JIJE These discrepancies may
be the result nf methndnlngic differences amnng studies.
In nne study, the reverse crunch flat was perfnrmed by
having subjects raise the lnwcr half cf the bndy eff the
table as far as pnssible; ‘5‘ in tvvn nther studies, the subjects
were instructed tn pnsterinrly tilt the pelvis and flex the
hips tn maximal extent.39*3‘ Hnwever, during the reverse
crunch inclined 3D", which invnlved a higher degree nf
difficulty cnmpared with bnth the crunch and reverse
crunch flat, activity in the upper rectus abdnminis, in‘
ternal nblique, and external nblicjue muscles was signifi-
cantly greater than in the crunch and reverse crunch flat,
but nn significant difference was repnrted in lnwer rectus
abdnminis activity between the reverse crunch inclined
3i)” and the crunch-19 {Table 1}. These data shnw that
the increasing difficulty nf the reverse crunch inclined
30” results in prnpnrtinnal increases in muscle activity.
Summary
Understanding hnw different exercises elicit cnre muscle
activity and lnad the lumbar spine is useful tn therapists
and nther health care nr fitness specialists whn develnp
specific cnre exercises fer the rehabilitatinn nr training
needs nf their patients nr clients. It is impnrtant tn be
knnwledgeable abnut the relevant literature regarding cnre
stability, cnre muscle activity during cnmmnn abdnmi-
nal exercises, and lumbar spinal lnading and injury risk
during exercises cnmmnnly used tn enhance cnre stability.
The cnre exercises discussed in this chapter activated ab‘
dnminal muscles and lnaded the lumbar spine in varinus
ways such as actively flexing the trunlr, cnntrnlling trunl-r
extensinn, flexing the hips with pnsterinr pelvis rntatinn,
nr a cnmbinatinn nf flexing the trunk and flexing the hips
with spinal and pelvis rntatinn. Several nnntraditinnal
ahdnminal exercises generated substantially greater rectus
abdnminis, internal nblique, and exten'lal nblique activity
cnmpared with traditinna] ahdnminal exercises such as the
crunch and bent-knee sit-up. Althnugh bnth the crunch
and bent-knee sit-up demnnstrated similar amnunts nf
ahdnminal activity, the crunch may be a safer exercise
fnr individuals with lnw baclc pathnlngies because nf rel~
atively high rectus femnris activity and lumbar intradiscal
pressure generated during the bent-knee sit—up. Rnll-nut
exercises {fnr example, ier Wheel rnll-nut, Swiss Ball
rnll-nut, Ab Slide, and asn Track} were shnwn tn be the
mnst effective exercises in activating rectus abdnminis,
internal nblique, external nblique, and latissimus dnrsi
fl lflld American Academy nf Urrhnpaedic Surge-nus

muscles while minimizing lumbar paraspinal and rectus
femeris muscle activity. The Pewer Wheel pike, Swiss Ball
pike, Pewer Wheel knee—up, Swiss Ball knee—up, hanging
knee-up with straps, and reverse crunch inclined 3i)" were
all shewu te be effective exercises in activating recrus ah-
deminis, internal eblique, external eblique, and latissimus
dersi muscles, but at a cest ef alse producing relatively
high rectus femeris er lumbar paraspinal activity [which
can be preblematic fer individuals with lumbar pathel—
egies}. Many exercises that generated high activity frem
multiple cere muscles, such as abdeminal bracing, alse
preduced the greatest cere stability as well as relatively
high lumbar cempressive leads {which can increase injury
risk tn the lumbar spine}. Exercises that activated enly a
few muscles, such as abdeminal hellewing, may net be
effective in producing the level ef cere stability needed
fer many functieual activities, such as lifting, running,
and jumping. Hewever, these types ef exercises may be
apprepriate early in a cere stabilizatien pregram, as well
as fer individuals whe cannet telerate high lumbar cem-
pressien leading. Many individuals, such as athletes whe
are training, use a wide array ef spurt-specific functien-
al exercises te develep cere muscles and enhance cere
stability. Hewever, research invelving the effectiveness
ef perferming higher level functieual exercises en cere
stability are needed, and this sheuld be the fecus ef future
research.
Key Study Peints
e An understand ef the impertancc ef the cere, the
muscles that cemprise the cere, and which mus-
cles centribute the mest te cere stability is imper—
tant te previde effective rehabilitatien er training
pregrams.
- Eiemechanical differences exist between abdeminal
hellewing {drawing-in maneuver] and abdeminal
bracing techniques.
* Biemcchanical difffleuces exist between abdeminal
exercises that cause active hip er trunk flexien er
centrel hip er trunk extensien.
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Sci Ree lflfl1;29{1}:16-31. Medline DUI
IE! lfllfi American Academy ef Urthepaedic Surgeens
Chapter 15': Cute Stabilisatieu
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stability ebtaiued at levels ef intrawabdeminal pressure
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Urthepaedic Knewledge Update: Sperts Medichie 5
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c
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.E
4.!
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I'll
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E
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fl sets American Academy ef Urthapaedic Serge-ens

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uvsvuuavuva :1:-
49. 1lilera-IIGarcia F], Grenier SG, McGill SM: Abdeminal mus-
cle respense during curl-ups en b-eth stable and labile
surfaces. Phys Ther lflflfl;3fl{6}:SS4-SSS. Medline
Si}. Calatayud ], Berreani S, lCelade JC, Martin F, Regers ME:
Muscle activity levels in upper—bedy push exercises with
different leads and stability cenditiens. Phys Spertsrned
2e14;4a{4}:1es-11a Medline D0]
The authurs cempared the muscle activatien levels during
push-up variatiens {such as suspended push-ups with.If
witheut visual input en different suspensien systems, and
push-ups en the fleer withfwitheut additiunal elastic re-
sistance} with the bench press exercise and the standing
cable press exercise beth perfermed at Sflh’n, Tfl‘ir’u, and
35% ef the ene-repetitien maximum. Level ef evidence: II.
51. Lehman G], MacMillan B, MacIntyre I, |[Shivers M,
Fluter M: Sheulder muscle EMG activity during push up
variatiens en and eff a Swiss ball. Dyn Med lflflfififl.
Medline DUI
SI. Marshall PW, Murphy BA: Increased delteid and ab—
deminal muscle activity during Swiss ball bench press.
] Strength Cend Res lflflS:2fl{4]:?45-?5fl. Medline
53. Nerweed JT, Andersen GS, Gaeta MB, Twist PW: Elec-
tremyegrapbic activity ef the trunk stabilizers during
stable and unstable bench press. I Strength Bend Res
lflfl?:ll{2}:343-34?. Medline
S4. Par {3, Maia M, Sautiage F, Lima V, Miranda H: Muscle
activity ef the erecter spinae during Pilates isemetric ex-
ercises en and eff Swiss Hall. I Sperts Med Phys Fitness
2e14;54{s}:sn—5se. Medline
The authurs investigated the muscle activity ef the erecter
spinae during Pilates isemetric exercises perfermed en and
eff a Swiss ball. Level ef evidence: I].
55. 1|ilii'erltman JC, Decherty I}, Parfrey KC, Eehm DG: Influ-
ence ef pelvis pesitien en the activatien ef abdeminal and
hip flexer muscles. ] Strength I{Send Res lflflSgfliS }:1 553-
1569. Medline DUI
Drtbepeedic Knewledge Update: Sperts Medicine S
 Sectinn 4: Rehabililltltinn
56. McGill S, Julter D. Krepf P: Apprnptiately placed surface
EMG electrncles reflect deep muscle activity {psuras, qua-
dratus lumbnrum, abdnminal wall} in the lumbar spine.
jflinmeci: 1996:29i11]:15fl3-1501Medline DDI
5?. Juker D, McGill S.I Krnpf P, Steffen T: Quantitative intra-
muscular myeelectric activity nf lumbar pe-rtic-ns nf pseas
and the ahdeminal wall during a wide variety nf taslts.
Med Sci Spurts Exet'c 1993;3fl{2}:3fl1-31ll Medline Dfll
SS. Sinalti M: Exercise fur patients with nstenpnrnsis: Man-
agement nf vertebral c-nmpressinn fractures and trunk
strengthening fur fall preventinn. PM E 2fl12;4{11,l:332-
383. Medline DUI
The anthers examined the effects ef exercise fer patients
with nstenpnrnsis and the management nf vertebral cum-
pressiun fractures and trunk strengthening fer fall pre-
4: Fiehabilitatiun
ventien. Leml nf evidence: II.
firthnpaedic Knewledge Update: Sperts Medichie 5
59. Tenn 15. Lee JH, Kim 15: The effect nf swiss ball sta-
biliaatinn exercise an pain and heme mineral density {if
patients with chrcvnic lnw back pain. J Phys Ther Sef
1013;25[3]:953—955.Mcdlinc D0]
The anthers examined the effects ef a 16—week lumbar
stabilisatinn exercise pregram using a Swiss ball targeting
patients with chrc-nic lnw back pain nn alleviating the pain
and increasing brine mineral density. Level of evidence: II.
ED. Halpern 151A, Bleclc EE: Sit-up exercises: An electrnmyn-
graphic study. [Hie Ortbnp Refer Res 19?9;145:i?1-1?3.
Medline
51. Willett GM, Hyde JE, Uhrlaub ME, Wendel CL, Karst
GM: Relative activity of abdominal muscles during cem-
mnnly prescribed strengdtening exercises. } Strength Grind
Res 1001;15{4}:43fl-435. Medline
fl lfllfi American Academy ef Cirrhnpaedic Surge-ens
 tio ’

Head and Spine

Chapter 30
Concussion
Siobhan Ivl. Statute... MD. CAQSM John M. . =
Ieremy L. Riehm, DC]
Abstract
Concussion is, undoubtedly, one of the most prevalent
topics within the sports medicine arena. New discoveries
are improving understanding of what exactly occurs on
the subcellular and cellular levels, and how they man-
ifest certain clinical Features displayed by the athlete.
Despite these advances in knowledge, each concussion
presents and plays out in a unique fashion that depends
on variables such as sport played, position of the athlete,
and age of the athlete. Several tests are available to
help diagnose concussion and track symptoms. Using
these data, medical providers can help guide the athlete
back into sports in a safe, stepwise pattern. |Concussion
complications such as postconcussive syndrome and
second—impact syndrome are real entities that could
have lasting effects and devastating results. Education
} and early identification of these conditions is crucial.
Keywords: concussions: sports-related concussion
Introduction
Concussion is currently one of the most frequently dis—
cussed topics in sports medicine. Concerted efforts have
been made on the national and local levels to improve edu-
cation regarding concussions in an attempt to better diag—
nose and manage this condition. Special attention is being
directed to improve understanding of what specifically
Di: Maclt’night or an immediate family member serves as
a board member. owner. offices or committee member
of the American College of Sports Medicine. None of the
following authors or any immediate family member has
received anything of value from or has stuck or stoclt options
held in a commercial company or institution related directly
or indirectly to the subject of this chapter: Di: Statute. Di:
Kent. and Dr. Riehm.
fl lflld American Academy of Drthopaedic Surgeons
occurs both acutely and over time within the brain, and
to answer some important questions: What transpires on
the cellular level? Can this cellular activity explain the
subsequent alterations observed in athlete behavior and
function? What are the long-term effects of concussion?
Concussions can result from simple falls, motor vehicle
accidents, assaults, or any similar motion causing sudden
acceleration or deceleration to the brain. The annual inci-
dence of recreational or sports-related concussion {SEC}
is estimated to be 3.3 million,“ although these values are
considered low because of underreporting.
Certain behaviors place an individual at increased risk
for sustaining a concussion. In athletic activities, certain
sports and athlete positions produce more concussion
events than others. Contact sports confer the greatest
risk, particularly American football, ice hockey, soccer,
'.-'."
boating, and rugby. Athletes with a previous history of I
SEC are at increased risk of sustaining another coucussive m
n.-
D.
event. The accumulation of concussion episodes, severity Eu
3
of the concussion, and growing symptom duration cor- CL
on
relate with prolonged recovery. Female athletes are more 'E.
5
rs
likely than male athletes to sustain SEC in similar sports.
Children and adolescent athletes appear to have a higher
risk of coucussive events, with prolonged recovery courses
or a subsequent catastrophic event.]
The term “concussion“ is derived from the Latin word
concutere, meaning “to shake violently ” and often is re-
ferred to as commotio cerebri in countries outside the
United States. No single, agreed-on definition for con-
cussion exists. Concussion can be categorized as a mild,
diffuse brain injury resulting in clinical symptoms but
not necessarily attributed to a pathologic injury. When a
coucussive head injury occurs, the brain sustains a con-
tusion. If the head is stationary and is struck by a moving
object, a coup injury ensues, resulting in a focal injury
of the brain under the site of skull impact. A contrecoup
injury—or bruise to the opposite side of the brain—likely
results when the moving head strikes an immobile object.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 5: Head and Spine
Although often used interchangeably with the term “mild
traumatic brain injury“ {mTBI}, concussion refers to a
specific, less severe subset of the traumatic brain injury
[TBIJI spectrum.1 Symptoms are generally limited, with
resolution within a few weelrs.L2
1"ili'hen the head is jolted, the biomechanical forces im—
parted to the brain trigger a complex neuronal patho-
physiologic cascade, resulting in changes to personality,
emotional and physical status, and rate and precision of
cognition. Each concussion is unique in its presentation,
yet according to the consensus statement released at the
4th International lL'Jonference on li'fjoncussion in .‘.'i1::~ort,2
the following generalities appear to hold true:
1. |Concussion may be caused by a direct blow to the
head, face, neck, or other part of the body, with an
impulsive force transmitted to the head.
2.. |Concussion typically results in the rapid onset of a
short-lived impairment of neurologic function that
resolves spontaneously. In some cases, symptoms and
signs may evolve over several minutes to hours.
3. |liloncussion may result in neuropathologic changes, but
these acute clinical symptoms largely reflect a function-
al disturbance rather than a structural injury; there—
fore, no abnormality is seen on standard structural
neuroimaging studies.
4. Concussion results in a graded set of clinical symptoms
that may or may not involve the loss of consciousness.
or
.E Resolution of the clinical and cognitive symptoms typ-
o.
m
'U
ically follows a sequential course. It is important to
r: note that symptoms may be prolonged in some cases.
as
1:5
n: The diagnosis can include a single impairment or more
a:
I in one or several clinical domains, including physical
Li-i
symptoms or signs, behavioral changes, cognitive impair-
ment, or sleep disturbances.
Pathophysiology
Questions have been raised rcga rding what occurs on the
microscopic level that effects such behavioral and emo-
tional changes. Studies reveal that, following a concussivc
force to the brain, neurologic changes result without mac-
roscopic neural damage.J As each individual concussion
differs, the threshold needed to sustain a clinical concus-
sion also differs among athletes. At the neural cellular
level, an alteration occurs to the mechanopotation of
the membranes, which triggers an abnormal exchange of
substances into and out of the neurons—the neurometa-
bolic cascade. The neurotransmitter glutamate is leaked,
followed by an ionic flux. Potassium exits the cells while
an influx of sodium and calcium occurs. This ion fluc-
tuation can result in a cellular depolarization, which in
turn affects the reactivity of voltage or ligand-gated ion
firthopaedic Knowledge Update: Sports Medicine 5
i
E
E
=
1E. .
3,, k, Calcum
1. "-"u I- I
4 5 E T-Il'}
clays
Cflfflbl'fll Bhfld FlIIEi'lIliIr
Diagram shows the acute cellular biologic
processes occurring after concussion or mild
traumatic brain injury. (Reproduced with
permission from Giza EC, Hovda DA: The new
metabolic cascade of concussion. Neurosurgery
2m 435911535.)
channels, resulting in a state of sluggishness {Figure l}.
The brain is left in a state of ionic disarray. Adenosine
triphosphate {ATM-dependent pumps go into action to
attempt to restore homeostasis. This process requires
energy obtained via hyperglycolysis, which rapidly leaves
the brain in a state of energy depletion and with a sur-
plus of adenosinc diphosphate {ADP}. Consequently, a
demand for an increase in energy reserves occurs at the
same time as a paradoxical drop in cerebral perfusion. An
energy crisis ensues because of this mismatch of supply
and demand?
This disarray continues on the mitochondrial level as
well as the cellular level. The cells receive an overwhelm-
ing influx of calcium. To manage this influx, mitochon-
dria attempt to sequester the excess, but doing so leads to
mitochondrial dysfunction. Mitochondria play a crucial
role in oxidative metabolism, responsible for the forma-
tion of ATP. If they are malfunctioning, the mitochondria
exacerbate the energy crisis by slowing down the recycling
of ATP. In addition to the mitochondrial malfunction,
shifts in subcellular metabolic pathways occur, resulting
in the production of damaging free radicals. This process
leaves the brain even more vulnerable to reinjury. After
the initial insult and neurometabolic cascade, glucose
metabolism rates slow paradoxically. This slowness can
last up to T to 10 days and has been observed to result in
behavioral and learning impairments in animal models}
The structure, or cytoskeleton, of the brain also can
be affected by these traumatic biomcchanical forces.
The delicate axons, dendrites, and astrocytic process-
es are thought to undergo a loss of structural integrity,
subsequently leading to an interference of normal neu—
rotransmission. [in a more severe level, axonal stretch is
fl lflld American Academy of Orthopaedic Surgeons
 |L'ihapter 3i]: l|i'..‘oncl.lssions

postulated to lead to atrophy and shrinkage of neurons

without necessarily resulting in cell death. The damaged
cell is likely incapable of normal function, as demon— Concussion Modifiers
strated in different animal models. Factors Modifier
Symptoms Number
Classification of Concussion Duration [31!] days)
T31 is a spectrum of pathology ranging from mild to Severity
severe, with SEC representing a subset of mild Tli'lI.4 Signs Prolonged LO: (:1 min}. amnesia
The Glasgow Coma Scale [GCSl helps assess the level of Seguelae Concussive convulsions
consciousness following head trauma using an objective Temporal factors Frequency — repeated concussions
scoring scale that is reliable and reproducible. GCS scores over time
for moderate head trauma range from 9 to 11; in severe Timing - injuries close together
trauma, scores drop to a range of 3 to 3. For concussions, in time
the (SSS is typically normal, and any alterations of con- Recenty - recent concussion or
scinusness or amnesia are relatively brief. Grading sysmms TBI
for concussions have been proposed in the past but are no Threshold Repeated concussions occurring
longer used because of their inability tn reliably predict with progressively less impact
severity or patient outcomes} force or slower recovery after
The most recent concussion management guidelines use each successive concussion
a more generalized scheme of predicting severity instead Age Child and adolescent {<13 years)
of grading scales1 {Table 1}. in this revised system, each Eomorhidities Migraine. depression or other
predictor is not necessarily cumulative. The provided list and mental health disorders. ADHD,
of symptoms is not all-inclusive, but can be used as a man- premorbidities LD, sleep disorders
agement tool on an individualized basis when attempting Meditation Psychoactive drugs,
anticnagulants
tn predict intractable symptoms. Loss of consciousness
{LDC} is no longer considered an important prognostica- Behavior Dangerous style of play
Sport High-risk activity. contact and '.-'."
tor of SEC. Most LGC events during concussions last only I
seconds and thus are not predictive of severity. Consensus collisinn sport. high athletic m
n.-
level D.
guidelines recommend considering LDC that lasts longer to
:l:
than 1 minute as a possible predictor of greater severity.2 LDC I loss of consciousn ess, min = minute, TBI = traumatic brain CL
on
injury, ADHD = attention deficit hyperacu'vity disorcl er, LD = learning 'E.
disahlllty 5
re
Evaluation and Assessment Tools Reproduced with permission from McErory F; Meeuwisse W, Aubry
M. et al‘: Consensus statement on concussion in sport—die iith
The evaluation for SEC ideally begins in the preseason international conference on concussion In sport held in Iurldi.
with the preparticipatinn physical examination. This November 2fl12. {fin Jinn-'15 Mecl' 2H1];23[2:I:BEI-i11

in—depth, detailed examination offers the provider time

tn uncnver any preexisting conditions that are potential
concussion modifiers as listed in Table 1. Additionally,
the athlete also can complete baseline neurocngnitive
and balance tests at this time tn assist with management
and treatment plans. These tests will be discussed later
in this chapter.
During sideline coverage, the astute physician must
be aware of what is occurring on the playing field as
well as along the sideline. The outward, objective signs
of a concussion may be very subtle. A concussed athlete
may simply wobble upon standing or have a vacant stare.
1llli'hen the physician does not personally lcnow the af-
fected athlete, he or she should rely on athletic trainers
and assistants, who prove invaluable in providing input
on possible emotional or personality changes.
If the sports medicine provider suspects an SEC, the
coaches should be made aware that the athlete is be-
ing assessed by the medical staff and is not available
for participation. Evaluation of the athlete begins with
basic life support. After the athlete is deemed stable, the
secondary survey can commence, specifically focusing
on the athlete’s mental status, any neurnlngic deficit, and
possible cervical spine injuries. Findings such as focal
neural deficits, progressively worsening symptoms, or
prolonged LDC as well as suspicion of a skull or cervical
spine fracture warrant further evaluation with conven-
tional neuroimaging.
If and when the athlete is deemed stable following the
secondary survey, the provider should proceed with a
more detailed sideline evaluation for concussion. During

IE! Eillfi American Academy of flrthopaedic Surgeons Drthnpaedic Knowledge Update: Sports lvledicme S
 Section 5: Head and Spine

Symptom Evaluation
How do you feel? Score yourself on the following symptoms, based on how you feel now.

i
Symptom Hone Mild Moderate
Headache {1

dd-‘d‘d-‘d‘d‘jd—I—i—I—I—I—IJJ

MMMMMHHHHHHHHHHHMHMHMH

wwwwwwwwwwwwwwwwwwwww

##hhhfihhhhhhhhhhhhhhh

mmmmmmmmmmmmmmmmmmmmm

mmmmmmmmmmmmmmmmmmmmm
Pressure in head

ununaaaaaaaaaaaoaaau:
Neck pain
Nausea or vomiting
Dizziness
Blurred vision
Balance problems
Sensitivity to light
Sensitivity to noise
Feeling slowed down
Feeling like "in a fog"
“Don't feel right"
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Drowsiness
Trouble falling asleep
as Feeling more emotional
.E
o.
m Irritability
'U
t:
as
1:5 Sadness
n: Nervousness or anxiety
so

fl!-
.p.

LII
to
-‘

I
ri-i Heprocluced with permission from McCrory P. Meewwisse W. Aubry M. et aI: Consensus statement on concussion in sport—the 4th international
conference on concussion in sport held in Eurich. November 2111:. Clin JSports Med mismatches-11?.

this time, the player is removed from play for sideline This checklist is associated with a Likert scale allowing
testing. Removing a vital piece of equipment, such as a for the assessment of symptom severity and has proved
helmet, can assist in preventing the athlete from returning to be a reliable and valid predictor of concussions. The
to play prematurely without approval by the physician. sports medicine provider also can use the symptom check-
Several commonly used sideline concussion assessment list in the continued management of SEC through ongo—
tools are available, including the Sport Concussion Assess- ing, serial assessments.'5
ment Tool 3’“ edition {SCAT3}, the Centers for Disease The Standardized Assessment of Concussion {SAC}
Control and Prevention Acute Concussion Evaluation, is the tool classically used for neurocognitive testing on
and the National Football League Sideline Concussion the sidelines. It evaluates four categories: orientation, im-
Assessment Tool. The 5CAT3 is the most widely used mediate memory, concentration, and delayed recall. The
sideline tool and has been validated in athletes older than SAC takes approximately 5 minutes to complete and can
13 years. The Child-SEATS is a variation that has been be administered by physicians or nonmedical personnel.
validated in athletes age 5 to 12 years.l Included in each of It is scored on a scale in which the normal scores average
these assessments is a symptom checklist, a questionnaire 26.5 to 3-D. Concussed athletes average 23 to Si], or a
assessing neurocognition, and a balance test. 15-point drop below baseline. The SAC is most successful
The sideline assessment begins with a symptom check— in identifying concussion early in the injury process and
list such as the one contained in the SCATJIJ {Table 2}. is therefore valuable for the acute sideline situation}:El

firthopaedic Knowledge Update: Sports lvledicine S D lflld American Academy of Orthopaedic Surgeons
 |lilllapter 3B: CflREflEElflflE

Figure 2 Photographs show positions from the modified Balance Error Scoring System. A, Double—leg stance. B, Heel-to—toe
stance. E. Single-leg stance on nondomina or foot. The athlete should maintain hands on hips. and eyes closed for
each position for a period of El] seconds on a firm surface. Any position changes. eye opening. or hands coming
ofi hips are recorded as errors.

Balance dysfunction is a hallmark of SEC. Balance,

or postural stability, demands a cornplezc coordination
between the brain and the musculoskeletal system. A
concussed brain demonstrates disturbances in the neu-
ral pathways governing balance, and concussed athletes
display balance deficits for 3 to .5 days after injury? The
'.-'."
Balance Error Scoring System {BESS} is a brief interven- I
tion to assess for such a balance dysfunction. The BESS at
n.-
D.
uses three stances on two surfaces, firm and soft. The u:
:l:
athlete’s goal is to maintain balance in each stance with CL
Lfi
the eyes closed for a Ell-second interval.“ The test su- 'E.
5
re
pervisor keeps a record of the number of errors, such as
eyes opening or loss of balance. The modified BESS is a
scaled-down version using a firm surface {Figure 2} and
is most applicable for sideline evaluation. Yet another
option is the tandem gait test {Figure 3} as described in
the SEATS, which can substitute for the modified BESS Figure 3 Photograph shows the tandem gait test. in
test. "With this test, the subject is asked to walk heel-to-toe which the patient is asked to walk heel-to-toe
to assess balance.
baclc and forth over the length of a S—m line of athletic
tape. Grading for this test assesses errors such as stepping
off the line as well as completion time. The average time impairments via vertical ground reactive forces, allowing
of completion for a nonconcussed individual is approx- assessment of the somatosensory, visual, and vestibular
imately 11 seconds. Although simple to complete, the systems. The SUIT is sensitive to tiny changes in postural
tandem gait test is limited because of a lack of evidence stability, thus it is superior to the BESS test for detecting
and validity in the concussed individualf‘ balance disturbances. Although the SET is more accurate
Technologic advances have prompted the develop- than the BESS, its limitation is the cost of the machine?
ment of more precise, increasingly objective methods to Uther examples include the increasingly popular software
measure subtle physical deficits. Dne such application programs designed to use an accelerometer in smart-
is demonstrated with the Sensory Organization Test phones to measure balance. These programs have shown
{SOT}, another method of testing balance. This system is some promising results. The software uses the BESS test
more sophisticated, using force plates to measure minute as a framework and detects errors while the subject holds

IE! this American Academy of flrthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medichse S
 Sectinn 5: Head and Spine
the smartphnne. These smartphnne applicatinns are cnm-
mnnplace and easy tn use but are limited by the type nf
data that are cnllected.”
Apart frnm the sideline evaluatinn, fnrmal neurnpsy-
chnlc-gic evaluatinn is an effective tnnl tn evaluate SEC.
Twn fnrms nf neurnpsychnlngic testing are available: pa—
per and pencil questinnnaires nr cnmputer-based testing.
Cnmputcr-based testing has bccnme the prednminant
methnd because nf its ease nf administratinn and interpre-
tatinn. The cnmputer testing allnws a brnader spectrum nf
health care prnvidcrs such as team physicians nr athletic
trainers tn use the testing results than dn paper—and—pencil
tests, which require interpretatinn by ne urnpsychnlngists.
1il'arinus cnmputcr—bascd neu rnpsychnlngic tests are avails
able, including Immediate Pnst-Cnncussinn Assessment
and Cngnitive Testing {ImPACT, ImPACT Applicatinns),
Cnmputerieed Cngnitive Assessment Tnnl {CCAT, Cng—
state Spnrts], Cnmputerised neurncngnitive test battery
[CNS Vital Signs}, and Autnmated Neurnpsychnlngical
Assessment Metrics {ANAM, 1|tfista LifeSciences}. Each
test takes apprnximately 15 tn 3f} minutes tn cnmplete
and assesses catcgnries such as reactinn speed, prncessing
time, and memnry. A final perfnrmance scnre is calculated
and cnmpared with pnpulatinn-hased nnrmative values
as well as individual baseline results."~”
|l'IJnmputer—based tests are best used as management
tnnls after a cnncussinn has been diagnnsed. Althnugh
cu
.E they can assist in the diagnnsis nf SEC, cnmputer-based
n.
m
'U
tests are far less effective as a snle diagnnstic tnnl. Instead,
I: they typically are used after the resnlutinn nf cnncus-
re
1:5
:1: sive symptnms tn assist decisinn making en the athlete’s
cu
I readiness tn return tn participatinn. I.'.]'Ibtaining baseline
Li-i
cnmputer-based neurnpsychnlngic testing has becnme the
na, because it accnu nts fnr individual variability inher-
ent in the test and gives the prnvider annther data pnint tn
help in the diagnnsis and management in the cnncusscd
athlete. Snme uncertainty remains abnut the usefulness nf
nbtaining baseline testing because it lacks evidence, fails
tn take intn cnnsideratinn the randnm errnr inherent in
each test, and is time prnhibitive and cnst prnhibitive.”
Speculatinn regarding pnnr athlete effnrt nr intentinnal
pnnr perfnrmance has been a further cnncern abnut the
validity nf this test.
Additinnal tnnls are available that the spnrts medicine
prnvider can use tn assist with the diagnnsis nf cnncussinn.
Due such instrument is the King—Devick test (Figure 4).
The King-Deviclc test nriginally was develnped tn study
abnnrmalities in the saccadic eye mnvemcnts nf children
with reading difficulties but was later shnwn tn be effec-
tive in diagnnsing SEC. The King-Deviclt test specifically
evaluates prncessing speed, saccadic eye mnvemcnts, and
visual tracking using single-digit numbers displayed nn
firthnpaedic Knnwledge Update: Spnrts Medicine 5
three cards. The patient reads the numbers alnud frnm
left tn right as accurately and quickly as pnssible. The
test administratnr recnrds the time tn cnmpletinn and
the number nf errnrs, which are cnmpared with baseline
testing cr nnrmative data. The King-Deviclr test has good
reliability and has shnwn results equivalent tn thnse nf
cnmputer-hased neurncngnitive testinn“ IEi'verall, stud-
ies are limited fer the King-Deviclr test, but it appears tn
be a prnmising tnnl that is quick, inexpensive, and readily
administered by a laypersnn in the setting nf a suspected
cnncussinn.
Cnncussinns are nnt discriminating injuries, and they
have far-reaching neurnphysinlngic effects. Cine area nf
the brain that SEC alters is the vestibular system, evi-
denccd by the pnstural instability uncnvercd in the BESS,
the SOT, and ether balance tests. Balance is cnntrnlled
thrnugh the vestibular—spinal system. SEC alsn affects
the vestibula r-ncular system. Recent studies have lnnked
tn the eyes as “a windnw tn cnncussinn.“ SEC affects
saccadic eye mnvemcnts, near cnnvergence, and smnnth
pursuit. Cnncussed athletes have mnre prnnnunced sac-
cadic mnvemcnts as well as distnrted near-cnnvergence
and smnnth pursuits. Administering these eye tests alsn
will prnvnke cnncussinn symptnms. Dngning studies are
eaplnring vestibular-ncular screening tests fnr cnncussinn
diagnnstic purpnses. At this pnint, additinnal data are
needed tn determine the reliability and validity.
In the ideal setting, the athlete with a suspected SEC
wnuld be fnrthright in declaring his nr her symptnms, but
this rarely happens in reality. Athletes have been nntnri-
nusly unreliable in repnrting, thus rendering the subjective
symptnm scnre invalid. Subsequently, the diagnnsis nf
SEC becnmes expnnentially mnre challenging. The search
cnntinues fnr mnre nbjective measures tn add tn the avail—
able diagnnstic apprnaches. Einmarkers and advanced
neurnimaging are twn prnmising mndalities gaining in-
creasing rcsearch attentinn. The ideal binmarkcr wnuld
be a quick and reliable substance that is easily acquired
an the sideline er in the lnclrer rnnm. Blend, saliva, urine,
and cerebrnspinal fluid are all pntential snurces fnr bin—
markers, althnugh tn date, nn single binmarker has met
the previnusly described criteria. Certain substances shnw
prnmise, but nnne are withnut substantial flaws. The mnst
studied binmarl-ter is the 51'0l prntein, which is fnund
within astrncytes. Other binmarkers include neurnn-speu
cific ennlasc, glial fibrilla ry acidic prntein, and myelin ba-
sic prntein, amnng ntbers. Given the relatively early stages
nf research, mnre data are essential b-efnre applicatinn cm
the sideline nr in the clinical setting is feasible.”
Althnugh cnncussinn is a clinical diagnnsis, neurnim-
aging such as CT nr MRI are beneficial tn rule nut a pns—
sible secnndary prncess such as a hemnrrhage. Research
fl lflld American Academy nf Orthnpaedic Surge-ens
 |illtapter 3d: Cflflmlfllflfli

I E i H II"

3—! I I- I

I 3 I I II

I I T l- 5

1—5 " 9 I

i I 5 T I

l_1 I a .

Demenstratien card Temt

I f 5 9 D

I I II" I I
I- I 'l I ll

1 '1 7 i l 'i a l I I
7 i ll 1 'I'

T H il- I' D 3 I l- l I
'l '- 5 'l I

-l s t 1 r 1' f ‘" ' '

I ‘I E I 'I

'I' I I- I E
'.-'."
I
I I E I 5' at
e.-
D.
m
3
Test II Test III CL
m
'E.
5
Figure ii- Dernenstratien and test cards fer the King-Devidt test. a candidate re pid sideline screening fer sperts-rele'ted re
cencussien based en the time te perfenn rapid number naming. {Hepred used with permissien frem Galetta ttlv'l,
Brandes LE. Matti It. et al: The fling-[levies test and sperts-related cencussien: Studyr ef a rapid visual screening teel
in a cellegiate cehert. J Neural Sci 2fl11:3fl9:34-39.}

is underway te explere using ether mere advanced itn—
aging medalities te assist with the actual diagnosis and
evaluatien ef cencussien. Specifically, functienal MRI,
diffusien tenser imaging, magnetic resenance spectres—
cepv, and pesitren emissien temegraphv have shewn
petential, because findings in these images appear te cer-
relate with symptem severity and cencussien reselutien.
Altheugh these medalities are premising, uncertainties
remain abeut hew te interpret er incerperate them inte
the evaluatien and management precess ef SEC.”
If the sideline assessments reveal ne werriseme signs,
plans fer the athlete's departure heme ma}.r begin. It is
advisable te previde the athlete and caregiver with written
infermatienal guidelines as a reliable reseurce te which
thev can refer. This handeut sheuld include a list ef specif-
ic red-flag signs and symptems that necessitate immediate
medical attentien. Such cencerning findings include fecal
weakness, seizure, er increasing cenfusien. Additienallv,
an explanatien detailing the definitien ef “apprepriate
phvsica], mental, and emetienal rest” sheuld be included,
cevering cemmenly everleel-ted exertiens such as videe
games, watching cemplex televisien shews, er testing.
Athletes with SEC must be reminded te aveid substances
that can impair judgment and cegnicive functien, such
as bensediaeepines, alcehel, er even cemmen ever—the-
ceunter preducts such as ceugh medicines. Extra cautien
sheuld be taken with certain masking medicatiens, which
can treat svmptems and give a false sense ef receverv. Ac-
etaminephen is permitted fer simple headaches; hewever,

IE! lfllfi American Academyr ef flrrhepaedic Surgeens Drthepeedic Knewledge Update: Sperts Medichse 5
 Section 5: Head sud Spine
antiplatelet drugs such as aspirin or ibuprofen should be
avoided, given the acute concerns for latent intracranial
bleeding. The athlete must be closely followed to ensure
a pattern of improvement, particularly during the first
several days after injury.
Sports activities are restricted to maximise the body’s
ability to resume normal cerebral perfusion and ensure
the greatest likelihood of resuming normal function. Al-
though the athlete should continue physically resting from
sports until asymptomatic, low to moderate activity levels
are reasonable to maintain daily activities.
Beyond limiting physical activity, cognitive rest also is
recommended. This can prove challenging, particularly in
middle school, high school, and collegiate arenas, where it
is expected that the athletes maintain academic standards.
Prompt communication with academic staff is important
to facilitate a reasonable modification to the student ath—
lete curriculum without unnecessary delay. Interventions
to minimize symptom aggravation should he considered
such as limiting continuous hours of reading or restricting
screen time. Allowance of additional testing time or due
date adjustments also may be warranted as the concussed
athlete recovers. The creation of an individualized i"re—
turn-to-learn“ plan allows reintegration into the normal
curriculum with as little disruption as possible.
Throughout this entire process, anticipatory guid—
ance for family members, teachers, and coaching staff is
as
.E critical, particularly given the individual nuances of the
o.
m
1:
recovery process. II'L'I'ften, no outward, objective signs of
t: injury are present with cnncussinns, so the individuals
n:
1:5
n: surrounding an affected athlete naturally may have an
ts
I underappreciatinn of the proper rest and activity mod-
li-i
ifications required for recovery. Most athletes become
asymptomatic by the end of the first week,” but remind-
ing all involved that some cases can take longer will help
manage expectations.
Return tn Flay
Under no circumstances should the athlete be allowed a
same-day return tn any physical play.'-3-” This is a rel-
atively recent yet paramount difference tn the way cnn-
cussinns were managed just a few years ago. Although a
player suffering an insult capable of resulting in a concus-
sion ideally should be examined by a medical professional,
such a professional may not always be available. This is
particularly true in the younger or more rural athletic
populations. Consequently, mounting efforts to educate
parents, coaches, and referees regarding better recogni-
tion of cnncussinn have arisen. This heightened awareness
reduces the risk of returning tn play after such an injury.
Assessment by a health professional in the aftermath is
firthnpaedic Knowledge Update: Sports Medicine 5
recommended and is now required by law in most states
before return tn play.
A gradual return tn normal social and academic activ-
ity precedes a return to sport. A health care professional
should make note of this when clearing the athlete and
approving initiation into a graduated retu rn—to—play pro—
gram. A commonly used protocol is that offered by the
consensus statement presented at the 4th International
Conference on Concussion in Sport2 {Table 3}, which
delineates a stepwise return. Advancing through each
progressive stage depends on successfully completing the
related level of activity without a recurrence of symptoms.
Typically, each level should take advantage of a 24-hour
time frame tn allow for the exertion and for the mon*
itoring of symptoms. If no exacerbation of symptoms
occurs, the entire prntncnl takes approximately 1 week.
If symptom recurrence occurs at any point, however, the
athlete should revert tn the level at which no symptoms
nccurred tn allow further recnvery. 1When the athlete has
no symptoms, the progression may resume until complete
reintegration into full play occurs.
Postconcussion Syndrome
Postcnncussion syndrome {PCS} is a relatively rare but
well—described concussion complication characterised by
persistent symptoms that may last weeks or, more typi-
cally, months or even years. Most cnncussinns follow a
characteristic period of resolution. Although 3fl% to 9fl%
of cnncussinns resolve within 1 weeksfi” the accepted
period for recovery is not scientifically established and is
influenced by factors such as age, sex, and history of prior
cnncussinns.” The World Health |liil'rganiratinn defines
PCS as “a syndrome that occurs following head trauma
{usually sufficiently severe to result in loss of conscious-
ness] and includes a number of disparate symptoms such
as headache, dizziness, fatigue, irritability, difficulty in
concentration and performing mental tasks, impairment
of memory, insomnia, and reduced tolerance to stress,
emotional excitement, or alcohol.“213 Headache is the most
common clinical feature and is often the symptom that
prompts medical attention. Athletes also may report vi-
sion disturbance, light and sound sensitivity, restlessness,
cognitive intolerance, executive dysfunction, vestibular
dysfunction, provocation of symptoms with exercise, and
concurrent depression.
The progression of a concussion tn PCS is poorly de-
fined and understood. Predictors of PCS are not known
with certainty, but some clinical variables appear to
increase the risk. They include a history of prior con-
cussions, male sex, younger age, a history of cognitive
dysfunction, and affective disorders such as anxiety and
fl lfllfi American Academy of Orthopaedic Surgeons
 |IL'Zhapter 3i]: llilonoussioos

Protocol for a Graduated Return to Play

Rehabilitation Stage Functional Exercise flbiective
1. No activity Symptom-limited physical and cognitive rest Recovery
2. Light aerobic exercise Walking. swimming. or stationary cycling. keeping Increase heart rate
intensity cilil‘la maximum permitted heart rate
3. Sport—specific exercise Skating drills in ice hockey, running drills in soccer; Add movement
no head impact activities
4. Honcontact training Progression to more complex training drills, eg, Exercise, coordination, and
drills passing drills in football and ice hockey: may cognitive load
start resistance training
5. Full-contact practice Following medical clearancer participation in Restore confidence and assess
normal training activities functional skills by coaching
staff
6. Return to play Normal game play
Reproduced with permission from McCrory P. lvleeuwlrsse W. Aubry M. et al: Consensus statement on concussion ln sport—the 4th lntematlonal
conference on concussion in sport held in Iuridi. November EDIE- Clin J Sports Med 2fl13:23{2}:59-111

depression."5‘~11 It has been shown that high school and
college athletes with LflC, posttraumatic and retrograde
amnesia, and greater symptom severity within the first 14
hours following concussion experience longer recoveries.”
1I'onth with a history of multiple concussions also have
been found to be at greater risk for prolonged recovery
and PC5311?- No study has yet identified injury severity
as a factor contributing to the development of PCS.
Formal evaluations should be performed by a neurolo-
gist andfor neuropsychologist experienced in caring for ins
dividuals with head injury to make a definitive diagnosis of
PCS. Important alternative diagnoses to consider include
cervical injury, migraine headaches, depression, chronic
pain, vestibular dysfunction, visual dysfunction, or a com-
bination of these conditions. A battery of neuropsycholog—
ic studies may be necessary to fully understand the degree
of impairment experienced by the PCS patient. Whenever
possible, some measure of baseline neu rocognitive testing
should be performed before contact sport exposure to al-
low postinjury comparisons. Conventional neuroimaging
can be used to rule out structural pathology, but currently,
insufficient data exist to recommend its routine use or the
use of advanced neuroimagiog techniques.2 As described
previously, several biomarkers also are being investigated
for potential use in the diagnosis of PCB. None to date
have been shown to consistently predict the development
of PCB after concussion, and further research is required
to determine their potential clinical utility.
The management of PCS is provided ideally by a health
care team that works with concussion on a regular has
sis. The basic management for PCS focuses on the same
general principles as those used for acute concussion.
Physical and cognitive rest are the primary interventions,
although several complementary therapies are becoming
increasingly accepted. PCS patients may derive benefit
from cognitive, vestibular, physical, and psychologic ther-
apies.2 Low—level subsymptom threshold exercise also
should be a core component of treatment for those slow to
recover from PCS. Athletes with persistent dizziness may
derive functional and symptomatic benefit from neuro-
motor retraining, sensorimotor retraining, and vestibular
'.-'."
physiotherapy. I
The most common medications prescribed for PBS are m
a.-
D.
antidepressants. Selective serotonin reuptake inhibitors to
:l:
have become the primary treatment of the depression CL
on
that is associated with head injury and also can improve 'E.
5
m
the cognitive deficits associated with concussion. Tricy-
clic antidepressants such as low-dose amitriptyline often
are used clinically to aid sleep and headaches in patients
with PCS, but no controlled trials exist that show their
efficacy in restoring normal function. Amantadine is an
accepted therapy for the management of moderate to se-
vere traumatic brain injury and can be a valuable therapy
in modifying the effects of PBS.
For competitive athletes at all levels, the development
of FIGS should stimulate discussion about the appropri-
ateness of returning to competitive athletics. These indi-
viduals, even after symptoms eventually resolve, maintain
a higher risk for reinjury than their nonconcussed peers,
and PCS symptoms are more likely to develop again if
the affected athletes experience additional concussions.
Second-Impact Syndrome
Second—impact syndrome {SIS}, or malignant cerebral
edema, is a rare but often fatal complication of multiple

IE! Efllfi American Academy of flrthopaedic Surgeons Drthopoedic Knowledge Update: Sports Medicine 5
 Sectinn 5: Head sud Spine
concurrent cnncussive injuries.13 Althnugh several cases
have been described in the literature, the existence nf
SIS remains cnntrnversial, and the underlying trigger—
ing mechanisms are still unclear.“ Classically, SIS arises
rapidly after an athlete suffers head trauma while still
symptnmatic frnm a print unresnlved cnncussinn.“ Al—
thnugh this secnnd impact nften nccurs relatively snnn
after the initial cnncussinn, SIS can nccur up tn 2 weeks
after the initial head trauma. This secnnd injury may
initially appear mild but can rapidly lead tn cnllapse,
LDC, respiratnry failure, and death.“
The exact pathnphysinlngy nf SIS is pnnrly understand.
Reinjury tn neurnnal cells during a vulnerable perind fnl-
lnwing previnus injury is pnstulated tn be the mnst likely
mechanism fnr SIS.” This reinjury then sets in mntinn a
cascade nf prncesses, including a less nf cerebral autnreg-
ulatinn, vascular eugnrgement, and a resulting massive
cerebral edemarlfl'l These changes, nften cnupled with
lncal hemnrrhage, then result in a rapid, marked increase
in intracranial pressure and ultimately tn cerebral herni-
atinn and death if unrecngniaed nr untreated.
Except in cases assnciated with bnxing, nearlyr all cases
nf SIS have been described in children and adnlescents
ynunger than 21 years, with a strnng male prednminance.
Research tn date has identified an definitive risk factnrs
fnr this cnmplicatinn, althnugh increased relative fragility
nf the ynunger brain is cnmmnnly pnstulated. atball
as
.E is the primary spnrt resulting in described 515 cases, but
n.
m
'U
any spnrt with cnntact nr cnllisinn risk may be implicated.
r:
as
‘ti
The preventinu nf SIS fncuses an a timely and accu-
:1: rate diagunsis nf the initial cnncussinn and apprnpriate
a:
I management, including disqualificatinn frnm spnrt, tn
d-i
prevent the risk nf “secnnd impact” expnsure. When a
cnncussinn is suspected, the athlete shnuld be remnved
immediately frnm all activity, and a cnncussinn screening
evaluatinn {SCAT3 nr an equivalent} shnuld be adminis-
tered. Every pntential cnncussive injury mu st be evaluated
in a systematic manner tn ensure an accurate diagnnsis
and tn determine whether the athlete may return tn spnrt
safely. Any dysfunctinn nn such assessment mandates a
disqualificatinn frnm nngning spnrt expnsure cm the same
day, at a minimum. If inadvertently allnwed tn return tn
spnrt in the face nf an active cnncussinn, the athlete is
at risk fnr SIS.
After a cnncussinn is diagnnsed, it is crucial that the
athlete be mnnitnred clnsely during the initial minutes
after injury. Athletes with SIS very rapidly deterinrate
clinically as their intracranial pressure increases. The
level nf cnnscinusness may decline precipitnusly, alnng
with marked declines in cognitive status. Affected athletes
can may present with fncal neurnlngic deficits relating
tn edema and cerebral bleeding. Edema and herniatinn
firthnpaedic Knnwledge Update: Spnrts Medicine 5
develnp sn rapidly that a favnrable nutcnme is likely nnly
in settings in which medical care is immediately available.
Develnpment nf any nf the clinical features described
previnusly is an indicatinn fnr immediate transpnrt fnr
urgent brain imaging via CT nr MRI and neurnlngic nr
neurnsurgical cnnsultatinn. Imaging findings nf marked
cerebral edema and impending heniiatinn mandate emer-
gent neurnsu rgical measures tn rapidly lnwer central ner-
vnus system pressure and prevent frank brain damage nr
even death. Additinnally, a recent review nf death caused
by blunt trauma fnund subdural bematnma tn be the cause
nf all 1? cases nf SIS.” It is unclear whether cnncussinn
increased the risk nf bleeding nr if the initial injuries were
nccult subdural injuries diagnnsed as cnncussinns.
Health care prnviders must always be aware that SIS
is inherently preventable. As such, it is critical that a cnn-
cussed athlete never return tn spnrt until a return—tn—play
prntncnl fnllnwing the current standard nf care guidelines
has been cnmplcted, and the athlete has been fnrmally
released tn resume full cnntact activities.
The understanding nf exactly what nccurs during a cnn-
cussive injury has advanced greatly, and spnrts medicine
physicians nnw cnmprehend that each and every cnu—
cussinn is unique tn the individual. Educatinn is imper-
ative fnr thnse invnlved at all levels, beginning with the
cnaching and athletic staff and incnrpnrating athletes
and their parents. Research cnutiuues tn achieve a greater
understanding nf head injury and tn find mnte expedient,
accurate methnds nf diagnnsis tn better treat thnse whn
are affected.
Key Study Fnints
'- The presence nf certain risk factnrs, including par-
ticipatinn in a cnntact spnrt, the pnsitinn played
within the spnrt, previnus athlete histnry nf cnncus-
sinn, female sex, and adnlescent nr child athletes,
increases the likelihnnd that a cnncussinn will result
frnm an insult.
1' A cnncussinn results frnm a fnrce that causes the
brain tn sustain a cnntusinn. A cnllisinn nr fall is
net necessary fnr this tn nccur.
I Cnncussinn can result in lnng-tenn neurnpathnlngic
changes, but acutely, clinical symptnms reflect a
functinnal disturbance.
1' Uuder nn circumstances shnuld the athlete be al-
lnwed a same—day return tn any physical play fnl~
lnwing cnncussinn.
fl lfllfi American Academy nf Orthnpaedic Surge-ans

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IE! lfllti American Academy ef flrrhepaedic Surgeens
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'.-'."
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a.-
pestcencussive symptems, and cencnssien interventiens. D.
an
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Drthepaedic Knewledge Update: Sperts Medicine S
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revisien. Available at: http:dapps.whe.intfclassificatinns.
Updated 1010. Accessed August 6, 2015.
This velu me ef the ICU-1G {Internatienal Statistical Clas-
sificatien ef Diseases and Related Health Pteblems it'll"
Revisien} cnntains guidelines fer tecntding and ceding,
aleng with much new material en the practical aspects ef
the classificatien’s use, as well as an eutline ef the hister-
ical hackgreund ef the classificatien.
2]. Guskiewics FEM, Marshall 51?, Bailes J, et al: Recurrent
cencnssien and risk ef depressien in retired prefessienal
fnnthail players. Med Sci Sperts Eatetc lflfl?;39{6]:9fl3-
909. Medline DUI
Kerr Z‘r', Marshall SW, Harding HP Jr, GufikiEW‘iCI KM:
Nine—year rislt ef depressien diagnesis increases with in-
creasing self-repertcd cencnssiens in retired prefe5sienal
feetball players. Am } Sperts Med 2011;4flflfllfllflfi-
2112.Medline D01
firthepaedic Knewledge Update: Sperts Medicine 5
The anthers used survey data ebtained ever 9 years te
prespectively study the effects ef recurrent cencussiens en
the clinical diagnnsis ef deptessien in a gtenp ef retired
Natienal Feethall League players. The risk ef depressien
increased as the numbers ef self-reperhed cencussiens rese.
23. Wetien NM, Pichelntann MA, Atkinsen JL: Secend
impact syndreme: Cencussien and secend injury brain
cemplicatiens. I Am Cuff Snrg Iflifl;211{4}:553-55T.
Medline DUI
The anthers previde a review ei the pathephysielegy ef
secend impact syndreme and the several mechanisms pes-
tuiated te play a rele in this cenditien. They review animal
research data and include illustrative case summaries.
24. McCtety P, Davis '3, Malcdissi M: Secend impact syn-
dreme er cerebral swelling after sperting head iniuty.
Curr Sperts Med Rep lfliltliilitli-fl. Medline DUI
The anthers reviewed scientific data regarding the exis-
tence ef secend-impact syndreme, its pathephysielegy,
the tislt facters fer its develepment, and issues relating te
preventien in athletes.
25. Weinstein E, Turner M, Rnama EB, Feuer H: Secend im-
pact syndreme in feetball: New imaging and insights inte
a rate and devastating cenditien. I Neurestttg Pedfdtt
1013,11f3):331-334.Medline DUI
The anthers reviewed a case ef secend impact syndreme
in which neureimaging was ebtained between the first
and secend impacts. This review effers new insights inte
the pathephysinlngy ef this precess and the petential risk
facters.
16. Cantu RC: Secend-irnpact syndreme. Ciir: Sperts Med
1993;1Fl1}:3?—44.Medline DUI
2?. Cantu RC: Recurrent athletic head ininry: Risks and
when te retire. Elie: Sperts Med lflfl3;22{3}:593-Efl3, 1:.
Medline DD]
23. Lenghi L, Sa atman RE, Fujimete 5, et al: Temp-eral win-
devv ef vulnerability te repetitive experimental cnncnssive
brain injury. Neuresurgery Eflflfitjfillltddd-flfi, discus-
sien 364-314. Medline DUI
.19. Themas M, Haas T5, Deerer ll: et a1: Epidemielegy ef
sudden death in yeung, cempetitive athletes due te blunt
trauma. Pediatrics 2fl11;123{1}:e1-e3. Medline DUI
The anthers analyzed the US Natienal Registry ef Sudden
Death in ’r'eung Athletes and tuned that deaths caused by
blunt trauma in athletes were uncemmen. Hi the tetal, a
large number eccnrred after head blews sustained after a
recent symptematic cnncnssinn.
fl lfllfi American Academy ef Drthepaedic Surge-ens
Chapter 31
Traumatic Spine Injuries
in the Athlete
Sephia it. Strike. MD Hamid Hassantadeh. MD
Abstract
As the feurth mest cemmen cause ef spinal cerd in-
jury, sperts participatien remains an impertant area
ef fecus in the study ef head and neck injuries. Spinal
cerd injury in the athlete is an impertant and petentially
catastrephic eccurrence. Histerical develepments have
led te impreved safety; hewever, these injuries centinue
te eccur. Understanding the pathephysielegy as well
as keys te initial, en-field, and in-hespital management
allews fer cemplcte care ef these patients. Centreversial
tepics include remeval ef pretective equipment, use ef
}stereids, and hypetherrnia.
Keywords: spine injuries: athlete: management
of spine injuries; spinal cercl injuries: transient
quadriparesis: neurapraisia
Intrecluctien and Epidemielegi'yr
As ef 2013, the incidence ef spinal cerd injury {SCI} in the
United States was estimated at 12,5 00 cases per year.1v1
ficcerding tn the Hatienal Spinal Cerd Injury Statistical
Center, the feurth mest cemmen cause ef SCI is spurts
participatien, with mere substantial damage eccurring
frem injuries te the cervical spine than te the lewet seg—
ments.“ Meter vehicle cellisiens and vielence, mest cem-
men ly frem gunshet weunds, centinue te be the first and
secend mest cemmen causes ef traumatic SCI, whereas
the prepertien ef SCI frem sperting events is declining,
and the prepertien frem falls has been rising since 2.0 05.1'3
Between 1991 and 1995, 35.9% ef SCIs resulted frem
Neither ef the feiievvinp anthers ner any immediate famiiy
member has received anything at vaiue frem er has stecir er
stuck eptiens heici in a cemmerciai cempany er institutien
related directly er in.::iirei:tiyr tn the subject of this chapter:
Dr. Stniire and Dr. Hassanaacieh.
fl 2016 American Academy ef Drrhepaedic Surgeens
meter vehicles cellisiens, 29.5% frem vielent acts, 20.3%
frem falls, and 13% frem spetting activities, with mere
recent rates reperted as 33% frem meter vehicle celli-
siens, 30% frem falls, 14.3% frem vielence and 9% frem
spetting activities between 2010 and 2014J~1~5 First—year
cests per mechanism ef injury were highest fer sperts-
related SCI, at $295,643 in 1995, and lewer fer the ether
three mest cemmen mechanisms ef SCI." Patients with
sperts-related injuries cemprised the yeungest greup, at
a mean age at 24 years? Per 1995, the aggregate everall
cest ef traumatic SCI frem all causes was estimated te
be $1236 billiens“
Sperts-related injuries tn the spinal card are asseciated
with feetball, ice heckey, gymnastics, wrestling, rug-
by, and trampelining.‘ Gymnastics and ice heckey have
'.-'."
higher rates ef severe head and spine injury, but feetball I
is asseciated with the largest tetal number ef catastrephic m
n.-
D.
cervical spine injuries, based en the pepularity ef the an
:15
sper1:.3 Accerding te the Natienal Center fer Catastrephic CL
Lfi
Spert Injury Research, an estimated 4.2 millien peeple 'E.
5
re
participate in feetball at varieus levels in the United States
annually. Meet ef these players participate in sandlet
er unerganiaed games, with 1.1 millien participants at
the high scheel level and appreaimately 100,000 par-
ticipants in cellege er mere cempetitive levels.‘ Between
1945 and 2000, 16% ef deaths in all levels ef feetball
were attributable te cervical spine injuries.‘l Between "194.5
and 1994, enly 1 year [1990} saw ne recerded fatality in
feetball frem head er cervical spine injury} Threugheut
this time, 604 fatalities in feetball eccurred, with 3.5%
due te head injuries {465 patients, 63%} er cervical spine
injuries {116 patients, 12%).? The highest percentage ef
feetball fatalities due te head andier cervical spine injury
eccurred in the decade frem 1965 te 19.11.? Mest ef the
fatalities frem cervical spine injury were fractures andi
er dislecatiensf Invelvement in an effensive er defensive
tackle was the mest cemmen activity at the time ef fatal
cervical spine injury?
The devclepment ef impreved feetball helmets reduced
the incidence ef feetball-related deaths frem intracranial
Drthepaedic Knewledge Update: Sperts Medicine 5
 Section 5: Head mid Spine
hemorrhages. A coincident increase in cervical spine in-
juries, including fractures and dislecatiens with resultant
quadriplegia, occurred because of the players’ newfound
ability to hit opponents headfirst, producing an axial load
along the cervical spine}4 The elimination of dangerous
methods of tackling subsequently reduced the incidence of
these injuries:l Similarly, changes in checking practices in
ice hockey were implemented in an attempt to reduce the
occurrence of cervical spine injuries.3 Multiple national
organizations have used epidemiologic data to effect a
reduction in head and neck injuries related te sperts ac-
tivities through improvements in the design and manufac-
turing of safety equipment, the elimination of dangerous
spurts practices, and increased public awareness of the
risks of such injuries.‘
The National Football Head and Neck Injury Regis-
try was established in 19?5 to evaluate national trends
in catastrophic football-related injuriesfi-i In 1915, 12
players sustained head or neck injuries while performing
a headfirst tackle or block, in Pennsylvania and New
Jersey.‘ In an analysis of head and neck injuries from
1959 to 1963, in comparison with the period 19?1 to
1915, the authors found that the number of intracrani—
al hemorrhages and deaths had declined, by 56% and
42%, respectively“ flver this same comparison period,
a 204% increase in cervical spine fractures andfer dis—
locations and a 116% increase in cervical quadriplegia
cu
.E eccurred.’5 The authors concluded that a concomitant
e.
m
'U
increase in cervical spine injuries occurred because of
i: improved head protection, resulting in an increase in
re
1:5
n: the beadfirst tackling technique, which subjected the
a:
I cervical spine to axial loadingfi‘ After the presentation
Li-i
ef these results in 1996, rule changes rendered head-
first tackling or “spearing” of opponents as well as butt
blocking illegal in an attempt to mitigate this upward
trend of cervical spine injuries.” From 1996 to 193?,
the number of cervical spine fractures, su bluxatiens, and
dislecatiens declined at the high school and college levels
by T09}: and 60%, respectively. Complete quadriplegia
from cervical spine injury followed a similar trend.'5
Between 1969 and 1993, 51 rules changes were made by
the National Collegiate Athletic Association to prevent
head and cervical spine injury in football} All helmets
now must be certified by the National Dperating IElem-
mittee on Standards for Athletic Equipment prior to use
by a high school or collegiate football player."r Proper
helmet fitting, education about and enforcement of safe
tackling techniques, improved physical conditioning of
athletes, and an increased presence of medical providers
on the sidelines all are factors thought to have reduced
the occurrence of death from head and cervical spine
injury in football}
firthepaedic Knowledge Update: Sports Medich'ie 5
Pathophysiolegy
Spinal Cord Injuries
The bony structures of the spine protect the spinal cord
from injury during leading. Anterior structures, includ-
ing the intervertebral disks and vertebral bodies, resist
cempressien, whereas posterior structures, including the
ligamentum flavum, interspineus ligament, and paraspi-
nal muscles, resist distraction. The facet joints prevent
the translation of vertebrae.3 The space for the spinal
cord is narrowest at the (34-? levels? For most contact
sports, the mechanism of injury is compression of the
cervical spine.3 Hyperextension of the cervical spine and
direct impact to the lower cervical spine from the poste-
rier rim of the football helmet were discredited as major
mechanisms of injury in the 1930s.T Compression forces
can lead to SCI through two major mechanisms. First, a
flexion pesture with compressive lead shortens the ante-
rior column of the spine while distracting the posterior
column, leading to overall instability} Second, flexion of
the neck during sperts activity moves the cervical spine
inte straight alignment and removes the paraspiual mus-
culature as a supportive shock absorber, and force is no
longer apprepriately transferred distally to the theraxfhbf
Initially, the energy of the axial lead is absorbed by the
intervertebral disks, but with the continued application of
force, failure of the disks andfer surrounding ligamenteus
and esseeus structures eventually eccurs, resulting in
fractures andi'er dislecatiens of the cervical spine.‘-’ Neck
flexien te Bil“ is described as the straightest position of
the cervical spine when it is most susceptible to injury
from axial leading.M A pure axial lead on the anterior
and pesterier celumns leads to a burst fracture, with SCI
resulting from the retrepulsien of bony fragments from
the vertebral body into the spinal canal? Bilateral facet
joint dislocations and burst fractures are associated with
BEL-'9‘” A herniated nucleus pulpesus, with the charac—
teristic symptoms of acute pesterier neck pain with or
witheut radicular symptoms, can lead to transient or
permanent cerd injuryfi" Klippel-Feil syndrome, edenteid
hypoplasia, and es edenteideum are important congenital
cervical spine abnormalities, and they must be considered
to be conditions that predispose a player to a traumatic
cervical spine injury}
Secondary mechanisms of SCI include ischemia, ede-
ma, and hemorrhage.9 1ivl'ascular trauma also must be
considered in the evaluation of the injured patient with
a neurelegic deficit. Dissection, thrombus or embolism,
and occlusion from direct trauma or secondary compres-
sien can occur. Above C6, the vertebral artery may be
damaged. Symptoms indicating dysfunction of a cerebral
hemisphere or a spinal cord syndrome can appear acutely
fl 211115 American Academy of Orthopaedic Surgeons

or develop over time.Ell Magnetic resonance angiography
or CT angiography should be performed emergently if
vascular trauma is a concern}?
Patients with neurologic deficit after a cervical spine
fracture or dislocation are more likely to have sustained
an injury to the lower cervical spine.11 Mean sagittal ca-
nal diameters decrease proximally to distally within the
cervical spine, with a nadir at (36, averaging 13.9 mm at
C1 to 1?.9 mm at CT." In a review of HS patients with
cervical spine fractures andl'or dislocations, the authors
found substantially smaller sagittal cervical spine canal
diameters in those patients with complete SCI than in
those with no neurologic deficits or incomplete deficits,
suggesting that a large spinal canal is a protective factor
for SCI."
Studies of squid axons suggest that the mechanical
deformation of axons alters membrane permeability and
thus the cytosolic calcium concentration, as well as local
vasospasm and the resulting incoming blood flow.” These
changes affect the ability of the axon to conduct signals,
to a reversible, partially reversible, or irreversible degree,
based on the applied amount of tension.3 In a transient
neurapraxia of the spinal cord, as discussed later, an
elastic deformation of axons is thought to occur, lead-
ing to a change in membrane permeability that causes a
minimal increase in intracellular calcium and thus only
a temporary alteration in function with no residual defi-
cit.E Injuries rendering the cervical spine more unstable
{such as unilateral or bilateral facet dislocations, severe
fractures} can lead to spinal cord deformation causing the
maximal elastic or plastic deformation of axons and thus
longer periods of anoxia and cytosolic calcium build-up.E
These intracellular changes result in incompletely revers-
ible or irreversible SCI.”
Ttansient Quadriparesis
Transient SCI, or transient quadriparesis, manifests
as weakness with or without sensory changes, most
commonly in all four extremities but occasionally only
hemiparetically.” The pathophysiology of transient qu ad—
riparesis is described as a physiologic—as opposed to an
anatomic—disruption in normal spinal cord signaling.3L
A neurapraxia results from “contusion” of the spinal
cord after dynamic narrowing of the spinal canal.3 As
in peripheral neurapraxia, symptoms last from minutes
to 1 days and resolve completelyfi‘i'i“ Symptoms include
bilateral upper-extremity or lower-extremity pain, par-
esthesias, andl'or tingling, with possible motor weakness
as severe as that seen in complete :quadriplegiafl‘vE As de-
scribed previously, transient guadriparesis typically is not
associated with cervical spine pain and, with resolution
of symptoms, full painless range of motion of the cervical
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 31: Traumatic Spine Injuries in the. Athlete
-
U n- ht-Flexlon .-_
Upricjht—.
A p g B NEMHI I:s:tensn.:--'|
-
Figure 1 Images show transient quadriparesis. The
upright flexion {A} and extension {IE} images
show spinal cord contusions at the E344 level
that resulted in the acute transient paralysis.
This was not visible on the neutral upright scan
{B}. {Eourtesy oflean Pierre]. Elsig, MD. Enrich,
Switzerland;I
spine is notedfi' Radiographs of the cervical spine are
negative for fractures andi'or dislocations.‘I
The pathophysiology of these “spinal cord concus—
sions“ had been postulated to be a temporary loss of sig-
nal transmission from an acute and transient impingement
of the spinal cordd‘ Permanent damage is not thought
to occur, and thus persistent radiologic changes are not
'.-'."
observed.9 A smaller anteropostefior sagitta] canal di- I
ameter in an athlete has been thought to predispose to run
a.-
D.
cervical spine neurapraxia. The etiology is thought to be an
3
mechanical and to be related to an acute compression of CL
to
the spinal cord between the posteroinferior aspect of the 'E.
5
re
supradjacent vertebral body and the suhjacent anterosu-
perior aspect of the spinal laminar line or vice versa, with
hyperflexion or hyperextension but without fracture or
dislocationfljFigure 1}.
Neurapraxia (Stingers and Burners}
Stingers is a term used to describe a transient sensation of
burning, pain, numbness or tingling in a unilateral upper
extremity. This sensation may be accompanied by motor
weakness.” Symptoms in bilateral upper extremities or
in either lower extremity should alert the clinician to the
possibility of a spinal cord injury, rather than to peripheral
nerve injury.” Stingers are thought to result from traction
on the brachial plexus or compression of a cervical spine
root at the level of the neuroforamenl'lrfljFigure 2}. A
dermatomal distribution of radiating pain with possible
weakness in the corresponding nerve root distribution
is indicative of an injury at the cervical nerve root level.
The mechanism of injury of cervical root impingement
is a compression loading on the neck through an axial
Drtbopaedic Knowledge Update: Sports Medicbie S
 Section 5: Head mid Spine
A
Figure 2 Drawings show the mechanlsms of Injury for burners. A. Traction to the brachial plexus from the lpsilateral
shoulder depression and contralateral lateral neck fleaion are shown. B, A direct blow occurs to the supraclavioalar
fossa at the Erh point. C, Compression of the cervical root or hrachial plexus from ipsilateral lateral fleaion and
hypereatensien is shown.
blow to the head or extension and ipsilateral rotation of
the net:lc.3'+”-~”| Burners or stingers involving the brachial
plexus are more likely to affect multiple muscle groups and
a wider sensory area.“ Brachial plexus stretch occurs after
a direct blow to the head or shoulder, causing extension
and traction in the region of the plexus.”*”
[n scholastic athletes, the Torg-Pavlov ratio {the spinal
canal AP width to the vertebral body AP width} and the
forameni'vertehral hody ratio {the height ratio of the neu—
roforamen to the suhjacent vertebra at the largest points}
were found to be substantially different in players who
had sustained burners than in control group players who
had not. This finding suggests that an increased risk of
to
.E cervical canal stenosis and foraminal stenosis is present
:1
U'll
1:
in players who have sustained a burner—type injury. No
t: stratification of players based on mechanism was per-
to
1:5
a: formed, however. It has been proposed that extensionv
cu
I compression mechanisms are more likely to be associated
ri-i
with root-level injuries. Further subgroup analysis may
have provided an even stronger association with cervical
canal stenosis and foraminal stenosis in this subset.‘3
For most patients, pain will resolve within minutes,
and full sensorirnotor symptoms will resolve within 1
to 2 days.-" Persistence or recurrence of symptoms, an
abnormal physical examination, or symptoms concern-
ing for a more central process preclude a player from
returning to the game and require further imaging such
as cervical spine MRI.” Symptoms that continue longer
than 2 weeks should be evaluated with electromyography
[I-il'lj.‘1 Although EMG will differentiate the level of
peripheral nerve injury, it typically is not useful until 3
weeks after injury.EI
Advanced Trauma Life Support
A primary survey of airway, breathing, and circulation
always must be performed in an injured player?“ A
firthopaedic Knowledge Update: Sports Medicine 5
neurologic evaluation and determination of consciousness
follows if the primary survey is negative for abnormality.9
Unconscious patients or those with neurologic symptoms
including burning, numbness, tingling, and weakness
should be managed as if a cervical spine injury is pres-
ent.9=” Cervical spine injuries during sporting events are
unique in the need to accommodate protective gear and
on-field conditions when evaluating and immobilizing
the potentially injured player}
Accessibility of the airway is necessary for the manage-
ment of injured players. In contrast to the prior recom-
mendation to leave a helmet in place for the player with
a cervical spine injury, the most current recommendation
from the National Athletic Trainers‘ Association {NATAj
is that the provider with the highest level of training re—
move all athletic equipment prior to transport to the hos-
pital including the helmet and shoulder pads, although
this recommendation remains controversial.“5 According
to the National Athletic Trainers’ Association {NATAL
exposure of the airway must he completed urgently. The
jaw-thrust maneuver for airway patency is preferred over
a head-tilt to protect the cervical spine from potentially
damaging motion.” For all sports, on—field personnel
should become familiar with the related protective equip-
ment and make all attempts to keep the cervical spine in
neutral alignmentflilf‘ Recognizing less severe but more
common soft-tissue injuries such as ligament and muscle
strains is important for the complete evaluation of the
athlete.‘4
Boarding and Transferring Patients
In a 2130? review of the literature on positioning of the
cervical spine when boarding an injured player, the au-
thors concluded that the shoulder pads and helmet should
be left in place in football and in ice hockey to keep the
cervical spine at zero elevation and allow maximal space
for the spinal cord within the canal, however, the updated
recommendation is to remove all protective equipment
fl ems American Academy of Orthopaedic Surgeons

Figure 3 Drawing shows the tre nsfer of a supine patient
to a spine board using the E + lift and slide
technique.
prior to transport to the hospital?” The lea st ideal posi-
tioniug is extension of the cervical spine; therefore, leav-
ing shoulder pads in place and allowing the head to rest on
the backboard is not recommended? NATA recommends
immediate stabilization of the cervical spine in a neutral
position when injury is suspected.” Immobilization of
the cervical spine and head should be maintained with
external devices (cervical collar, blocks, towel rolls} and
manual stabilization, if possible.”
Full-body immobilization in the form of a long board
or vacuum splint is also necessary for transfer.” The head
should be secured at the forehead and chin for optimal
immobilization of the spine.” Two techniques for trans-
ferring patients to the rigid board are currently used.
The six-person lift technique involves lifting the patient
approximately 6 inches off the ground and sliding a board
below {Figure 3]. Alternatively, the patient can be log
rolled onto a board placed beneath the patient to support
the cervical spine” {Figure 4}. MATH recommends the
lift—and—slide technique, citing less motion at the cervical
spine.15 At least three straps should secure the patient
IE! zms American Academy of flrthopaedic Surgeons
Chapter 31: Traumatic Spine Injuries in the Athlete
Figure 4 Drawing depicts the transfer of a supine patient
to a spine board using flte lug—roll technique.
to the board? An additional form of immobilization of
the head also should be used? A cervical collar provides
the best immobilization of the cervical spine? The spine
of the prone player should be examined prior to the log
roll.‘5 Repositioning movements on the long board should
'.-'."
be performed in a longitudinal direction rather than per-
I
re
pendicular to the axis of the spine.” a.-
D.
an
3:
CL
Lfi
'E.
5
re
Evaluation begins with a thorough examination and
cervical spine radiographs, including flexion and exten-
sion views. Radiographic evaluation is necessary in any
patient with symptoms or clinical signs of neurologic
injury? Transient bilateral sensory andIor motor deficits
occurring after a head or neck injury are suggestive of
an SCI.” l[Jervica] spine radiographs serve as the initial
modality? CT or MRI of the spine may be necessary to
detect bony or ligamentous injury as well as spinal cord
injury or nerve root compression.” MRI is the optimal
imaging study for the evaluation of a traumatic interver~
tebral dislt herniation, hematoma, or local swelling in the
cervical spine? MRI also allows evaluation of possible
spinal stenosis because it provides optimal visualization
of the vertebral bodies, the intervertebral disks, the spinal
cord, and the canal?”
In a review of cervical spine imaging in football
players, it was proposed that athletes with neurologic
symptoms have flexion and extension radiographs of the
cervical spine performed for the evaluation of stability.”r
Drthopaedic Knowledge Update: Sports lvledichte 5
 Section 5: Head turd Spine
Furthermore, it was proposed that any athlete with neu-
rologic symptoms and a sagittal canal diameter {measured
from the posterior vertebral body to the anterior aspect
of the lamina] less than two standard deviations below
the mean should undergo functional MRI for further
evaluation of the function reserve of the spinal canal.”
For helmeted athletes, CT is likely to be the most useful
initial diagnostic tool on presentation to the hospital, be-
cause radiographs will be limited by sporting equipment.
Similarly, MRI will have to be postponed until it is safe
to remove the protective gear.”
Return to Playr After Spine Injuryr
Although catastrophic spine injuries with a residual neu-
rologic deficit or concomitant head injury clearly neces-
sitate future abstinence from contact sports, less severe
injuries may allow the player to resume such activities.
Recommendations for return to play are largely expe-
rience based and are tailored to the player.9~“~'3 As an
overall guideline, return to play requires the absence of
neurologic symptoms and pain as well as full range of
motion of the cervical spine.”-‘ For stingers or burners,
the immediate resolution of symptoms with no recurrence
and a normal examination may allow same-day return
to sports activity.3 A neck roll to prevent hyperezttension
and a neck and shoulder muscular training program also
to
E should be considered to prevent future injury in these
on.
m
'U
players.13
r: A Bill]? study cites evidence that prodromal symptoms
n:
‘ti
:1: are unlikely to occur prior to catastrophic SCI? Further
a:
I more, no evidence shows that stenosis alone predicts a
li-i
future catastrophic injury.El Players with transient SCI—
and thus no permanent neurologic sequelae—as well as
preserved cerebrospinal fluid on MRI can be allowed
to return to contact sport? Radiologic evidence of disk
herniation, cord contusion or impingement from osteo—
phytes or surrounding ligaments, or instability should
preclude players from contact sports in the future? Repet-
itive episodes of transient quadriparesis warrant further
consideration for discontinuing participation in contact
sports?“ Congenital conditions involving the odontoid
{hypoplasia, os odontoideumj, atlauto-occipital fusion,
and Klippel-Peil anomaly involving fusion of the cervical
spine to the upper thoracic spine are absolute contrainu
dications to return to play.” Players with spear tackler
spine or the clinical combination of cervical spine stenosis,
persistent loss of cervical lordosis, posttraumatic radio—
graphic changes, and a history of spear tackling should
not return to play at any time.” Players with stable spine
fractures, such as spinous process fractures and compres—
sion and endplate vertebral body fractures with no sagittal
firthopaedic Knowledge Update: Sports Medicine 5
changes or concomitant ligamentous injury and without
neurologic symptoms may be considered for return to
play.” Stability must be confirmed with flexion—eittension
cervical spine radiographs.5r Players must not have any
neurologic symptoms or cervical spine pain.” Players with
spinal fractures requiring surgical stabilisation or spinal
cord injuries are advised against return to contact sports?
Players who have previously undergone spine surgery
specifically for disk herniation may return to play after
bony fusion is complete? In the absence of neurologic
symptoms and pain, fusion of one vertebral level does not
prohibit play, whereas the fusion of two to three levels is
a relative contraindication. Having four or more levels of
fusion is an absolute contraindication to return to play.”
Controversies
Steroid Protocol
The systemic use of steroids in acute SCI has been pro-
posed as a method to reduce the effect of secondary
mechanisms of damage such as edema and inflammation.
A Cochrane review of randomized trials using methyl-
prednisolone sodium succinate in SCI patients revealed
only eight adequate studies; however, practice guidance
has been based on these outcomes.” Treatment of SCI
with methylprednisolone within 3 hours of injury has
become standard practice and is supported by the re-
viewed trials.” The closing and duration of treatment
are based on the time from injury. Patients given methyl-
prednisolone within 3 hours of injury should receive a
bolus of SD mg:Irkg intravenously for 15 minutes followed
by a maintenance infusion of 5.4 mgi'kg starting 45 min-
utes later for the next 23 hours; no benefit is gained by
continuing therapy longer than 24 hours. Patients give
en methylprednisolone between 3 and 8 hours from the
time of injury should receive the same initial bolus but
should receive 43 hours of total therapy, because motor
and functional outcomes are improved with an increased
length of therapy in this group of patients.” Furthermore,
the reviewed trials showed no evidence of an increase in
medical complications or mortality from changing to
the 43-hour regimen of dosing from the 24-hour regi-
men}? Since the publication of that review, the Congress
of Neurological Surgeons has recommended against using
methylprednisolone, citing the offvlabel use and the lack
of well—designed studies.” In a survey of the members of
the Cervical Spine Research Society, researchers found
a significant reduction from 39% to 56% of members
using methylprednisolone in acute SCI in 2fl13 versus
in 1006. Members cited sepsis, gastrointestinal bleed-
ing, and SCI occurring more than 3 hours prior to the
possible administration of steroids as the most common
fl lfllfi American Academy of Orthopaedic Surgeons

cbntraindicatibns.11 Similarly, accbrding tb recbmmen-
datibus by NATA, treatment bf acute SCI with methyl-
prcdnisblbnc remains a cbntrbversial technique. Its use in
the injured athlete requires a discussibn bf the risks and
benefits with the patient and the family.15 In cbntrast,
peripheral neuraprattias, including stingcrs and brachial
pleatbpathies, are a cbntraindicatibn tb sterbid use.“
Hypothermia
The benefits bf additibnal interventibns in the setting bf
an acute SCI include mitigating the secbndary injury and
increasing the patient’s chances fbr imprbved future func—
tibn.=3 Mbderate systemic hypbthermia has been prbpbsed
as a mechanism fbr reducing pbtentially irreversible histb—
pathblbgic changes within the spinal cbrd? Well-defined
prbtbcbls fbr using hypbthermia in the acute management
bf SCIs are nbt available, lIDWEVEI'.9‘23’“
A Natibnal btball League player whb sustained a
(33-4 fracturefdislbcatibn and an SCI graded A an the
American Spinal Injury Assbciatibn {ASIA} impairment
scale was treated with surgical decbmpressibn, intrave-
nbus methylprednisblbne, and early mbderate hypbther-
mia. The player’s neurblbgic functibn imprbvcd within
weeks, and at the time bf the repbrt, his neurblbgic status
was graded as ASIA D.” Based bu this single repbrt, the
imprbvement in neurblbgic status cbuld nbt be attributed
entirely tb systemic hypbthermic treatment; hbwever, the
case highlights the need and pbtential clinical utility bf
further studies bn its use in SCI.25 In a case series bf 20
patients with a cbmplete SCI treated with surgical decbm-
pressibn, glucbcbrticbids, and lbcal spinal cbrd cbbling,
bverall imprbvements in neurblbgic status were bbserved.
With cbnfbunding treatments and rib cbntrbls, clinical
applicatibn is limited, but the authbrs suggest that, based
bn this experience, well-designed clinical trials using lbcal
hypbthermia are wbrth undertaking.IE
The American Assbciatibn bf Neurblbgical Surgebns
{AANiCbngress bf Neurblbgical Surgebns [CNS] Jbint
Sectibn bn Disbrders bf the Spine and Pct-ipheral Nerves
and Jbint Sectibn bn Trauma released an update tb their
initial Elli]? pbsitibn statement bn using hypbthermia in
SCI, nbting the lack bf cbmparativc studies available art
which tb base recbnu‘nendatibns.” The authbrs cite insuf-
ficient evidence fbr br against using hypbthermia in acute
SCI and nbte prbmising level IV evidence that hypbthermia
is a pbtentially safe interventibn requiring further study.”
Hypbthermia was used briginally as a lbcal treatment
perfbrmed by surrbunding the espbsed spinal cbrd with
cbld saline during decbmpressibn prbcedures, with bcca-
sibnal beneficial results. This technique was cbnfbunded
by the surgery itself as well as by the use bf sterbids in
the acute setting, thus precluding its standard adbptibn.”
IE! lfllfi American Academy bf flrrhbpaedic Surgebns
Chapter 31: Traumatic Spine Injuries in the Athlete
Lbcal cbbling was advantagebus because systemic re-
spbnses tb hypbthermia, such as arrythmias, hypbtensibn,
venbus thrbmbbembblic events, acute respiratbry distress
syndrbme {AR D5} flfldfflt‘ infectibn, are avbidedfifl‘l Sur-
face cbbling using blankets and water baths help facilitate
hypbthermic treatment, given its nbninva sive nature; hbw-
ever, the prbcess is variable, and depending bn patient size
can be inefficient in prbducing hypbthermic cha ngesfi‘l In-
travascular cbbling allbws mbre cbntrblled hypbthermia
but is assbciated with the previbusly described risks.” In
bne study bf 14 patients receiving mbderate hypbthermia
fbr the preventibn bf SCI, mbst cbmplicatibns were respi-
ratbry {pneumbnia, atelectasis, ARDS, pulmbnary ede-
ma]. It was unclear whether this result cbuld be attributed
directly tn the hypbthermic prbtbcbl, hbwever, because nb
significant difference, except pulmbnary edema, was seen
when cbmpared with cbmplicatibns in a matched cbntrbl
grbupfi‘m‘ Impbrtantly, 6 patients {41.3%} imprbved in
neurblbgic status frbm ASIAIInternatibnal Medical Sb-
ciety bf Paraplegia impairment scale grade A at initial
presentatibn and maintained this imprbvement after dis-
charge, with a greater number bf patients cbnverting tb
a better ASIA status than in the cbntrbl grbupfiE ac
bf the patients dembnstrated an ascending neurblbgic
level.13 In a rat mbdel bf spinal cbrd cbntusibn treated
with pbst-SCI hypbthermia, the treatment grbup was
nbted tb have increased gray and white matter vblumes,
'.-'."
increased neurbn cell preservatibn near the site bf injury, I
and maintenance bf lbng—tract reticulbspinal axbnsfif re
a.-
D.
Clinically, the rats shbwed increased rates bf lbcbmbtbr an
:li
recbvery and increased limb strength.“ CL
m
Multiple pathbphysiblbgic mechanisms are thbught tb 'E.
5
re
prbyide prbtectibn in mbderate hypbthermia. Reduced
cerebral metabblic demands prbvide an increased energy
sburce fbr the area bf damage.“ Hypbthermia is thbught
further tb decrease the release bf glutamate, an excitatbry
neurbtransmitter. The expressibu bf relevant neurbtrans-
mitter receptors, including N—methyl-b-aspartic acid alsb
seems tb be altered by temperature changes.13 An bverall
change in the excitatbry state bf the brain is thbught tb
prbtect neurbnal vulnerabilityflfli' Hypbthermic states
reduce vascular permeability and thus prevent the less
bf the blbbd-brain barrier.” Intracellularly, multiple sig-
naling pathways affecting calcium cbncentratibn and the
cytbskeletal infrastructure alsb seem tb be sensitive tb tem-
perature alteratibns.” Inflammatbry respbnses, via cytb-
kines such as tumbr necrbsis factbr—ct and interleukin-1,
are thbught tb be blunted by therapeutic hypbthermia,
prbtecting neurbns frbm secbndary insults'ljl An bverall
change in the ability tb retard tissue damage after trau-
matic insult tb the spinal cbrd underlies the mechanisms bf
prbtectibn prbduced by mild tb mbderate hypbthermia.”
Drthbpaedic Knbwledge Update: Spbrts Medichte 5
 Section 5: Head and Spine
S u :11 me ry
Cervical spine trauma in the athlete is a significant oc—
currence, with potentially catastrophic results. Football
remains one of the most common and most well-studied
sports activities associated with spine injuries. Transient
spinal cord and peripheral nerve injuries may manifest
as quadriparesis or burnersistingers with symptoms that
resolve completely. More severe spinal cord injuries, typi-
cally from atrial loading on the cervical spine, cause bilat-
eral symptoms with residual neurologic deficit. Advanced
Trauma Life Support principles always must be applied
to the player with a potential spine injury. Reducing the
movement of the cervical spine through immobilization
and accessing the airway, either through removal of all
protective equipment or just removal of the facemaslr
while leaving appropriate padding in place remains con—
troversial, but is key to managing and transferring SCI
players off the field. The use of steroids in acute SCI re-
mains controversial. Moderate systemic hypothermia
provides theoretical benefits for reducing spinal cord
damage in the setting of an acute injury. Although this
technique has been studied in the laboratory, only a few
clinical trials have been performed, and further research is
necessary before routine implementation of hypothermia
protocols can be recommended.
to Hey Study Points
.E
I].
U'll
1:
t: ' Sports participation has consistently been the fourth
to
1:5 leading cause of spinal cord injury, with the most in-
a:
I
a: juries occurring in football players. Although deaths
from intracranial hemorrhage decreased with use of
ti-i
helmets, an initial increase in cervical spine injuries
was halted by rules changes forbidding head-first
tackling and other dangerous maneuvers.
I: Initial management of players with a potential spi-
nal cord injury includes applying the principles of
Advanced Trauma Life Support, especially securing
an airway. Removal of protective athletic equipment
continues to be a controversial topic with recent
recommendations by the National Athletic Train-
ers’ Association to do so on the field. Boarding and
transfer require stabilisation of the cervical spine to
prevent additional injury.
- Controversial treatments for spinal cord injury in-
clude steroid protocols and use of acute hypother-
mia. Although laboratory data suggest a theoretical
benefit, clinical use is not yet prevalent.
firthopaedic Knowledge Update: Sports Medich'ie 5
Annotated References
Injury SC: (SCI) Facts and Figures at a Glance. National
Spinal Cord Injury Statistical Center. August ISM. Avail-
able at: https:iiwww.nscisc.uab.eduiPublicDocumentsi
faet_figures_doesiFacts%2fl2fl 14.pdf Accessed on August
13,2fi15.
The uputn-date demographics of spinal cord injury patients
are summarized and reviewed. Lifetime costs, life expec—
tancy, and cause of death are also discussed.
. Annual Survey of Football Injury Research: 1931—2013.
National Center for Catastrophic Sport Injury Research.
Available at: http:iinccsir.unc.eduifilesilfll4iflSiAnnu-
al—Footba|[-2DIS—Fatalities-Final.pdf Accessed on August
13, 2015.
A summary of survey results from the American Football
Coaches Association is presented regarding fatalities relat-
ed to football participation, with the goal to prevent future
fatalities and improve the safety of the sport.
Eanerjee R, Palumbo MA, Fadale PD: Catastrophic cer-
vical spine injuries in the collision sport athlete, part 1:
Epidemiology, functional anatomy, and diagnosis. Am
,rspsre Med lflfl4,31{4}:1fl??—1fl31 Medline not
Cooper MT, McGee KM, Anderson DG: Epidemiolo-
gy of athletic head and neclc injuries. Ciin Sports Med
lflfl3jllit4ET-443, vii. Medline DUI
De‘iiivo M]: Causes and costs of spinal cord injury in
the United States. Spinal Cord 199?;35l12}:3{}9-313.
Medline DUI
Torg JS, Vegso J], |CII"I"~Ieill M], Sennett E: The epidemi-
ologic, pathologic, biomechanical, and cinematographic
analysis of football-induced cervical spine trauma. Am
I Sports Med ISSDtiISjljfiD-SI Medline DCI'I
Mueller FD: Fatalities from head and cervical spine injuries
occurring in taclrle football: Sti years‘ experience. Ciin
Sports Med lSSS;1?{1}:lSS-ISE. Medline DDI
Torg J5, Thibault L, Sennett E, Pavlov H: The Nicolas
Andry Award. The pathomechanics and pathophysioln-
gy of cervical spinal cord injury. Clio Drthop Refer Res
1995;321:2551-2551. Medline
Bailes JE, Petschauer M, Gushiewica KM, Marano G:
Management of cervical spine injuries in athIEtes. I Arie!
Trait: lflfl?;42{1j:116—134. Medline
10. Coelho DC, Brasil AV, Ferreira NP: Risk factors of neu-
rological lesions in low cervical spine fractures and dis-
locations. Arq Neuropsiqeierr EDUDfiSHJflGSD-lflfi-i.
Medline DD]
11. Eismont F], Clifford S, lGoldberg M, Green B: Cervical
sagittal spinal canal size in spine injury. Spine (Foils: Po“
IPFE} lSS4;SI{Tj:SES-Edd. Medline DUI
fl lflld American Academy of Orthopaedic Surgeons

12. Cantu RC: Stingers, transient quadriplegia, and cervical
spinal stennsis: Return tn play criteria. Med Sci Sperts
Esters 199?:29i'F, Snppl}S.133-5235. Medline DUI
13. Kelly JD W, Alique D, Sitler MR, Ddgers E, Meyer RA:
Assnciatien nf burners with cervical canal and fnraminal
stennsis. Am J Sperts Med senfl;23{1]:214-21?. Medline
14. Chiselli C, Schaadt C, McAllister DR: ICl‘n-the-lield evalu-
atinn nf an athlete with a head er neclt injury. Ciirr Sports
Med 2003:22{3]:445-465. Medlinc DUI
1.5. Swarts EE, lie-den BF, Ceursen KW, et al: Natinnal athletic
trainers“ asseciatinn pesitien statement: Acute manage-
ment of the cervical spine-injured athlete. I Athl Train
2fl09;44{3j:3fl6-331.Medline DUI
Recnmmendatinns en the acute management nf players
with pnssible cervical spine injury are made by the Na-
tinnal Athletic Trainers Assnciatinn. This includes airway
management, transfer, and the cnntreversial tnpic nf re-
mnval ni athletic pretective equipment.
16. Natienal Athletic Trainers" Asseciatinn: Apprnpriate Care
cf the Spine Injured Athlete: Updated Frem 19.93 dncuv
ment, 21115. Available at: httpu'twwwmata.ergtsitestde-
faultifilesiExecutive-Summary-Spine-Injury.pdf Accessed
en Dctnber ED, 2015.
The executive summary update nf the 1.993 dncnment
prnvides revised recnmmendatinns regarding management
nf athletes with cervical spine injuries.
1?. Heraeg R], Wiens J], Dillingham MF, Sentag M]: Netmal
cervical spine mnrphemetry and cervical spinal stennsis
in asymptnmatic prnfessinnal fnntball players. Plain film
radiegraphy, multiplanar eemputed temngraphy, and mag-
netic resnnance imaging. Spine {Phiia Pa 1976,} 1991:1646,
ISuppl}:S1T".'S-S1£llii.Medline DCII
IS. Terg JS: Cervical spine injuries and the return tn fentball.
Sperts Health 2009,1{5 }:3?6—333. Medline DE}!
A systematic review cf the Hatinnal atball Head and
Neck Registry as well as relevant literature was perfermed
te previde recemmendatieus nu return tn fnntball play
after cervical spine injury. The majnr recemmendatic-n
is that any player returning tn fentball shnuld be pain
free, withnut neurnlngieal deficit, and with intact range
{if cervical spine metinn.
19. Bracken ME: Sternids fer acute spinal cerd injury. Ce-
ch raise Database Syst Ree 1fl12;1:CD 0D1fl46. Medline
Randnmiaed cnntrnlled trials c-f sternid treatment in acute
spinal cerd injury are reviewed. Methylpredniselnne is
identified as the nuly pharmacelegic therapy shewn tn
have any benefit, and a call fnr mere research is made.
ll}. Hurlbert R], Hadley MN, 1it'lli'alters EC, et al: Pharmace-
legical therapy fer acute spinal cerd injury. Mentesargery
llfifillfiuppl 2]:93-105. Medline ["31
The anthers reeemmend against use nf methylprednis—
nlnne er CM-l ganglinside in the acute management bf
ID lfllfi American Academy ef Drthnpaedic Snrgeens
Chapter 31: Traumatic Spine Injuries in the Athlete
spinal cerd injury based en a literature review. They cite
the limited number nf pharmacnlngic agents studied and
the need fer mere research.
21. Sehreeder GD, Ewen BK, Eclt JC, Savage JW, Hsu WK,
Patel AA: Survey nf Cervical Spine Research Snciety
members en the use ef high-dese sternids fer acute spinal
cerd injuries. Spine (Phiia Pa 1 FE} 1014;39{12}:9?1-9?T.
Medline DDI
Data item a questiennaire survey nf the members ef the
Cervical Spine Research Seciety regarding use ef meth-
ylpredniseleue and trends ever time are presented. The
number ef surgeens using high-dese sternids has decreased
ever time. Side effects including gastrnintestinal bleeding,
sepsis, and late presentatinn are reperted as reasens fer
the decrease in use.
. Castrn FP Jr: Stingers, cervical cerd neuraprastia,
and stennsis. Elia Sperts Med 2fl03:22[3}:433-492.
Medline DDI
2.3. Dietrich WD, Levi AD, Wang M, Green EA: Hypethermie
treatment fer acute spinal cerd injury. Nenretherapeuties
2011;3{2}:219—239. Medline Dfll
A review ef the histerical use, clinical studies, and pathe-
physinlngy ni induced hypnthermia in the treatment nf
spinal cerd injury is presented. Additinnal research nn
detailed clinical pretncnls is needed.
14-. Levi AD, |Creen EA, 1|ill-"hug MY, et al: Clinical applicatinn
nf medest hypnthermia after spinal cerd injury. J Nea-
rntraaraa 2fl09:26{3J:4D?-415. Medline DD]
'.-'."
A case series ef 14 patients with spinal cerd injury treated
with hypnthermia is presented. The authnrs detail their
I
re
a.-
prete-cel and repert an effective system fur maintaining D.
In
a censistent bedy temperature with the geal tn previde 3
hackgrenncl infnrmatien fer future studies.
CL
u:
'E.
5
In
2.5. Cappuccinn A, Eissen LJ, Carpenter B, Maren], Dietrich
TD II I, Cappuccinn H: The use nf systemic hypetherrnia
fur the treatment nf an acute cervical spinal cerd injury
in a prefessinnal fnntball player. Spine {Phila Pa HTS}
lfllflt35jlltEST-E62.Medline DUI
The anthers discuss the case nf an NFL feetball player
whe sustained a spinal curd injury and was treated with
hypnthermia. The patient rapidly recnvered neurelngic
functinn.
16. Hansebnut RR, Hansebnut CR: aal cnnling fnr trau-
matic spinal enrd injury: Dntenmes in 20 patients and
review cf the literature. I Nettrnsrrrg Spine 2fl14;2flj5}:55ll-
561. Medline DD]
Twenty patients with spinal cerd injury undergeing a cem-
binatien nf surgical decempressinn, glucncnrticeid admin-
istratinn, and hypnthermia are discussed. The anthers
repert impreved results ever standard treatments and call
fnr mnre research in these areas nf acute management.
2?. Pesitien statement: lDtenle J, 1|illli'ang M, Raiser M. Hypn-
thermia and human spinal cerd injury: Pesitien statement
and evidence based recemmendatiuns frem the AANSJ'
Drtbepaedic Knnwledge Update: Sperrs Medicine 5
 Section 5: Head anti Spine

CH5 Juint Sectinn nn Disnrclers nf the Spine and the
HANS-ICES Jnint Sectinn nn Trauma. Available at: httpt
www.spinesectinn.nrgi'hjrpntherrniaphp.
This pnsiticm statement repnrts insufficient evidence tn
recnnnnend in: the use nf reginnal as systemic hypnther—
mia in the management nf spinal curd injn rs.
2:3. Levi AD, lEasella G, Green EA, et a]: lL'Illinical nutcnntes
using mn-dest intravascular hypnthermia after acute cervi-
cal spinal curd iniur'y. Neurnsrrrgery 2D10;EE{4}:E?D-E?1
Medline DD]
A retrnspective review nf 14 patients with spinal curd
injury managed with intrasrascular hypflthermia was per-
fnrmed. Cnmplicatinn rates were cnmparable tn thnse nf
patients with nnrmnthcrmia.
19. Ln TP Jr, Chn KS, Garg MS, et al: Systemic hypnther-
mia imprnves histnlngical and functinnal nutcnn'ie after
cervical spinal cnrd cnntusinn in rats. J Comp News!
lflfl9;514{5}:433-443. Medline DUI
A rat mun-tie] nf spinal curd injury.r was used In studsr the
effects nf transient hyputhcrmia. Histnlngic and Functinnal
results suggest that mild systemic hypnthermia may.r slaw
tissue damage and reduce neurnlngic deficits.

as
E
D.
m
'U
r:
n:
1:5
a:
a:
I
li-i

firthnpasdic Knnwledge Update: Spun-Its Medicine 5 fl lfllfi American Academy at Drrhnpaedic Surge-nus
Chapter 32
The Cervical Spine
William R. lvliele, ll Brian I. bleuman, MD A. lay Khanna. MD. MBA
Injuries to the cervical spine constitute a range of con-
ditions from acute traumatic injuries to chronic overuse
and degenerative conditions. In addition to trauma to the
cervical spine, several degenerative conditions present in
athletes, and may be of substantial consequence to long—
term function and career longevity. The sports physician
will benefit from being familiar with examination of the
neck and cervical spine, the neurologic examination,
and presenting histories of common conditions, and
imaging modalities and findings.
Keywords: spine; sports medicine; spinal injuries
Introduction
0f the approximately 10,0Di] cervical spinal cord injuries
in the United States each year, will. are sports related,
with most of these injuries occurring in unsupervised
or informal sporting events and activities.1 More than
11,0flfl cervical spine injuries resulting from football
injuries alone are evaluated in emergency departments
Dr. lt'hanna or an immediate family member serves as a
paid consultant to Grthofirc has stoclr or stoclr options held
in New Era Urthopaedics, Cortical Concepts, and Avitus
Orthopaedics; has received nonincome support {such as
equipment or services}, commercially derived honoraria, or
other non-research-related funding {such as paid travel}
from Siemens Healthcare and Thieme Medical Publishers;
and serves as a board member; owner, officer; or commit—
tee member of the American Academy of Grthopaedic
Surgeons, the Johns Hopkins {Center for Bioengineering,
innovation, and Design, and the North American Spine
Eociety. Neither of the following authors nor any immedi-
ate family member has received anything of value from or
has steel: or stock options held in a commercial company
or institution related directly or indirectly to the subject
of this chapter: Dr. Mieie and Dr. Neuman.
fl lflld American Academy of Drthopaedic Surgeons
yearly.1 Cervical spine injuries in the athlete can range
from minor cervical strain to permanent quadriplegia.
Contact and collision sports are of the most concern
for cervical spine injury. Df football players, will: to
15% sustain a cervical spine injury at least once in their
careers,3 and injuries are seen at all levels of play. Clue
study found that up to 32% of college football recruits
had radiographs demonstrating prior cervical spinal in-
jury or degenerative changes.‘ Even at the highest level of
play, injuries are not infrequent. A study of spine injuries
in professional football players demonstrated that spine
injuries comprise Fills of all football injuries, with 44%
of spine injuries occurring in the cervical spine.5
The occurrence of cervical spine injury in the contact
athlete is of particular concern; one study of professional
football players demonstrated that incurring a cervical
disk herniation resulted in a 23% chance of the athlete
never returning to play.’i Another study demonstrated a
'.-'."
substantial negative effect on the careers of athletes with I
cervical spine pathology. Football players who underwent m
u.-
D.
preexisting cervical spinal surgery or conditions were an
3
less likely to be selected in a draft pick and had shorter CL
Lfi
careers.i 'E.
5
m
Despite the focus on cervical spine injuries in collision
contact sports, such injuries occur across sporting events,
including hockey, skiing, diving, track and field, cheer-
leading, baseball, lacrosse, and wrestling.E a review of the
clinical features of some sports—related cervical spine con-
ditions is important for the physician to make a clinical
diagnosis. The potential for catastrophic cervical spinal
cord injury or substantial time lost from participation
threatens with any cervical spine injury.
History and Physical Examination
Acute Injuries
Prior to any contact sport event, preparations should
be made to ensure that the basic equipment needed to
support the evaluation, on—field treatment, and trans-
port of injured players is on hand. Necessary supplies
include tools for the removal of protective equipment, an
emergency cervical collar, a spine board, and sandbags
or another cervical immobilization system for helmeted
Drthopaedic Knowledge Update: Sports lvledicine 5
 Sectien 5: Head turd Spine
players. First-aid supplies and airway access instruments
sheuld be readily available, and trained persennel sheuld
be present and able te prepcrly ceerdinate an emergency
siruatien and previde en-field evaluatien and emergency
treatment. Recent recnmmendatiens are available fer the
management ef the cervical spine—injured athlete."
Unstable er uncenscieus patients sheuld be treated
accnrding tn American Heart Assnciatinn Basic Life Sup-
pert guidelines. Attentien sheuld be given te maintaining
immebilixatien ef the cervical spine. Any player with a
suspected cervical spine injury sheuld undergn a physical
and neurelngic evaluatien en the field befere being meved
er befere the neck is manipulated. Fellewing neurelngic
assessment, examinatien ef the neck can include palpatien
ef the pesterier beny elements, palpatien fer muscular
spasm, and assessment ef pain with axial cempressien er
isemetric resistance. Active range ef metien may be as—
sessed if the player is able te meve the neck witheut pain.
Players with findings indicative ef cervical spine injuries
sheuld net be mevcd, and the neck must be immebilixed.
If the helmet ef a player with a suspected cervical spine
injury cannnt be remnved withnut mnving the cervical
spine, the helmet and sheulder pads sheuld net be re—
meved.“l The facemask may need te be remeved fer air-
way access, and the helmet alsn may need tn he remnved
if the faccmask alenc cannet be rcmnvcd. Prempt transfer
tn a medical facility must be arranged fer players whe
tu
.E are uncnnscinus nr whn have persistently altered menta-
D.
m
1:
tien, neurelngic symptems in twe er mere extremities,
t: substantial neck pain, er cervical spine bnny tenderness
H:
‘ti
:1: with a cenceming injury mechanism.
a:
I Players with acute injuries must be immebilixed in a
d-i
rigid cervical cellar. The patient’s neck is immebilieed in
the midline and neutral in flexien-cxtensien. The cellar
must fit snugly, se that ene er twe fingers can be placed
beneath the patient’s clnsed jaw and the cellar chin-piece.
The neck sheuld be fit inte the cellar via gentle straight—
ening and distractien if necessary, but any defermity er
malangulatinn nf the neck sheuld nnt be fnrcibly straight-
ened. Players with nermal mentatien, ne beny tenderness,
full active range ef metien, and ne neurelngic symptems
nr substantial distracting injuries typically may be deemed
free ef cervical spine injury.
Determining the mechanism ef injury and the ameunt
ef ferce sustained by the neck are ways ef rapidly ascrib-
ing a level ef risk. Mest spinal cerd injuries in sperts
result frem axial leading injuries incurred during spear
tackling in feetball, head cellisien inte beards in heckey,
and diving injuries. Impertant cempenents ef the patient’s
acceunt include pain nr neurelngic symptems at the time
ef injury and the duratien er persistence ef symptems
(Table 1}. The histery and physical examinatien must
flrfliepaedic Knewledge Update: Sperts Medich'ie 5
—_
Key Patient Histery Facters in
Evaluatinn nf Spinal Cnrd Injury
Lecetien and quality ef pain in the neck
Lecetien and quality ef pain in the arms
Presence ef numbness andfer paresthesia
Presence ef limb weakness er functienal disability
Pattern and timeline of the pregressien nf symptems
include a detailed neurelngic assessment. Neurelegic in-
juries fellew repreducible pattrxns and typically can be
differentiated en the basis ef the histery and physical
examinatien.
Stingers and Burners
Stingers and burners are a ferm ef cervical nerve rent er
brachial plexus injury. A feetball tackle cenducted with
the sheulder while the neck is laterally flexed is part ef the
typical histery. This pnsitinn places the brachial plexus
centralateral te neck lateral flexien in maximal tensien
and maximally narrews the cervical neureferamina ip-
silateral tn neck lateral flexinn nn impact. The result is
brachial plexus stretch er cervical nerve reet cemprcssien
injury. A blew tn the supraclavicular regien alse can re-
sult in brachial plexus injury. Stinging nr burning pain
in the sheulder radiates tn the arm and hand. Sensery
symptems are transient and typically reselve after several
minutes, altheugh they can remit and recur in an episedic
fashien. The sensery symptems may precede weakness
nf the sheulder, arm, er hand that eccurs up tn 1 week
latenm Stingers eccur frequently in feetball, with mere
than 5fl‘h’: ef cellege-level players reperting at least ene
nccurrence."
Nerve Rent Injury
Cervical nerve rnnt injuries are mnst nften the result nf
reet cemprcssien by intervcrtcbral disk herniatien, al—
theugh any cemprcssive lesien, including fracture frag-
ments nr dislncatinn, may result in radiculnpathy. The
mest censtant features ef nerve rent injury are radicular
pain, paresthesia, and sensery less. Meter examinatien in
cervical nerve reet injury may be nermal er can demen-
strate weakness in a myetemal distributien. The less ef a
deep tenden reflex can reflect nerve reet injury, and reflex
less may be neted even if full meter strength is present.
Transient Quadriplegia er Quadriparesis
Transient quadriplegiafparcsis {transient cervical cerd
neurepraxiaj is diagnesed when ne acute fracture er
fl lfllfi American Academy ef Urthepaedic Surge-ens

Iigamentous injury occurs and neurologic symptoms com-
pletely resolve. Symptoms may last from a few minutes to
36 hours, with the player demonstrating motor deficit in
two or more extremities. Extremity heaviness, functional
limitation, and paresthesia also can occur. Neurologic
examination initially may demonstrate weakness, sen—
sory deficit, and limb apraxia that improve to normal.
One study demonstrated that more than 90% of players
experiencing a single episode of transient quadriparesis
had abnormal radiographs or MRI despite the complete
resolution of symptoms,12 and the probability of substan-
tial structural pathology in players with this presentation
must be considered. The syndrome is associated with
cervical spinal stenosis.13
Spinal Cord Injuryr
Spinal cord injury most typically presents in one of three
patterns: complete spinal cord injury, incomplete spinal
cord injury, and central spinal cord injury. The level of
injury is determined in reference to the most caudal spinal
level with completely normal function. Complete spinal
cord injury indicates no spinal cord function below the
level of the injury. Incomplete spinal cord injury can be
sensory incomplete or motor incomplete.
Central spinal cord injury is a form of incomplete inju-
ry that most often presents with neurologic deficit in the
distal cervical levels [wrist and hand function}, dysesthet-
ic upper extremity pain, and sometimes a deficit in the
lower extremities. Lower extremity deficit is present to a
lesser degree than in the upper extremities. The mildest
form of central cord syndrome presents with bilateral
burning pain and tingling in the hands and is sometimes
referred to as burning hand syndrome. It is important to
clinically differentiate this condition from a stinger or
burner. Central spinal cord injury is most often the result
of hyperextension injuries.
The American Spinal Injury Association {ASIA} Im—
pairment Scale worksheet is useful in determining the
level and classification of spinal cord inju ry.“ In complete
spinal cord injury, reflexive movement may be present.
The ability to withdraw to deep pain or pressure in the
absence of voluntary movement commonly is not seen
in spinal cord injury. Lower limb flexion to pain may
have the appearance of limb withdrawal, and attention
must be given to differentiating withdrawal from reflexive
flexion. Spontaneous flexion movements can be seen in
complete spinal cord injury and should not be mistaken
for voluntary movement.
A deficit of sensation below a spinal level can help de-
termine the level of injury. Somatic sensation is tested best
with light touch and pin sensation. Touching the skin with
an open safety pin is the easiest method of testing somatic
IE! ems American Academy of flrrhopaerlic Surgeons
Chapter 32: The Conical Spine
sensation via the spinothalamic tracts. Sensory ftmction
of the dorsal column-medial lemniscus pathway is tested
via joint position sense at the distal interphalangeal joints
of the hand and the interphalangeal joint of the great toe,
as well as via deep pressure and vibratory sense.
Although not generally part of an on—field examina-
tion, detailed reflex testing should be conducted after a
patient with a suspected spinal cord injury arrives at the
hospital. Involuntary reflexes to be tested include deep
tendon reflexes, the abdominal cutaneous reflex, and the
anal sphincter and bulbocavernosus reflexes. Myelopa-
thy most classically results in deep tendon hyperreflexia
below the level of injury. This is typically a late finding,
however, and may be hypoactive or absent in acute spinal
cord injury reflexes.
Suhacute Presentations
The duration, severity, time and setting of onset, exac-
erbating or alleviating factors, functional impairment,
and history of prior problems are all important factors.
Any musculoskeletal and neurologic symptoms should
be solicited.
Many comprehensive resources are available for re—
viewing the clinical examination and anatomy!”5 The
surface anatomy is examined with the patient in a neutral
position, seated or supine. Simple inspection will allow
assessment of the neutral head position, the symmetry of
'.-'."
the posture, and the gross appearance of the neck. With I
the patient in a neutral sitting or standing position, lateral re
a.-
D.
viewing of the cervical spine should evidence a gentle an
3
lordosis, with the head centered over the trunk. Viewed CL
Lfi
anteriorly, the chin should be centered over the sternal 'E.
5
re
notch, and symmetry of the sternocleidomastoid muscles
should be apparent.
Active range of motion in the cervical spine is observed
with the patient seated and should be full and pain free.
Full flexion results in contact of the chin and chest, and
full extension allows the patient to bring the face parallel
to the horizontal. Normal rotation allows 60" to 90" of
axial rotation in either direction. Lateral bending should
allow the ear to touch the shrugged shoulder.
The posterior spinous elements from the inion to the
upper thoracic spinous processes should be palpated, and
any point tenderness, step-off deformities, malalignment
of spinous processes, or spasm of the pa raspinal muscula-
ture should be noted. The inion and C2 spinous process
are easily palpable, {33-5 are small bifid processes that
may not be individually palpable, and C6, (3?, and T1 are
typically prominent. The lateral masses and facet joints
are not palpable individually, although tenderness lateral
to the adjacent spinous process can corroborate facet
pathology at that level. Anteriorly, the midline structures
Drthopoedic Knowledge Update: Sports Medicme 5
 Section 5: Head and Spine

——
Clinical Signs in Evaluation of the Cervical Spinal Cord and Nerve Roots
Spurling sign The head is extended slightly and axially rotated to the affected side, and gentle axial
compression is applied. The reproduction of radicular symptoms suggests neurofnraminal
stenosis.
Lhermitte sign The patient performs maximal active flexion of the neck and trunk. The resulting electrical.
shooting, or other paresthesia symptoms down the spine or into the bilateral arms suggest
cervical spinal stenosis.
Bomb-erg sign The patient is asked to stand with the feet together and the arms outstretched, with palms
up. The patient then closes the eyes. An inability to maintain balance suggests dorsal
column dysfunction. This test can help to identifyr myelopathy in patients with gait or
balance problems.
Hoffman sign The distal phalanx of the third digit is fliclted at the distal interphalangeal joint. Thumb
flexion in response is considered a positive sign and may indicate cervical myelopathy. The
Hoffman sign demonstrates a hyperactive CE deep tendon reflex. not a pathologic reflex.

that can be palpated are the hyoid bone, trachea, thyroid
and cricoid cartilage, sternocleidomastoid muscles, ca-
rotid tubercle of CS, and carotid arteries. Neck strength
can be tested in flexion, extension, lateral bending, and
axial rotation. The sternocleidomastoid muscle rotates
the neck in a contralateral direction.
Heurologic examination is conducted as described
previously. Special maneuvers include the Spurling, Lher-
mitte, Romberg, and Hoffman tests {Table 2). Dermato—
mal sensation is tested via pin tip and light touch. Deep
to
.E tendon reflexes may be tested at the C5, C6, CT, and
I].
U'il
1:
CS roots. Deep tendon reflexes in the lower extremir
t: ties, plantar stimulation {the Babiuski maneuver}, and
n:
1:5
In distal joint position sense in the lower extremities are
a:
I mandatory tests in patients with symptoms that suggest
d-i
cervical spinal stenosis. Symptoms of spinal cord injury
may be apparent by patient history before physical signs
of myelopathy appear. Subjective numbness, pa resthesia,
hand weakness, dyscoordination or functional limitation
in the extremities, poor coordination, gait problems, or
imbalance all can be seen with myelopathy. Unilateral
or bilatEral cervical radicular symptoms may be present.
and AP open-mouth odontoid views. The swimmer view
is used to assess the cervicothoracic junction. Dblique
views are useful in assessing for foraminal stenosis or os—
teophytes. Cervical alignment is assessed best with neutral
upright AP and lateral radiographs. Lateral projections
are used to assess alignment; the anterior spinous line,
posterior spinous line, spinolamiuar line, and spinous
process line are evaluated. Fracture, listhesis, segmental
angulation, loss of lordosis, splaying of the spinous pro—
cesses, or widened prevertebral soft tissue all can be signs
of cervical spine injury. Lateral and open-mouth odontnid
views allow assessment of the occiputrCl-Cl junction.
Lateral flexion-extension radiographs are the basis for
excluding instability of the cervical spine. If confirmed
to have normal static radiographs, no neck pain, no neu-
rologic symptoms, and full active range of motion, the
patient may have flexion—extension radiography. Patients
with substantial distraction injuries should not have flex-
ion-extension radiographs obtained and instead may need
to remain in the cervical collar andl'or undergo MRI.
Full excursion in range of motion must be evident on
radiographs for the examination to be valid.

Imaging
Plain Radiography
CT has virtually supplanted plain radiography for emer-
gency assessment. 1|When CT cannot be performed exu
pediently, cross-table lateral radiographs are useful for
assessing for cervical dislocations in unconscious patients
or in those who cannot be examined for other reasons.
Plain radiography can be useful as an initial study before
the removal of protective equipment.
1"l'ii'r'hen plain radiographs are obtained as a primary ra—
diographic evaluation, images should include AP, lateral,
Computed Tomography
Most CT protocols now include multiplanar reconstruc-
tion in the coronal and sagittal planes that readily allow
the identification of fractures, malalignment, and dislo-
cations. CT should be performed for any patient with
abnormal plain radiographs following injury or when
adequate plain radiographs cannot be obtained.
Magnetic Resonance Imaging
MRI can be performed to assess for injury to the nouns-
seous structures in the cervical spine. Image sequences
to be reviewed include Tl-weighted, short tau inversion

firthopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons

recevery {STIR}, Tl-weighted, and axial gradient echeiIr
fast field echn iGREfFFE} sequences. TE-weighted images
effer the best centrast ef cervical spinal structures and
are the easiest tn interpret. STIR sequences are the next
mnst useful. STIR is nptimised tn highlight tissue edema
and makes pessible the identificatien ef acute fractures,
ligamentnus disruptinn, er acute spinal cerd centusiens.
T1-weighted images are nf limited usefulness in emer-
gency cervical spine imaging but have the best spatial
reselutien and can help te distinguish abnermal signal
in areas that are equivncal nn ether imaging sequences.
GREJFFE axial images are high—centrast sequences al—
lewing imaging ef the spinal canal and neural elements
in a manner cemparable te CT myelegraphy and are a
useful adjunct.
Imaging in Cervical Cnllar Management
Acute cervical spine injuries are managed initially by
immnbiliaatien in a rigid cervical cellar. Patients with a
radingraphic injury, nnrmal radiegraphs but substantial
pain, er distracting injury are maintained in a cervical
cnllar. In patients with nn apparent injury whn have been
placed in a cervical cellar, snme breadly accepted criteria
are available fer determining which patients need imag-
ing. The Eanadian If3-Spine Rule and {biannual Emergen-
cy X—Radiegraphy Utilizatien Study} Lew—Risk Criteria
are twe cemmenly used sets ef guidelines.”
Cellar clearance prntncnls fer patients undergeing
imaging vary by practice, and snme cnntreversy exists.
In general, patients with nnrmal plain radingraphs er
CT, ne neck pain, full active range nf metien, and ne
distracting injury can have the cervical cellar remeved.
Patients with substantial distracting injury need tn have
either flexien-extensien lateral radingraphs er MRI cen-
firmed as nnrmal befere the cervical cellar is remeved. in
patients with nnrmal plain radingraphs nr ET and neck
pain witheut neurelegic deficit, snme prntncnls recem—
mend immebilixatien in a cellar fellewed by repeat clin-
ical evaluatinn and flexinn-extensinn radingraphs after
pain subsides and full and pain—free range ef metien is
achieved. IEither prntncnls recemmend MRI. MRI sheuld
be perfnrmed in all players with neurnlngic deficit nr
symptnms fellewing a cervical spine injury.
Types nf Cervical Spine Injuries
Dcciput. C1. and C2 Injuries
flccipitecervical C1 and C2 injuries eften present witheut
neurelegic injury. Axial leading injuries, high-energy
blnws tn the head, nr acceleratinn-deceleratinn injuries
are the must cemmen mechanisms ef injury. Imaging fer
high-energy cervical injuries sheuld include multiplanar
IE! Ellie American Academy ef flrrhnpneclic Surgeens
Chapter 32: The Ccn'ical Spine
recenstructien CT and MRI. Seme practitieners recem-
mend vascular imaging for all players presenting with C1
er C1 fractures. Treatment algerithms fer C2. fractures
may invelve immnbilixatien in a cervical cellar, capital
fixatinn via haln vest, nr surgical fixatinn.
Uccipital ceudyle fractures eccur via axial leading
ef the skull ente the C1 lateral mass, with a resulting
fracture nf the cnndyle. They alsn can ncc ur frem lateral
hyperflexien. lEliccipite-atlantal disseciatien typically is
seen enly in the setting ef high-energy injuries and results
frnm disruptinn nf the alar ligaments and tectnrial mem-
brane. These injuries can be fatal in adults; nenfatal itera-
tiens need te he censidered highly unstable. Twe metheds
are available fer assessing fer eccipiteatlantal dissecia-
tien en radingraphs: the Pewcrs ratie, which identifies
nnly anterinr subluxatinn, and the basinn-axial interval!
basien—dcns interval lBAII’BDI] methnd.
Atlanteaxial instability may be demenstrated by a
widened atlantn-dens interval {ADI} nr dynamic changes
In ADI en flexien-extensien radingraphs. ADI is less than
3.- mm in the healthy adult male, less than 1.5 mm in the
healthy adult female, and less than 5 mm in children age
15 years er yeunger.
C1 fractures mest typically result frem axial leading
injuries, resulting in a burst fracture {Jeffersnn fracture},
with fragments meving eutwa rd and away frem the spinal
canal [Figure 1, A). Axial T2-weighted images en MRI
'.-'."
assess the integrity nf the transversei’cruciate ligament. I
Rupture ef the transverse ligament is suggested by ever- re
a.-
D.
hang cf the C1 lateral masses nn C2 tntaling mnre than Ev
:5
F mm en AP radingraphs {Figure 1, B}. CL
m
lDdenteid fractures are the mest cemmen type ef C2 'E.
5
re
fractures, accnunting fer nne-half nf all Cl fractures. The
mechanism ef injury is hyperflexien er hyperextensien
(Figure l, C threugh E). Hangman fracture is a hyper-
extensinn and axial leading injury resulting in bilateral
C2 pars fractures (traumatic spendylnlisthesis}. It is mest
cemmenly seen in diving injuries in the sperts setting.
Subaxial Cervical Spine Injuries
Mere than ene-half ef subaxial cervical spine injuries
are hyperflexinn injuries. The ferce is greatest at (34-?
in hyperflexieu, and injury mest cemmenly eccurs at
{35-6. Hyperflexien injuries can result in end plate er
cempressinn fractures, burst fractures, facet dislecatien,
and injury re the pesterier ligaments.
A cempressinn fracture is an anterinr wedge fracture
ef the vertebral bedy. It is censidered te be a stable injury
if ne evidence exists nf severe kyphetic angulatien, canal
cnmprnmise, nr assnciated severe ligamentnus disruptinn.
Flexien teardrnp fracture is a fracture threugh the an-
terinr vertebral bedy, with an anterinr-superier fracture
Drthnpnedic Knnwledge Update: Sperts Medicine 5
 Section 5: Head and Spine

Figure 1 Images show fractures of Cl and C2. A. An axial CT scan displays a Jefferson fracture of C1 in a 22-year-old man
following an axial loading injury during a helmeted fall. Because of the ring structure of the C1 vertebra. fracture
to is obligatory at two or more sites. B, (to ron al CT reconstruction of a Jefferson fracture. Combined lateral mass
.E overhang [red lines} of greater than 1 mm is thought to indicate rupture of the transverse ligament. Coronal {C}
o.
m and sagittal CT reconstruction {D} show a type II fracture of the dens. E. Follow—up lateral radiog ra ph shows slight
'U
r: anterior displacement that was not evident on the initial CT. The patient was treated with odontoid fixation via an
to
I, ante rio rly placed cannulated lag screw and postoperative immobilization in a cervical collar for treatment of an
n: associated Jefferson fracture. (Panel B reproduced with permission from Radcliffe itE, Sonagli MA. Rodrigues LM.
to
I Sidhu E5, Albert Ti, 1lilaccaro Hi: Does E1 fracture displacement correlate with transverse ligament integrity? flrthop
in Sorg 2D13:5:94—59.}

fragment, often associated with posterior displacement of
the posterior aspect of the vertebral body into the spinal
canal and an interspinous ligament tear {Figure 2, A and
B}. A facet capsule injury can be unilateral or bilater-
al. Du lateral radiographs, the facet joint should be no
more than 2 mm wide and should align evenly with the
remaining facet joints. Distraction of a facet, or perched
facet, is indicative of joint dislocation {Figure 2, C} and
can be associated with fractures or discoligamentous in-
jury. Locked facet dislocation, or jumped facet, occurs
when the inferior articular process is pulled anteriorly
and ventrally over the superior articulating process of the
level below. It can be unilateral or bilateral. A high rate
of cervical spinal cord injury occurs in bilateral locked
facet dislocation, with sea of patients presenting with
complete spinal cord injurym {Figure 2, D}.
Extension injuries can occur with direct facial trauma.
Ligamentous injury of the anterior longitudinal ligament,
intervertebral disk injury, pediclcfpillar fractures, spi—
nous process fractures, or facet fractures all can be seen
in hyperextension injuries. ISlay shoveler’s fracture is a
fracture of the spinous process tip. It most commonly
occurs in the cervical spine at spinous process CE or C?
and can occur in the upper thoracic spine {Figure 2, El.
Spinous process apophysitis is seen at prominent spinous
processes C6 or C? that can appear as calcifications of
supraspinatus ligaments or small fracture fragments of the
spinous process tip, and indicates repetitive microtrauma
{Figure 2, F and G].
Axial loading injuries most typically result in sub-
axial cervical injury in combination with another force
vector. Flexion-compression injury is seen in diving in-
juries, spear tackling, or other instances of uncontrolled
impact to the top of the head. Dislocations in the subastial

firthnpaedic Knowledge Update: Sports Medicine 5 fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 32: The Cervical Spine

E
'.-'."
Figure 2 Images shew subaaial cervical spine injuries. A, Lateral cervical radiegraph demenstrates a flesien teardrep I
m
fracture ef :5. A cerenallyr erientecl fracture is seen threugh the vertebral becly. and pesterier displacement ef n.-
D.
the dersal fracture fragment else is seen. E, Atrial LT scan de menstrates the same vertebral bedy fracture and an
:li
shews widened facet jeints. C, Sagittal CT recenstru ctien shevvs a facet capsule injury resulting in uncevering uf CL
the CE articular surface secencla ry te anterier sublusatien ef the E5 facet [black arrewi ancl dislecatien at CE-ir' m
resulting in a perched facet {white arrew}. D, Sagittal ET rece nstructien depicts anterier translatien ef a dislecated 'E.
5
fa cet, resulting in a leclced dislncatien er jumped facet {a rrevv}. E, A lateral radieg raph shews a fracture ef the re
E5 spineus precess. er clay sheveler's fracture {a rrew}. which was first described as a result of avulsien by vielent
pa raspinal muscle centractien. Fractures ef this type are seen in hyperesrtensien injury. Sagittal recenstructien CT
[F] and atrial CT {El demenstrate calcificatiens superficial te 1fte ET spinnus prucess tip {arrnwsl in an 13-year-eld
man with a cervical strain injury. {Panels A and B repreduced with permissien frem Fisher CE. Dverak MFS. Leith
J, Wing P: [em pa risen ef eutcem es fer lewer cervical fleaien teard rep fractures managed with hale theracic vest
versus ante ricIr cerpectemy and plating. Spine {Phr'fa Fa HIE} 2H2;2?:1Efl-1EE. Panels 1: and D re preduced with
permissien frem Raniga SB. l'vlenen v. AI Muaahmi KS. Butt 5: MDCT ef acute su basial cervical spine trauma: A
mechanism based appreach. Insights imaging 2014;533:1333. Panel E repred uced with permissinn frem Mcltellar
Hall RD: Clay-sheveler's fracture...‘ Bane Jer'nt Surg Am manganese-vs.)

cervical spine are must cemmenly the result at fleecien
cemhined with axial leading; diving injury is a classic
mechanism ef injury.
Ligamenteus Injury
The anterier and pesterier lengitudinal ligaments, inter—
spineus ligaments, and facet capsules previde flexibility
and structural integrity tn the subaxial cervical spine,
and injury te ene er mere ef these structures can cem—
premise the stability ef the cervical spine. Ligamentens
injury is diagnesed when radiegraphs er CT demenstrates
signs ef ligamenteus instability, er when direct imaging
ef ligamenteus disruptien er edema is evident en MRI
[Figure 3). Injuries ef this type va ry in severity frem miner
(asseciated with an serieus risk ef late spinal instability er
neurelegic injury} te highly unstable {requiring surgical
fisatien}. Fer this reasen, the injured player with nermal
static plain radiegrapbs er CT sheuld net be presumed
te be witheut a destabilizing injury.

IE! ems American Academy ei' flrrbepaedic Surgeens Dnbepeedic Knewledge Update: Sperrs Medicine 5
 Section 5: Head and Spine

Spinal Stenosis increased incidence of spinal stenosis has been observed in

Spinal stenosis can take the form of congenital stenosis or players with transient quadriparesis or neurologie injury.”
developmental {degenerative} spinal stenosis in the athlete. Dn lateral radiographs, the ratio of the spinal canal
The relationship between spinal stenosis and cervical to the AP diameter of the vertebral body can be used as
spinal cord injury has been a topic of study because an an indicator of congenital spinal stenosis {Figure 4, A}.
A Torg ratio less than {1.3 indicates congenital spinal
stenosis.” Problems arise in using the Torg ratio to de-
fine spinal stenosis because a Torg ratio less than [LS has
been shown to have low predictive value for future spinal
cord injury.”l Another study demonstrated that 49% of
professional football players had a Torg ratio less than
[1.3, but only 13% had stenosis on advanced imaging.” A
diagnosis of spinal stenosis has important implications for
return to play following neurologic injuries or transient
quadripa resis.”*13*“'” MRI is the test of choice to evaluate
for true spinal stenosis because spinal canal diameter with
respect to the spinal cord is the true determinant of spinal
stenosis. Contact of the structural spinal tissues with the
surface of the spinal cord is thought to be the best indi-
Figure 3 Images show cervical ligamentous injury cator of functional spinal stenosis [Figure 4, B and C}.
and traumatic: subluaation. A. Short Tl
inversion recovery Tl—weightecl sagittal MRI
d emonstrates hyperintensity of the interspinous Congenital Anomalies
ligaments of [4-5. EE-E . and {is-T {arrow} In a Congenital anomalies of the cervical spine may be of
ED-yea r—old man following an injuryr sustained
during downhill skiing. B. Lateral radiograph interest to the sports physician in screening for clearance
shows a C? superior articular process fracture or return to play, or can be seen as incidental findings.
and ante rolisthesis of CE on E? {arrow}. Some types of Klippel—Feil anomalies, os odontoideum,r
to
.E
o.
m
'U
r:
n:
1:5
a:
cu
I
li-i

.‘ ‘ ‘4- ‘1“
. _f_‘4 V

Figure 4 Images of the Torg ratio. A, Illustration depicts the Torg ratior defined as the ratio of the spinal canal AP
diameter (ai to the vertebral body AP diameter lb). A Torg ratio less than {LE is considered radiogra phic evidence
of congenital or developmental spinal stenosis. B, Lateral radiog raph demonstrates the measurements of the
vertebral body and the spinal canal AP diameter at E3. E. Sagittal Tl-weighte-d magnetic resonance image
demonstrates a congenitally narrow spinal canal. hypertrophy of the posterlor longttucllnal ligament. and a central
disk bulge at £334 to {16—1

firthopaedic Knowledge Update: Sports Medich'le 5 fl lfllfi American Academy of Orthopaedic Surgeons

cengenital assimilation ef the atlas, and ether cenditiens
can be asseciated with an increased risk ef spinal cerd in-
jury te centact athletes, and these players may be advised
against engaging in centact sperts. A full discussien ef
cengenital anemalies ef the cervical spine and recem-
mendatiens en suitability fer sperts participatien were
prepesed in 199'? and reviewed in 200131-13
lEervical Strain and Sprain
Sperts-related cervical sprain and strain acceunt fer a sub-
stantial pertien ef all neck injuries. A review ef epidemi—
elegic data feund that 24% ef all cervical sprain er strain
injuries seen in the emergency department, excluding
these frem autemebile accidents, resulted frem sperts in-
juries.“ Sprain and strain injuries are seft-tissue injuries,
and the presenting histery is ef axial neck pain, stiffness,
er painful range ef metien fellewing neck injury.
Cervical strain is defined as a stretch injury tn the
muscles and tendens ef the neck witheut injury tn the
vertebrae er ligaments. CT and MRI are nermal in cer-
vical strain. Plain radiegraphs may demen strate a less ef
cervical lerdesis, which indicates muscular spasm. The
treatment ef acute cervical strain censists ef immebiliaa-
tien in a cervical cellar. Patients typically are immebilised
for 1 weeks er until they are pain free. Remeval ef the
cervical cellar is censidered when the patient has ne neck
pain and has pain-free, full, active range ef metien. Lat-
eral flexien—extensien radiegraphs need te be ebtained te
ensure that ne instability is present befere discentinuing
the cervical cellar.
Cervical sprain is a term describing nendestabilixing
cervical ligamenteus injury. Miner ligamenteus injuries
can manifest clinically enly as axial neck pain, with MRI
demenstrating miner tears er edema ef ene er mere liga-
meets. Acute ligamenteus injury is demenstrated best by
fecal STIR sequence hyperintensity en MRI. MRI with
STIR sequences can be perfermed within T2 heurs ef
injury te evaluate fer ligamenteus injury. After T2 heurs,
MRI leses sensitivity fer ligamenteus edema.
Fer cervical strain injuries, cervical sprains sheuld be
managed initially via immehilisatiee in a cervical cellar.
The cervical cellar can be remeved when axial neck pain
is reselved and the patient has pain-free, full, active range
ef metien. Lateral flexienuextensien radiegraphs are ebu
tained at that time. Dynamic instability may warrant
centinued rigid immehilieatien er surgical stabilisatien.
Severe ligamenteus injuries alse may be symptematic
enly as axial neck pain, but imaging may shew signs ef
substantial ligamenteus disruptien, listhesis, malangula—
tien, er injury te multiple ligaments. Severe cervical spinal
ligamenteus injury typically is treated via immebiliaatien
IE! lfllti American Academy ef flrthepaedic Surgeens
Chapter 32: The Cert-deal Spine
in a rigid cervical cellar fer 6 er mere weeks, and desta-
bilizing injuries may require surgical stabilizatien. Severe
er destabilizing ligamenteus injury generally is net cen-
sidered a cervical sprain.
Because athletes with cervical strains and sprains may
net present acutely, management ef the athlete presenting
with a subacute injury suggestive ef cervical strain er
sprain typically sheuld he the same as fer these presenting
acutely. If the player has pain that prevents nermal active
flexien and extensien, then immebilizatien in a rigid
cervical cellar is indicated. Plain radiegraphs sheuld be
ebtained, and fer mild instances witheut limitatien ef full
active range ef metien, lateral flexien-extensien radie-
graphs are ebtained te exclude instability. Athletes with
spinal instability er abnermal imaging er these unable
te underge radiegraphic assessment fer instability are
immebilized in a cervical cellar. Lateral flexien—extensien
radiegraphs can be perfenned after pain has reselved and
the patient can participate in full, active range ef metien.
In the absence ef instability, ne cervical cellar is need-
ed, altheugh immebilizatien may previde symptematic re-
lief. Treatment censists ef withdrawal frem play, NSAIDs,
and ice applicatien.
{Cervical Disl-r Herniatien
Athletes may be at increased risk fer cervical disk de-
'.-'."
generatien, and the implicatien ef this diagnesis fer the I
athlete is impertant.“ Cine review demenstrated that re
a.-
D.
cervical disk herniatien resulted in an average ef 85 days tv
:li
lest frem play in prefessienal feethall players, a figure CL
Lfi
superseded enly by fractures ef the cervical er theracic 'E.
5
re
spine? Altheugh the surgical management ef cervical disk
herniatien demenstrates excellent functienal results in
the general pepulatien, the diagnesis can result in career
limitatien fer elite athletes.
Symptematic disk herniatien results in ene ef several
manifestatiens: neck pain, radiculepathy, er myelepathy.
Often, the initial, er enly, reperts are axial neck pain and
interscapular pain, which may precede the develepment ef
radicular symptems. Twe cemmen patterns ef injury can
result in symptematic disk herniatien: acute disk hernia-
tien and chrenic “hard disk” er disk-esteephyte cemplex.
Acute disk herniatien may result in a herniated nucleus
pulpesus fragment cempressing the exiting cervical nerve
reet er spinal canal stenesis. Chrenic er repetitive injury
may result in the develepment ef esteephytes and disk-es-
teephyte cemplex, which leads te neureferaminal stenesis
and chrenic er recurrent radicular symptems [Figure 5,
A threugh C}. Patients with radicular er myelepathic
symptems are evaluated best with MRI. Large er central
disk herniatien can result in stenesis ef the spinal canal,
Drthepaedic Knewledge Update: Sperts Medicine 5
 Section 5: Head and Spine

Dislr. ianulus Transverse

Lineinate fibmsusi Disk (nucleus
'3”m vertebral arch F rooess

Spinal nerve "-55.- 3"

root _ “I'll, .
. -. .-_-__-'_'-j Postenor tubercle
Pedal-e fit Superior arlioular
Lateral ' iaoet fiUl‘lflflB
mass - - Gumpressed
Posterior ' . nerve root
in longitudinal
.E ligament Epinoua process
I].
1;; E
E Figure 5 Images show cervical dislt herniation. A, Midline TI-weighted magnetic resonance image demonstrates ICE-E and
E 125-? disk he rniations in a 29-year-old man who plays basketball. B. Fa ram edian image shows prominent foramlnal
:5 disk bulges. C. Axial T2-weighted image at ICE—T demonstrates a rig ht pa ra median disk herniation abutting the
LI"!
spinal cord and narrowing the rig ht CE-ir' neu roforamen. Axial illustrations {D and E} show the difference between
paramedian disc herniation abutting a nerve root. and central dislr. herniation compressing the spinal cord. A left
posterolate ral disk protrusion to, arrow} results in mild deformity of the cord and compression of the exiting nerve
root. EeMral canal stenosis and cord impingement secondary to a large central disk protrusion {E, arrow} is shown.

compression of the spinal cord, and symptoms of mye-
iopathy. In the most extreme instances, a large traumatic
cervical disk herniation can result in acute spinal cord
injury {Figure 5, D and E}.
The management of cervical disk herniation varies
according to its presentation. Patients with radicniar
symptoms alone and all motor functional groups greater
than 35 in strength can initially be treated nonsurgically.
Oral corticosteroids, NSAIDs, and oral analgesics can
help relieve radicniar pain. Most cases of acute cervical
radicniopathy resolve with nonsurgical management. Epi-
dural or transforaminal steroid injections may provide
relief of radicniar pain if oral medications are ineffective.
For intractable symptoms, surgery may he recommended.
In patients with a severe motor deficit on presentation,
immediate surgery can facilitate motor recovery. Patients
with motor power of 2:5 or less in the distribution of
the affected nerve should undergo urgent surgery. The
surgical treatment of paramedian cervical disk herniation
resulting in radiculopathy consists only of posterior cer-
vical laminoforaminotomy, anterior cervical diskectomy
and fusion (ACDFJ, or total disk arthroplasty {TBA}.
Currently, TBA is not considered a treatment option for
athletes planning a return to contact sports.

firthopaedic Knowledge Update: Sports Medicine 5 fl lfllfi American Academy of Orthopaedic Surgeons

Bord Compression on MRI or Clinical Evidence of Myelopathy?
g 1'I'iss
Restrict from play
l
—h Honsurgied hashnent
i Treat clinical symptoms
No
— I Syrmtoma remlvact?
.l the
Repeat l'ulFtl
i
Persistent cord compression?
Hl't‘iaa
—1'* Gonsider surgery
li solidly fused
Algorithm shows the proper management of players with spinal cord compression on MRI or clinical myelopathy.
1lt'ideo 32.1: Anterior lnterbody Fusion in
E. Cervical Disc Herniation. Cesare Faldinir
MD; Alessandro Gasharrini, MD; Mo—
hammadreaa Chehrassan, MD; Maria
Teresa Miscione, MD: Francesco Arci, MD;
Michele d'Amato, MD; Luca Boriani, MD;
Stefano Boriani, MD; and Sandro Gianni-
ni, MD {13 min}
Some controversy exists in the current management of
cervical radiculopathy in professional athletes over non-
surgical versus surgical treatment of players with chronic
or recurrent cervical radicular symptoms. In one study,
National Football League {NFL} players returning to play
after undergoing so rgery for one-level disk herniation did
not have a shortened career or reduction in performance
level.E Furthermore, T2% of players undergoing surgery
returned to play, compared with 46% of players treated
nonsurgically. A subsequent study of 15 professional foot-
ball players and wrestlers undergoing ACDF for radicular
and myelopathic symptoms demonstrated that all players
were approved for return to play following surgery, with
13 players eventually returning to professional play at an
average of 6 months following sorgeryfii‘5 In a study of 16
NFL players treated for cervical disk herniation, all play-
ers treated nonsurgically for radiculopathy returned to
play.” Return to play should be considered after neck pain
has resolved and pain-free, full, active range of motion is
IE! lfllfi American Academy of flrrhopaedic Surgeons
Chapter an The Conical Spine
No
'll‘
%\‘
'.= Fletum to sport
present. Players with persistent neck pain, limited range
of motion, radicular symptoms, myelopathy, or radio-
graphic spinal cord compression should not return to play.
'.-'."
Decisions regarding return to play following surgery are I
controversial, but it is generally believed that players with It!
a.-
D.
one-level or two-level cervical fusions can return to play an
3
after demonstrating a solid arthrodesis on CT. CL
Lfi
Cervical disk herniation can have a substantial effect 'E.
5
rs
on athletes in noncontact sports. a review of cervical disk
herniation in 11 Major League Baseball pitchers demon-
strated substantial morbidity.“ Seven players underwent
ACDF and one player underwent TDA. 0f eight players
undergoing surgery, seven returned to play, and one of the
three treated nonsurgically returned to play. The mean
time for return to play for the eight players who did so
was 11.5 months. lCareer longevity extended to a mean
of 63 games pitched over a mean of 3.? years, figures
interpreted as successful management.
Players presenting with spinal cord compression may
require urgent or emergent surgery. Acute disk herniation
with myelopathy is managed surgically for decompres-
sion of the spinal cord. Substantial radiographic cord
impingement or Tl-WfllghtEdfSTIR signal change within
the spinal cord on MRI may warrant surgical treatment
even in asymptomatic patients. An algorithm has been
proposed for the management of myelopathy from cervi-
cal disk herniation in NFL athletes” {Figure 6}.
Drrhopaedic Knowledge Update: Sports Medicine 5
 Section 5: Head and Spine

Spear Taticler Spine

Spear tackling {or spearing} refers to the use of the hel-

met to make initial contact while tackling in American
football. Spear tackling was made illegal by a rule change
in 199'6 after the recognition of a substantially higher
incidence of cervical spine injuries in players initiating a
tackle with the helmet. The incidence of cervical spine
fractures and quadriplegia dropped appreciably in high
athnnl and college football between 19795 and 1973.3“?
The natural flexibility of the cervical spine protects
the structural components from fracture or dislocation
through dissipation of force. Strong supporting cervical
paraspinal muscles and the intervertebral disks allow con—
trolled movement and help to absorb and dissipate applied
forces. The mechanism of spear tackling places the cer-
vical spine in slight flexion, and the nonlotdotic cervical
spine is unprotected from failure during the application of
axial loading forces. A 1993 study popularised the term
“spear tackler spine” to describe the clinical entity and its
biomechanics.fl Players with the clinical syndrome were
considered to be predisposed to spinal cord injury when
subjected to axial loading forces. The recommendation
that players meeting the criteria for spear tackler spine
be precluded from further participation in contact sports
is widely acceptedFL”
Three radiographic features define spear tackler spine:
to
.E cervical spinal stenosis. the loss of lordosis or kyphosis.
n.
m
'U
and imaging findings consistent with prior cervical spine Figure 1" Sagittal lvlFll demonstrates the features of
t: injury. All three findings in conjunction with a prior his- spear tackler spine in a 25-year-old man
to
‘ti who plays professional football following an
:1: tory of engaging in spear tackling qualify a player for this episode of transient quadriparesis. Congenital
to
I diagnosis {Figure '5']. or developmental cervical stenosis. the loss of
Li-i cervical lordosis. and findings of prior cervical
spinal injury are the three characteristic
Cervical Spinal Stenosis radiog ra phic findings in spear tackler spine.
Congenital or posttraumatic developmental spinal steno— Having the three radiogra phic features
precludes play in contact sports by current
sis was present in all players in the initial series.12 In one guidelines. {Reproduced with permission
study of 23 players experiencing an episode of transient from Torg .lS, Flam seyelvlermen .IA: Suggested
management guidelines for participation
quadriparesis, all were shown to have a Torg ratio of in collision activities with congenital.
less than 0.3.” A normal Torg ratio does not exclude developmental, or postinjury lesions involving
spinal stenosis. MRI is the imaging modality of choice for the cervical spine. Med Sci Sports Exercise
1991;29:295-292.]
the diagnosis of spinal stenosis and is more useful than
plain radiographs in players presenting with neurologic
symptoms.
involvement in contact sports, although a return of lor-
Loss of Lorclosis or Ityphosis dotic alignment in reversible cases was thought to warrant
Players in the study on spear tackler spine all demon— reassessment.
strated persistent abnormal straightening of the cervical
spine on neutral upright lateral cervical radiographs.12 Posttraumatic Findings on Radiographic Studies
Players with an abnormal loss of lordosis were catego- Prior compression fractures, limbus vertebrae. interver-
rized as having permanent loss of lordosis. presumably tebral dislr. herniation, ligamentous laxity. subluxation,
secondary to repetitive trauma, or reversible loss of lor— and other radiographic findings consistent with prior cer—
dosis. Either finding was considered reason to preclude vical spine trauma were present on imaging studies. The

firthopaedic Knowledge Update: Sports Medicine S Q lflld American Academy of Orthopaedic Surgeons
 Chapter 31: The Cervical Spine

'.-'."
I
re
a.-
I D.
Eu
3
CL
Figure 5 Images depict atlanto axial rotatory subluxation. A, Illustration shows the cocit robin torticollis position. The head m
is held in approximately 20" of lateral flexion and 2t)" of co ntralateral rotation. The patient can actively correct 'E.
5
the deformity to neutral but cannot turn the head beyond neutral to the contralateral direction. B and C, Lateral re
flexion and extension radiographs. respectively, demonstrate a fixed widened atlanto-dens interval in a 34-year-
old man after a fall. D. AF“ open-mouth odo ntoid view demonstrates a skewed dens-E2 lateral mass relationship.
a finding that can be easily missed on the AP open -mouth view. E, Th ree-dim ensional ET reformat demonstrates
rotation of C1 aho ut the right {1-2 articulation, with fixed su bluxation of the El lateral rnass anterior to the E2
lateral mass. A fracture of the left E2 superior articular surface is seen. {Panels I. C. D. and E reproduced with
permission from Kim ‘r'S, Lee Jill. Moon S], Kim SH: et al: Posttraumatic atlantoaxial rotatory fixation in an adult.
Spine {Phila PA HIE) 2Dfl?;32:EEEI-EEEI}

clinical presentation of players in the original description
of injury was in all 15 cases, either for “neck injury“ or
for neurapraxia localizing to the cervical spinal cord,
cervical nerve roots, or brachial plexus.21
Atlantoaxial Hotatory Suhluxation
Atlantoaxial rotatory suhluxation [EARS], also called
atlantoaxial rotatory dislocation or atlantoaxial rota—
tory fixation, is an uncommon injury following cervical
spine trauma. The condition occurs most commonly in
children. A recent review of isolated AARS in adults iden—
tified the condition as case reportable, with only 14 cases
appearing in the literatnrc.3‘3'=3'1 Few data in the sports
literature address the condition. Several reports describe
AARS occurring following rugby injuries and one fol-
lowing a diving injury.“ Current guidelines denote the
condition as an absolute contraindication to return to
contact sportsfurfl
People with syndromes of ligamentons or connective
tissue laxity are thought to he at increased risk. In chil-
dren, AARS can occur after minor trauma. In one series,
patients had a mean age of El} years and presented most
often following upper respiratory infection or major or
minor trauma.”- The classic presentation is torticollis,
with the head held approximately 20" in lateral bending

IE! lfllfi American Academy of flrthopaedic Surgeons Drrhopaedic Knowledge Update: Sports Medicine 5
 Section 5: Head and Spine

El
Figure 9 A. Axial CT image shows axial rotation and greater than 5 mm anterior suhluxation of Cl on C2 in a rEl-year-
old boy with neck pain and torticollis. B, Three-dimensional CT reconstruction shows rotatory displacement
of [1 on C2 and in situ fusion in the rotated position. This CT was obtained 14 months following the unset of
sym ptoms. highlighting the likelihood of delay in the diagnosis of children with atla ntoaxial rotatory suhluxation.
(Reproduced with permission from Roche El. D'Malley M. Dorgan it; Larty HM: A pictorial review of atla nto-axial
rotatory fixation: Key poinlx for the radiologist. Clio l't‘ao'i'o.t 2Dfi1;55:§4?-953.}

and 20" in coutralateral axial rotation with slight flexion,
the “cock robin” position {Figure 3, A}. Sternoclcidomas—
toid muscle spasm may be present, and patients are able
to
.E to voluntarily correct their deformity but cannot move
o.
m
'U
their head beyond neutral. In one series, the average delay
r: in diagnosis was 11.6 months. Plain radiographs detected
n:
1:5
n: only six of eight cases in another series of patients with
to
I radiographs followed by CTE”3 The wide availability of
li-i
multiplanar reconstruction CT may improve the sensitiv-
ity [Figure 3, B through E and Figure 9].
The treatment algorithms for AARS are controver-
sial, and it should he considered that pediatric AARS
following only minor trauma and AARS in skeletally
mature athletes from higher energy injuries are different
entities. In unilatEral antarior subluxation without injury
to the transverse ligament or another associated fracture
or ligament injury, traction reduction and immobilization
in a cervical collar comprise a commonly recommend-
ed treatmentfilvflrh'“ |IEIontroversy exists over whether
reduction is necessary in pediatric cases, and current
evidence is limited to small case series and expert opinu
ion.“ Immobilization in a halo vest or surgical fixation
may be indicated in recurrent cases. In one series of sev-
en pediatric patients, six patients with recurrent AARS
eventually required surgical fixation.35 Recurrence was
seen only in patients first presenting with symptoms of
3 weeks‘ duration.
In the athlete presenting acutely with neck injury and
AARS, the management is the same as that for an unsta-
ble cervical spine injury. Halter traction or Gardner—Wells
traction can he applied to help reduce the subluxation in
the context of any associated fractures or ligamentous
injury. Immobilization in a halo vest or surgical fixation
may be necessary. Heurologic deficit, transverse liga-
ment rupture, and fractures are indications for surgical
reduction and fixation. Substantial spinal canal stenosis
or neural element compression may require emergent sur-
gical reduction or decompression and surgical fixation.
(31-2 fusion is considered an absolute contraindication to
return to sports in commonly used guidelines.“
S Li m in a ry
Cervical spine injuries in the athlete range in severity
from minor transient injuries to catastrophic injuries
with permanent neurologic disability. A thorough un-
derstanding of the types of injuries, presenting history
and examination findings, and radiographic findings is
vital for the sports physician to treat and counsel players
with injuries and disorders of the cervical spine. Minor
injuries and chronic conditions can result in substantial
time away from play, and can be associated with the risk
of further injury to the sports participant. Differentiating
injuries and conditions that are self-limiting from those
necessitating referral to a spine specialist is important in
the management of both injuries and chronic conditions.

firthopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons

Available evidence fer the management ef spine injuries
as relevant te prefessienal and high-perferming athletes
i5 mestly limited It: flbSEWfltlflfli-“ll Silldlfli
Itey Study Peints
it A cempIEte neurelegic examinatien is mandatety in
players with suspected cervical spine injuries. Play-
ers with abnermal neurelegic examinatien results
er histeries that suggest neu relegic invelvement are
evaluated best with MRI.
Understanding the differential diagnesis ef cervical
spinal injuries and the lecalisatien ef neurelegic in-
jury via histery taking and physical examinatien is
parameunt fer the sperts medicine previder.
Axial leading and hyperflexien injuries are the must
cnmmen causes ef sperts—related catastrophic cer-
vical spine injuries. Uncentrelled impact te the tep
ef the head in recreatienal sperts acceunts fer mest
sperts—related spinal cerd injuries.
Cervical sprains and strains are stretch injuries tn
the musculetendineus units er ligaments ef the
cervical spine. Sprains and strains typically de net
have majer late censequeuces, but players sheuld be
withdrawn frem play until the reselutien ef neck
pain and the return ef full, active, pain-free range
ef metien.
Patients with cervical disk herniatien can present
with neck pain, radiculepathy, er myelepathy. The
diagnosis has a substantial effect en players and
results in a mean time away frem play ef 35 days.
Radiculepathy may be managed symptematically
er surgically. Myelepathy er radiegraphic spinal
cerd cempressien may require surgical treatment.
Spear tacl-tler spine is defined as the cencemitant
eccurrence ef cervical spinal stenesis. the less ef
cervical spinal lerdesis er develepment ef cervical
kyphesis. and radiegtaphic findings censistent with
print cervical spinal trauma. Players with this cen-
ditien are at increased risk ef spinal cerd injury and
may net participate in centact sperts.
AARS is an uncemmen injury in adults and can
present in children fellewing seemingly miner trau-
ma. Children with spentaneeus terticellis er players
with acute terticellis fellewing sperts injury sheuld
be evaluated fer AARS.
IE! Ellie? American Academy ef flrthepaedic Surgeens
Chapter as The Cen'ical Spine
Aflflm HEfEl'EflEES
1. Mareun JC, Bailes JE: Athletes with cervical spine in-
jury. Spine {Phila Pa 19%} 1996:21{19}:2254—2299.
Medline DD]
2. Rihn JA. Andersen DT, Lamb F... et al: Cervical spine
injuries in American feetball. Sperts Med 2dfl9;39{9]:69?—
TBS. Medline DUI
This review discusses reetr'btachial plexus neutepraJ-tia:I
cervical cerd neuraptaxia, catastrephic neurelegic injury,
early evaluatien and management, and return te play in
the centext ef American feetball.
Themas BE, McCullen GM, Yuan HA: Cervical spine
injuries in feetball players. I Am Acad' Drtleep Surg
199 9;?{5 1:333—341 Mcdlinc
AlhrighrJP, lvieses li, Feldiclr HG, Delan ED, Eurmeis-
ter LF: Nenfatal cervical spine injuries in interschelastic
feetball. IAMA 19?E;235[11]:1243-1245. Medline DUI
Mall NA. Buchewslti]. Zebala L, Brephy RH. Wright RT.
Matava M]: Spine and axial sl-teleten injuries in the bla-
tieual Feetball League. Am ] Sperts Med1012;40j3j:1?55-
1?61. Medline. DUI
This epidemielegic study reviews 11 years ef data en in-
juries re the spinal and axial skeleten sustained by NFL
players. Spine injuries resulted in a mean ef 15.? days lest
frem play per injury:I and cervical disk herniatien resulted
in a mean ef 35 days lest per injury. Level ef evidence: II-C.
'.-'."
I
Hsu 1Wit: flutcemes fellewing nenepetative and eperative re
a.-
treatment fer cervical disc herniatiens in Natienal Feetball D.
an
League athletes. Spine {Phile Pa 1935} lflllfifijlfljdlflil- 3
305. Medline DD]
CL
Lfi
'E.
5
This retrespective cehert study used newspaper archives re
and team data bases te identify NFL players in whem cer-
vical dislt herniatiens had been diagnesed. |Elf all players,
?2% returned tn play fellewing surgery fer disc herniatien
cempared with 46 “ii:- ef these managed nens urgically.
Level ef evidence: IV.
Schreeder GD, Lynch T5, Gibbs DE, et al: The impact
ef a cervical spine diagnesis en the careers ef Natiun-
al Feetball League athletes. Spine (Phillis Pa 197%?)
2014;35l12]:94?—952. chttp:l'lld:v..dei.ecgf1l.'l.109?":r
Eflfiflflflflflflflflflflflflflfill Medline DUI
This case-centrelled cehert study cempared the careers
ef entering NFL players with a diagnesis ef prier cervical
spinal injury er pathelegy with matched centtels. Players
with the cervical spine diagnesis were less likely te be
drafted ente a team and had sherter careers. Level ef
evidence: III-E.
Ewart: EE, Baden HP, IEeursen 11W, et al: Natienal athletic
trainers’ asseciatien pesitien statement: Acute manage-
ment ef the cervical spine-injured athlete. ] Ariel Train
2fl09;44{3}:3i]E-331.Medline DD]
Drthepaedic Knewledge Update: Sperrs Medicine 5
 Section 5: Head and Spine
This position statement from the NATE. outlines prepa-
ration for events, necessary training for personnel, and
on-field evaluation and management algorithms. This is
an in-depth review and treatment of available evidence
for the early management of sports players with cervical
spine injuries.
Waninger KN: Management of the helmeted athlete
with suspected cervical spine injury. Am J Sports Med
1dfl4;52{5}:1331-1350.Medline DC}!
III. Robertson WC Jr, Eichman PL, Clancy WC: Upper
trunk brachial plesapathy in football players. JAB-IA
19T9:241{14]I:145fl-1452.Medline DUI
11. 5allis RE, Jones K, Knapp W: Burners: lE'.*l'*fensive
strategy for an underreported injury. Phys Spartsrned
1991;2fl:4?«55.
12. Torg J5, Corcoran TA, Thibault LE, et al: Cervical
cord neuraprairia: Classification, pathomechanics,
morbidity, and management guidelines. J Neurosurg
199?b:5?{6}:543-55fl.Medliue DUI
13. Torg J5, Naranja R] Jr, Pavlov H, Galinat 5], Warren R,
Stine RA: The relationship of developmental narrowing
of the cervical spinal canal to reversible and irreversible
injury of the cervical spinal cord in football players. J Bone
Joint Sarg Am 1995;?5ifl}:1505-1514. Medline
14. ASIA Learning Center Materials - International 5ta ndards
for Neurological Classification of SCI {ISNCSCI} Exam
to Worksheet. Available at: httptifwwwasia-spinalinjury.
.E orgielearningJISP-ICSCIphp. Accessed August 1.1, 2615.
D.
m
1:
t:
to 15. Hoppenfeld 5: Physical examination ofrhe certricai spirre
1:5
a: and reinporonrandihaiar joint. Physical examination of
a: the spine iii" extremities. Upper Saddle River, NJ, Preotiee
I 112. Medline DUI
li-i Hall, 19%, pp 105-132.
1:5. Wetsel FT, Raider B: Cervical and thoracic spine, in Reider
B, ed: The Urrhopaedic Physical Examination, ed 1. Phil-
adelphia, PA, Elsevier Saunders, 2W5, p 2.91354.
1?. Stiell IG, Clement CM, McKnight RI}, et al: The lCanadian
|III-spine rule versus the NEKU5 low-risk criteria in patients
with trauma. N Engi J Med El] fl3;349(2 EltlfiIII-2.515.
Medline DUI
15. |Crant CA, Mirna 5K, Chapman JR, et al: Rislt of early
closed reduction in cervical spine sublustation injuries.
J Neurosurg 1995;9{i{5uppl 11:13-15. Medliue
15*. Pavlov H, Torg 15, Robie B, Jahre CZ: Cervical spinal ste—
nasis: Determination with vertebral body ratia method.
Radioiogy 193T;164{3}:??1-?T5. Medline DUI
21}. Hersog R], 1|illiiens I], Dillingham MF, 50a M]: Normal
cervical spine murphametry and cervical spinal steno-
sis in asymptomatic professional football players. Plain
film radiography, multiplauar computed tomography,
4-513 Urdmpaedic Knowledge Update: Sports Medicine 5
and magnetic resonance imaging. Spine {Piniia Pa 19%}
1991:16j5, 5uppli51T5-515ti. Medline DUI
21. Torg J5, Ramsey-Emrhein JA: Suggested management
guidelines for participation in collision activities with con-
genital, developmental, or postinjurj.T lesions involving the
cervical spine. Med Sci Sports Exerc 199?:29U, 5uppl]
5256-52?2. Medline DUI
22. Torg J5, 5ennett Ii, Pavlov H, Lemnthal MR, Glasgow 5G:
Spear tacltler's spine. An entity precluding participation
in tackle football and collision activities that expose the
cervical spine to axial energy inputs. Am J Sports Med
1993;21i5jtfi4fl-649.Medline DUI
23. Vaccaro AR, Klein GR, Ciccoti M, et a1: Retunt to play
criteria for the athlete with cervical spine injuries result-
ing in stinger and transient quadriplegiaiparesis. Spine
J' 2fl0252{5}:351—356. Medline DUI
24. Versteegen CJ, Kingma J, Meijler W], ten Duis HJ: Heck
sprain not arising from car accidents: A retrospective
study covering 25 years. Ear Spine J 1995:?{3}:2fl1-Zfl5.
Medliue DUI
25. Roberts DW, Rec (3], Hsu WK: Uutcames of cervical and
lumbar disk herniatiuns in Major League Baseball pitch-
ers. Urthapcdics 2011;54[5}:5fl2-609. Medline DUI
Eleven Major League Baseball pitchers with a diagnosis
of cervical disc herniation were identified. fit an average
of 1.6 months following diagnosis, eight returned to play.
Eight underwent surgical treatment. Management contro-
versies are also discussed. Leml of evidence: IV.
26. Maroon JC, East JW, Petraglia AL, et al: Uutcames after
anterior cervical discectomy and fusion in professional
athletes. Neurosurgery 2fl13;?3{1}:1fl3-112, discussion
A series of 15 professional football players or wrestlers
who underwent anterior cervical diskectamy and fusion
was retrospectively studied. All players were eventually
cleared for return to play, with 13 actually returning a
mean of 5 months pastopcratively. Level of evidence: W.
1?. Meredith D5, Jones K], Barnes R, Rodeo 5A, Cammisa FP,
Warren RF: Dperative and nonoperative treatment of cer-
vical disc herniation in National Football League athletes.
Am J Sports Med 2913;41j9}:2fl54-2D53. Medline DCII
Sixteen NFL players with a diagnosis of cervical dislt
herniation were identified. (If the players, three were
treated surgically, one of whom returned to play. In the
nonsurgical group, 5 of 13 returned to play. Management
strategies are reviewed. Level of evidence: IV.
15. Torg J5, Trueit RJr, Quedenfeld TC, Burstein A, Spealman
A, Nichols E III: The National Football Head and Neck
Injury Registry. Report and conclusions 19TH. JAMA
19?9;241[14}:14T?-14?9.Medliue DUI
19. Torg J5, 1ii'egso J], Bennett B, Das M: The National
Football Head and Neck Injury Registry. 14-year report
U ems American Academy of Orthopaedic Surgeons

en cervical quadriplegia, 19T1 thruugh 1934. IAMA.
1935;154{E4}:3435—3443. Medline DUI
EH}. Creek TE, Eynuu CA: Traumatic atlantcaitial rotate—
ry suhluaatien. Emerg Med j 2Dfl5:22{9}:6?1-fi?2.
Medline DUI
31. VEHkfltEfiflfl M. Ehatt R. Newey ML: Traumatic atlante-
axial rutatury subluitatiun {TAARS} in adults: H. repurt uf
five cases and literature review. Infur'y 1011;43{?}:1111-
1215. Medlinc Dfll
The authurs discuss a case presentatinn and review ef 12
papers presenting cases nf traumatic atlanteaitial retatury
subluitaticrn in adult patients. The repurt describes trau-
matic EARS and the management as applicable tn spurts
and ether injuries in skeletally mature patients. Lewl cf
evidence: IV.
32. Fielding JW, Hawkins R]: Atlante-axial rutatury fixatiun.
{Fixed rutatcrry snbluxatien {if the atlantn-aatial jnint}.
j Enas jail-st Snag Am 19??;59{1]:3?-44. Medliue
33. Wuudring JH, Lee C: The rule and limitatiens nf cum-
puted terms-graphic scanning in the evaluatiett cf cervical
trauma. ] Trauma 1992:33l5}:693-Tflfl. Medline DUI
IE! lfllfi American Academy tif flrthupaedic Surgeens
Chapter 32: The Cert-deal Spine
34. Pang D: Atlanteaitial retatcrry fixatien. Neurusargery
lfllflgl‘ifild, SuppllltSI—IBS. Medline DUI
The hiemecha nics ef the {31—2 jeint in AARS is described
extensively, and the pathnphysiultigy chi HARE in children
is hypethesized and a clinical grading system is presented.
A management algnrithm based cm the grading system is
prupc-sed. Level c-f evidence: IV.
35. Suhach BR. McLaughlin MR, Alhright AL, Pnllaclt IF:
Current management ef pediatric atlantnaaial rntatery
suhluxatiun. Spine (Phila Pa 19176} 1993;13{lfl}:21?4-
El'fl. Medline DUI
36. Kiln Y5, Lee JK, Mean 5], Kim SH: Pest—traumatic atlan-
tnaitial retatery fiaatinn in an adult: A case repeat. Spine
(Phila Pa 1935} 200?:32l23}:E632-E63?. Medline DUI
Videe Reference
31.1: Faldini C. Gasharrini A. Chehrassan M. et al: Viden. Aa-
teritn' Interbed'y Fusion in Cervicai Disc Herniat‘iun. Bfllfigflfl,
Italy, University ef Belugna Istitutcr Drtcpedicc Riaaeli, 11111.
'.-'."
I
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D.
u:
:l:
CL
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5
at
Drthupeedic Knnwledge Update: Sperts Medicine 5
®
Chapter 33
Thoracolumbar Spine
Anuj Singla, MD Christopher A. Burks, MD
Low back pain and related symptoms are common rea-
sons for clinical visits to spine surgeons. The incidence
of back pain continues to increase, which is attributed
to lifestyle changes and increased involvement in sport-
ing activities. Careful attention should be paid to the
inciting event while eliciting history and neurologic ex-
amination as well as radiologic evaluation. Some of the
most common reasons for nonremitting and recurring
back pain include disk degeneration, disk herniation,
spinal stenosis, spondylolysis, and spondylolisthesis. The
management of spinal problems is highly individualised,
based on pathology, symptomatic involvement, and the
activityiphysical demands of the patient. Conservative
treatment is usually the first line of treatment for most
of these disorders. Return to activity {including sports]
is a big challenge and often requires aggressive and
prolonged rehabilitation.
Keywords: thoracic spine: lumbar spine:
degeneration: spondylosis; clislt herniation:
spondylolisthesis
Introduction
Low back pain is one of the most common symptoms for
which patients seek medical care. The lifetime incidence
ranges between 60% and 910%, with 25% of people re—
porting an episode of low back pain within the previous
3 months.1 Direct medical cxpcnditu res for the treatment
of low back pain is more than $100 billion annually and
is increasing} Low back pain is a significant source of
Dr. Burks or an immediate family member has stock or stock
options heici in Smith a iliephew. Neither Dc Sinpia nor any
immediate family member has received anything of value
from or has stock or stock options heici in a commerciai
company or institution reiateci directly or indirectiy to the
subject of this chapter.
fl lflld American Academy of Drthopaedic Surgeons
short-term and long-term disability, lost productivity, and
work absenteeism. Up to 25% of all missed work days in
the United States are attributed to low back pain}I The
condition is also common in the adolescent population,
with more than 3% of episodes having no clear diag-
nosis.‘1 The common nontraumatic spinal pathologies
affecting the thoracolumbar spine include disk degener-
ation, disk herniation, spinal stenosis, spondylolysis, and
spondylolisthcsis. The management of thoracolumbar and
lumbosacral spine-related pain differs, depending on the
exact etiology of the patient‘s symptoms.
History and Physical Examination
The approach to the active patient with low back pain
with or without leg pain begins with a thorough history
and physical examination. It is important to establish
'.-'."
a timelinc for the patient’s symptoms and to identify I
the nature, duration, onset, and characterisation of the m
n.-
D.
symptoms. When eliciting the history, the physician must Eu
:li
focus on any inciting event and the presence or absence CL
m
of certain red flags. Red flag signs indicate the potential 'E.
5
m
for an underlying pathology that warrants a timely and
focused workup. Evaluation of a patient presenting with
low back or leg pain and a history of fevers, chills, weight
loss, cancer, immunosuppression, andior intravenous drug
abuse should prompt the clinician to consider infection or
malignancy as a possible etiology. Evaluation of a patient
presenting with back pain and rcports of clu msincss, gait
instability, or bowel, bladder, or sexual dysfunction should
prompt the physician to carefully assess for causes of spinal
cord dysfunction, such as cervical or thoracic myclopathy.
Asking the patient to describe the pain in relation to
certain activities can help identify a possible etiology.
Discogenic pain related to disk degeneration or disk her-
niation may be worse in flexion, while sitting, or with pro—
longed axial loading and often is described in a diffuse,
band—like distribution. Facet-mediated pain related to
facet arthrosis or spondylolysis may be worse in extension
and is often activity related and well localised.
A thorough examination should begin by observing the
patient walk, which allows an assessment of coordination,
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 5: Head and Spine

-—
Common Physical Examination Findings
Level Motor Sensory Reflex
L1 None Inguinal crease Hone
L2 Hip flexion Anterior upperrinner Hone
thigh
L3 Hip flexio nfadduction Anterion'inner thigh None
L4 itnee extension Lateral thighr anterior Patellar
ltnee, medial leg
L5 Ankleftoe dorsiflexion, Lateral leg, dorsum of None
hip abduction foot
51 Ankle plantar flexion. Posterior leg. lateral foot Achilles
foot eve rsion
52 Toe pla ntar flexion Fla ntar foot Hone
53-4 Bowelr'bladtler Perianal Cremasteric

strength, and symmetry of motion. Palpation of the back
should assess for any points of maximal tenderness such
as in the facets, the paraspinal musculature, or the sacro-
iliac joints. Assessing the range of motion of the hips can
help to rule out referred pain due to hip arthrosis. A thor-
ough sensorimotor examination should follow {Table I}.
Provocative tests can be performed to elicit responses
that corroborate physical examination or imaging find-
cu
.E ings. These tests may include testing for nerve mot tension
I].
U'll
1:
signs such as a straight leg raise, contralateral straight
t: leg raise, or femoral nerve stretch test. For the purpose
H:
‘ti
:1: of detecting lumbar disk herniation, the straight leg raise
cu
I test is more sensitive but less specific than the contra-
Ii-i
lateral straight leg raise test in patients with single-leg
radicular pain?
The provider must he aware of possible indications of
nonorganic or psychologic pain etiology. The five catego-
ries of signs for such an etiology, as described by Waddellfi
are tenderness, simulation, distraction, regional distur-
bances, and overreaction. The presence of three or more
Waddell signs should prompt the physician to evaluate
for other etiologies of the symptoms such as depression,
hypochondriasis, or secondary gain issues. The presence
of three or more 1|illiiaddell signs does not discount the
possibility of a spine problem but is associated with higher
pain scores and poorer treatment outcomes overall.
Thoracic Herniated Disk
Epidemiology
Symptomatic thoracic disk herniation has an incidence
of approximately H.594: in the population and occurs
most commonly in males between the ages of 4D and 5D
years? It can occur at any level in the thoracic spine, but
75% occur below T3, with most occurring at T11-12
because of increased relative mobility at this level. In a
study of Mills of asymptomatic individuals, Tfi'ilis had
disk degeneration, and 19% were found to have thoracic
disk herniation with a resultant spinal cord deformation.“
Clinical Presentation
Thoracic disk herniation may present in a variety of ways.
Approximately half of patients will identify a specific
traumatic event that led to the onset of symptoms; many
will report insidious onset consistent with chronic degen‘
erative changes, however. The most common presentation
is axial pain in the mid to low thoracic spine that may
extend into the lumbar spine. The second most common
presentation is radiating pain in a dermatomal pattern
that may be unilateral or bilateral. Common dermatomal
reference levels are the nipple line corresponding to T4,
the xiphoid process corresponding to TT, the umbilicus
corresponding to Till], and the inguinal crease corre-
sponding to T12. Percussion of the posterior elements
of the thoracic spine may reproduce or exacerbate axial
andfor radicular pain. Lower thoracic disk hemiations
may even present with an isolated unilateral footdrop
associated with upper motor neuron signs?
The least common presentation, but one that must be
readily identified, is that of progressive myelopathy. Be-
cause of the chronic degenerative process associated with
disk herniations, patients often will present with a myriad
of symptoms consistent with more conunon lumbar spine
etiologies. A thorough assessment of root level sensorimo-
tor function and upper motor neuron function should oc—
cur. In a review of 42? patients with symptomatic thoracic

firthopaedic Knowledge Update: Sports Medicine 5 fl lfllfi American Academy of Orthopaedic Surgeons

stenosis due to disk herniation or ossified ligamentum
flavum, 31% had lower extremity weakness, and 64% re-
ported lower extremity sensory deficits.m Bowel, bladder,
and sexual dysfunction may be noted in 15% to 2fl% of
patients.11 Sustained clonus, a positive Bahinski sign, hy-
perreflexia, and altered gait should prompt the physician
to consider cervical level or thoracic level disk spinal cord
compression in the diagnosis. A positive Romherg test is
highly sensitive for early myelopathy due to dorsal col-
umn dysfunction, resulting in decreased proprioception.
Although most often considered part of the routine evalu-
ation of idiopathic scoliosis, abdominal reflexes also may
he asymmetric in patients with thoracic myelopathy.
Diagnostic Imaging
Diagnosis of a symptomatic thoracic disk herniation re-
quires confirmatory imaging. The most common imaging
modality for the detection of thoracic disk herniation is
MRI, which is highly sensitive and therefore associated
with a high rate of false-positive results. {line potential
drawback to MRI is its limitations with respect to evalu-
ating for calcified disk fragments or ossified ligamentum
flavum. In patients in whom a high suspicion exists for
disk or ligamentum ossification or in those with an inabil-
ity to undergo MR1, CT myelography provides a viable
option. Like MRI, CT myelography identifies a high rate
of asymptomatic herniations. Plain radiography is of little
utility in the diagnosis of thoracic disk herniation but is
useful in assessing for transitional anatomy or the pres—
ence of any instability or malalignment and to compare
with intraoperative localization in the surgical patient.
Treatment
Symptomatic thoracic disk herniations have a variety of
presentations varying from mild pain to frank parapa-
resis. Therefore, the treatment timeline and treatment
strategy can vary significantly. Most symptomatic tho—
racic disk herniations may be treated with nonsurgical
measures similar to those used for lumbar disk hernia-
tions. These treatments include NSAIDs, muscle relax—
ants, short-term narcotics, antineuropathic medications,
and physical therapy. For the patient with acute pain,
physical therapy initially should be restricted to passive
treatment modalities such as heat, ultrasound, and mas-
sage, but as symptoms diminish, more active therapy
such as extension-based exercises, core strengthening, and
range-of-motion exercises can he introduced. For patients
with substantial radicular pain, an intercostal nerve block
may be an effective adjunct treatment option.” Except in
the case of acutely progressive myelopathy, nonsurgical
treatment should be undertaken for a minimum of 4 to
5 weeks before surgery is considered.
IE! Eillfi American Academy of flrthopaeclic Surgeons
|i.'Illa1:iter 33: Thoraoolumhor Spine
Thoracic disk herniations are associated with more
lost time from games and practice than are lumhar disk
herniations. In a retrospective review” of the National
Football League’s {NFL} surveillance database, players
with thoracic disk herniations missed significantly more
practices and games {T2 and 1?, respectively? on aver-
age than those with lumbar disk herniations {39 and 11,
respectively}.
Surgical treatment is appropriate for patients with
radicular pain recalcitrant to prolonged nonsurgical
management, weakness, and acute myelopathy. Approxi-
mately 4% of thoracic disk herniations present with acute
myelopathy with severe functional limitations {Figure 1}.
Some authors have advocated a more aggressive, urgent
approach to surgical decompression and stabilization in
these patients.” One of the most challenging aspects of
the surgical treatment of thoracic disk herniation is the
appropriate localization of the correct level intraopera-
tively.” Proper localization is paramount to successful
surgical treatment and the avoidance of litigation.
The thoracic spinal cord is not as amenable to manip-
ulation as is the thecal sac in the lumbar spine. Multiple
surgical approaches are used to decompress the thoracic
spine—the anterior approach through a thoracotomy or
comhined thoracoahdominal approach, the direct lateral
retropleural approach, the posterolateral approach via a
costotransversectomy, and the transpedicular approach,
'.-'."
as well as posterior thoracic laminectomy—although no I
strategy has been shown to be consistently superior, and m
n.-
D.
each is associated with its own risks and complications. n:
3
Regardless of the approach taken, the decision to per- CL
Lfi
form instrumentation and fusion is dependent on the 'E.
5
re
degree of instability imparted by the approach.” Recently,
minimally invasive endoscopic techniques have been de-
scribed with promising results in small case series."5~”' In
appropriately selected patients, these newer techniques
may result in less morbidity and allow an earlier return
to play for athletes.
Lumbar Disk Herniation
Lumbar disk herniation is a common finding on MRI
of the lumbar spine. Although often an asymptomatic,
incidental finding, it can be associated with significant
back and extremity pain, as well as sensory and motor
deficits. Although lumbar disk herniation can occur in
children and young adults, it is most common in people
older than 51'} years, representing a single point in the
degenerative cascade of the intervertebral disk, much like
a degenerative meniscus tear. The herniation occurs as a
result of tensile failure of the anulus fibrosus following
internal disk disruption.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 5: Head and Spine
G. .
I F}!- I.
a. ass-L '-
Figure 1 Axial {A} and midsagittal {E} TE-weighted MRI
scans demonstrate a large Tfi-fi central disk
herniation in an active 55-year-old woman
who presented with severe pain and bilateral
lower-extremity weakness. She unde rwent Tfivfi
diskecto my and TB-TEI instrumented fusion via
a posterior extracavitary approach. AP {C} and
to lateral {DJ radiographs show postoperative
.E views. The patient experienced immediate
o.
m improvement in pain and lower extrem ity
'U weakness.
t:
to
1:5
at
ca
I the nerve root {Figure 2.}. Plain radiographs cannot show
li-i
Lumbar disk herniations can be characterized by their
location and the integrity of the annulus and posteri-
or longitudinal ligament. With regard to location, disk
herniations may be central, paracentral, foraminal, or
extraforaminal; paracentral herniations are most com—
mon because of the relatively reduced strength of the
posterior longitudinal ligament. A dislt herniation also
may be described as a bulge or protrusion when the anulus
fibrosus is intact; conversely, it may be extruded through
an annular or ligamentous defect or sequestered without
attachment to the native disk. IZ'I'besity, occupations that
involve heavy lifting, exposure to persistent vibration,
smoking, and genetics have been identified as risk factors
for lumbar disk herniation.”
Clinical Presentation
The clinical presentation of symptomatic herniated disks
may include isolated back pain, single-leg radicular pain,
weakness, or numbness, or cauda equina syndrome. 0f—
ten, a prodromal history of low back pain is noted by the
firthopaedic Knowledge Update: Sports Medicine 5
patient when describing the symptoms. Most patients are
unable to pinpoint a specific inciting event but relate that
it began spontaneously. As always when presented with a
patient with low back pain andfor leg pain, it is impera-
tive to rule out potentially serious etiologies by inquiring
about bowel and bladder dysfunction, the presence of
fever, or progressive neurologic deterioration.
a thorough physical examination can help to elicit
weakness and sensory deficits, but most commonly, the
patient’s description of radicular symptoms can give a clue
or provide further information to confirm a diagnosis.
Dbserving the patient’s gait can be useful in detecting
subtle weakness. Nerve root tension signs such as the
straight leg raise and femoral stretch test are more specific
for lumbar disk herniation than is dermatomal distribu-
tion, because significant overlap exists. Straight leg raises
are considered positive when pain is reproduced between
35” and T5 “, which is the point at which stretch is applied
to the sciatic nerve. An assessment of reflexes should he
performed, because hyporeflexia would be expected to
be present in cases of nerve root compression from a
herniated disk.
Diagnostic Imaging
The most common imaging study used to identify a lum-
bar disk herniation is MRI. TEE—weighted axial and sag-
ittal images best delineate the space-occupying nature of
the disk in relation to the thecal sac, given the contrast
provided by the cerebrospinal fluid. T1—weighted sagittal
images provide the best view of the exiting nerve root and
the overall foraminal space because of the fat surrounding
disk herniations, but they may demonstrate disk space
narrowing, spondylolisthesis, or spasm-induced scoliosis,
although these findings may be nonspecific and may not
indicate a specific spinal level. In patients with contrain-
dications to MRI or those having lumbar instrumentation
from prior surgery, CT myelography can provide similar
information regarding space-occupying lesions. In pa-
tients with prior surgical decompression, MRI enhanced
with gadolinium can help to delineate recurrent herniation
from postoperative scar tissue.
The location of the disk herniation dictates which
nerve root is affected. The most common location is para-
central, because of the relative weakness of the posterior
longitudinal ligament. This type will cause stenosis within
the lateral recess, impinging on the traversing nerve root
exiting under the caudal pedicle. A disk herniation within
or lateral to the foramen will impinge on the root exit-
ing through that foramen. For example, a left-side L4-5
paracentral disk herniation most likely will impinge on
the left L5 nerve root, whereas a foraminal herniation
fl zeta American Academy of Orthopaedic Surgeons

axial {A} and parasagittal {E} Til—weighted MRI scans demonstrate a left—side paracentral disk herniation at L5—51
impinging on the traversing 51 nerve root and show the loss of dislt height and signal changes within the dislc at
L5-51. Sagittal T1vweighted MRI scan {Cl demonstrates nerve roots [dark] surrounded by fat [white] within the
intervertebral foran'lren. Note the decrease in fat signal around the nerve root at L5-51 as a result of dislt height
loss.
will impinge on the L4 nerve root as it travels under the
left L4 pediele in the intervertebral foramen.
Although the condition is rare, care must be taken to
appropriately identify patients with cauda equina syn-
drome caused by a large central disk herniation. Cauda
equina syndrome is a clinical diagnosis confirmed with
correlating imaging. It is associated with progressive bilat-
eral sensorimotor changes, bowel or bladder dysfunction
such as retention or incontinence, and perianal sensory
deficits as the result of a centrally based space-occupying
lesion compressing the lumbosacral nerve roots distal to
the conus medullaris. Quick identification and urgent
surgical decompression is imperative in these patients to
mitigate the risk of permanent neurologic dysfunction.
Treatment
Lumbar radiculopathy resulting from a disk herniation
often responds to a course of nonsurgical management.
Multiple modalities, including HSAIDs, muscle relax-
ants, short—term narcotics, antineuropathic medications,
physical therapy, and epidural or transforaminal steroid
injections may be used. No consensus exists about the
optimum nonsurgical treatment strategy for lumbar radic—
ulopathy secondary to disk herniation. Steroid injections
have provided short-term improvement of symptoms of
lumbar radiculopathy. A prospective randomised con-
trolled trial demonstrated a greater than sues reduction
in pain at 1 month in 54% of patients who received a
transforaminal steroid injection, which was significantly
better than the results in those receiving normal saline or
local anesthetic injections.” Repeat injections were noted
to be less likely to provide substantial relief.
In a study of 1? NFL players treated with epidural
steroid injections for lumbar radiculopathy secondary to
lumbar disk herniation, 39% {24 patients} returned to
IE! lfllfi American Academy of flrthopaeclic Surgeons
|IL'Zhapter 33: "I'horaoulumbar Spine
play with an average loss of 2.3 practices and [LS games.“
Three players eventually required surgery, and all were
noted to have sequestered disk herniations along with
weakness. In an analysis of 342 professional athletes with
lumbar disk herniations, 31% {1311] of 342;} were able to re-
turn to play; of those who underwent surgical decompres-
sion, 31% {134 of 126} returned to play}I Major League
Baseball players had a higher rate of return to play than did
NFL players. No consensus exists on the return—to—play
criteria; however, the resolution of preinjury symptoms
'.-'."
and the completion of a structured rehabilitation program I
have been advocated.11 A recent review article summarized m
u.-
D.
the available case series and expert opinion regarding re- an
3
turnato-play criteria following lumbar microdiskectomy, CL
m
demonstrating wide variability. The time to return to play 'E.
5
m
was reported as 1 to 2 months for golf, 6 to 3 weeks for
noncontact sports, and Z to 6 months for contact sports.”
Patients in whom nonsurgical management has failed
as previously described and with good correlation be-
tween imaging and physical examination may benefit
from surgical decompression. In a recent prospective
study on the cost effectiveness of continued medical
management of lumbar disk herniation in surgical can-
didates, it was shown that continued nonsurgical treat-
ment strategies were not cost effective.“ After ti weeks
of nonsurgical treatment, outcome measures failed to
improve with continued nonsurgical care in patients with
imaginguconfirmed spine pathology. In an analysis of 137
NFL players with lumbar disk herniations, those who un-
derwent surgery experienced greater career longevity {36
games played} compared with those treated nonsu rgically
(Ell games playedj.”
The gold standard for the surgical treatment of lumbar
disk herniation is diskectomy. lConsiderable debate exists
about the best surgical technique. Multiple systematic
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectien 5: Head sud Spine

reviews have failed te demenstrate a censistent benefit

ef any single technique, including epen discectemy, mi-
credisltcctemy, tubular micrediskectemy, pcrcutaneeus
er endescepic discectemy, ever any etherF'S‘“
The Spine Patients Outcemes Research Trial was a
multiccnter trial that fellewed patients with multiple
lumbar spine diagneses. Altheugh initially designed as
a randemiaed centrelled trial with a seceudary ebser-
vatienal greup, significant cressever in the randemiaed
patients has led te the data being evaluated “as treated.“
The ehservatienal arm ef the study has previded sub—
stantial data en lumbar disk herniatien and the effect
ef multiple treatments. Despite demegraphic differences
between these whe underwent surgery and these whe
did net, these whe underwent surgery dcmenstrated im-
prevements in all primary eutceme measures at 2, 4, and
3 yearsffli These with symptems lasting lengcr than a
menths, sequestered fragments, and increased back pain, Pa rasaqittal CT slice demehstrates the
and these whe were net werlting experienced greater pincer effect ef the infe rier facet ef L4
benefits frem surgery?” Subgreup analysis ef the data and the superier facet cf 51 en the L5 pars
intera rticula ris with resultant spendylelysis.
shewed that preeperative epidural stereid injectien did net
influence surgical eutceme and that ehesity is asseciated
with a lewcr clinical benefit frem surgical er nensurgical
treatment.:"1‘-":’I ef the pars interarticularis, a narrew isthmus ef belle
cennecting the superier and in ferier facets ef the lumbar
Tetal Disk Replacement vertebra. It is mest cemmen at L5 because ef the de-
Tetal disk replacement {TUE} is an appealing eptien fer creased distance between the L4 inferier facet and the 51
tu
.E yeunger patients in whem nensurgical management has superier facet, which leads te excessive repetitive leading
e.
m
1:
failed, with the theeretical advantage ef saving metien ef the pars interarticularis ef L53? {Figure 3}. This cendi~
t: segments and minimizing adjacent segment disease when tien particularly affects athletes invelved in sperts that
H:
1:5
a: cempared with fusien. TDR typically is net indicated fer require repetitive hypercxtensien ef the lumbar spine,
tu
I the treatment ef lumbar disk herniatien but instead fer such as gymnasts, feetball linemen, rewers, and seccer
Li-i
the treatment ef degenerative disk disease and discegenic players. The cenditien ence was theught te he cengenital;
back pain. The mainstay treatment fer degenerative disk hewevcr, multiple studies have shewn it te be an acquired
disease and discegenic back pain centinues te be nen- defect.”
surgical. Multiple clinical trials have determined lumbar
TDR te be “net inferier” te circumferential lumbar fu— Epidemielegy
sien; cencern fer bias exists with many ef these stud- The exact incidence ef spendylelysis is unkuewn, because
ies?” Due study examined lumbar TDR in a cehert cf it eften may he asymptematic. The everall prevalence was
39 yeung, athletic individuals. The athletes were allewed feund te be 4.2% in a cadaver study ef appreximately
te return te nencentact sperts at 3 menths and re centact 4,2flll specimens.“ It eccurs predeminantly at L5 {35%}
sperts at 4 te 6 menths. Uf the tetal, 95% {3? cf 39} re- and less eften at L4 {10% te 15%] in a 2:1 male-te-female
turned te sperts activity, with 35% {33 ef 39} reperting ratie; hewevcr, female athletes may be at a higher risk
impreved perfermance frem the preeperative status.” than males because ef the female athlete triadffldl It is
High-quality clinical studies are needed te determine the bilateral in Bfl‘iih ef cases and rarely {4%} feund at mere
efficacy ef tetal lumbar disk replacement cempared with than enc level."r2
current cenventienal treatment in the athletic pepulatien.
Clinical Presentatien
Spendylelysis mest eften is asymptematic and may be an
Seendylelysis
incidental finding en radiegraphy; back pain frequently
Spendylelysis is cemmenly asseciated with yeu ng athletes devcleps in active yeuth with spendylelysis, which leads
and is a stress reactien leading te esteelysis er fracture re a physician visit. The enset ef pain may eccur after

firthepaedic Knewledge Update: Sperts Medicine 5 fl lfllfi American Academy ef Urthepaedic Surge-ens

a specific inciting event, but nften symptnm unset will
nnt be readily definable. Initially, patients may have
back pain unly with activity that impruves with rest,
but chrnnic, luw-level pain may be present at all times.
The mnst cnmmnn repnrt is nf back pain that increases
with high—intensity activity; huwever, radicular pain intu
the buttncks nr pusteriur thigh may be present rarely in
isnlated spnndylnlysis. In spnndylnlytic spnndylnlisthesis,
fnraminal stenusis may cause radicular symptnms.
Dn physical enaminatinn, fncal tenderness tn palpatinn
nften is nnted adjacent tn the midline and in the paraspi-
nal musculature at the level nf spnndylnlysis. Furward
flexinn dues nut elicit any pain [in cnntrast tn extensinn,
which may be limited}. Estensiunfhypereittensiun uf the
spine may be painful. |Either physical examinatiun find-
ings may be hamstring tightness, antalgic gait, functinnal
sculiusis due tu muscle spasm, palpable step-uff uf the
spinnus prucess in cases uf spundylulysis with spundylulis-
thesis, and increased lumbar lnrdnsis. A single-leg lumbar
hyperezstensiun test can be used tu assess fur unilateral
versus bilateral spnndylnlysis, but it has pnnr specificity
fnr spnndylnlysis because it may be pusitive in multiple
lumbar spine disurders. A thuruugh neurulugic examina-
tinn shuuld be perfnrmed but is nften nnrmal.
Diagnustic Imaging
Patients with persistent activity-related back pain withnut
neurnlngic symptnms shnuld be evaluated with standing
AP and lateral lumbar radiugraphs. Histnrically, ublique
views alsn were nbtaiued tn evaluate fnr spnndylnlysis, but
they have nut been shuwn tn increase diagnnstic accuracy,
and they increase cnst and radiatinn ertpnsure.“3 Plain ra-
dingrapbs were shnwn tn be diagnnstic in 36% nf patients
whu had spundylulysis.‘M The lateral view demunstrates
a lucency nr lytic defect in the pars interarticularis and
allnws assessment nf any spnndylnlistbesis. This view
alsn assesses lumbnpelvic parameters such as slip angle,
pelvic incidence, and sacral slupe, which help tn predict
the risk nf slip develnpment nr progressinn.
In ca ses uf suspected spundylulysis with negative radin—
graphs, nther imaging mndalities can be used, althuugh
the must apprnpriate study tn use is a tnpic nf debate.
diunuclide bone scans and single phutun emissinn CT
{SPECT} can be used and are based cm the metabnlic ac-
tivity uf the regiun. "Hut“ buue scans indicate increased
radinnuclide uptake as a result uf increased metabnlic
activity in areas nf active spnndylnlysis. They may be
“culd” ut nnrmal in chrnnic cases that have ceased the
attempted reparative prncess. SPECT has imprnved sen-
sitivity and specificity than radinnuclide bnne scans and
allnws better delineatinn uf bnny anatnmy but has higher
cnsts and radiatinn espusure.“
IE! Eillfi American Academy nf flrtbupaedic Surgeuns
|IL'IlIaptes' 33: Tburannlumbnr Spine
CT has high sensitivity and specificity fur detecting
bnny defects nf the pars interarticularis and is the gnld
standard fur characterising fractures because nf its excel-
lent visualisatiun nf bnny anatnmy. Care must be taken
when evaluating bntb the axial and sagittal images tn
avnid mistaking facets fur pars interarticularis defects.
CT alsu can be used tn evaluate the healing prncess. The
drawback tn CT is its high radiatinn expnsure, pnnr eval-
uatiun uf suft—tissue structures, and inability tn evaluate
prelysis cnnditinns.
Recently, MRI has been used in the assessment nf the
yuung patient with back pain in whnm spundylulysis
is a cnncern. MRI is better than CT at characterizing
the suft tissues uf the lumbar spine and detecting ears
ly stress-related changes in the pars interarticularis. A
classificatinn system was develnped fnr using MRI in the
diagnnsis uf stress reactinns thruugh cnmplete fractures
uf the pars interarticularis.“ A recent study shnwed that
MRI was equivalent tn bnne scans in ability tn detect
stress reactinns uf the pars interarticularis withnut uvert
fracture and equivalent tn CT in ability tn detect cnmplete
injuries.‘*'5 because nf its ability tn assess active versus in-
active stress reactiuns, MRI largely has supplanted bnne
scan and SPECT in the diagnnsis nf spnndylnlysis. A rule
fnr CT remains in the diagnnsis and assessment cf the
treatment fur spnndylnlysis.
'.-'."
Treatment I
Spundylulysis is must nften treated nunsurgically, which m
n.-
D.
may include cessatinn nf spurts participatinu, activity an
3
mudificatiun, physical therapy, and bracing. The key tn CL
m
successful treatment begins with the early diagnnsis uf an 'E.
n
m
acute pars interarticularis fracture. In a study nf 32 ynung
athletes with radingraphically negative, bune scan-pnsi-
tive spnndylnlysis fnr an average uf 9 years, 91% {29 uf 32
athletes} repnrted gnud tn excellent lnw back functinnal
nutcnmes at final fulluw—up, despite the absence uf healing
un radiugraphs.“
In a recent retrnspective review,43 the effect nf spurts
cessatinn cumpliance un lung-term results was studied
in 132 pediatric patients with spundylulysis withnut
spnndylnlisthesis. Mthnugb nn nunsurgical treatment
strategy was unifurmly applied, all patients were advised
tn cease spnrting activities fur a minimum uf 3 mnnths.
Sixty-five percent uf patients {36 uf 132} stupped their
spurts activity fur at least 3 munths and 35% {4d uf
132} stupped fur a variable perind nf time. Patients whn
stupped spurts activity fur 3 munths were 16 times mure
likely tn experience excellent resnlutinn uf their symp-
tnms. Enny fusinn did nut have an assnciatinn with a
better uutcume; huwever, it was mure likely tn uccur
with cessatinn uf spurts activity.
Drtbnpaedic Knnwledge Update: Spurts Medicine 5
 Section 5: Head and Spine
y' ._'I
T
Figure 4 AP (All and lateral [B] radiog raphs show direct
pars repair with interla minar screw fixation of
bilateral L4 spondylolysis.
There is a lack of high—quality studies examining the
effectiveness of nonsurgical modalities such as bracing,
functional rehabilitation, and electric stimulation because
most studies are small case series. Studies indicate that
athletes should be asymptomatic before being allowed
to return to sports, and nonunion or fibrous union is
not associated with a failure to return to play or good
functional outcome.”m
The indications for surgical treatment of spondylolysis
without spondyloiisthesis are failure of 6 months of non—
surgical treatment or 9 to 12 months of persistent back
cu
.E pain with nonunion}1 The goals of surgical treatment are
o.
m
'U
débridement of any fibrous nonunion and stabilization of
r: the pars interarticuiaris. Many surgical techniques are
as
1:5
:1: available, including single—level fusion using screw—rod
cu
I constructs, transverse process wiring, and noninstru-
ti-i
mented posterolateral arthrodesis. More recently, direct
pars interarticuiaris repair with ddbridemcnt and inter-
laminar screw fixation has gained favor following failed
nonsurgical treatment but requires a healthy interverte-
bral disk”- {Figure 4].
The choice of bone graft or bone graft substitutes for
the augmentation of bony healing remains controver-
sial. The authors of a 2014 study reported on 31 patients
treated with direct interlaminar screw repair with iliac
crest autograft for spondylolysis.53 Elf the total, 9fl% re-
ported successful outcomes with reduced postoperative
visual analog scale scores, and ?6% of the competitive
athletes in the series returned to their respective sports.
Another study“ reported on 15" pars interarticuiaris de—
fects in competitive athletes treated with direct screw
repair and recombinant human bone morphogenetic
protein; bony fusion was achieved in all but one defect,
and 100% return to play was seen. Conversely, a pro-
spective outcomes study was conducted on 4'? military
members who underwent pars screw repair following
firthopaedic Knowledge Update: Sports Medicine 5
failure of nonsurgical management.“ Fifty-five percent
achieved union, with 53% of patients satisfied with their
outcome. flswestry Disability Index and IZ—Item Short
Form Health Survey scores were significantly improved
from baseline at ti months but had a tendency to decline
after 12 months. Return to high—intensity sports activity
following surgical stabilization is possible if the patient is
asymptomatic, has a demonstrated fusion, and has fully
rehabilitated to prior playing status.“ As in lumbar disk
herniation, return-to-play criteria following surgery are
based on expert opinion and vary widely. For patients
who have undergone single—level lumbar or iumbosacrai
fusion for spondylolysis or spondyloiisthesis, various au-
thors have advocated waiting a range of times before
allowing a return to sports participation, including 6 to 12
months for noncontact sports, 1 year for contact sports,
or never for contact or collision sports.“~5*‘~5?
Spondylolisthesis
Spondylolisthcsis refers to the translation of one vertebral
body in relation to an adjacent body. The ‘w'iltse classifi-
cation of spondyloiisthesis has five types” I:Table 2}. The
most common are types I and II, which will be the focus of
this section. Type III, degenerative spondyloiisthesis, oc-
curs as a continuation of the degenerative cascade of disk
degeneration, with progressive facet capsule incompetence
leading to instability and subsequent translation without
structural changes in the vertebrae. Type IV is a result of
traumatic or iatrogenic defects of the posterior elements.
Type ‘v" results from a pathologic process. Despite the
1llll’iltse classification’s widespread use, it does not provide
any prognostic value, but it does allow communication
between providers for these distinct processes.
Dysplastic spondyloiisthesis, type 1, occurs secondary
to a developmental defect in the facet complex, resulting
in poorly restrained motion, most commonly at the L5—51
complex. The superior 51 facet or inferior L5 facet may
be missing, underdeveloped, or oriented in the sagittal.
plane. Spina bifida occulta often is seen in conjunction
with dysplastic spondyloiisthesis. Compared with spon-
dylolysis, which is more prevalent in males, dysplastic
spondyloiisthesis is twice as common in females and ac~
counts for 15% to lfl‘l’h of pediatric spondyloiisthesis.”
Isthmic spondyloiisthesis, type II, can be divided
into three subtypes, based on the integrity of the pars
interarticuiaris. Type HA is defined as a defect of the
pars interarticuiaris secondary to a stress fracture as de-
scribed previously in the section on spondylolysis. Type
113, isthmic spondyloiisthesis, is defined as an elongation
of the pars interarticuiaris without a defect, caused by
repetitive microtrauma and bony remodeling of the pars
fl lfllfi American Academy of Orthopaedic Surgeons
 |IL'IlIapter 33: Thomeolumbar Spine

Classification of Spondylolisthesis
Type Description Key Notes
I Dysplastic Developmental anomalies of the facet complex or posterior elements
II Isthmic Defect in pars interarticularis
IIA Spondylolytic Stress fracture of the pars interarticularis
IIEI Elongated pars Elongation of the pars interarticularis fmm bony remodeling
IIC Traumatic Acute fractures of the pars interarticularis
Ill Degenerative Secondaryr to chronic facet complex instability
IV Posttraumatic Prior posterior element fracture or iatrogenic instability
v Fathologic Secondary to generalized disease process with destruction of posterior
elements

interarticularis. Type [1C is a traumatic pars interarticu—
laris fracture and is the least common isthmic subtype.
Clinical Presentation
Spondylolisthesis in the young active patient presents most
commonly with back pain of insidious onset, except in
the case of acute pars interarticularis fractures. Radicu—
lopathy is uncommon but when present, is most often bi-
lateral. The most common level of isthmic and dysplastic
spondylolisthesis is LS—Sl, with the LS nerve root the most
commonly affected root. The nerve root may be irritated
as a result of two different mechanisms. In higher grade
slips, traction on the nerve root may cause irritation. in
the spondylolytic and isthmic types, repeated attempts at
healing the defect may lead to a proliferation of fibrous
tissue, which impinges on the exiting nerve root and in
some cases also may irritate the traversing nerve root.
A thorough physical examination may indicate sub-
tle weakness in the extensor hallucis longus or a slight
Trendelenburg gait due to hip external rotator weakness;
pain with lumbar extension is the most common finding.
lCine of the most common signs associated with spondy-
lolisthesis is a decreased popliteal femoral angle due to
hamstring tightness. No neurologic basis exists for the
tightness; it is likely a manifestation of chronic postural
changes made in an attempt to maintain normal sagittal
balance.“ Palpation of the lumbar spine may demon-
Strate a step-off at the L4-LS spinons process in isthmic
spondylolisthesis and, conversely, at the LSuSl junction
in the dysplastic type.
Diagnostic Imaging
Plain radiography of the lumbar spine is sufficient to
demonstrate most cases of spondylolisthesis. As described
previously, oblique views were historically obtained to
evaluate for isthmic spondylolisthesis, but this practice
has been shown to be associated with a higher rate of ra-
diation exposure without any increased diagnostic utility.
The lateral standing radiograph can be used to calculate
multiple spinal alignment parameters, the most useful
of which is the slip angle. The slip angle is the angle
formed by a line perpendicular to the posterior cortex of
the sacrum and a line parallel to the inferior end plate of
LS. Slip angles greater than 55" are associated with an
increased risk of slip progression.“
CT can be useful in evaluating for subtle pars interar-
ticularis fractures or spina bifida occulta. Detection of
'.-'."
spina hifida occulta is important when surgical correction I
is planned, to reduce the risk of inadvertent dnrotomy or re
s.-
D.
neurologic injury. MRI should be used in patients with an
3
neu rologic symptoms to evaluate the site or sites of com- CL
to
pression for preoperative planning. 'E.
5
re
Tl'Efltf'l'IEl'lt
Asymptomatic or minimally symptomatic spondylolis-
thesis in the young, active patient can be successfully
treated nonsurgically. Surgical treatment is reserved for
patients with symptomatic spondylolisthesis in whom
nonsurgical management has failed and for those with
significant functional limitations, high—grade slips with a
high slip angle, and altered sagittal alignment. Multiple
surgical techniques can be used, including instrumented
and noninstrumented in situ arthrodesis or reduction
of the slip with instrumented fusion. The addition of
interbody grafts, performed via an anterior, lateral, or
posterior approach, has been shown to increase the rate
of fusion in spondylolisthesis and result in greater resto-
ration of lordosis and disk space height, compared with
instrumented posterolateral fusion alone in the treatment
of spondylolisthesis.film One systematic review of the
evidence for in situ arthrodesis versus spondylolisthesis
reductionEM found a higher rate of pseudarthrosis in the

IE! Elllli American Academy of flrchopaedic Surgeons Drtbopaedic Knowledge Update: Sports Medicine 5
 Section 5: Head and Spine

-------

I.‘. .._ fffff

en
E
o.
m
'U
r:
n:
1:5
n:
u:
I
d-i
-I' I! _’_ --___ ;,t_—.J'-l.', .
a-._ 1-.-r,-,;.i;'-‘-_e;_.--; ’-I-.'-
-
'I=_ '-
fu"'ullr.l.- _.‘.I. _

Figure 5 AP {All and lateral {B} radiographs and sagittal {C} and axial {Di ET slices depict a grade 4 dysplastic
spo ndvlolisthesis in a 15-year-old boy. AF {El and lateral {F} radiogra phs show the results of reduction and LS-SI
instrumented fusion.

in situ group (113% versus 5.5%], greater improvement
in slip angle and percent slip in the reduction group, and
no difference in the incidence of postoperative neurologic
deficit between the groups. The reduction of high-grade
slips has been shown to lead to an overall improvement
in global sagittai alignment, providing optimal spinal
biomechanics to mitigate the risk of adjacent segment
disease” {Figure 5].
A recent retrospective review of 53 adolescents with
high-grade spondvlolisthesis demonstrated that those who
were asvmptornatie or ruininiall}.r svmptoniatie could be
treated nonsurgicallv without risk of neurologic prob—
lerns.‘56 In addition, those who were treated surgically
because their symptoms progressed had long—term re—
sults similar to those who did not have surgery. Those
with higher slip angles had worse long-term outcomes,
as measured by the Scoliosis Research Society {5R5} 3i}
questionnaire, independent of surgical or nonsurgical
treatment. Another studv examined the improvements in
health~related quality of life {HRQGL} as measured by
the 51-15 22 questionnaire in 23 patients with high-grade
slips” and reported a significant improvement in HRQOL
in surgicallyr treated patients, with patients having lower
baseline scores experiencing the most improvement. Re-
turn—to—pla}.r criteria for surgicaliv treated spondvlolisthe—
sis are described in the section on spondvlolvsis.

flrdiopaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons

‘Evumr'rlarjyr
Low back pain is a common report of the young, active
patient and most often is a self-limiting episode without
underlying etiology. Careful attention to the history and
a diligent physical examination can help diagnose those
cases of underlying spinal pathology. Nonsurgical treat-
ment is often successful in cases of thoracic and lumbar
disk herniation, spondylolysis, and spondylolisthesis. In
patients who require surgery, a return to sports or activity
is certainly possible following successful rehabilitation.
No standardised return—to—play guidelines are avail—
able for any of the previously discussed conditions and
treatments. The surgeon must make an individualized
plan for each athlete that takes into account the athlete’s
participation level, individual sport requirements, and
overall treatment outcome.
Key Study Points
1* Low back pain and thoracolumbar spine—related
issues continue to increase in adolescent and young
adults. |Careful attention should be paid to any in-
citing trauma, history, and related symptoms.
i Lumbarithoracic disk pathology and herniation,
spinal stenosis, sponclylolysis, and spondylolisthesis
are some of the common diagnoses associated with
chronic back pain, and require detailed clinical and
radiologic evaluation.
1* Nonsurgical treatment is usually first, unless sub-
stantial or worsening neurologic involvement, in—
fection, or spine instability are present.
' Return to sports or high—demand activity is often
possible with either surgical or nonsurgical treat-
ment, after successful rehabilitation.
Annotated References
1. Deyo RA, Mirna 5K, Martin BI: Back pain prevalence
and visit rates: Estimates from LLS. national surveys,
2002. Spine (Piniia Pa nave; lflflfi;31{13}l:1?24-2?21
Medline DUI
2. Martin BI, Deyo RA, lviiraa SK, et al: Expenditures and
health status among adults with back and neck problems.
iAMA lflflflfiffiflfijfiifi-fifi-i. Medline DDI
3-. Devereaux lvl: Low back pain. Med Ciin North An:
measure-swam, x. Medline not
This article provides a detailed overview of low back
pain and is especially targeted at general practitioners
IE! lfllfi American Academy of Drtbopaeclic Surgeons
Gimpter 33: Thoraoolnmbnr Spine
and family physicians. The important points of history
taking and clinical and radiological examination to be
considered when managing low back pain and related
issues are discussed.
Ehatia MN, Chow G, Timon 5], Watts HG: Diagnostic
modalities for the evaluation of pediatric back pain: A
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Andersson GE, Deyo aa: History and physical examina-
tion in patients with herniated lumbar discs. Spine fPiriiri
Pa 19%} 1996;2H24, SuppljlflS-IES. Medline DD]
Waddell G, l'v'IcGulloch JA, Kummel E, Venner RM: Non-
organic physical signs in low-back pain. Spine fPiriia Pa
19.76) 193fl;5{2}:11?—125. Medlinc DUI
Arce CA, Dohrmann G]: Herniated thoracic disks. Memo!
Giin 1935;3{2}:333-392. Medline
1'iiliood KB, Garvey TA, Gundry E, Heithoff KB: Mag-
netic resonance imaging of the thoracic spine. Evalua-
tion of asymptomatic individuals. ,i Hone joint Snrg Arn
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Zhang G, Blue T, Wang P, Yang 2, Dai Q, Zhou I-IF: Foot
drop caused by single—level disc protrusion between Tlfl
and LI. Spine (Pbiiri Fri 19%;} 2fl13;33[25}:2295-23l}1.
Medline DUI
The authors present their experience in this case series of
25 cases of unilateral foot drop in patients with a single
disk herniation between T10 and L1. Level of evidence: W. '.-'."
I
m
10. Hou I, Sun C, Liu I, et al: Clinical features of thoracic e.-
spinal stenosis-associated myelopathy: A retrospective
D.
to
DE
analysis of 42'? cases. _i Spinoi Disord 'I'eeiilI 2014 [Epuh EL
Lfi
ahead of print]. Medline DID] 'E.
5
m
The authors report on the epidemiology of thoracic steno-
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in 42'? consecutive patients treated surgically at a single
institution. Level of evidence: III.
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lflflflgfifljdjfl—lfig. Medline
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This review article discusses the indications and technique
of epidural and selective nerve root injections in the cer-
vical, thoracic, and lumbar spine.
13. Gray EL, Euchowslri ll, Eumpass DE, Lehman an Jr,
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Drthopaedic Knowledge Update: Sports Medicine 5
 Section 5: Head and Spine
14. Cornips EM,]anssen ML, Benls EA: Thoracic disc herni-
ation and acute myelnpathy: Clinical presentation, neuro-
imaging findings, surgical considerations, and outcome.
} Henrnsnrg Spine EDI 1;14[4I:SZG-SZS. Medline DUI
The authors report their experience with the surgical treat—
ment of thoracic disk herniations presenting with acute
myelopathy in a series of eight patients.
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An update. Spine {Phiio Po 19715,} 2014;39i6):E4EHi 43.411.
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The author provides an updated look at the outcomes
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herniations.
16. |Ehoi KY, Eun SS, Lee SH, Lee HT: Percutaneous endoscop-
ic thoracic discectomy; transforaminal approach. Minirn
Invasive Neurosnrg lfllfl;53{1]:25-ZS. Medline DUI
In this case series, the authors describe their technique
and the outcomes of 14 patients treated with percutaneous
endoscopic thoracic diskectomy for soft disk herniations.
Level of evidence: IV.
1?. Smith JS, Eichholz KM, Shafieadeh S, flgden AT, D’Toole
JE, Fessler RG: Minimally invasive thoracic micrnendn—
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1[Siorilsi Neurosnrg 1313;3fll3 -4}:411-42T. Mcdlinc DUI
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tions. Level of evidence: IV.
to
.E IS. Hadjipavlnn AG, Trermiadianos MN, Eogduk N, Zindriclv:
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u":
'U
ME: The pathophysiology of disc degeneration: A criti-
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In
a:
I
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lumbar radicular pain. Pein Med lfllfi:11{li}:1149-IIISS.
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In this randomised controlled study, the authors sought
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versus intramuscular—for the treatment of lumbar radic-
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Sci Sports Exerc 2011;44i1}:193—19fl. Medline DUI
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tn-play time in professional football players with symp-
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firthopaedic Knowledge Update: Sports Medicine 5
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functional outcomes, and return-to-play criteria are
discussed.
24. Parker SL, Godil SS, Mendenhall SK, Zuckerman SL,
Shau DH, McGirt M]: Two—year comprehensive med-
ical management of degenerative lumbar spine disease
{lumbar spondylolisthesis, stenosis, or disc herniation}: A
value analysis of cost, pain, disability, and quality of life:
Clinical article. _,i' Neurosnrg Spine 2014;21{2}:143—149.
Medline DUI
The authors used a prospective quality-of-life spine reg-
istry to perform a cost-benefit analysis of nonsurgical
treatment options after .5 weeks in patients with identifi—
able surgical lesions. They fonnd no benefit to continued
nonsurgical therapy.
2.5. Hsu WK: Performance-based outcomes following lum-
bar discectomy in professional athletes in the National
Football League. Spine (Pbiin Pt: 19%} Bill fl;35{12}:114?—
1251. Medline
The author presents the results of 13? NFL players treated
for lumbar disk herniation. Surgically treated berniations
resulted in improved career longevity.
26. Hamper S], |Ifilstelo KW, Rubinstein SM, et al: Minimally
invasive surgery for lumbar disc herniation: A systematic
review and meta-analysis. Enr Spine _,i 2014:23i5 1:102]-
1043. Medline
The results of a systematic review and meta-analysis of
available clinical trials comparing conventional open
discectomy with minimally invasive diskcctomy are
presented.
2?. Rasouli MR, Rahimi—Movaghar V, Shokraneh F,
Moradi-Lalteh M, Chou R: Minimally invasive discectomy
versus microdiscectomyi'open discectomy for symptom-
atic lumbar disc herniation. Cochrnne flntnirese Syst Rev
2D14:9:CDDIUSES. Medline
Cochrane review data of available clinical trials comparing
conventional open discectomy versus minimally invasive
diskectnmy are presented. Level of evidence: II.
IS. Jacobs WC, van Tulder M, Arts M, et al: Surgery ver-
sns conservative management of sciatica due to a
fl lfllfi American Academy of Orthopaedic Surgeons

lumbar herniated disc: A systematic review. Eur Spine
,I set 1;1i}{4j:513-522. Medline nut
This systematic review discusses the effectiveness uf surv
gery versus the nunsurgical management uf sciatica due
tu lumbar dislt herniatiun. It fuund that early surgery
demunstrated earlier pain relief than did nonsurgical man—
agement. Level uf evidence: I‘v".
29. LurieJD. Tustesun TD. Tustesun AM, et al: Surgical versus
nunuperative treatment fur lumbar disc herniatiun: Eight-
year results fur the spine patient uutcumes research trial.
Spine ['Phiia Pa 19%) 2fl14:39l[1}:3-16. Medline DUI
This article presents the 3—year uutcumes data from the
Spine Patient Uutcumes Research Trial {SPURT} in pa-
tients whu underwent treatment uf lumbar disk herniatiun.
Nu degradatiun in uutcumes was seen in the surgical ur
nunsurgical gruup. Level uf evidence: II.
Si}. Kerr D, Zhau W, Lurie JD: What are lung—term predic-
turs uf uutcumes fur lumbar disc herniatiun? A rand-am-
ized and ubservatiunal study. Clin Urtfaup Refat Res
sa15;4vs{s}:1asa—1ssa.Medan: nut
Evaluatiun {if the 3-year SPURT data fur lumbar dislt
herniatiuns demunstrated the fulluwing facturs as assu—
ciated with better uutcumes with surgery: higher levels uf
baseline baclt pain accumpa nying radiculupathy, a lunger
duratiun uf symptums. and patients whu were neither
wnrlting nut disabled at baseline. Level uf evidence: II.
31. Lurie JD. Faucett SIS. Hanscum B. et al: Lumbar dis-
cectumy uutcumes vary by herniatiun level in the Spine
Patient Uutcumes Research Trial. I Rune Juint Snrg Ann
lflflfl;90{9}:1311—1319.Medline nut
32. Rihn JA, Radcliff K, Hilibrand AS, et al: Dues ubesity
affect uutcumes uf treatment fur lumbar stenusis and de-
generative spundylulisthesis? Analysis cf the Spine Patient
Uutcumes Research Trial {SPURT}. Spine {Haifa Pa 19%)
2012:S?{ES}:1933-1946.Medline DUI
This subgruup analysis cf the SPURT data shuwed that
ubese patients impruved with surgery fur lumbar stenusis
and spundylulisthesis, but the gains were luwer than in
patients whu were nut ubese. Level uf evidence: II.
33. Rihn JA. Kurd M, Hilibrand AS, et al: The influence uf
ubesity un the uutcume uf treatment uf lumbar disc her-
niatiun: Analysis cf the Spine Patient Uutcumes Research
Trial {SPURT}. I Buns faint Sarg An: 2013;95l1}:1-S.
Medline DUI
This subgruup analysis cf the SPURT data shuwed that
ubese patients impruved with surgery fur lumbar disk
herniatiun but the gains were luwer than in patients who
were nut ubeese. Level uf evidence: II.
34. van den Eerenbeemt RD. Ustelu RW, van Ruyen B], Peul
WC, van Tu lder MW: Tutal disc replacement surgery fur
symptumatic degenerative lumbar disc disease: A system-
atic review cf the literature. Ear SpineI ll] 10:1 FISHERI-
1230. Medline DUI
ID lfllfi American Academy uf Urthnpaedic Surgeuns
|L'Iluapter 33: Thurauulnmbar Spine
This article is a systematic review uf available clinical trials
evaluating lumbar disk arthruplasty fur the treatment uf
degenerative disk disease. Invel uf evidence: III.
35. Jacubs W. 1It'an der IISaag NA. Tuschel A. et al: Tutal
disc replacement fur chrunic back pain in the presence
uf disc degeneratiun. Cucbrane Database Syst filesr
2012:9:UDU03326. Medline
This article is a Euchrane Review uf available clinical tri-
als evaluating lumbar dislt arthruplasty fur the treatment
uf degenerative disk disease. Level uf evidenve: III.
36. Siepe C], Wiechert K, Khattab MP, Kurge A, Mayer HM:
Tutal lumbar disc replacement in athletes: Clinical re-
sults, return tu spurt and athletic perfurmance. Ear Spine
J 200?;16{?}:1flfll-1{113. Medline DUI
SP. Zehnder SW. Ward CV. Draw A]. Alander D. Latimer B:
Radiugraphic assessment uf lumbar facet distance spac-
ing and pediatric spundylulysis. Spine (Haifa Pa 19.76}
lflfl9534i3l:135-290.Medline DUI
This retrnspective radiugraphic review describes narruwed
intrafacet distance as a pussible etinlngy nf lumbar pars
defects. Level uf evidence: III.
33. Reitman CA. Gertsbein SD, Francis 1'illl'litjr: Lumbar isth-
mic defects in teenagers resulting frum stress fractures.
Spiney sunglasses-sea. Medline nu:
39. Ruche ME, Ruwe GU: The incidence uf separate neural
arch and cuincident bune variatiuns: A summary. }' Bane
Iain: Surg Am 1952:34-Ai2}:491-494. Medliue
'.-'."
I
4D. Taltemitsu M. El Rassi G. 1|I'iii’nratanarat P. Shah SA: Lmv run
a.-
back pain in pediatric athletes with unilateral tracer D.
Eu
uptake at the pars interarticularis un single phutun :1:
CL
emissiun cumputed tumugraphy. Spine (Phila Pa HIPS} u:
2Ufl5:31{8}:9{19-914.Medliue DUI 'E.
5
I'D
41. Kim H]. Green D‘iili': Spundylulysis in the adulescent ath-
lete. Carr Upin Pediatr 2011:23i1}:GS-?2. Medline DUI
This review article discusses the presentatiun, diagnustic
wurltup, and treatment uf spundylulysis in the pediatric
athlete.
41. Gurd DP: Back pain in the yuung athlete. Spur-ts Med
Artfflrusc 2fl11;19i1}:?-16. Mudline DUI
This review article discusses the presentatiun. diagnus-
tic wurltup, and treatment uf baclt pain in the pediatric
athlete.
43. Eeclt NA, Miller R, Baldwin K, et al: Du ublique views
add value in the diagnusis uf spundylulysis in adulescentsi'
} Bane faint Snrg Am 2013:95i1fl}:e65. Medline DUI
This radiugraphic study evaluates the utility uf ublique
lumbar views fur the detectiun uf spundylulysis. The au-
thurs cunclude that the views are nut necessary nur wurth
the cast uf radiatiun enpusure. Level uf evidence: III.
Urthupaedic Knuwledge Update: Spurts Medicine S
 Sectiun 5: Head and Spine
44. Miller E, Beck NA, Sampsun HR, Zhu X, Flynn JM,
Drummund D: Imaging mudalities fur luw back pain in
children: A review uf spundyluysis and undiagnused me-
chanical back pain. I Pediatr' fifths-p EDI 3:33i3}:131—233.
Medline DUI
This retruspeetive study evaluates the epidemiulugy uf
mechanical back pain in the adulescent, the utility uf im-
aging studies, and the cummun causes uf back pain. Level
uf evidence: III.
45. Hullenberg GM, Eeattie PF, Meyers BF, Weinberg EP,
Adams M]: Stress reactiuns cf the lumbar pars interarticu-
laris: The develupment uf a new MRI classificatiuu system.
3pm.:- (Phir'a e:- revs; ass1,2v{e}:1s1—1ss. Medline nu:
45. Rush JR, Astur N, Scutt 5, Kelly UM, SawyerjR, Warner
1|i'Iii'IEJr: The use uf magnetic resunance imaging in the eval-
uatiun uf spundylulysis. I Pedierr Drthup EDIE:35(31:2?1-
215. Medline
The authurs explure the efficacy uf MRI in the diaguusis
and evaluatiun uf spundylulysis cumpared with CT in
the management at spundylulysis. Level uf evidence: III.
4?. Miller 5F, Cungeni J, Swausun K: Lung-term functiunal
and anatumical fulluw-up uf early detected spundylulysis
iu yuung athletes. Arr: I Spurts Med 20 fl4;32i4]:923-933.
Medliue DUI
43. El Rassi G, Takernitsu M, Glutting J, Shah SA: Effect uf
spurts mudificatiun un clinical uutcume in children and
adulescent athletes with symptumatic lumbar spundylul-
a: ysis. Arr: I Phys MeciI Rebabii' 2013;92i12]:1fl7[l-1fl?4.
.E Medliue DUI
u.
u":
'U The authurs evaluated die impact uf spurts cessatiun un
r:
n:
1:5 lung-term uutcumes in the treatment uf symptumatic
a: lumbar spundylulysis. Spurts cessatiun fur a periud uf 3
a:
I muuths was assuciated with the impruved pussibility uf
Li-i an excellent lung-term uutcumc. Level uf evidence: HI.
49. Standaert C], Herring 5A: Expert upiniuu and cuntruver-
sies in spurts and musculuskeletal medicine: The diagnusis
and treannent uf spundylulysis in adulescent athletes. Arch
Phys Med Rehabii' Eflfl?;33{4}:53?-54fl. Medline DDI
Si}. Euuras T, Kuruvessis P: Management uf spundylulysis and
Iuw—grade spundylulisthesis in fine athletes. A cumpreheu-
sive review. Ear ] flatbup Saar-g Traaaretui 2fl15;25{5up—
pl llrlllEFT-ITS. Medliue DUI
The authurs present an excellent review cf the manage-
ment uf spuudylulysis and spundylulisthesis in athletes,
with a fucus un surgical treatment mudalities.
51. Radcliff RE, Kalantar SE, Reitmau CA: Surgical manage-
ment cf spundylulysis and spundylulisthesis in athletes:
Indicatiuns and return us play. Carr Sparta Med Rep
2fl09;3{1‘1:35-4fl.Medline DflI
In this review article, the authurs discuss the surgical
management cf type 1 spundylulisthesis and the clinical
criteria fur return tu play.
firthupaedic Knuwledge Update: Spurts Medicine 5
52. Draain D, Shiraadi A, Jeswani 5, et al: Direct surgical
rcpair uf spundylulysis in athletes: Indicatiuns, tech-
niques, and uutcumes. Nearusrrrg Fucrrs 2011;31{5]:E9.
Mudline III-DI
This article is a systematic review cf the available literature
un the surgical management uf spundylulysis in athletes.
The authurs cunclude that the ideal candidate is yuunger
than EU years and withuut degenerative disk changes.
53. Menga EN, Kebaish KM, Jain A, Carrinu jA, Spuuseller
PD: Clinical results and functiunal uutcumes after direct
intralaminar screw repair uf spundylulysis. Spies {Phiie
Pa 1976) 2fl14;39{1}:1D4-11fl. Medline DUI
This study describes the results uf a cuhurt uf patients with
spundylulysis treated with direct repair via interlaminar
screw fixatiun. [avel uf evidence: IV.
54. Snyder LA, Shufflebarger H, U’Erien MF, Thind H, The—
udure N, Ka lta rla UK: Spundylulysis uutcumes in adules-
cents after direct screw repair uf the pars interarticularis.
j Nearussrrg Spine 2fl14:11[3}:329-333. Mudline DUI
This meta—analysis luults at the relevant surgical literature
un the uutcumes ut' pars repair with direct fixatiun. Level
uf evidence: III.
55. Lee (3W, Lee SH, Sub EG: Direct repair surgery with
screw fixatiun fur yuuug patients with lumbar spundy-
lulysis: Patient—repurted uutcumes and fusiun rate in a
pruspective interventiunal study. Spine {Phil’s Pa 19%,!
2fl15;4fl{4l:E234-E241.Medline DUI
This study discussed the results uf direct repair tn treat
lumbar spundylulysis, and it was cuncluded that this sur-
gery in yuung patients with lumbar spundylulysis may
lead tu subuptimal results 1 year pustuperatively. Level
uf evidence: II.
56. Eclt JC, Riley LH III: Return tu play after lumbar spine
cuuditiuns and surgeries. Ciir: Spurts Med lilfl4;13{3}:36?—
3T5, viii. Mcdliue DUI
In this review article, the authurs discuss return-tuvplay
criteria fur spine cunditiuns fulluwing surgical and nun-
surgical management.
57. Rubery PT, Bradfurd D5: Athletic activity after spine sur-
ry in children and adulescents: Results uf a survey. Spine
{sees Pa revs: sunglasses—427. Medline nu:
In this study, the anthers pulled spine surgeuus uu their
return-tu-play criteria fur a variety uf lumbar spine candi-
tiuus. Significant variability was nuted amuug respunses.
Level uf evidence: V.
53. Wiltse LL, Newman PH, Macuab I: Classificatiun uf spun-
dylulisis and spundylulisthesis. Ciir: Orthup Refs: Res
19?fi:11?:23-29. Medliue
55". Newman PH: Surgical treatment fur spundylulisthesis
in the adult. Elia: Drtbup Heist Res 19?E;117:1i}6-111.
Mudline
fl lfllfi American Academy uf Cirrhupaedic Surge-ans

6i}. Barash HL, Galante JU, Lambert UN, Rav RD: Spen-
dvlelisthesis and tight hamstrings. j Bene Jeint Surg Am
19?fl:52{7}:1319-1323. Medline
I51. l'viin WK. Lee CH: Eemparisen and cerrelatien ef pel-
vic parameters between law-grade and high-grade spun-
dvlnlisthesis. j' Spine-i Diseni Tech 1D14;2?{3}:162-165.
Mcdline DUI
This radingraphic stnclj-rr leeks at the differences in variens
spinepelvic parameters in patients with lew-grade versus
high-grade spendvlelisthesis.
I52. Liu X, Wang Y, Qiu G, Weug K, Tu E: ii. systematic re-
view with meta-analvsis ef pustetier interbedv fusieu
versus pesterelateral fusien in lumbar spendvlelisthesis.
Eur Spine I 2014;33lnt43-55. Medliue DUI
The anthers perferm a svstematic review ef the surgical
nutcnmes ef degenerative lumbar spnndvlelisthesis based
en surgical technique. Level ei evidence: III.
63. Mummaneni PV, Dhall 55, Belt III, et al: Guideline update
fer the periermance ef fusien precedures fer degenerative
disease ef the lumbar spine. Part 11: Interhedv techniques
fer lumbar fusiun. I Neurnsnrg Spine lfll4;21{1l:ET-T4.
Medline DUI
This article is a guidelines update regarding the best new
evidence for the use ef interbedv devices in the treatment
{if lumbar spendvlnlisthesis.
E4. Lenge UG. Leppini l'vl, Remee G. Maffulli N. Denare V:
Evidence-based surgical management nf spendvlnlisthesis:
Reductien er arthredesis in sitn. ] Rene faint Snrg Ann
2014;96i1]:53-53.Medline DUI
IE! lfllfi American Academy ei' Urrhepaedic Surgeens
|IL'Ihapter 33: Thnrannlumbar Spine
This systematic review shews that reductiun ef spundv-
lelisthesis is asseciated with imprevements in spinal hie-
mechanics but net with an increased risk ef neurelegic
deficits. Level ef evidence: III.
I55. Themas D, Eachv M, |Illa-nurvnisier A, Duh-er}? A, Buuluussa
H, 1ii'ialle R: Prugressive resturatieu uf spinal sagittal
balance after surgical cerrectien ef lumhesacral spen-
clvlelisthesis hefere skeletal maturity. j Nenresnrg Spine
2fl15;22{3}:194-30fl.h{edline DUI
In this radiegraphic study, the authers evaluate the pre-
nperative and pestnperative radiegraphic spinepelvic pa-
rameters in patients managed with surgical reductien ef
high-grade dvsplastic spendvlulisthesis.
66. Lundine KM. Dawis S]. Al-Auhaidi Z. Alman E. Heward
AW: Patient eutcumes in the uperative and nenuperative
management nf high-grade spendvlnlisthesis in children.
I Pedieir Uri-“hep 2fl14:34l5]:433~439. Medline DUI
The anthers perfermed a retrespective review ef patients
with high-grade spnudvlelisthesis. Thev fuund that de-
laved surgical interventieu dues net lead te werse eut-
centre in patients whe are minimallv svmptentatic. Level
ef evidence: III.
67. Ben rassa~lvlerean E. Mac-Thieng JM. Jencas J. Parent 5..
Labelle H: Qualityr uf life [if patients with high-grade spen-
dvlelisthesis: Minimum 1-year felluwdup after surgical
and nunsutgical treatments. Spine j 201 3;13I{T}:?Tfl-T?4.
Medline DUI
The anthers fellewed 23 patients fer 2 years fellewing
treatment {if high-grade spundvlulisthesis. Thejir fuund
impreved health-related qualitv—ef—life scnres with surgical '.-'."
I
treatment. Level ef evidence: I]. m
u.-
D.
an
3
CL
m
'E.
5
re
Urthepaedic Knewledge Update: Sperts Medicine 5
®
Miscellaneous Topics
Chapter 34
The Team Physician and the
Ethics of Sports Medicine
Andrew M. Watson. MD. MS Warren E. Dunn. MD. MPH
Team physicians are confronted with a wide range of
unique ethical dilemmas in providing care to athletes.
The primary goals of medicine and athletic competition
are not always aligned and the considerable internal
and external pressures to prioritize short—term benefit
and athletic success can potentially influence medical
decision-making. As the media exposure and economic
effect of sports increase in modern society, team physi-
eians and athletes alike are presented with a number of.
potemial conflicts of interest that threaten the principles
of traditional medical practice. It is recommended that
the team physician properly recognize these pressures
and conflicts of interest tn adopt a shared decision‘mak-
ing model that engenders trust, prnmntes patient au-
tonomy and prioritizes long-term health outcomes for
the athletes in his or her care.
Keywords: ethics; team physician
Introduction
Sports and medicine have had nppnsing objectives ever
since organized athletics and rational medicine emerged
in ancient Greece.‘ The goal of athletic competition is
victory, and that of medicine is health. These goals come
into conflict if the pursuit of athletic success threatens
the health of the athlete. The rigorous training regimens,
dietary habits, obsessive corrunitment, and personal sacri-
fice characteristic of an athlete’s lifestyle stand in contrast
Dr. Dunn or an immediate famiiy member serves as a paid
consultant to or is an employee of CGNMED Linvatec and
serves as a board member. owner. officer: or commit-
tee member of the American Academy of Orthopaedic
Surgeons, the American flrthopaedic Society for Sports
Medicine. and the American Shouider and Eibow Surgeons.
fl lflld American Academy of Drrbopaedic Surgeons
to the moderation promoted by rational medicine. As a
result, medicine and sports historically have had an ad-
versa rial relationship. The relationship evolved during the
course of the 20th century with the emergence of sports
medicine as a specialty dedicated to facilitating athletic
achievement by improving both performance and health.
The role of medicine in athletic culture shifted from obser-
vation and even disapproval to recognition of the value of
sports and active involvement that is intended to improve
the health of athletes, who are a vulnerable population.
Sports medicine has become integrated into athletic cul—
ture, and the role of the team physician increasingly is
integrated into organized athletics.1
The new relationship of medicine and sports presents
unique ethical challenges. The divergent objectives re-
main and can threaten the ethical foundations of medical
practice“t Beneficence, a fundamental principle of med-
icine, obligates physicians to give first priority to their
patients’ well—being, even at a potential cost to themselves.
Physicians and patients traditionally work cooperatively
toward a common goal of improving patient health, but
physicians and athletes may not have the same goals.3t For
example, some athletes are willing to risk health damage
and violate the law by taking a drug to impmve athletic
success.4 This divergence of goals presents a greater chal-
lenge to the classic physician-patient dyad than is found
in other medical specialties.
The demands of a team sport can exert external F'."
pressures on the athlete and physician and can lead to E
the emergence of an ethically challenging physician-pa-
fir
n
E
tient-team triad.1 The financial and employment relation- F
5
ships of players, physicians, and teams vary considerably I'D
D
E
by levels of competition. The physician may be acting as H'I
.4
a volunteer with a local recreational or scholastic team, D
"E.
the medical director of a large-scale single event, a gen-
n
”I
eral practitioner caring for athletes, an employee of a
university athletic department, or a specialist who has
paid for the right to treat the players on a professional
team.‘ These relationships are different from those in a
typical office-based medical practice. Potential conflicts
Drthopaedic Knowledge Update: Sports Medicb'ie 5
 Sectiun 5: Miscellaneous Tupics
uf interest and threats tu cunfidentiality and patient an-
tunumy are inevitable, and in mudem spurts they are
exaggerated by the increasing influence uf prestige, mar—
ket puwer, advertising, media cuverage, and interested
third partie s33“ In an attempt tu guide physicians cun-
frunted with ethical dilemmas, several urganisatiuns and
governing budies have develuped cudes uf cunductfi'm
Nunetheless, nu widely accepted cude uf ethics has fully
dealt with the varied situatiuns in spurts medicine. As the
spurts landscape cuntinnes tu rapidly change, new and
challenging scenarius are lilrely tu appear.
Cunflitts uf Interest
Fur the practicing spurts medicine physician, the greatest
threat tu the principle uf beneficence arises frum divergent
uppusing guals within the physician—patient—team triad.2
Pm athlete’s decisiun making can be significantly influ-
enced by real ur perceived external pressu res unrelated tu
her ur his uverall ur lung—term health, and the pressures
are exacerbated by media presence and the ecunumic
effect uf spurts} The must ubviuus cunflict uccurs if an
athlete’s health and athletic success require different inter—
ventiuns. Fur example, an athlete with a repairable menis-
cus tear incurred near the end uf the cumpetitive seasun
cuuld be treated with a meniscus repair ur a meniscectu—
my. The meniscectumy cuuld alluw a mute rapid return
tu play, with participatiun in pustscasun cumpetitiun, and
thus wunld further the gual uf team success. Huwever,
the meniscus repair cuuld decrease the lung-term risk uf
degenerative juint disease and thus further the gual uf
impruving the athlete’s lung-term health. The physician
may believe that the lung-term benefits uf meniscus repair
uutweigh the shurt—term benefits uf a rapid return tu play,
but the patient andfur the team may held the uppusite
upiniun. Fur the high schuul player in cumpetitiun fur
an athletic schularship, an early end tn the seasun cuuld
jeupardiae the unly uppurtunity fur eullege acceptance.
Athletes are under cunsiderable internal pressure be-
cause uf the real ur perceived financial effect uf injury and
E
IE
time lust frum play. In high-level spurts, players increas-
I—
In ingly are mutivated by financial cunsideratiuns such as
:5
D
IIll
salary and advertising revenue, and early return tu play is
E
J! likely tu becume a higher priurity than lung-term health.
E The less uf a partial ur entire seasun uf play can have
.E
5
LE
a cunsiderable financial impact un an athlete as well as
family and friends whu stand tu benefit frum the athlete’s
success." An athlete may attempt tu hide past injuries
frum a new physician, team, ur athletic urganiaatiun fur
fear uf being prevented frum further participatiuu. The
perceived threat tn the athlete’s financial success can cre—
ate a dysfunctiunal relatiunship with medical staff?
flrdinpaedic Knuwledge Update: Spurts Medicine 5
The perceptiun that the public prises athletic tuughness
and teamwurlc can create great pressure tu play thrungh
injury ur sacrifice individual health tu benefit the team
ur achieve individual success. The icunic image uf an in-
jured athlete fighting tu cumpcte and struggling thrungh
pain tu glury represents an extremely strung influence
un athletes. Such athletes are almust deified in televi-
siun, muvics, advertisements, and the public eye. lviany
athletes have a strung desire tu please a cuach ur anuther
authurity figure, and their decisiun-making prucess may
be strungly influenced by a belief that a certain decisiun
will displea se the cuach. A research study fuund that min-
imiaing the severity uf pain and playing thrungh pain are
learned behaviurs that develup in yuung players at least
partly in respunse tu athletic cuachiug.” Spurts partici-
patiun uften is an impurta nt part uf an athlete’s identity.
Athletes may fear that injury—caused luss uf playing time
will undermine their pusitiun un a team as well as their
standing with teammates and in the cummunity.”L 0n a
prufessiunal level, the financial cunsequences uf lust time
can cause an athlete tu fear inability tu satisfy ubligatiuns
tu family members and friends. Actiuns resulting frum
such mutivatiuns can significantly cunflict with actiuns
designed tu ensure the athlete’s health.”
Team physicians are expused tu psychusucial pressures
that can influence their decisiun making. As a member
uf a team, the team physician naturally has an emutiun-
al attachment tu the team‘s success, and typically it is
accepted, if nut expected, that the team physician is an
active snppurter cf the team. This factur can cunsciuusly
ur uncunsciuusly influence the physician‘s decisiun mak-
ing in the care uf an individual athlete. A physician alsu
may be respunsible fur cuvering the care uf players un an
uppusing team, and this factur upens a further pussibility
fur cunflict with the beneficence principle. Althuugh it is
clearly unethical tu prumute a team's chance uf success
at the expense uf an athlete’s health, the putential fur
uncunsciuus influence must be recugniaed. This eunflict
is unique tu spurts medicinef'
High—level spurts decisiuns can be cumplicated by the
influence uf media expusnre. The physician may be subject
tu public scrutiny uf his ur her medical decisiuns and inter-
ventiuns. Fur example, the physician’s chuice uf treatment
fur an athlete with a turn meniscus cuuld becume publicly
cuntruversial.1 A decisiun tu pursue meniscus repair rather
than meniscectumy might be in the best lung—term interest
uf the patient but cuuld be negatively perceived by the
public. The cummunity may revere a physician whu is
able tu quickly return athletes tu play, but there is little
acclaim fur a physician whu enables a player tu retire
years later with a nunarthritic juint. This surt uf decisiun
making can have cunsiderable persunal and prufessiunal
fl lflld American Academy uf Urthupaedic Surge-ens

consequences for a high-level team physician, and the
potential influence of the media should not be minimized.
In general, ethical questions surround team physicians
affiliated with a professional sports organisation. Affil-
iation with a professional sports organisation can be so
financially beneficial that physician groups and hospitals
are willing to pay a considerable sum to obtain the affil-
iation.3 The public may believe that a team physician’s
affiliation with a professional team is a function only of
clinical experience or skill, although in fact it may have
resulted from a bidding competition. Paying to become a
team medical provider is not reconnnended, but the cur—
rent reality is that the positiun of team physician is directly
linked to marketing contracts, particularly in professional
sports. Team physicians should attempt to minimise the
inherent conflict.2 The American Academy of fireho-
paedic Surgeons Committee on Ethics recommends that
publicity should not be used in an untruthful, misleading,
or deceptive manner.” Team physicians should disclose
relevant financial arrangements in an attempt to ensure
that the patients who seek their care are motivated by
their ability to manage medical conditions rather than
their relationship with a sports organization.
Athletic teams have an obvious interest in players’ and
physicians“ medical decision making, and the rule of the
team within the physician-patient—team triad should not
be minimized. At all levels of athletic competition, team
administrators, coaches, and teammates of an injured
player feel pressure to succeed. Desire for short—term sucv
cess may outweigh concern for the long-term health of the
athlete with an injury. Particularly during the competitive
season, emotions are strong, and the desire to return an
athlete to play despite the risk can be overwhelming.
In addition, the team may have a substantial financial
investment in the player, and the pressure for un-field
success may be in conflict with medical decision mak-
ing based on long—term patient health? The result is real
or perceived pressure on the athlete and team physician
to return the athlete to play as quickly as possible. The
pressure can be particularly intense if the team physician
is employed by or otherwise formally affiliated with the
athletic organisation; the physician may feel torn between
an obligation to the athlete’s health and the priorities, de-
mands, or expectations of the employer. Failure to ensure
an athlete‘s rapid return to play can jeopardize the relav
tionship between a team physician and the professional
sports organization and may threaten the benefits of the
affiliation for the physician.2 Such a situation is similar
to that of a company-employed physician who must make
a medical decision affecting the speed of an employee’s
return to work after a workplace injury, with a substantial
effect on the financial success of the company.
IE! Eillti American Academy of flrrhopaedic Surgeons
Chapter 34tTlleTeom PhysitdanandtheEtbicsuffipurtsMedidne
These conflicts can create complex and unique con-
cerns for the team physician.” In no other medical spe-
cialty are practitioners so often confronted with disparate
goals and motivations, with substantial financial and pub-
lic relations ramifications. In successfully counseling and
caring for athletes, team physicians should actively work
to understand the internal and external pressures affect-
ing an athlete’s priorities and health decisions. Failure to
recognize these influences threatens the physicia n-patient
relationship and can lead to adversarial interactions, often
at the expense of an athlete‘s health and performance. The
ethical team physician must resist such influences and be
guided solely by the best interests of the individual athlete.
Three Principles of Modern Medical Practice
Patient Autonomy
The practice of medicine traditionally has been predicated
on the principle of beneficence; in modern medical prac-
tice, beneficence has been superseded by patient auton-
omy. Medical practice fundamentally was paternalistic
until the second half of the 10th century. Physicians were
thought to be better able than patients to understand
the risks and benefits of treatment options and therefore
were capable of making the appropriate decision for the
patient. This model failed to account for the values and
priorities of the individual patient, however. As society
increasingly emphasised individuality and personal val-
ues, a shared decision—making model came to dominate
modern medicine. The process of medical decision mak-
ing now is expected to incorporate not only the experience
and knowledge of the medical practitioner but also the
experiences and values of the individual patient.
The evolution from a paternalistic to a shared deci-
sion-making model may be contributing to resolution
of some of the conflicts between medicine and athletics.
Recognition of patient autonomy as a principle of medi-
cal ethics can improve the functional relationship of the
physician and athlete. In a paternalistic environment,
the physician’s recommendations based on the patient’s F'."
long-term health might be ignored in the interest of short- E
term athletic success. Recognizing and incorporating the
fir
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athlete’s goals and values enables physicians to develop F
5
and present treatment options that do not necessarily re- I'D
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I:
quire the sacrifice of athletic success. Although the goals H'I
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of athletes and physicians still differ, the shared deci- El
"E.
sion-making model has facilitated an improved working
n
”I
relationship between the physician and the athlete.
In modern medicine, the patient’s freedom to choose
is paramount, even if the patient’s choice is believed
to be poor.“ Athletes should enjoy the same ability to
make their own health care decisions as patients in other
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectinn 5: Miscellanemls Tnpics
medical settings. True autnnnmy may require an individ-
ual tn be free nf any nutside influence, hnwever. Athletes
may nnt be capable nf true autnnnmy because nf the cnn—
siderable internal and external pressure they experience.”
During a game, the internal and external pressure fnr
an athlete tn return tn play is extremely strnng, and the
athlete may be willing tn risk her nr his individual health
in the interest nf shnrt-term persnnal nr team success.
Snrne retired athletes were fnund tn regret their decisinns
when they lnnked back with a lnng-term perspective and
experience cf the cnnsequencesf Snme researchers argue
that spnrts medicine practitinners have an nbligatinn tn
prntect players frnm the risk nf dangernus injury and
shnuld cnnsider a paternalistic interventinn tn cnunter
undue pressure tn risk injury."r Others argue fnr a shared
decisinn-making mndel in which the physician prntects
the patient’s autnnnmy thrnugh an unbiased presentatinn
nf treatment nptinns that include the implicatinns fnr
lung-term health nutcnmesF-i'"
Informed Ennsent
The principle nf infnrmed cnnsent is designed tn satisfy
the need fnr patient autnnnmy. Thrnugh the presentatinn
nf all relevant treatment nptinns, the patient is able tn
make a truly autnnnmnus decisinn based en a full under-
standing nf the implicatinns nf each treatment nptinn.”1”'
The American Medical Assnciatinn Cnde nf Medical Eth-
ics subsectinn nn spnrts medicine states that “physicians
shnuld assist athletes tn make infnrmed decisinns abnut
their participatinn in amateur and prnfessinnal cnntact
spnrts which entail risks nf bndily injury.” The Inter-
natinnal Federatinn nf Spnrts Medicine Cnde nf Ethics
makes an even stranger statement: “Never imp-rise ynur
authnrity in a way that impinges cm the individual right
nf the athlete tn make hisl'her nwn decisinns....A basic
ethical principle in health care is that nf respect fnr autnn-
nmy. An essential cnmpnnent nf autnnnmy is knnwledge.
Failure tn nbtain infnrmed cnnsent is tn undermine an
athlete’s autnnnmy?”
Adherence tn the principle nf patient autnnnmy can
3
IE
be interpreted as requiring the team physician tn depend
I—
In entirely nn infnrmed cnnsent tn satisfy the duty tn benefi-
:5
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cence. Unable tn exert paternalistic influence, a physician
E
J! in any setting must rely nn being able tn cnnvey infnr-
E matinn sufficient fnr the patient tn make a decisinn that
.E
5
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truly is in the patient’s best interest, and the infnrmatinn
must be cnnveyed withnnt deliberately influencing the
patient tnward any particular interventinn. It is nbvinus
that an attempt tn deceive nr mislead the patient threat-
ens aurnnnmy, but autnnnmy is similarly undermined by
the physician’s failure tn fully identify and disclnse the
available nptinns in a way that is understandable tn the
firthnpaedic Knnwledge Update: Spnrts Medicine 5
patient. Because nf the increasing vnlume and cnmplexity
nf available treatment nptinns as well as the difficulty nf
cnnveying sufficient infnrmatinn tn a patient whn has nn
medical backgrnund, snme researchers have suggested
that this gnal is net truly attainable."5 In fact, it has been
suggested that physicians’ attempts tn fully infnrrn and
educate athletes during game situatinns are meaningless.“
Tn snme extent, the team physician is relieved cf the
necessity nf nbtaining infnrmed cnnsent by the nbligatinn
tn maintain the safety and well-being nf the athlete. The
American Medical Assnciatinn Cnde nf Medical Ethics
includes this statement: “The prnfessinnal respnnsibility
nf the physician whn serves in a medical capacity at an
athletic cnntest nr spnrting event is tn prntect the health
and safety nf the cnntestants. The desire nf spectatnrs,
prnmnters cf the event, nr even the injured athlete that he
nr she shnuld nnt be remnved frnm the cnntest shnuld nnt
be cnntrnlling. The physician’s judgment shnuld be gnv-
erned nnly by medical cnnsideratinns.” The Internatinnal
Federatinn nf Spnrts Medicine ICnde nf Ethics includes a
similar statement: r"It is the respnnsibility nf the spnrts
medicine physician tn determine whether the injured
athletes shnuld cnntinue training nr participate in cnm-
petitinn. The nutcnme nf the cnmpetitinn nr the cnaches
shnuld nnt influence the decisinn, but snlely the pnssible
risks and cnnsequences tn the health nf the athlete.’”“
Despite the difficulties inherent in truly infnrmed
cnnsent and the pntential fnr external influence cm the
athlete’s decisinnrmaking prncess, team physicians are
cnnstrained by the ethics cf the medical prnfessinn. If the
safety nf an athlete nr annther participant is in jenpardy,
the team physician is always required tn prntect individ-
ual safety withnut regard tn individual nr team athletic
success. In nther situatinns, hnwever, mndern medicine
relies nn patient autnnnmy, and athletes have the right tn
make decisinns fnr themselves. This principle can relieve
the physician nf the burden nf decisinn making but re—
places it with the necessity nf presenting a large amnunt
nf infnrmatinn in an easily understandable fnrm. This
ability shnuld be develnped as nne nf the mnst impnrtant
clinical skills nf the team physician because it can have
a substantial impact en the ability nf athletes tn actively
participate in their nwn care.
Cnnficlentiality
In a traditinnal medical setting, physicians are nbligated
tn maintain cnniidentiality regarding a patient's med-
ical cnnditinn. Cnnfidentiality is cnnsidered invinlable
by mnst health care cndes nf ethics. Health care prn-
viders are legally bnund tn maintain patient cnnfiden-
tiality unless withhnlding infnrmatinn might harm the
patient nr annther persnn. [n spnrts medicine, the right tn
fl lfllfi American Academy nf Urthnpaedic Surge-nus

confidentiality may be challenged if a medical condition
threatens the patient’s ability to participate in the sport.
For example, an athlete who has sustained a concussion
is required to be removed from the game and not be re-
turned to play.13 The athlete may wish to keep the team
physician’s diagnosis of concussion confidential so as to be
allowed to return to play. Because a return to play would
directly threaten the athletes health, the physician would
need to violate patient confidentiality by informing the
coaches of the diagnosis, thereby precluding the athlete’s
return to play and ensuring his or her safety. In high-level
sports, extensive media attention can undermine patient
confidentiality. The team physician should disclose to
the media only the information clearly authorized by
the athlete.
There may be an ethical and practical distinction based
on whether a physician is acting as a team physician or an
athlete’s personal physician.3 A physician hired by a team
is an agent for the team and is obligated to give priority to
the goals of the team. The team physician should inform
the patient that the physician has an obligation to disclose
relevant medical information to team officials, even if the
patient has specifically requested that the information
remain confidential. An athlete’s personal physician has
no obligation to the team and must honor the athlete‘s
confidentiality. This distinction has been applied to the
US Health Insurance Portability and Accountability Act
of 1996 {HIPAA}.” Team physicians can disclose a pro-
fessional athlete’s medical information to coaches and
team officials because the information is part of the ath-
lete’s employment record and therefore is not protected
under HIPAA. However, a physician who independently
cares for a professional athlete in the physician’s medical
office is obligated by HIPAA to maintain confidentiality
and cannot disclose information to team officials. lflare
provided to athletes through a university health service is
regulated by the Federal Educational Rights and Privacy
Act, which allows health care information to be disclosed
only to educational entities unless the patient has given
consent. Both the Federal Educational Rights and Privacy
Act and HIPAA allow health information to be provided
to other health care providers without patient consent.
Although athletic trainers have not been fully defined as
health care providers, this status typically is assumed,
particularly in the context of emergency evaluation and
treatment during a game.”
The unique context of medical care during sports
events and within an athletic organization should be
clarified for athletes, team physicians, coaches, and staff.
Athletes should be informed that the team physician may
need to disclose personal or private information to other
providers in the interest of providing optimal care.” For
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 34tTheTeam PhysitdanandtbeEtlricsoports Medicine
example, the coaching staff and athletic trainers in the
rehabilitation program may need to know an athlete‘s
prognosis after an injury or illness. It is possible, how-
ever, that fear of repercussions may lead the athlete to
avoid disclosing the informationf' This is an important
consideration, and the physician should seek to promote
a common understanding of the nature of proper care
in a team environment. A breach of confidentiality is
the greatest threat to a successful physician-patient—team
relationship, and establishing appropriate expectations is
a required part of professional conduct.6 Athletes should
be advised that health care providers will be careful to
avoid inadvertently revealing information to anyone not
involved in the athletes care and that aspects of the ath-
lete’s care that are not immediately relevant to sports
participation or the safety of others will be kept strictly
confidential.
Concussion
Sports-related concussion has received considerable media
attention in recent years and has become a major public
health concern.Ill Concussion is common in many sports
and can have both short-term and long-term effects on an
athlete's cognitive function and quality of life. Recurrent
concussions appear to be associated with an even higher
risk for dementia and other long-term deleterious effects
on behavior and neurocognitive function.“1 In response
to the emerging body of evidence, all 50 states and the
District of Columbia have adopted legislation governing
concussion ma nagement.“ These laws generally cover re-
moval from play if an athlete has a suspected concussion,
return to play after a concussion diagnosis, and education
on concussion for coaches, athletes, and parents. State
laws differ substantially, and there is no federal concus-
sion legislation. Team physicians must be familiar with
their responsibilities under the laws of their state.
There is a universal recommendation that an athlete
with a concussion should be immediately be removed
from play for the remainder of the day. A team physician F'."
can encounter difficulty in identifying concussion during E
competition, however. Athletes often are motivated to
fir
n
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hide concussion symptoms to avoid being removed from F
5
play.“ Because of the subjective nature of many concus- I'D
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sion symptoms, such as nausea, headache, and dizziness, H'I
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the team physician may be unable to reach a definitive El
"E.
diagnosis within a brief period of time on the sideline. A
n
”I
gradual return to play, typically over 5 days, is required
after a concussion diagnosis, and a concussion diagnosis
during a busy season may preclude an athlete from partic-
ipation in multiple events.“4 This situation is difficult for
the team physician. An underdiagnosis places an athlete
Drthopaedic Knowledge Update: Sports Medichte 5
 Sectinn 5: hfisncllancnus Tupics
at risk nf subsequent injury, but an nverdiagnnsis may
unnecessarily preclude an athlete frnm participating in
multiple events, tn the detriment nf the athlete and the
team.
Because cf the significant pntential fnr harm, guide-
lines typically recnmmend withholding an athlete with
any evidence nf a cnncussinn fur the remainder nf the
cnmpetitive event. There shnuld be a fnrth right discussinn
nf the risks tn ensure that the athlete understands that
the decisinn tn withhnld frnm cnmpetitinn was nnt made
lightly}1 blnnetheless, the athlete may disagree with the
diagnnsis and resist medical advice. An athlete with a cnn—
cussinn may have impaired capacity fnr decisinn making.
Despite the physician's nbligatinn tn respect patient autnn—
nmy, in this situatinn the athlete‘s immediate well-being is
mnre impnrtant than the desire tn resume participatinn.
The team physician, trainers, and cnaches must agree if
they are tn prevent a player frnm returning tn play against
medical advice, and a breach nf cnnfidentiality therefnre
is justified. Une cnmmnn means nf preventing a fnntball
player with a cnncussinn frnm immediately reentering the
game is tn take away the helmet.
The recnmmended prncess nf recnvery Etnm cnncussinn
incnrpnrates a stepwise return tn play that is cnntingent
nn resnlutinn nf initial symptnms and cnntinuing absence
nf symptnms.”El Neurncngnitive testing snmetimes is neces—
sary. Mnst cnncussinn symptnms are resnlved within days
nf the injury and allnw a relatively quick return tn play
nver the next several days. Occasinnally, the symptnms
nf cnncussinn persist fnr weeks nr mnnths, hnwever, and
the athlete is precluded frnm cnmpeting fnr an extended
perind nf time. There may be external pressure frnm mul-
tiple directinns tn prematurely return the athlete tn play,
pnssibly tn the benefit nf the team but at great risk tn the
athlete’s well-being. The team physician must npenly dis-
cuss expectatinns and milestnnes fnr return tn play with
the athlete, cnaches, and team administratnrs as snnn as
pnssible after the injury. Premature return tn play after
cnncussinn shnuld he understnnd as unacceptable under
any circumstance. If all members nf the team understand
3
IE
the reasnns fnr a prngressive return-tn-play prncess {Ta-
I—
In ble 1}, external pressure tn vinlate the standard nf care is
:5
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likely tn diminish in impnrtance.
E
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E as well as the physician’s surveillance and management
.E Perfnrmance—Enhancing Drugs
5
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The team physician may be apprnacbed by athletes abnut
the use nf petfnrmance-enhancing substances, nr the
physician may inadvertently learn abnut the use nf such
substances when an athlete’s use is expnsed. Athletes are
strnngly mntivated tn seek a cnmpetitive advantage, and
scandals invnlving the use nf banned substances are nnt
firthnpaedic Knnwledge Update: Spnrts lvledich'le 5
Graduated Return tn Play Prntncnl
Step 1: Nn activity [symptnm limited physical and
cngnitive rest}
Step 2: Light aernbic exercises (walking, swimming nr
statinnary bike keeping intensity -c 10% maximum
permitted heart rate. Nn resistance training]I
Step 3: Spnrt—specific exercise {such as running drills in
snccer. Mn head-impact activities}
Step 4: Nnncnnta ct training drills {prng ressinn tn mnre
cnmples training drills based nn spnrt}
Medical clearance required prinr tn prnceecling with
step 5
Step 5: Full—cnntact training
Step 6: Return tn cnmpetitinn
Adapted with permissinn frnm McCrnry Ff, Meeuwisse WH, Aubry
M, et al: Cnnsensus statement nn cnncusslnn In spnrt: The 4th
Internatinnal Cnnference an Cnncussinn in Spclrt held in Enrich.
aarnber ran. HrJ' Sparts Med 2D13;4?{S):25fl-253.
uncnmmnn. lvlndern ethical guidelines are unequivncal
in cnndemning the use nf banned substances. The Inter-
natinnal Federatinn nf Spnrts Medicine Cnde nf Ethics
specifically fnrbids the use nf certain substances as hav-
ing adverse effects and prnviding an unfair advantage
tn the athlete.IEI Gnverning hndies such as the Natinnal
Cnllegiate Athletic Assnciatinn, the American Cnllege nf
Spnrts Medicine, and the Internatinnal IC'I'ly'mpic IEnm—
mittee alsn cnndemn nnntherapeutic drug use} Athletes
snmetimes disclnse the use nf such substances tn the team
physician, hnwever, and as a result the physician must
recnncile a cnnflict between the principles nf beneficence
and cnnfidentiality. Under nn circumstances shnuld a
team physician prescribe a banned substance, and the
physician has an nbligatinn tn dennunce the use nf banned
substances. Hnwever, if there is nn immediate threat nf
significant harm tn the athlete, the physician can hnnnr
patient cnnfidentiality and need nnt disclnse the use nf a
banned substance tn cnaches nr team nfficials. The phy—
sician need nnt terminate the relatinnship with an athlete
if the athlete chnnses tn ignnre the advice tn discnntinue
the use nf a banned substance. The athlete prnbably will
benefit frnm cnntinuing infnrtnatinn nn the risks nf use
nf any adverse effects.
Althnugb an athlete’s use nf a legal, accepted perfnr-
mance--enhancing drug may nnt be unethical, the team
physician nnnetheless shnuld he cautinus. Uver-the-cnunt-
er analgesics, fnr example, may be perfnrmance enhanc-
ing if they facilitate a return tn play while the athlete has
injury symptnms, with the risk nf wnrsening the injury.1
fl lfllfi American Academy nf Urtbnpaedic Surge-ans

If a legal substance is nut universallyr available, its use by
these with access has the putential tn viulate the spirit
uf cumpetitiun.3 In general, team physicians shuuld dis—
cuurage the use uf any substances that are assuciated
with a health risk fur the athlete ur unfairly benefit the
athlete thruugh a perfurmance advantage. The physician
shuuld establish a trusting relatiunship with the athlete
that prumutes the disclusure uf infurmatiun and alluws
the disseminatiun uf infurmatiun, su that patient autun—
umy is preserved and the risk tu the patient’s health is
minimised.
Eenumits
The develupment uf different types uf genetic testing
and their widespread availability have created new eth-
ical dilemmas in spurts medicine. Genetic testing can
be used tu determine an individual’s health risks related
tu spurts participatiun. Fur example, testing is useful in
a patient whu may have l'vlarfan syndrume ur lung QT
syndrume ur whu has a family histury uf hypertruphic
cardinmynpathy ur certain types uf arrhythmiasfil“
lGenetic testing has been used in an attempt tu identify
genes predicting athletic perfurmance; such testing cuuld
lead us discriminatiun if used tn direct yuung athletes
tuward ur away frum certain activities? The U5 Genetic
Infurmatiun Nundiscriminatiun Act pruhibits the use uf
genetic in furmatiun in empluyment decisiuns, and the use
uf genetic testing fur athlete selectiun cuuld be cunsidered
a viulatiun uf this act.15
Certain genetic tests can yield infurmatiun un increased
risk affecting participants in a specific spurt. Fur example,
the develupment uf a test fur apulipuprutein E4 cuuld have
impurtant ra mificatiuns fur athletes in cuntact spurts such
as fuutball because adults with apulipuprutein E4 un even
a single allele are at significantly increased risk uf a peer
lung—term neurucugnitive uutcume after traumatic brain
injury? Screening cuuld result in athletes with a pusitive
genutype being restricted frum play. In general, there is
nu cunsensus regarding the questiun uf huw much risk a
fully infurmed player shuuld be alluwed tu accept.
When genetic inform atiun is available tn the team phy-
sician, the acceptability uf using the infurmatiun is nut
always clear. Fur example, if a team physician furbids
participatiun based un a genetic test, the decisiun cuuld be
cunsidered discriminatury and in viulatiun uf the Genetic
[nfurmatiun Nundiscriminatiun Act.” Huwever, ignnring
the infurmatiun and alluwing an athlete tu play cuuld
have catastruphic cunsequences, such as sudden cardiac
death in an athlete knnwn tu be at risk fur dysrhythmia.
If an athlete ignures the advice tu withdraw frum play,
disclusing infurmatiun tu team ufficials ur cuaches cuuld
IE! Eillli American Academy uf flrthupaeclic Surgeuns
Chapter 34tThe Team Physician and the Ethics uffipurts Meditine
represent a breach uf cunfidentiaiity, depending un the
severity cf the risk. It is nut always clear whether genetic
testing infurmatiun is useful. Fur example, the value uf
cummercial genetic tests that purpurt tu identify an indi-
viduals athletic abilities has nut been prc-ved. The extent
uf the risk assuciated with apulipuprutein E4 in athletes
participating in cuntact spurts alsu is unknuwn. Team
physicians shuuld be knewledgeahle abuut the accuracy
and usefulness uf such tests in estimating the risk tu in-
dividual athletes. This infurmatiun is essential tu alluw
the team physician tu pruperly advise an athlete, while
maintaining buth autunumy and cunfidentiality.
Medical Innuvatiuns
Innuvatiuns in spurts medicine—related drugs, supple-
ments, surgical techniques, and rehabilitatiun are plentiful
and rapidly advancing, but many medicatiuns ur pruce-
dures lack a sufficient evidence base tu guide their use.”
Athletes, teams, and the public uften believe that “new-
er is better,” even if evidence is lacking. In prufessiunal
spurts, the media attentiun and financial cunsideratiuns
assuciated with medical and surgical interventiuns can.
place the team physician in a difficult pusitiun. The rapid
pace nf develupment and the relatively small number uf
athletes available fur research studies uften precludes the
cullectiun uf suund evidence en the use uf new prucedures
ur medicatiuns. Paraduxically, the evidence remains scant
until the mudality is used un a large scale.it
The deliberate pursuit uf truly infurmed cunsent is
paramuunt whenever a new treatment is being cunsidered.
The physician is ubligated tu hunestly and thuruugbly
evaluate the available evidence related tn the prupused
treatment. If a treatment has nut been investigated ur if
unly minimal, anecdutal evidence exists, the physician
must fully infurm the athlete cf the experimental nature cf
the treatment. If a physician has participated in the devel-
upment uf a treatment as an inventur, industry cunsultant,
ur researcher, this infurmatiun alsu must be disclused.
The physician may need tu seek the infurmal advice uf F'."
physician culleagues befure cunsidering an unpruved ur E
experimental treatment. The team physician shuuld fully
fir
n
E
cunvey the risks and benefits assuciated with a treatment F
5
su the physician and the athlete can cuuperatively arrive I'D
D
I:
at an infurmed decisiun.l H'I
_.1
El
"E.
n
”I
Summary
The spurts medicine clinical envirunment is unique in
that medical decisiun making uften invulves cunflicts
uf interest related tu the physician—patient—team triad.
Athletes, teams, and physicians are subject tu real and
Drthupaedic Knuwledge Update: Spurts lvledicine .‘i
 Sectinn 5: Miscellanenus Tupics
perceived pressures that are exacerbated by the increas-
ing media visibility and ecnnnmic impact nf spnrts in
mndern snciety. Team physicians are required tn deal
with situatinns in which the lnng-term health interests
nf an athlete are in cnnflict with shnrt-term individual
nr team success. The medical treatment nf athletes snme—
times requires fnllnwing legal and ethical guidelines that
reflect a delicate balance amnng beneficence, autnnnmy,
and cnufidentiality tn achieve nptimal care nf an athlete.
Physicians shnuld actively identify the pressures that can
mntivate athletes and teams and shnuld treat an athlete
within a shared decisinn—making mndel that engenders
trust. Infnrmed cnusent always shnuld be snught tn pre-
serve the athlete’s autnnnmnus decisinn—making ability.
Au athlete’s infnrmed decisinu that nppnses the advice nf
the team physician shnuld be respected, and an nngning
cnnperative relatinnship shnuld be pursued. Patient autnu—
nmy may need tn be sacrificed, hnwever, if there is a sig-
nificant risk nf harm tn the athlete nr nthers. In a rapidly
changing envirnnment, team physicians are nbligatcd tn
remain aware nf natinual nrganisatinn recnmmendatinns
as well as state and federal legislatinn related tn the ethical
care nf the athlete.
Hey "Studyr Pnints
' The practice nf spnrts medicine is cnnirnnted with
a wide range nf ethical dilemmas because nf the
cnusiderahle external pressures and pntential enn-
flicts nf interest that may prnmnte the sacrifice nf
lnng-term health nutcnmes fnr shnrt-term benefit
and athletic success.
l The physician-patieut-team triad is a unique health
care mndel with impnrta nt implicatinns fnr patient
cnnfidentiality, autnnnmy, and beneficence.
I: As a health care prnvider, the team physician is
nbligated tn identify and minimise cnnflicts nf in-
titrest {fnr hnth himselfr'herself and the patient} in
pursuit nf a shared decisinn-making mndel that fa-
cilitates truly infnrmed cnusent and prntects patient
autnnnmy.
E?
IE
I—
In
l Team physicians are nbligated tn remain up tn date
:5
D nu emerging therapeutic mndalities, spnrt science,
IIll
E and the relevant legislatinn tn ensure that athletes
J!
E are truly iufnrmed befnre participating in unprnven
.E
5 nr experimental modalities.
LE
firthnpaedic Knnwledge Update: Spnrrs Medicine 5
Annotated References
. Mathias ME: The cnmpeting demands nf spnrt and health:
An essay cm the histnry nf ethics in spnrts medicine. Ch}:
Spin-rte Med 2004;23l2}:19§—214, vi. Medline DUI
. Dunn WE, Genrge M5, Churchill L, Spindlcr KP: Ethics
in spnrts medicine. An: I Spurrs Med 2i] BESSIE 1:34fl-344.
Medliue DD]
. Bernstein J, Perlis C, Bartnlnssi AR: Hermative ethics in
spnrts medicine. Elie: 011p Relat Res 2fl04;42fl:309-
313. Medline DDI
. Gnldman B, Bush P], Klara E: Death in the aker Rnnm:
Stars-ids and Spnrts. Snuth Bend, IN, Icarus Press, 1934.
. Hnlm S, McNamee M], Pignasi F: Ethical practice and
spnrts physician prntectinn: A prnpnsal. Br} Spur-rs Med
2fl11;45{15]:11?fl-11?3.Medline DUI
The authnts present a prnpnsal fnt the navigatinn nf the
ethical dilemmas that cnnfrnnt the spnrts medicine phy-
sician. They argue that the cnntests are varied, but ant
unique, and can he apprnached by drawing en the ethics
nf public health.
. Stnvits SD, Satin DJ: Ethics and the athlete: 1Why spnrts
are mnre than a game but less than a war. Elie: Spurts
Med 2Gfl4;23{1}:215-225,vi. Medline nnr
. Testnni D, Hnrnilt CP, Smith PE, Benjamin DH. jr, McK-
inney RE Jr: Spnrts medicine and ethics. Ass Jr Binerb
2fl13:13[1fl}:4-12.Medline DUI
The authnrs prnvide a thnrnugh evaluatinn nf the ethical
principles that shnuld guide spnrts medicine physicians in
their apprnach tn the care nf athletes. They specifically
address the implicatinns nf paternalistic versus shared
decisinn-malting mndels.
. American Cullege nf Epnrts Medicine: Cede nf Ethics.
Available at httpu'i'www.acsm.nrgfjnin-acsmi'member-
ship-resnurcesfcnde-nf-ethics. Accessed Nevember 14,
IBM.
The cnde nf ethics frnm the American Enllege nf Sp-nrts
Medicine prnvides the practicing team physician with
guidance tn deal with the unique ethical dilemmas cnu-
frnnted in clinical practice.
. American Medical Assnciatinn: Imade nf Medical Ethics.
httpdiwwwama-a ssn.nrgi’amai'lpubi'physician-resnurceslf
medical-ethics.l'cnde-medical-ethics.l'npininn.3lilii'i.pageil
Accessed Nnvember 10, 2014.
This cnde frnm the American Medical Assnciatinn prn—
vides guidelines fnr clinical practice in the care nf athletes.
It identifies pntential cnnflicts nf interest fnr hnth athletes
and physicians and makes recnmmendatinns fnr hnw tn
apprnach them ethically.
fl lflld American Academy nf Cirrhnpaedic Surgenns

1f]. International Federation of Sports Medicine: Code of Eth-
ics. Available at http:#www.fi ms.orgfen:'generalicode-of-
ethics“. Accessed November 1i], NH.
The guidelines provided by this governing body attempt
help the practicing team physician identify and manage
ethical dilemmas in the care of athletes.
11. Greenfield EH, West CR: Ethical issues in sports medii
cine: A review and justification for ethical decision mak-
ing and reasoning. Sports Health 2012:4{6}:4TS-4?9.
Medliue DUI
The authors present the inherent difficulty for healthcare
providers in making return-to-play decisions for ath-
letes, and the ethical principles that should guide proper
decision-making.
12. Malcom NL: “Shaking it off“ and “toughing it out": So-
cialization to pain and injury in girls' softball. J Contemp
Ethnogr' 2fl05535[51:495—52 S. DCII
13. Nixon HL: Social network analysis of sport: Empha-
siting social-structure in sport sociology. Soct'oi.r Sport
J 1993;1fli3lt315-321.
14. Hensinger EN: The principles of medical ethics in ortho-
paedic surgery. J Bone Joint Surg Arr: 1992;?4l10}:1439-
144D. Medline
1.5. Johnson R: The unique ethics of sports medicine. Clt'rt
Sports Med roo4;sso}:1vs—1ss. Medline not
15. Bunch WH, Dvonch UM: Informed consent in sports
medicine. Cfin Sports Med lflfl4;23{2}:133-193, v.
Medline DUI
1?. Sim J: Sports medicine: Some ethical issues. Br I Sports
Med 1993:2Tilh95-1flfl. Medliue DUI
IS. McCrory P, Meeuwisse WH, Aubry M, et al: Consensus
statement on concussion in sport: The 4th International
Conference on Concussion in Sport, Zurich, November
2012. J Atbi Train lfllS:4S{4l:SS4-5TS. Mcdline DUI
This consensus statement uses the best available evidence
to provide guidelines in the identification and management
of sport-related concussion.
19'. Magee JT, Almekinders LC, Taft TN: HIPAA and the team
physician. Sports Med Update Iflfld:March—April;4-S.
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 34: The Team Physician and the Ethics of Sports Medicine
ID. Waddington I, Roderick lvl: Management of medical
confidentiality in English professional football clubs:
Some ethical problems and issues. Br J Sports Med
2UD2:36{1]:113-123, discussion 123. Medline DD]
21. Kirschen MP, Tsou A, Nelson SE, Russell JA, Larrivicre
D; Ethics, Law, and Humanities Committee, a Joint Com-
mittee of the American Academy of Neurology, Amer-
ican Neurological Association, and Child Neurology
Society: Legal and ethical implications in the evaluation
and management of sports—related concussion. Neurology
2fl14;33{4}:352—SSS.Mcdlinc DUI
The authors present the ethical dilemma that faces the
team physician in the context of identifying and managing
sport-related concussion, and draw on a number of ethical
principles to guide decision making.
12. Torres Dl'vl, Galctta KM, Phillips HW, et al: Sports—related
concussion: Anonymous survey of a collegiate cohort.
Neuroi' Elie Prnct 2013;3{4}:2?9-EST. Medline DDI
The authors present the results of a survey of collegiate
athletes that suggests that although most are aware of
the signs and symptoms of concussion, a large percentage
reportedly knowingly withheld symptoms to continue
participation.
23. Pelliccia A, Fagard R, Ejernstad HH, et al; Study Group
of Sports Cardiology of the Working Group of Cardiac
Rehabilitation and Exercise Physiology; Working Group
of Myocardial and Pericardial Diseases of the European
Society of Cardiology: Recommendations for competi-
tive sports participation in athletes with cardiovascular
disease: A consensus document from the Study lGroup of
Sports Cardiology of the Working Group of Cardiac Reha-
bilitation and Exercise Physiology and the Working Group
of Myocardial and Pericardial Diseases of the European
Society of Cardiology. Ear Heart ] lflfl5;36{14l:1422-
144.5. Medline DUI
24. Trusty Jhd, Eeinborn DS, Jahangir A: Dysrhythmias
and the athlete. AA CM Clirt Issues 11104;.1 S{31:431-443.
Medlinc DD]
15. Nemeth P, Bonnette TW: Genetic discrimination in em-
ployment. Michigan Her I 200.9: January; 43-45.
16. No pain, no gain: The dilemma of a team physician. Br
J Sports Med lflfl1;35{3}:141~142.
F'."
This article outlines the Genetic Information Non-Dis- E
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ployment decisions based on known genetic information. F
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Drthopaedic Knowledge Update: Sports lviedichte S
Chapter 35
Research Studies and Registries
in Sports Medicine
Robert H. Brophy, MD Matthew V. Smith, MD
abstract
Prospective multicenter studies are an increasingly
important component of medical research, including
research related to orthopaedic surgery and sports med-
icine. Several recent publications related to rotator cuff
disease, anterior cruciate ligament primary and revision
reconstruction, and meniscus tears have resulted from
prospective cohort studies and registries related to the
shoulder and knee.
Keywords: anterior cmciate ligament
reconstruction; meniscus tear: registry; rotator cuff
tear
Introduction
The increasing emphasis on evidence-based medicine
has led to a need for high-quality clinical research in
orthopaedic surgery that is designed to improve patient
care and identify risk factors for poor outcomes. For the
purpose of conducting research or critically evaluating a
published study to determine whether the conclusions are
relevant to their clinical practice, orthopaedic surgeons
must understand the fundamental principles of study
design and statistical analysis.
Collaborative multicenter studies are increasingly
important to orthopaedic surgery and sports medicine
research. The importance of such studies cannot be over-
Stated. By studying large cohorts from multiple sites, re-
searchers are able to substantially increase the power
Dr. Brophy or an immediate family member has stock or
stock options held in Ostesys' and serves as a board mem-
her. owner. officer; or committee memher of the American
Orthopaedic Society for Sports Medicine. Dr. Smith or an
immediate family member serves as a paid consultant to
lSTG Technologies.
@ lfllfi American Academy of Drthopaedic Surgeons
and generalizability of research."1 Multicenter studies are
less common in orthopaedic surgery and sports medicine
than in other medical specialties, although the gap is
narrowing:1
There is an important distinction between prospective
multicenter studies and registries. A prospective multi-
center study is designed to collect data for the purpose
of answering a specific question or set of questions. In
contrast, a registry simply collects data on one or more
types of surgical procedures. A research question can be
investigated retrospectively in the context of a prospective
multicenter study, but by design the research questions
are retrospective in a registry-based study. The quality of
a registry’s data often is lower than that of a prospective
cohort study’s data. Although registry~based studies are
useful, prospective multicenter studies generally provide
a higher level of evidence and better—quality research.
Research Question
Many important clinical questions cannot be answered
completely with a single study. Instead, a series of studies,
using different study designs, may be required to charac-
terize the distribution of a disease or injury in a popula-
tion {a descriptive study}, investigate the risk factors for
the disease or injury in the population {an analytic study},
and evaluate the efficacy of treatment {an experimental
F!"
study]. The choice of a study design depends on an assess- 5
ment of the accessibility of information, the prevalence of ill
‘1
the disease in the population, and the findings of earlier 11—!
:l
research. -I'I'
o
1:
Several factors must be considered as a research pro- H
tocol is developed. The starting point is identification 5'
'9.
of an important clinical question that is not adequately lil
answered in the available literature. The research ques-
tion is developed using the FINER criteria3 (Feasible,
Interesting, Novel, Ethical, Relevant} {Table 1}. The study
should be focused to answer a specific question. The re-
search design also may provide insight into secondary
Orthopaedic Knowledge Update: Sports Medicine S
 Section ti: iviiscelianeous Topics

The FINER Criteria for Developing an Cirthopaedic Research Question

Criterion Defining Questions
Feasible Is the number of research subjects adequate?
Does the research team have adequate technical expertise?
Can the research be completed with the available time and money?
Is the research manageable in scope?
Interesting Is the research topic of interest to the investigator?
Is the research topic of interest to orthopaedic surgeons?
I'Ilovel Will the research results confirm or refute previous knowledge?
Will the research provide new insight into what is already lcnown?
Will the research add to the body of knowledge?
Ethical Will the research violate or uphold ethical principles?
Ilelevant Will the research add to scientific knowledge?
Will the research results lead to future additional research?

questions, but the primary outcome of interest should Types of Studies

the main focus of the research design. 1l'lfhen the primary
research question has been formulated and the FINER
criteria have been met, each component of the research
protocol should be carefully considered. Fully vetting a
study protocol before starting a research project is useful
for identifying pitfalls that could impede the progress of
the study or make it impossible to complete. Completing
a research template helps to focus the research plan and
ensure that key components of the study are thought out
in advance {Table 2}.
Research Hypothesis
With the exception of a purely descriptive study, most
clinical research should be hypothesis driven. The null hy-
pothesis {Ha} proposes that no difference exists between
two variables. In contrast, the alternative hypothesis {H,}
proposes that a difference exists between two variables.
The hypothesis should be specific to the primary outcome
variable and should reflect the expected change in the
LEI
primary outcome variable. For example, the following
.E
S hypothesis statement is not sufficiently specific because
the primary outcome variable is not clearly defined: “Pa—
'—
Studies can be observational or experimental. In an ob-
servational study, a population of interest is observed for
a disease at a single point in time {a cross-sectional study},
observed for exposure and resulting disease prospectively
or retmspeccively {a cohort study}, or observed to deter-
mine the exposure history of those with and without a
specific disease (a case—control studyj.“ Dbservational
studies can be descriptive or analytic. Analytic observa-
tional studies examine associations between exposure and
disease. Descriptive studies examine the features of the
study population such as the number of patients with a
particular disease. Descriptive studies may establish the
incidence or prevalence of a problem in a given popula~
tion. Experimental studies evaluate an outcome of an
intervention by assigning participants to a treatment and
following them over time. Often an experimental study
includes control subjects for comparison. The interven-
tions may or may not be randomly assigned or blinded
to participants and observers.
Case Report and Case Study
Case reports and case studies are observational studies

U'l
J
o
e1l: tients with a full-thickness rotator cuff tear will have that explore outcomes in a limited group of patients with
E better outcomes after undergoing surgical treatment than a similar disease or with similar treatment of a disease.
E
U nonsurgical treatment.” This hypothesis must be refined There are no control subjects, so the ability to make com~
to provide a precise statement of the expected outcome parisons regarding treatment efficacy is limited, and it
IE

E
of the study, as in the following statement: “Patients with is difficult to critically evaluate causation. Such studies
a

a full—thickness rotator cuff tear will have an average produce low—level evidence, but they are beneficial for
American Shoulder and Elbow Surgeons shoulder score describing treatment outcomes in uncommon diseases
10 points higher after undergoing surgical treatment than and can generate ideas for higher level controlled studies.
after undergoing nonsurgical treatment.”

I180 flrrhopaedic Knowledge Update: Sports Medicine 5 El ll] 16 American Acadenw of Cirrhopaedic Surgeons
 Chapter 35: Research Studies and Registries in Sports Medicine

Template for a Research Protocol

Component Description
Study question State the primary question the research aims to answer. The question should be
focused and specific.
Significance Describe why the research is important:
I What is known?
I What is unknown?
I How will the study results be beneficial?
Hypothesis State what you think the answer to the study question will be in specific terms.
Primary outcome State the main outcome variable of interest.
Secondary outcomejs} State other included outcome variables that may be important.
Study design Describe the specific study design you intend to use to answer the study
question.
Setting Describe where the study will take place:
I Who will be involved in subject recruitment?
I Where will data be collected?
I Will other institutions be included in the study?
Subjects Describe the population you intend to study to answer the study question:
I How many subjects will be enrolled?
I How will subjects be recruited?
I What are the inclusion and exclusion criteria?
Statistical approach Describe the statistical methods you plan to use to analyze the data:
I What criteria will be included in the power analysis?
I What statistical tests will be used?
I How do you plan to deal with missing or incomplete data?
Anticipated outcome Deso'ibe how you think the findings from the study will add to the current
literature

Ease-Control Study
A case—control study is an observational study that ana-
lyxes the relationship between disease and exposure. The
disease of interest already has occurred in the popula-
tion of interest. The researcher selects an appropriately
matched group of individuals who do not have the disease
[control subjects) from the same source population as
individuals with the disease {patients or cases}. The ex—
posure history of individuals in both groups is evaluated
to identify risk factors for disease. The odds of an expo-
other studies that analyse causality, but they provide a
lower level of evidence because of the inherent bias in
the study design.
Cross-sectional Study
A cross-sectional study measures the prevalence of a dis-
ease. Prevalence is defined as the total number of inci-
dences at a single point in time. Because a cross—sectional F'."
study identifies disease and exposure at the same time, E
it is helpful for identifying multiple possible risk factors
fir

n
E
sure in the control subjects compared with the patients for a disease in a specified population. Possible exposures F
5
provides an odds ratio {DR} for the disease related to the can be identified for consideration in a cohort study. This I'll
ID
I:
identified exposure. type of study cannot provide a good assessment of the HI
_.1
IEase-control studies provide evidence of causality be“ relationship between exposure and disease, and it is not ID
"E.
tween an exposure and the disease of interest. Conclusions suitable for identifying rare outcomes. A cross-sectional
n

”I

regarding causality are limited by recall and sampling bi—
ases. This study design is useful for identifying possible
causes of a relatively uncommon disease or little-known
causes of a common disease. Case-control studies typ—
ically are less expensive and less time consuming than
study is relatively quick and inexpensive to perform.
Cohort Study
Cohort studies are observational studies that can be den
scriptive by defining new incidences of disease or analytic

IE! EDIE American Academy of flrthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medichie S
 Seetien 5: Miscellaueeus Tepies
by identifying risk facters fer the develepment ef disease.
In eehert studies, an expesed study pepulatien is assessed
ever time fer disease develepment. A eehert study can
be prespective er retrespective. In a prespective eehert
study, the exposed pepulatien is selected and fellewed fer
a peried ef time te identify the eutceme ef interest. Fer
example, patients whe underge a partial meniscectemy
[the expesure} are fellewed inte the future te assess their
risk fer the develepment ef esteearthritis {the disease}.
Any additienal facter that may influence the eutceme,
such as patient weight, sex, eccupatien, activity level, er
trauma, is centrelled fer in the statistical analysis. The
eehert study design prevides a pewerful assessment ef
the facters asseciated with the develepment ef disease.
Prespective eehert studies are adva ntageeus because they
reliably assess expesure witheut relying en recall ef events
by the study participants. The resulting evidence is rela—
tively strung fer cause and effect in the develepment ef
disease. The disadvantage ef a prespective eehert study is
that it is time censuming and eften expensive te cenduct.
In a retrespective cehert study, the expesure is in the
past and the researcher is leeking ferward frem the time
ef expesure te identify risk facters fer the develepment
ef disease. Fer example, patients whe underwent CT 10
years earlier can be fellewed during the subsequent study
peried te evaluate their risk fer cancer. A retrespective
eehert study prevides a reasenable assessment ef the risk
facters asseciated with a disease, but its disadvantage is
the limited reliability ef infermatien gathered from charts
and infermatien recall by study participants.
A retrespective case study leeks backward in time te
determine what expesure individuals with the disease
ef interest had. In eentrast, a retrespective cehert study
leeks backward in time at individuals with a particular
expesure te determine whether the disease develeped. A
rettespective eehert design prevides the higher level ef
evidence fer causality.
lCiften twe ceherts frem a given pepulatien, ene greup
with expesure and the ether witheut expesure, are fel-
lewed fer the same perie-d ef time {Figure 1}. In such a
E
IE
dual eehert study, cemparisens can be made abeut the
I—
us risk ef disease in these whe were expesed er net expesed.
:5
D
IIII
Case-centrel studies previde an DH. fer a disease after an
E
J! expesure. In eentrast, eehert studies previde a relative
E risk {RR} ef disease in individuals whe were expesed
.E
5
LE
er net expesed. The RF. is defined as the incidence ef
the disease in individuals whe were expesed divided by
the incidence ef the disease in individuals whe were net
expesed. The UK and the RR are net the same, altheugh
the figures calculated fer them may be similar if the in-
cidence ef the disease is lew. As the disease incidence
increases, the discrepancy between the DR and the RR
firthepaetlic Knewledge Update: Sperts Medicine 5
Hehespaefive eehert Hespecfive eehert
i.
@
'-
"I
Exposed—i Ne disease
Disease Disease
Unexpesad—< He dlsaase Unexpeee
his disease
Chart depicting the difference in starting
peint fer a retrespective cehert study and a
prespective eehert study. When evaluating
heth expesed and unexpesed greups, it is
censidered a dual eehert study.
alse increases.
A nested case-centre] study can be perferrned frem
eehert study data. Cehert study data en participants
whe develep the disease can be analysed with detailed
expesure infermatien. Expesure frequency in these par-
ticipants can be cempared with that ef centrel subjects
in the same cehert.
Cehert studies alse previde disease incidence data. The
incidence is defined as the number ef new eccurrences ef
the disease in the pepulatien during a specific time peri-
ed. The disease incidence can be derived frem a eehert
study in which a pepulatien is evaluated repeatedly ever
time. Disease incidence is distinctly different frem disease
prevalence. The duratien ef the disease affects beth the
incidence and the prevalence. Fer example, if sheulder
pain in a baseball pitcher typically is reselved when the
pitcher steps threwing, the prevalence ef sheulder pain in
baseball pitchers may be high during the baseball seasen
and lew during the eff-seasen, regardless ef the incidence
ever the entire year. Hewever, the incidence ef esteear-
thritis may be lew during a specific year but the prevalence
ef esteearthritis still will be high because esteearthritis
is a chrenic, permanent disease.
Clinical Study
Clinical studies are experimental studies that evaluate
the eutceme in patients whe underge an interventien
cempared with eentrel subjects. |i'liinical studies can be
randemiaed er nenrandemised. Blinding ebservers and
participants te treatment—arm assignments further reduc-
es inherent bias. Blinded eutcemes ebservatien is difficult
te achieve in surgical studies. Randemisatien reduces the
inherent bias in the study by balancing the variables acress
the study greups. Randemixatien may net be pessible if
it weuld vielate the need fer clinical equipeise, hewever.
Altheugh randemieed studies are censidered the geld
fl lflld American Academy ef Cirrhepaedic Surgeens

standard ef clinical evidence fer therapeutic studies, many
clinical questiens invnlve surgical interventien and are
net amenable te a randemised centrel study. Randem—
iced centrelled studies are expensive, cemplex, and time
cens'uming te cenduct.
Systematic Review
A systematic review is a summary ef the available pub-
lished studies with an evaluatien ef their quality. The
strength ef the evidence in a systematic review is enly as
geed as the study with the lewest level ef evidence that is
included in the analysis. A systematic review ef high—lev—
el evidence that cembines the infermatien frem several
welladene studies prevides the highest level ef evidence.
If the eutceme measures used in the studies are similar, a
meta-analysis ef the data can previde strength tn the cen-
clusiens by adding pewer te the studies. Beth systematic
reviews and meta-analyses can identify areas ef weakness
that future studies can build en. The challenges in cen-
ducting a systematic review lie in identifying a fecused
questien, using strict inclusien and exclusien criteria, and
dealing with the hetcrngeneity ef the included studies.
Statistics
Type I and Type II Errers
The use ef prebabilities in hypethesis testing carries a
risk ef falsely rejecting er accepting the null hypethesis?
A false rejectien ef the null hypethesis, alse called a type
I er a errer, censists ef a decisien that a difference exists
between greups, when in fact there is en difference. The tt
value is a standard set befere the statistical analysis is cen-
ducted and is used te determine hew extreme an ebserved
result must be te allew the null hypethesis te be rejected;
the purpese is te minimise the risk ef a type I errer. The
e value typically is set at 0.05 but can be adjusted if the
research questien requires tighter centrel fer false—pesitive
results. An :1 value ef i105 simply means that, under the
null hypethesis, a result at least this extreme will eccur
by chance 5% ef the time.
A false acceptance ef the null hypethesis, alse called a
type II er [5 errer, censists ef a decisien that that there
is ne difference between greups when in fact there is a
difference. Stated differently, it is the failure te detect a
difference when a difference is present. Te minimize the
risk ef a type II errer, the sample size must be adequate
te detect the magnitude ef difference between the cem-
parisen greups. Te detect a small change, the sample
size needs te be larger. The generally accepted chance ef
a type II errer in a study is lfi‘l’fi, but this percentage can
be adjusted if it is impertant te minimise the number ef
false-negative results in the research eutcemes.
IE! lfllfi American Academy ef Drthnpaeclic Surgeens
Chapter 35: Research Smdies and Registries in Sparta Meditine
Fewer Analysis
Fewer in a study is defined as the Iikeliheed ef detecting
a true pesitive result. Usually studies are pewered te an
30% likeliheed ef detecting a true pesitive result. Pewer
analysis talces inte censideratien type II {er [3] errer. If the
accepted type II errer is 20%, the pewer is 1— [3 er 30%. If
the chance ef false negative results needs te be decreased
fer the study questien te lfl‘lfi er 5%, the pewer can
be changed te 93% er 95% Ill-B}. Increasing the pewer
increases the number ef subjects needed fer the study. A
pewer analysis is needed fer cemparisen studies se that
an adequate sample size is available te aveid a type II
errer? A pewer analysis includes the e value, the I3 value,
the variability ef the data, and the expected change in the
eutceme ef interest [the effect size].
Variables
A variable is a measurable trait that has a changing value.
A variable is either categerical; er centinueus. Statistical
tests are chesen based en the type ef eutceme variable.
When designing er critically analysing a research study,
it is impertant te understand which statistical tests are
apprepriate fer use with a particular type ef variable. A
categerical variable is assigned a specific rank {erdinal}
er name {neminal}. Fer example, the turner stage in a
patient with cancer is an erdinal variable, and the patient’s
sex is a neminal variable. A centinueus variable changes
aleng a centinuum ef values. Centinueus variables can be
nendiscrete er discrete. A nendiscrete variable can take en
any value aleng a centinuum; weight, temperature, and
ameunt ef surgical bleed less are examples. Hendiscrete
values can be fractienated. A discrete variable is a spe-
cific value, such as the number ef hespital admissiens er
surgical precedures per year. Discrete values cannet be
fractienated. Fer example, a patient can weigh Hill lb
(a nendiscrete value], but an individual surgeen cannet
perferm 35.2 surgical precedures in 1 menth (a discrete
value}.
Descriptive statistics eften are used te describe centin-
ueus data (Figure 1]. Descriptive statistics help te find the F'."
central tendency ef the data and determine its distribu- E
tien.I5 The mean {average}, median {middle number in the
fir
n
E
dataset], and mede jmest cemmen number in the dataset} F
5
are examples ef descriptive statistics. Mean, median, and I'D
D
I:
mede de net describe the dispersien ef the data. 1iunfariance H'I
_.1
and standard deviatien {SD} define the dispersien ef the El
"E.
data frem the mean.5 The dispersien ef the data is cleser
n
”I
te the mean as variance and 5D values beceme cleser.
Descriptive statistics are used te determine whether
the data are nermally distributed in the study pepulatien.
Nermally distributed data sheuld appear as a bell—shaped
curve when pletted with a histegram. Many statistical
Drthepaedic Knewleclge Update: Sperts Medicine 5
 Seeticm 5: M'IseeIIaneees Tepies

I want In I “rent in prediet

deten'n‘ne the an euteeme trem
. , Hew many Greups'sarnfies Greupsrsamples - -
Type {if data Dam distritutlen greens? are independent are related mmsma ("39%n
variables variables

' Independent I
samples ttest
Dependent
2 greups samples ttest Pearem {Fr}
Hennelly eerrelatinn Simple
distributed eeeflicient [fine predicted
(gaussian): er multiple
Parametric AHUVA {2+ predtetela]
tests regraasren
ANDVA with
3+ greeps ' repeated
I measures
|Llentinueus *
data Mann-Whitney
U-test
wuserefi " '
Abnermally 2 9111q | lsignedvranit teatl Spearrnan rhe
distributed eerlelatien _ _
{Skewed er eeetlieient Loglsher'nen-
hurtetie}: parametne
“'1"- _ Hmakal-Wallis ”Hm-“m
parametric test
tests
3+ greeps I : Frledrnan test

catsgsriser | s+ I l ._ .
data l greups Chi square er Fisher attest test |

Figure 2 Flew diagram shewing hew centinueus and categerical data are analyzed based en the features at the data
such as nermel er ebnermal distributien. the number greups analyzed. whether the date are dependent er
independent. and whether cerrelatiens exist. [Hepreduced with permissien 'irem Hart J: Biesta'tistics and research
design, in Miller M, Them psen 5, eds: Review ef firthepaedirn‘, ed 1 Philadelphia, Frill,r Elsevier' 1015, figure 13-5.]

{parametric} tests used te analyze centinueus data assume
a nermal distributien ef the data te estimate prebability.
Given a nermel distributien, there is a 34% prebability
that a randemly selected data peint frem the sample pepu-
latien falls between the mean and 1 SD abeve er belew the
mean. Therefere, there is an appretrimately 63% chance
E
IE
A dees net fall within the value 95% prebability distri-
butien ef Treatment B, there is a statistically significant
difference between the twe variables. Because hypethesis
testing deals with prebability, it is inaccurate te say the
null hypethesis er the alternative hypethesis is abselutely
cerrect er incerrect. Rather, we reject the null hypethesis

that a randemly selected data peint frem the sample pepu- in faver ef the alternative hypethesis.
I—
us lstien will be within 1 SD frem the mean. Similarly, there
:5
D
IIll
is a 95% prebability that a randemly selected data peint Means Cemparisen
E
J! frem the pepulatien is within 2 SDs frem the mean. The Student t test is a statistical test used re cempare the
E In hypethesis testing using nerrnally distributed cen- means ef centinueus variables between twe greups. The
.E
5
LE
tinueus variables. prebahilities are used te cempare eut— Student t test assumes that the variables are independent
cemes acress the study pepulatien. Fer example, if a and the data are nermally distributed. An unpaired Stu-
researcher wants te cempare the effects ef Treatment A dent t test cempares means frem unrelated greups. A
and Treatment B in the study pepulatien, statistical tests paired Student t test cempares means frem the same sub-
will preside a prebability {a P value} that a difference ject taken en separate eeeasiensfd This testis net useful
between the treatment effects exists er net. Given an :1 fer cemparing mere than twe means. Analysis ef variance
set at {1.05, if the mean and SD distributien ef Treatment {ANDVA} is used te cempare three er mere means.

ass firthepaedic Knewledge Update: Sperts Medicine 5 fl lflld American Academy ef Cirrhepaedic Serge-ens

I{Comparing means with data that are not normally
distributed requires a nonparametric statistical test. Non-
parametric tests do not rely on the inferences of proba—
bility based on normal distribution of the data? Urdinal
variables are not normally distributed and, therefore, they
require a nonparametric test. The sign test can be used
when two observations from the study population are not
independent, as in a paired Student t test. The difference
between the observations is labeled as positive or negative
depending on whether an increase or decrease occurred
between the observations.E4 The number of positive and
negative changes is used in the statistical analysis. The
1liil'ilcoxon signed-rank test is more commonly used than
the sign test for two independent, nonnormally distribut—
ed groups.Ii As in the sign test, a positive or negative sign
is applied, but the magnitude of difference is ranked and
included in the analysis.
Categorical Data Analysis
The analysis of nominal data or other categorical data is
different from that of continuous data. Continuous data
sometimes also are categorical. To measure the associa-
tion between categorical variables, the chi—square if} test
is used to examine the proportion {frequency} of events. A
chi-square test compares the observed frequency of events
to the expected frequency of events? This test does not
provide a measure of the magnitude of the association,
but it does provide a P value indicating whether there is
an association. If the study is small, a chi—square analysis
is not accurate, and a Fisher exact test should be used.
|I.’Iorrelation and Regression Analysis
Correlation establishes whether a relationship exists be-
tween two continuous, nondependent variables. Both
correlation and regression analysis quantify the extent
of the linear relationship between variables. The Pearson
correlation coefficient, called r, is the interdependent asso—
ciation between two variables. An 1' equal to 1 indicates
a perfect positive correlation. An r equal to —1 indicates
a perfect negative correlation. An at equal to D indicates
no correlation. A correlation coefficient does not imply
causality, and it assumes that the data are normally dis-
tributed. If the data are not normally distributed a Spear-
man ranlc coefficient can be used.
Linear regression analysis seeks to use one or more
variables {simple or multiple regression} to predict another
variable.“ To use linear regression, the outcome variable
must be continuous. Linear regression assumes there is a
linear relationship between variables. Logistic regression
is used if the outcome of interest is categoric. For logis-
tic regression, the data are logarithmically transformed
to obtain the logarithmic odds. Logistic regression is
IE! lfllli American Academy of flrthopaeclic Surgeons
Chapter 35: Research Soldier: and Registries in Sports Medicine
then used to identify variables that are predictors for the
outcome of interest, estimate the DR of the outcome for
each one—unit change in the predictor, and estimate the
absolute risk of the outcome of interest.“ Multiple regres-
sion analysis, which is performed in linear and logistic
regression, allows modeling of several variables while
controlling for others. In addition, multiple regression
analysis identifies potential interaction between predictor
variables that affect the outcome variable.
Survival Analysis
Survival analysis is a nonparametric test that evaluates the
probability of an event over a period of time, and it is used
if one variable explains the time to an event such as death
or hospital readmission. The I-{apla n-Meier method of
survival analysis calculates the cumulative probability of
an event {a nd survival} based on conditional probabilities
at each event time.” A Kaplan-l'vleier curve is most com-
monly used for a graphic display of survival probability.
Cox proportional hazard modeling can assess the effect
of multiple covariables on survival.
Multicenter and Reqistry—Based Research in
Sports Medicine
Shoulder Research
The Multicenter Drthopaedic Outcomes Network
{MUDN} Shoulder Group was formed to conduct large
multicenter studies on conditions of the shoulder.”
The MUON Shoulder Group is made up of 16 fellow-
ship—trained orthopaedic surgeons and research person-
nel from nine academic and private practice sites in the
United States. The group initially was formed to iden-
tify research questions related to treatment of rotator
cuff disease but has expanded its scope to include other
shoulder pathology. To study rotator cuff disease, the
group developed and standardized imaging protocols,
assembled validated patient-oriented outcome forms, and
conducted validation studies on the classification of rota-
tor cuff tears based on MRI and arthroscopy videotapes F'."
as well as radiographic findings associated with rotator E
cuff disease.“'” After a systematic review to determine the
fir
n
E
effectiveness of physical therapy for treatment of rotator F
5
cuff disease, a standard physical therapy protocol was I'D
D
I:
developed based on the evidence.” This process led to a HI
_.1
prospective study of nonsurgical treatment of atranmatic El
"E.
full-thickness rotator cuff tears in a population of patients
n
”I
with symptoms, fewer than 25% of whom underwent sur-
gery within the next 2 yearsfl" Subsequent studies found
that duration of symptoms, pain, and activity level were
not correlated with the severity of rotator cuff disease in
this population.”'"
Drthopaedic Knowledge Update: Sports Medichie S
 Section 6: Misoellaueous Topics
Knee Research
MUD" Knee Group
The MEI UN Knee Group was formed in 1993 and evolved
into a network consisting of seven institutions {Cleveland
Elinic Foundation, 0H; Hospital for Special Surgery,
NY, The Elhio State University, EIH; University of Col—
orado, EEI; University of Iowa, IR; Vanderbilt Ertho-
paedic Institute, TN; Washington University, MO} and
I? surgeons. To establish a model for prospective, lon-
gitudinal, hypothesis-driven research, the MDEIN Knee
IIIiroup began with interrater agreement among surgeons
and focused on patient—reported outcomes.” "Within 10
years, this group generated more than 40 publications.
More than 4,4130 patients were enrolled in a prospective
study of anterior cruciate ligament {REL} reconstruction.
Recent publications included predictors of activity level
and subsequent surgery after REL reconstruction."3‘=m R
significant interaction was found between activity level
and graft choice with respect to the success or failure
of REL reconstruction.21 Elutcomes and return to play
data were reported after REL reconstruction in foot-
ball and soccer players, and reconstruction was found
to be a cost—effective treatment of REL tears based on
the MElElN data?“
Multicenter REL Revision Study
The finding of MEIEN and other studies that revision
REL reconstruction was associated with worse outcomes
than primary REL reconstruction provided the impetus
for formation of the Iviulticenter REL Revision Study
{MRRS}.”'“ This prospective longitudinal cohort study
was developed through the Rmerican Drthopaedic Soci-
ety for Sports Medicine lRflSSMj, which has more than
2,0fll} members from private practice and academic set-
tings predominantly in the United States and Eanada.
MARS was designed with multiple sites and multiple sur-
geons to determine modifia ble predictors of outcome after
revision REL reconstruction.1H Rll RDSSM members were
invited to participate in MARS, and four training sessions
were provided. Participating surgeons were required to
E?
IE
read the final manual of operating procedures, obtain
I—
us institutional review board approval, complete a trial data
:5
D
IIII
form, and sign an agreement to follow the manual of
E
J! operating procedures. R total of 83 surgeons from 52 US
E and Canadian sites have enrolled patients in the study.”
.E
5
LE
Initial MRRS cohort reports were on the epidemiol-
ogy of the revision REL reconstructions and reflected
slightly more allograft use than autograft use {54% and
45%, respectively}, with just over 1% using combined
autograft and allograftfi‘H Duly lfl'ii- of patients had in-
tact menisci and articular cartilage at the time of revi—
sion REL reconstruction.“ R comparison of knees at
£186 firthopaedic Knowledge Update: Sports Medicine 5
the time of revision REL reconstruction and primary
REL reconstruction found that knees undergoing revision
REL reconstruction were less likely to have new lateral
meniscus tears but more likely to have lateral compart-
ment and patellar-trochlear chondral damage.” Previous
partial meniscectomy but not previous meniscus repair
was significantly associated with chondrosis at the time of
revision REL reconstruction.“ Patients undergoing initial
revision REL reconstruction had higher activity levels,
were less likely to have chondral damage in the medial
and patellofemoral compartments, and had a higher rate
of traumatic, recurrent injury of their graft compared to
patients undergoing a multiple revision.31
Early Arthritis Therapies Study
The Early Arthritis Therapies {ERRTH} study of patients
with REL is being developed by R05 SM. R feasibility
study found that 93% of healthy adults age 13 to 30 years
who had an REL tear without earlier joint injury would
be willing to participate in a randomised controlled study
of early interventions to prevent osteoarthritis}1
REL Registries
Several studies recently have been published from REL
registries in Denmark, Sweden, Norway, and the United
States. The initial reports focused on epidemiology and
early results.”-“ The Norwegian registry study found that
the risk of cartilage injury increased with the length of
time between REL injury and reconstruction.“ This find—
ing was reinforced by the findings of the US-based Kaiser
Permanente REL Registry.JLIE In comparison with patients
in the MEIEIN cohort, the patients in the Norwegian
registry were more likely to be men, were older, and were
less likely to have an allograft.” The Kaiser Permanente
REL Registry was more similar to the Norwegian registry
than the MDDN Knee cohort in terms of patient age and
seat.3E Bone—patellar tendon—bone autografts were found
to be used more often in relatively young male patients
and by surgeons and centers with a high volume of such
procedu res.39 R study that combined the Norwegian and
Kaiser registries reported a higher incidence of concom-
itant medial collateral ligament injuries with REL tears
among Rmerican football players than basketball players;
basketball players were more likely to have cartilage and
lateral meniscus injuries.” In the Kaiser registry, patients
who underwent primary and subsequent revision REL
reconstruction were more likely to have chondral injury
and less likely to have a meniscus injury at the time of
revision than at the primary surgery.“
Rs longitudinal studies from these registries are re-
ported, the difficulty of patient follow—up has become
apparent; follow-up percentages of 41%, 413% to 64%,
fl lflld Rmerican Reademy of Orthopaedic Surgeons

and 54% uf patients have been repurtedfi'“ Huwever,
the cumpleteness uf registratiun {the percentage uf ACL
recunstructiuns captured in the registry} in the Danish
registry increased frum ease in 2fl05 tu 36% in 2011.“
Despite these challenges, interesting findings have been
reported. The shurt—term reuperatiun rate after ACL re—
cunstructiun was luw in the Kaiser registry, and appruiti-
mately half cf reeperatiens were related tu the meniscus.”
Anuther study frum the Kaiser registry repurted that
hamstring autugrafts were assuciated with a higher rate uf
deep infectien after ACL recunstructien than ether types
uf grafts.“ Studies frum the Danish and Nurwegian regis—
tries and a puuled analysis uf the Scandinavian registries
fuund a higher rate uf revisiuu ACL recuustructiun when
hamstring rather than bune-patellar tendun—bune autu-
graft was used in the primary ACL recenstructienff‘i“ In
the Swedish registry study, the risk uf cuntralateral ACL
injury was ahnust three times greater in patients yuunger
than 10 years than in elder patients.“
Meniscal Tear in Usteuarthr‘rtis Research Study
The Meniscal Tear in Osteuarthritis Research {ME-
TEOR} study was designed tu cumpare the efficacy uf
arthruscupic partial meniscectumy with that uf a stan-
dardised physical therapy regimen fer patients with a
symptumatic meniscus tear and cuncumitant mild tu
muderate usteuarthritis.51 This US Natiunal Institutes
uf Health-funded pruspective, randumised centrulled
study was cunducted at seven academic medical centers
{Brigham and Wumen’s Huspital, MA; Cleveland Clinic,
|DH; Huspital fur Special Surgery, NY; Mayu Clinic, MN:
Rush University Medical lIiIIenter, IL; Vanderbilt Universi-
ty, TN; Washingtun University, MD}. In this study, 351
patients age 45 years ur ulder with a meniscus tear and
imaging evidence uf mild tu muderate usteuarthritis were
randumly assigned te surgery and pestuperative physical
therapy ur tu a standardised physical therapy regimen
{with the uptiun tu cruss uver tu surgery at the discretiun
cf the patient and surgeenlfi'3 In an intentien-tu-treat
analysis, functiunal imprevement based en the 1Western
Untariu and McMaster Universities flsteuarthritis Index
physical functien scere did net differ significantly after 5
munths, althuugh there was a Efl‘h‘s crussuver tu surgery
in patients assigned tu physical therapy alune.
Summary
An understanding uf fundamental principles is required
fur successful spurts medicine research. Multiccnter cu-
hurt and research registry studies are becuming mere
cummun in urthupaedic spurts medicine. Despite the
challenges uf designing and implementing such cumpleir
IE! lfllfi American Academy uf flrthupaedic Snrgeuns
Chapter 35: Research fimdies and Registries in Sparta Medicine
research effurts, the putential rewards are significant.
Recent puhlicatiuns frum such studies previded impurt-
ant infurmatiun un the treatment uf rutatur cuff disease,
ACL recunstructiun, revisiun ACL recunstructiun, and
meniscus tears. Tu elevate the level uf evidence and the
generalisability uf future research, urthupaedic spurts
medicine urga niaatiuns shuuld cuntinue tu invest in these
studies.
Hey Study F'uints
II An understanding uf the fundamental principles and
terminulugy uf research and the putential benefits
uf pruspective multicenter research cuhurt studies
and registry-based studies will lead tu impreved
patient care.
I: An understanding cf the primary published findings
uf such studies as related tu the shuulder and knee
in urthupaedic spurts medicine can help impruve
uutcumcs.
Annuteted References
1. Sprague 5, Matta JM, Bhandari M, et a1; Anteriur Tutal
Hip firthruplasty l{Eullaburative {ATHHC} Investigaturs:
Multicenter cullaburatiun in ubservatiunal research: Im-
pruving generalirability and efficiency. j Burrs jurist Snrg
Am lflflflgfiflfiuppl 3J:3fl-Efi. Medline DUI
The successful cundnct ef multicenter studies requires
careful study urganizatiun, a dedicated and experienced
methuds center, and mutivatcd participating surgcuns and
study staff at the clinical sites as illustrated by a tutal hip
arthruplasty cullaburative.
2. Bruphy RH, Smith MV, Latterman C, et al: Multi-in-
vestigatur cullaburatiun in urthupaedic surgery re-
search cumpared tu uther medical fields. I Drthup lies
2fl12;30{1i}}:1523-1523.Medline DUI
IDrthupaedic surgery has fewer publicatiuns frum cullab-
urative research and cuntributiug authurs and institutiuns
than uther medical specialties. There is an uppurtuuity Fl"
3
te stimulate this type ef research in urthupaedic surgery.
fir
Level uf evidence: IV. n
E
F
5
3. Farrugia P, Petrisur BA, Farrukhyar F, Phil M, Ehandari I'D
D
M: Research questiuns, hyp-utheses and ubjectives. Cart I:
H'I
_.1
] 5mg. lflll};53{4}:2?3u231. Medline El
"E.
n
”I
4. Kuhn JE, Greenfield ML, 1|ilifuitys EM: fl statistics primer:
Types uf studies in the medical literature. Am ] Spurts Med
199?;25f2}:2?2-274.Medliuc DUI
Drthepaedic Knuwledge Update: Spurts Medichse 5
 Section 5: hfisoellaueous Topics
Kuhn JE, Greenfield ML, Wojtys EM: A statistics primer:
Hypothesis testing. Arr: ] Sports Med 1996;24[51:?fl2-Tfl3.
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Greenfield ML, Kuhn JE, 1|lilll'ojtys EM: A statistics prirner:
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Greenfield lL, Wojtys El'vI, Kuhn jE: A statistics
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199?;25l6}:332-334.Medline DUI
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Kuhn JE, Greenfield ML, 1iii'iojtys EIvI: A statistics prim-
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199?;15H]:535-536.Medline DUI
Ii]. Kuhn JE, Dunn WK, Sanders R, et al; MDIDH Shoul-
der Group: Effectiveness of physical therapy in treating
atraumatic full-thickness rotator cuff tears: A multi-
center prospective cohort study. I Shoufder Elbow Snrg
2fl13521[1il}:13?1—13?9.Medline oor
Nonsurgical treatment using physical therapy is effective
for treating atraumatic full-thickness rotator cuff tears in
approximately TEES: of patients followed up for 2 years.
Level of evidence: IV.
11. Banmgarten KM, |flarey JL, Ahhoud JA, et al: Reliability
of determining and measuring acromial enthesophytes.
HSS ] 2011;?[3}:213-222. Medline DUI
There is fair to moderate reliability among fellow-
ship-trained shoulder surgeons in determining the presence
of an acromial enthesophyte but poor reliability among
observers in measuring the site of the enthesophyte. Level
of evidence: IV.
12. Kuhn JE, Dunn WE, Ms B, et al: Multicenter lIIIIIrthopaedic
|ifllutcomes Network-Shoulder {MDDN Shoulder Group}:
Interohserver agreement in the classification of rotator cuff
tears. Am J Sports Med lflfl?;35{3}:43?—441. Medline
IS. Spencer EE jr, Dunn WK, Wright KW, et al: Shoulder
Multicenter Orthopaedic Dutcomes Network: Interoh-
server agreement in the classification of rotator cuff mars
using magnetic resonance imaging. Jim } Sports Med
2UUS;36{1}:99-lfl3.Medline DUI
E
IE
I—
no
:5 14. Kuhn JE: Exercise in the treatment of rotator cuff im-
D
IIll pingement: a. systematic review and a synthesized evi-
E
J! deuce-based rehabilitation protocol. ] Shoulder Iriffslorsr
E Sssrg lflflfltlflf 1}:133u15fl. Medline DUI
.E
5 This systematic review demonstrated that exercise has
LE
statistically and clinically significant effects on pain reduc-
tion and improving function, but not on range of motion
or strength for patients with rotator cuff impingement.
Level of evidence: II.
15. Unruh KP, Kuhn JE, Sanders E, et al:I MDUN Shoul-
der lGroup: The duration of symptoms does not correlate
£183 firthopaedic Knowledge Update: Sports Ivledichie 5
with rotator cuff tear severity or other patient-related fea-
tures: A cross-sectional study of patients with atraumatic,
full-thickness rotator cuff tears. I Shoulder Elbow Surg
1014;23{?}:1052-IGSS. Medline DUI
In patients with atraumatic, full-thickness rotator cuff
tears, duration of symptoms does not correlate with more
severe rotator cuff disease, weakness, limited range of mo-
tion, tear sise, fatty atrophy, or validated patient—reported
outcome measures. Level of evidence: III.
15. Dunn WK, Kuhn JE, Sanders R, et al: Symptoms of pain
do not correlate with rotator cuff tear severity: A cross-sec-
tional study of 393 patients with a symptomatic atraumatic
full-thick ness rotator cuff tear. }' Boise joint Surg Am
2014;9I‘5llfllfi93-Sflfl.Medline DUI
In patients with atraumatic, full-thickness rotator cuff
tears, anatomic features defining the severity of atrau-
matic rotator cuff tears are not associated with pain level,
whereas comorhidities, lower education level, and race are
associated with pain level. Level of evidence: III.
1?. Brophy RH, Dunn WK, Kuhn JE: MDDN Shoulder
Group: Shoulder activity level is not associated with the
severity of symptomatic, atraumatic rotator cuff tears in
patients electing nonoperative treatment. sin: I Sports Med
2314:42l5lfllfifl-1154. Medline DUI
In patients with atraumatic, full-thickness rotator cuff
tears, shoulder activity level is not associated with sever-
iry of the tear but is associated with patient age, sex, and
occupation. Level of evidence: III.
IS. Lynch TS, Parker RD, Patel KM, Andrish JT, Spindler
KP: MDDN |Group: The impact of the Multicenter Dr-
thopaedic Outcomes Network [MUDN] research on an-
terior cruciate ligament reconstruction and orthopaedic
practice. I no: need flrthop Surg 2015;23i3}:154-1t53.
Medline DDI
The Multicenter Orthopaedic l[l'utcomes Network consor-
tium has enrolled more than 4,4flfl ACL reconstructions
to establish a large level I prospective cohort. Studies from
this cohort support the use of autograft for competitive
athletes in their primary ACL reconstructions.
19. Dunn WK, Spindler KP; MUDN Consortium: Predic-
tors of activity level 2 years after anterior cruciate liga-
ment reconstruction {ABLE}: A Multicenter llilirthopaedie
Dutcomes Network {MGDN} ACLK cohort study. Am.
j Sports Med 2013;33{1fi}:2fl4fl-2fl5fl. Medline DflI
Higher baseline activity and lower body mass index pre-
dicted higher activity levels 2 years after ACL reconstruc—
tion while revision ACL reconstruction, smoking within 6
months of surgery, and female sex predicted lower activity
levels. Level of evidence: II.
20. Hettrich CM, Dunn WE, Reinl-te EK, Spindler KP; MUGN
lGroup: The rate of subsequent surgery and predictors after
anterior cruciate ligament reconstruction: Two- and 6-year
follow-up results from a multicenter cohort. Am J Sports
Med 2fl13:41[?}:1534-154{i. Medline DDI
fl lfllfi American Academy of Orthopaedic Surgeons

The rate nf subsequent surgery is 13.9% en the ipsilaters
al knee within 6 years nf ACL recnnstructinn, higher in
ynunger patients and allngraft recnnstructinns. There is
a similar rate nf ipsilateral graft tears {TERM and cnntra-
lateral ACL tears {6.4%1. Level nf evidence: III.
21. Kaeding CC, Arns B, Pedrnaa A, et al: Allngraft versus
autngra ft anterinr cruciate ligament recnnstructinn: Pre-
dictnrs nf failure frnm a MDDN prnspective lnngitudinal
cnhnrt. Spnrts Hedftfa 2fl11;3{1}:?3-31. Medline DD]
Patient age and ACL graft type predict graft failure fnllnw-
ing ACL recnnstructinn. Highest percentages nf failures
nccurred in patients 10 tn 1? years nf age. Odds nf graft
rupture are fnur times higher with allngraft than with
autngraft recnnstructinns.
21. McCullnugh KA, Phelps KD, Spindler KP, et al: MGDN
Grnup: Return tn high schnnl- and cnllege-level fnntball
after anterinr cruciate ligament recnnstructinn: A Mul-
ticenter Urthnpaedic Dutcnmes Netwnrk {MODE} cn-
hnrt study. Arr: }' Spnrts Men! 2fl12;40{11}:2523-1519.
Mcdline DUI
Return tn fnntball after AEL recnnstructinn was 63% in
high schnnl athletes and 69% in cnllegiate athletes. I[lnly
43% repnrted getting back tn the same self-described level
nf perfnrmance. Level nf evidence: III.
23. Brnphy RH, Schmitr L, Wright KW, et al: Return tn
play and future ACL injury risk after AEL recnnstruc-
tinn in snccet athletes frnm the Multicenter flrthnpaetlic
Clutcnmes Netwnrk {MDDN} grnup. An: ] Spnrts Med
2012;4U[11}:251?—2522.Medline Dfll
Return tn snccer after ACL recnnstructinn was 12%, high-
er in ynunger and male athletes. There was a 3% risk nf
graft re-tear and a 9% risk nf cnntralateral ACL tear.
Level nf evidence: III.
24. Mather RC III, Knenig L, Kncher MS, et al: MD DH Knee
Grnup: Sncietal and ccnnnmic impact nf anterinr cruciate
ligament tears. I lines Inlet Serg Am 2013:95j19]:1?51-
1159. Medline DUI
ACL recnnstructinn is the preferred cnst-effective treat-
ment strategy fnr ACL tears cnmpared tn rehabilitatinn,
reducing sncietal cnsts nnce indirect cnst factnrs, such as
wnrk status and earnings, are cnnsidered.
25. Wright R, Spindler K, Hustnn L, et al: Revisinn ACL
reennstructinn nutcnmes: MUGN cnhnrt. Jl Knee Snrg
lflll;24{4j:139-294.Medline DDI
Revisinn ACL recnnstructinn resulted in a significantly
wnrse nutcnme as measured by Knee Injury and Listen-
arthritis Dutcnme Scnres, Knee Related Quality nf Life,
Spnrts and Recreatinn and Pain subscales, Internatinnal
Knee Dncumentatinn Cnmmittee, and Mars activity level
at 2 years cnmpared tn primary ACL recnnstructinn.
26. Wright RW, Gill CS, Eben L, et al: IZl'l'utcnme nf revisinn
anterinr cruciate ligament recnnstructinn: A systematic re-
view. ] Bnnefnr'nt SurgAm 2012:94i6}:531-53fi. Medline
IE! ERIE American Academy nf flrthnpaedic Snrgenns
Chapter 35: Research Studies and Registries in Spnrts Meditine
Revisinn ACL recnnstructinn has nearly three tn fnur
times the failure rate nf primary ACL recnnstructinns.
Patient-repnrted nutcnme scnres were inferinr cnmpared
tn previnusly published results nf primary ACL recnnstruc-
tinn, but these differences may nnt be clinically impnrtant.
2?. Lind M, Menhert F, Pedersen AB: Incidence and nutcnme
after revisinn anterinr cruciate ligament recnnstructinn:
Results frnm the Danish registry fnr knee ligament re-
cnnstructinns. Am I Spnrts Med 2U12;4i}{?]:1551-1551
Medline D0]
The rate nf revisinn fnllnwing primary ACL recnnstruc-
tinn was 4.1% cnmpa red tn 5.4% fnllnwing revisinn ACL
recnnstructinn after .5 years in the Danish knee registry.
Age ynunger than 2|] years was assnciated with a higher
revisinn rate fnllnwing primary AEL recnnstructinn. Level
nf evidence: II.
23. Wright RW, Hustnn L], Spindler KP, et al: MARS
Grnup: Descriptive epideminlngy nf the MulticentEr
ACL Revisinn Study [MARS] cnhnrt. Am] Spurts Merll
1010;33llfl}:19?9—1936. Mcdline DUI
Surgenns deemed traumatic reinjury tn be the mnst cnm-
mnn single mnde nf failure fnr knees undetgning revisinn
ACL recnnstructinn. A cnmbinatinn nf factnrs represented
the must cnmmnn mnde nf failure. Over 90% nf knccs
had meniscal andfnr cartilage injury. Level nf evidence: II.
29. Rnrchers jR, Kacding {If}, Pedrnaa AD, Hustnn L],
Spindler KP, Wright RW: MDDN Cnnsnrtium and the
MAKE Grnup: Intra-articular findings in primary and
revisinn anterinr cruciate ligament recnnstructinn surgery:
A cnmparisnn nf the HUGE and MARS study grnups.
An: I Spnrts Med lfllljfifi'jfllflflflfl-IEHE. Medline DDI
Meniscal tears are cnmmnn in primary and revisinn ACL
recnnstructinn. Previnus medial nr lateral meniscectnmy
increases the CIR nf articular cartilage damage in the cnr-
respnnding cnmpartment. Revisinns are mnre likely tn
have significant lateral cnmpartment and patellar-trnch-
lear chnndral damage. Level nf evidence: II.
3-0. Ernphy EH, Wright RW, David TS, et al; Multicentcr
ACL Revisinn Study (MAR 5} Grnup: Assnciatinn between
previnus meniscal surgery and the incidence nf chnndral le-
sinns at revisinn anterinr cruciate ligament recnnstructinn.
Am. } Spnrts Med sa:a,aa:4}:sns-s14. Medline nnt
The status nf articular cartilage at revisinn ACL recnn-
structinn relates tn previnus meniscal surgery. Previnus F'."
partial meniscectnmy is assnciated with a higher incidence E
fir
n
nf articular cartilage damage, whereas previnus meniscal E
repair is nnt. Level nf evidence: II. F
5
I'D
D
31. Chen JL, Allen CR, Stephens TE, et al:, Multiccnter ACL I:
H'I
Revisinn Study {MARS} Grnup: Differences in mecha-
_.j
DI
nisms nf failure, intranperative findings, and surgical "E.
n
characteristics between single- and multiple—revisinn ACL
”I
recnnstructinns: A IvIA R5 cnhntt study. Am] Spnrts Med
2fl13;41{?}:15?1-15?3.Medline DUI
Cntnpared tn initial revisinns, multiple-revisinn ACL re-
cnnstructinns have lnwer activity levels, mnre chnndral
injuries in the medial and patellnfemnral cnmpartments,
Drthnpnedic Knnwledge Update: Spnrrs Mediehie .‘i
 Sectinn 5: Miscellaneous Topics
and higher rate nf nnntraumatic, recurrent graft injury.
Level nf evidence: III.
32. Chu CR, Beynnnn ED, Dragnn JL, et al: EARTH Grnup:
The feasibility nf randomized cnntrnlled trials fnr ear-
ly arthritis therapies {EARTH} invnlving acute anteri-
nr cruciate ligament tear cnhnrts. Aw: I Spnrts Med
2fl12;4fl{11}:254S-3652.Medline DUI
Adequate sample sizes tn perform randnmiscd cnntrnlled
trials nf early interventinn strategies in ACL-injured cn-
hnrts cnmprising healthy ynung adults ages 13 tn 30 years
withnut prinr jnint injuries can be achieved.
33. Grauan LP, Fnrssblad Ivi, Lind IvI, Engebrctscn L: The
Scandinavian ACL registries lflfl4-2flfl7h Baseline epidemi-
nlngy. Acts firth-3p lilflii;flfl[5j:563 -5I‘i 'i'". Medlinc DUI
The annual incidence nf primary ACL recnnstructinns is
higher in Den mark than binrway, escept in ynung females.
Despite a similar apprnach amnng Scandinavian surgenns,
differences exist regarding graft and implant chnice and
treatment nf simultanenus meniscal and cartilage injuries.
34. Lind M, Menhert F, Pedersen AB: The first results frnm
the Danish ACIL recnnstructinn registry: Epideminlngic
and 2 year fnllnw-up results frnm 5,313 knee ligament
recnnstructinns. Knee 3mg Spurts Traumatnf Artbrnsc
2Ufl9;1?{1j:11?—114.Medline DUI
The initial 2-year fnllnw—up study frnm the Danish ACL
registry repnrted nn 5,3 T2 knees. lnst were recnnstructed
with hamstring autngraft [31%] and the nverall revisinn
rate was 3%. Fnllnw up Knee Injury and Ustenarthritis
Dutcnme Scnres subscnres were lnwer fnr revisinn and
multiligament recnnstructinns.
35. Granan LP, Eahr R, Lie SA, Engebretsen L: Timing nf an-
terinr cruciate ligament recnnstructive surgery and risk nf
cartilage lesinns and meniscal tears: A cnhnrt study based
en the Hnrwegiau Natinnal Knee Ligament Registry. An:
] Spnrts Med lflfl?:3?[5}l:953361. Medline DUI
Odds nf cartilage injury increase by 4% per mnnth frnm
the date nf ACL injury until the date nf ACL recnnstruc-
tinn surgery. Odds nf cartilage injury were nearly twice
as frequent if a meniscus tear is present, and vice versa.
Level nf evidence: II.
."s‘ 3S. |Cbhadia AM, Inacin MC, Maletis GE, Csintalan RP, Davis
S
I- ER, Funahashi TT: Are meniscus and cartilage injuries
In" related tn time tn anterinr cruciate 1' cut recnnstructinn?
.E
S“ Am I Spurn Med lflll:39{9l:1354-1399. Medline DID]
'—
IJ'I
:I
Increased time frnm ACL injury tn ACL recnnstructinn
D
l1 surgery is assnciated with increased risk nf medial menis-
2
E
cus injury, decreased meniscus repair rate, and increased
E
u
risk nf cartilage injury. Level nf evidence: III.
IE
E tinns and smnkers have wnrse nutcnmes. There is a signif-
3?. Magnussen RA, Granan LP, Dunn WE, et al: Crnss-cul-
a
tural cnmparisnn nf patients undergning ACL recnnstruc-
tinn in the United States and Nnrway. Knee Snrg Spnrts
Traumntni Artistes: lfllfl;13{1}:93-1i}5. Medline DID]
Patients were mnre likely tn be male and elder in the Hnr-
wegian cnhnrt. There was less time between injury and
Drthnpasdic Knnwlndge Update: Spnrts Medicine 3
surgery in the HUGE cnhnrt but mere meniscus and
articular cartilage injury and greater use nf allngraft.
33. Maletis GB, Granan LP, Inacin MC, Funahashi "IT, Enge-
bretsen L: Cnmparisnn nf cnmmunity-based ACL recnn-
structinn registries in the U.S. and Nnrway. j Burris-faint
5mg rim Eflllg93i5uppl 3}:3l—3n. Medline DUI
The age nf the Kaiser Permanent and Nnrwegian ACL
recnnstructinn cnhnrts were similar. The Kaiser Perma-
nente cuhurt had mnre males and a greater prevalence of
meniscus tears.
39. Inacin MC, Paxtnn EW, Maletis GB, et al: Patient and
surgcnn characteristics assnciated with primary anteri-
nr cruciate ligament recnnstructinn graft selectinn. An:
I Spnrts Med 2012;4fli2j:3353-34S. Medline DUI
Enneupatellar tendnnubnne autngrafts were used mnre nf-
tm in ynunger and male patients. Nnu—fellnwship-traiued
surgenns, lnwer vnlume sites, andinr lnwer vnlume sur-
genns were mnre likely tn use allngrafts nr hamstring
autngrafts than bnne-patellar tendnn-bnne autngrafts.
Level nf evidence: III.
4'3. Granau LP, Inacin MC, ivialetis GE, Fuuahashi TT, En-
gebretsen L: Spnrt-specific injury pattern recnrded during
anterinr cruciate ligament recnnstructinn. An: ] Spurts
Med 2D13:41[12j:2314-1313. Medline Dfll
Knee ligament injury patterns were assnciated with certain
spnrts. Skiing was assnciated with multiliga ment knee in-
juries while American fnntball was assnciated with medial
cnllateral ligament injuries and basketball was assnciated
with cnncnmitant meniscus and cartilage injuries. Level
nf evidence: III.
41. Wyatt KW, Inacin MC, Liddle KD, Maletis GE: Prevalence
and incidence nf cartilage injuries and meniscus tears in
patients whn underwent bnth primary and revisinn ante-
rinr cruciate ligament recnnstructinns. An: I Spnrts Med
2014;42IS]:134I-IS4E.Medline DUI
There was a higher prevalence nf articular cartilage dam-
age at revisinn ACL recnnstructinn cnmpared tn primary
ACL recnnstructinn. The prevalence nf medial meniscus
tears was the same but the prevalence nf lateral meniscus
tears was lnwer at revisinn ACL recnnstructinn. Level nf
evidence: IV.
42. Ahlde'n M, Samuelssnn K, Sernert N, Fnrssblad M, Karis-
snn J, Kartus J: The Swedish Natinnal Anteric-r lEruciate
Ligament Register: A repnrt nn baseline variables and nut-
cnmes nf surgery fnr almnst issue patients. Am ] Spnrts
Med 2912;4i}{1l]}:213fl-1235. Medline DDI
In the Swedish natinnal registry, all subscales nf the Knee
Injury and flstenarthritis Dutcnme Scnre imprnved after
primary ACL recnnstructinn. Revisinn ACL recnnstruc-
icant risk nf subsequent ipsilateral and centralateral ACL
injury in ynung female snccer players. Level nf evidence: IV.
43. Barenius E, Fnrssblad M, Engstriim E, Erikssnn K:
Functinnal recnvery after anterinr cruciate ligament
D lfllii American Academy nf Cirrhnpaedic Surge-nus

reconstruction: A study of health-related quality of life
based on the Swedish National Knee Ligament Register.
Here Serg Sports Traametol Arthrosc 2fl13:21{4}:914-
92?. Medline DUI
Male patients were more likely to have functional recovery
after ACL reconstruction than female patients. Surgical
treatment of the medial meniscus at HCL reconstruction,
previous meniscal surgery, and patellar tendon autograft
predicted poor functional outcome. Level of evidence: II.
44. Rotterud JH, Sivertsen EA, Forssblad M, Engebretsen L,
Aroen A: Effect of meniscal and fecal cartilage lesions on
patient-reported outcome after anterior cruciate ligament
reconstruction: A nationwide cohort study from Norway
and Sweden of 347% patients with 1-year follow-up. Arr:
j’ Sports Med 2fl13:41[3}:535—543. Medline DUI
Full-thick ncss cartilage lesions were associated with worse
outcome in all of the Knee Injury and Usteoarthritis Unt-
come Score subscales compared with patients without
cartilage lesions 1?. years after ACL reconstruction whereas
meniscal lesions and partial-thickness cartilage lesions
were not. Level of evidence: II.
45. Ram-Wagner L, Thillema nn TM, Lind MC, Pedersen AB:
Validation of 14,5flfl operated knees registered in the Dan-
ish Knee Ligament Reconstruction Register: Registration
completeness and validity of key variables. Cite Epidemiol
2fl13;5:219-213.Med1ine DUI
The completeness of the registration of patients in the Dan-
ish Knee Ligament Reconstruction Registry increased from
Efl'ii: in 2-305 to 36% in Eflll. Large—volume hospitals had
higher rates of completeness than small-volume hospitals.
45. Csintalan RP, Inacio MC, Funahashi TT, Maletis GE:
Risk factors of subsequent operations after primary an-
terior cruciate ligament reconstruction. Am ] Sports Med
as14,ss{s}:sis-sss.Mealine no:
Short-term reoperation rates after ACL reconstruction
are low, with median time to reoperation of SDI days.
Risk factors include previous meniscal repair, female seat,
allografts, prior surgery, older patient age, and having
a sports medicine fellowship-trained surgeon. Level of
evidence: III.
4?. Maletis GB, Inacio MC, Reynolds S, Desmond JL, Maietis
MM, Funahashi TT: Incidence of postoperative anterior
cruciate ligament reconstruction infections: Graft choice
makes a difference. Arr: 1 Sports Med 2013:41{S}:1?Sfl-
IT'SS. Medline DUI
The overall infection rate after REL reconstruction was
DASSS {0.31% deep infections, 0.16% superficial infec-
tions}. Hamstring tendon autografts had an 3.2 times
higher risk compared with bone-patellar tendon-bone
autografts. No difference in infection risk was identified
between allografts and bone—patellar tendon—bone auto-
grafts. Level of evidence: II.
4S. Gifstad T, Foss CIA, Engebretsen L, et a1: Lower risk of
revision with patellar tendon autografts compared with
hamstring autografts: A registry study based on 45,993
IE! EDIE American Academy of Urthopaeclic Surgeons
Chapter 35: Research Studies and Registries in Sports Medicine
primary ACL reconstructions in Scandinavia. Am } Sports
Med 2fl14;42{lfll:2319-2323. Mcdlinc DUI
Although most ACL reconstructions in Scandinavia use
hamstring autografts, there was a significantly lower risk
of revision using patellar tendon autografts compared to
hamstrings {UR {1.63}. Level of evidence: II.
49. Persson A, Fjeldsgaard K, Gjertsen JE, et al: Increased
risk of revision with hamstring tendon grafts compared
with patellar tendon grafts after anterior cruciate liga-
ment reconstruction: A study of 12,643 patients from the
Norwegian Cruciate Ligament Registry, 2&fl4-2fl11. Am
} Sports Med 2014:42l2l:235'291. Medline DUI
The failure rate of ACL reconstruction using hamstring
autograft was twice that when using bone-patellar ten-
don-hone autograft. Younger age was the most important
risk factor for failure. Level of evidence: II.
Si}. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind M:
Comparison of hamstring tendon and patellar tendon
grafts in anterior cruciate ligament reconstruction in a
nationwide population-based cohort study: Results from
the Danish registry of knee ligament reconstruction. do:
] Sports Med 2014;42t2):2?S-ES4. Medline DUI
Hamstring autografts had a higher failure rate than bone—
patellar tendon-bone autografts at 1 and 5 years after RCL
reconstruction. Level of evidence: II.
51. Andernord D, Desai N, Ejfirnsson H, Gillén S, Karlsson J,
Samuelsson K: Predictors of contralateral anterior cruciate
ligament reconstruction: A cohort study of 9061 patients
with 5-year follow-up. rim j" Sports Met;ll 2015;43f2]:295-
301. Medline DUI
Male and female patients younger than 20 years had an
almost three times higher 5 -year risk of contralateral ACL
reconstruction. Females undergoing reconstruction with
contralateral autograft hamstring had more than three
times higher 5 —year risk of contralateral ACL reconstruc-
tion. Level of evidence: II.
52.. Rats JH, Chaisson CE, Cole H, et al: The MeTeDR trial
{Meniscal Tear in Usteoarthritis Research}: Rationale and
design features. Cos-temp Clin Trials 2012:33{6}:1139-
11.96. Mcdlinc DUI
This study explained the Meniscal Tear in lDsteoa rthritis
Research Trial, a prospective randomised controlled trial
of arthroscopic partial meniscectomy with standardised F'."
physical therapy versus standardised physical therapy E
alone to treat symptomatic meniscal tears in knees with
fir
n
E
mild to moderate osteoarthritis. F
5
I'D
53. Rats JN, Brophy EH, Chaisson CE, et al: Surgery versus D
I:
physical therapy for a meniscal tear and osteoarthritis. N
H'I
_.1
Engl' ,l' Med 2013;363[1S}:15?S-1634. Medline DUI
U
"E.
n
”I
Intention—to—treat analysis demonstrated no significant dif—
ferences in fu nctiona] improvement at 6 months between
standardised physical therapy alone compared to arthro-
scopic partial meniscectomy and physical therapy: how-
ever, Sfl‘i’u of patients assigned to physical therapy alone
underwent surgery within 6 months. Level of evidence: I.
Unhopaedic Knowledge Update: Sports Medichie S
Chapter 36
Current Concepts in Tendinopathy
Trevor Wilkes. MD W. Benjamin Kibler. MD
Abstract
Tendinopathy is a common yet difficult-toatreat con-
dition. The orthopaedic surgeon should examine the
etiology and pathoanatomy of tendinopathy while ac-
knowledging the large gaps in knowledge about this
condition. It is important to be knowledgeable about
treatment of commonly involved anatomic regions,
including information on and physical therapy tech-
niques, platelet—rich plasma,and novel molecular and
gmetic therapies.
Keywords: tendinopafl'ly: tendon changes: tendon
Injury
Introduction
The scope and spectrum of tendinopathy are broad. Gs-
teoarthritis probably is the only orthopaedic disease that
rivals tendinopathy in prevalence, health care costs, and
resulting loss of productivity. The etiology and treatment
of tendinopathy continue to be extensively researched.
Since Elli}? approximately 401'} peer-reviewed articles on
tendinopathy have been published per year, and there
have been approximately 1Tb clinical studies. Tendinop-
athy continues to be an area of both basic science and
therapeutic interest.
The term tendinopathy is used clinically to describe
a persistently painful and poorly functioning tendon.
The model for understanding the etiology of tendinopa-
thy is often divided into intrinsic {cellular} and extrinsic
{overload} components. This model has limited usefulr
ness, however, because the factors in the development of
Dc Wilkes or an immediate family member is a member ofa
speakers‘ bureau or has made paid presen cations on behalf
ofArtbrex. Di'. icibier or an immediate family member serves
as an unpaid consultant to Aiignmed; bas stock or stool:
options beid in Alignment and serves as a board member;
owner; offices or committee member of the Arthroscopy
Association of North America.
@ lflld American Academy of Drthopaedic Surgeons
tendinopathy are numerous and interrelated. For example,
the magnitude and repetition of load on the tendon of
an assembly line worker cannot be precisely measured.
In addition, a proxy such as age or nicotine use may not
accurately define the physiology of an involved tendon.
The classic description of tendinopathy is that of a
failed healing response. Five primary histologic fea-
tures have been defined: collagen disruption, increased
proteoglycan content, abnormal tenocytes, altered cell
populations, and an increased number of microvessels
and micronerves. Recent evidence has challenged and
enhanced the understanding of this pathologic process.
Research into gene theraplr's tbe manipulation of cytolrines
and matrix metalloproteinases {MMPs}, and the induc-
tion of collagen cross—linking may improve the arsenal
of treatments.
Tendon Structure
The healthy tendon transmits the forces generated by
muscles to their osseous insertions lenthesesl. Thus, the
tendon acts as a tensile load-bearing structure that is
essential to joint motion. Tendons are composed of a
primary cell population, called tenocytes, and a careful-
ly organized collagen network whose structure reflects
its function {Figure 1} Type I collagen fibers are tightly
packed and highly cross—linked for stiffness. |I'lllnly small
amounts of type [I collagen exist in the normal tendon. In
addition, glycosaminoglycans lGAGs] promote hydration
of the extracellular matrix, fibril sliding, and collagen
fiber assembly.
F!"
Tenocytes, which exist throughout the tendon, are 5
derived from the fibroblast cell line. They are joined by iii
‘1
gap junctions into longitudinal and lateral arrays. The 11—!
:
tenocytes ace spindle-shaped cells encapsulated by a -I'I'
o
1:
pericellular sheath composed of versican, fibriliin, and H
type VI collagen that is believed to protect them from 5'
'9.
their environment. It is important to note that tenocytes iii
are responsive to load. Mechanical stimulation activates
metabolic pathways, and calcium-based signaling regu-
lates collagen synthesis along the vectors of tension and
stimulates extracellular matrix gene expression. These
pathways are critical for maintenance of tendon structure,
Orthopaedic Knowledge Update: Sports Medicine 5
 Section 5: Miscellaneous Topics

and their presence helps explain the manner in which

exercise promotes the health of tendons.
Tendon structure begins at the level of collagen fi-
brils, which are encapsulated by epitenon and divided
into fascicles by endotenon. The endotenon is a loose,
fibrous sheath with intrinsic vascular, lymphatic, and
nerve supply. More superficially, the tendon is surrounded
in its entirety by the paratenon. The paratenon contains
a similar fibrous sheath as well as a synovial lining with
types I and II syuoviocytes. The vascular supply to ten-
dons varies widely by location. Arteries and arterioles
course along the epitenon, and capillaries penetrate along
the endotenon. However, it is well established that the
blood supply to tendons is poor in certain regions such
as the lCodman none of the supraspinatus tendon or the
watershed zone of the Achilles tendon.

Acute Tendon Injury

The biology of tendons dictates that an acute injury
requires more time to resolve than is needed in more
vascular tissues. In addition, the anatomic location of
the tendon defines its healing potential. The phases of
the healing process include inflammation, repair, and
remodeling. During the first 14 to 43 hours after injury,
monocytes and macrophages migrate to the involved area
to devour necrotic material. After the first 43 hours, fi— Figure 1 Schematic drawings showing the structure of a
ten don. A, Normal architecture of the tendon.
broblasts and vascular cells facilitate the production of Primary fiber bundles, collagen fibers. and
reparative tissue such as type III collagen and GAGs. collagen fibrils are shown. B. Tendinopathic loss
of organized architecture is shown.
Regions within a tendon respond differently to injury.
The paratenon and endotenon are metabolically active
and produce more cellular signaling, proliferation, and
vascularity than the tendon itself. Remodeling extends cascade that occurs at the bonertendon interface where
over a period of months as cell activity decreases and the tendon is biomechanically wealc. Typical histologic
collagen matures. The tissue usually remains hypercellular changes are noted in enthesopathy including irregularity
and hypervascular, however. The histologic character— of the tidemarlc, narrowing of the cortical bone, local
istics of the healed tendon reflect permanent disorga- bone marrow edema, and the development of bone spurs.
nication, and its mechanical quality is poor. Regrown However, the underlying pathology appears to lie within
semitendinosus and gracilis tendons harvested for anterior the tendon itself.
LEI
cruciate ligament reconstruction were found to have less
.E
e‘ extracellular matrix, less collagen, and more cellularity
The Cellular Response to Injury
than the native tendon.I
'—

U'l
J
o
oI: Knowledge of the tendon’s response to injury and load
E at the cellular level is expanding. Repetitive loading in
E Chronic Tendon Injury
U the setting of insufficient adaptation to such loading and
The traditional belief is that a chronic tendon injury rep- insufficient repair appears to lead to collagen breakdown
IE

E
resents a failed healing response. All components of the and dysregulated fibril assembly, as has been confirmed
a

tendon including the epitenon, endotenon, and paratenon
can be involved in a chronic tendon injury, as can loca-
tions within the macrostructure of the tendon, ranging
from the musculotendinous junction to the tendon proper
and osseous insertion. Enthesopathy is the pathologic
in animal models of tendon overload. When rat rotator
cuffs were examined after induced treadmill running, in-
creased cellularity and disorganized collagen were found.E
Similarly, rats trained to perform repetitive reaching ma-
neuvers with one limb had fibril fraying and increased

flrdtopaedie Knowledge Update: Sports Medicine 5 El 1016 American Aeadenty of Urthopaedic Surgeons
 Chapter 35: Current Concepts in Tendinopathy

-—
Underlying Morphologic and Cellular |Changes in Tendinosis
Tendon Component Morphologic Changes Cellular Changes
Collagen Separation Increasing matrix metalloproteinase activ
Disorganization Increasing collagen synthesis
Fibril breaks or tears Increasing expression of collagen types I, II, III
Decreasing fibril diameter
Proteoglycan Microvessel thickening Increasing versican
Fibrocartilage metaplasia Increasing aggrecan
Scarring Increasing biglycan
Tenocytes Abnormal distribution Increasing proliferation
Mitotic figures Increasing apoptosis
Pylrnotic nuclei Increasing migration
Abnormal cell populations Mononuclear cells Increasing CD3
Eranulocytes Increasing CD63
Mast cells Increasing mast cell tryptase
Chondroid cells
Fatty degeneration
Vessels and nerves Vascular hyperplasia Increasing vascular endothelial growth factor
Neural sprouting Increasing substance P
Edema
Increased blood flow
Adapted from Scott A. Khan It: Tendon overuse pathology: Implications for clinical management. in ltibler WE. ed: Orthopaedic Knowledge
Update: Sports Medicine, ad 4. Basement, IL, American Academy of Orthopaedic Surgeons, zoos. p are.

macrophages in comparison with the contralateral limb."-
Increased levels of MMPs involved in collagen remodeling
and repair were found with varying levels and isoforms
in models of tendinopathy.l In this Pathologic setting,
collagen synthesis was mechanically inferior to that of a
normal tendon and had less cross-linking. Collagen pro-
duction predominantly was of type III rather than type
I collagen, perhaps because an endotenon phenotype is
assumed. The clinical implication is that regulation of
MMPs and induction of type I collagen production can
improve tendon integrity. Pilot studies found that the use
of aprotinin, a serine proteinase inhibitor that can reduce
collagenase activity, had positive results.1 However, a
randomized placebo-controlled study of peritendinous
injection in Achilles tendinopathy found no significant
benefit.1
The relationship between load intensity and tendon
response has been a recent focus of research. A rat fa—
in LIMP-13 and IL-lfi messenger RNA production. Thus,
it appears that a low load has a suppressive effect but a
moderate load leads to dramatically increased inflamma-
tory signaling and tendon damage. In addition, real-time
polymerase chain reaction of lacerated tendons revealed
uniform collagen type I {CDL-I} gene expression; fa-
tigue-loaded tendons had diverse CflL-I and ESL-3
subtype expression depending on the loading pattern”
{Table 1}.
Structural Changes in Tendinopathy
An increase in GAGs is found in pathologic tendons. The
F!"
hydrophilic nature of GAGs is believed to be responsible 5
for the increase in the tendon’s water content to 75%, iii
‘1
compared with the normal 65%} GAfls are responsible 11—!
:
for the increased Tl-weighted MRI signal and nltrasono- -I'I'
o
1:
graphic hypoechogenicity of tendons with tendinosis. An H

tigue cyclic-loading model was used to investigate the
relationship of MMP-13 and interleukin-1B {IL-15} to
osteoarthritis and general inflammation.’ Low strain
{fl.6%i produced isolated collagen kinking as well as a
striking T'O‘J’E: level of WIMP-13 and [Lid suppression. In
contrast, moderate strain (1.?%] produced evidence of
fiber separation, rearing, and a fivefold to sixfold increase
increase in vascular remodeling and cellular proliferation 5'
'9.
leads to increased GAG content. iii
Adipose and mast cells are examples of abnormal cell
populations found in tendinopathy. The relationship of
mast cells to nerves suggests a role in pain generation. His-
tologic specimens show chondroid metaplasia as another
type of dysregulated cell proliferation. These abnormal

El EDIE American Academy of flrfltopaedja Surgeons Drrhopaedie Knowledge Update: Sports Medicine .5
 Sectien ti: .l'viiscellxneeus Tepics
cell feci negatively affect the integrity and functien ef the
tenden. Therapeutic interventiens targeted at inhibiting
the vascular respense and abnermal cell preliferatien
can help reduce preteeglycan levels and premete a mere
nermal tenden architecture.
Perhaps the mest netable histepathelegic finding in
tendinepathy is angiefibreblastie dysplasia. Micrescep-
ic slides reveal preliferatien ef endethelial and smeeth
muscle cells censistent with micrevessel fermatien at a
rate as much as 301393 abeve that ef nermal tendens.1 In
additien, there is substantial preliferatien ef beth aute—
nemic and sensery nerves, which may be related re the
develepment ef chrenic pain and central nerveus system
hypersensitivity.
Nen surgical Therapeutic Interventiens
Exercise Pretecels
A patient-specific exercise prescriptien is censidered the
first-line, mest evidence—based therapeutic treatment fer
tendinepathy. Leading the tenden has myriad cellular,
structural, and pessibly ether autenemic effects. Research
en the effects ef exercise can be difficult In interpret be-
cause numereus parameters such as centractien type and
speed, lead, repetitiens, and velume {number ef sets} must
he centrelled.
Basic science research en the respense ef tendens te
exercise-induced lead fennd that the balance ef the an-
abelic changes stimulated by lead versus the catabelic
effects ef age and disuse is critical. Vascular flew can
increase threefeld, and exygen levels can rise twefeld te
fivefeld with exercise.‘ Tenecytes are stimulated te in“
crease pretein and specifically type I cellagen preductien
after a single sessien ef lead. 1EEi'ith repetitien and ever
time, lead fundamentally impreves the mechanical prep“
erties ef tendens by increasing stiffness and decreasing
strain. This imprevement can be accemplished withent
an increase in the cress-sectienal area ef the tenden.
Eccentric rehabilitatien pretecels were first prepesed
LEI
in 1934 and have preved te be the werkherse interven-
.E
e‘ tien fer tendinepathy. The therapeutic mechanism is net
entirely understeed, but it is believed that muscle-tenden
'—
U'l
3
e
el: lengthening alters the length-tensien curve ef the tenden
E unit. Evidence supperts eccentric exercise as prefflable
E
U te stretching in patients with lateral epicendylitis.5 In
additien, ballistic stretching was fennd te eutperferm
IE
E
a static exercise pregram in altering tenden stiffness?
a
In managing tendinepathyr in an athlete during his er
her spert seasen, it is crucial te censider the frequency
and intensity ef training sessiens and games as related
re the cumulative lead en the invelved tenden. Pregrams
knewn te be beneficial during the eff-seasen efren are net
flrfltepaedic Knewledge Update: Sperrs Medicine 5
advantageeus in seasen. It can be challenging te centre]
the pain level ef an athlete in the setting ef persistent
intense lead. Seme data suggest that rehabilitatien can
be successful if the subjective pain scere remains lewer
than 5 en a lfl—p-eint scale and diminishes tn 0 by the
fellewing merning.“
Tenden-specilic rehabilitatien pregrams are unlikely
te treat all ef the underlying facters that led tn the ten-
dinepathyd‘i Carefully assessing and treating the entirety
ef the kinetic chain is required. Athletic er werk-related
gait, pesture, and technique sheuld be examined. Muscle
imbalances and the flexibility ef beth the invelved jeint
and the jeints abeye and belesn.r it sheuld be investigated?
Evidence shews that a full functienal recevery allewing
the athlete’s sperts demands te be accemplished can de-
crease the number ef future episedes.‘l
In general, research has shewn eccentric exercise pre-
grams te be effective in lewer limb tendinepathy. Spe-
cifically, Achilles and patellar tendinepathies have been
extensively studied?Ii Heel—drep eccentric exercises were
fennd te be successful in 90% ef patients with Achilles
tendinepathy; this percentage can be used te encenrage
patients whe beceme frustrated with their rehabilitatien"r
{Figure I}. I."Jnntrelled studies ef eccentric exercise cem-
pared with ultraseund and massage fennd that eccentric
exercise had better eutcemes.j Net all studies have had
pesitive findings fer eccentric exercise, but histelegic in-
vestigatien fennd that eccentric exercise led te impreved
Achilles tenden structure and decreased vascularity.“
In the setting ef patellar tendinepathy, the therapeu-
tic respeuse elicited by single-leg eccentric squats per-
fermed en a 25" decline heard was superier te that ef
ether nensurgical treatments5 {Figure 3}. Imprevement
in tenden structure and excellent quadriceps activatien
was ebserved en electremyegraphy after the use ef this
exercise. The additien ef ultra seund has net been preved
beneficial? In-seasen pregrams have net had eutcemes
as pesitive as eut-ef-seasen pregrams.“4
Exercise pregrams fer upper extremity tendinepathy
have had equivecal results, perhaps in part because ef
the intrinsic diffflences between a weight-bearing and
a nen—weight-bearing tenden. Exercise appears te be
useful fer patients with lateral epicendylitis, but it is
questienable whether eccentric exercise adds value. Ex-
ercise was fennd te have better results than ultraseund,
and impreved ferearm strength can reduce the risk ef a
recurrence.9 Exercise pretecels led te greater leng-term
patient satisfactien than certicestereid injectienf' In the
retater cuff, eccentric exercise has net been well stud-
ied. A pregram ef retater cuff isetenic exercise was as
effective as arthrescepic subacremial decempressien for
treating tendinepathy.1
El ll] 16 American deadeniy ef Drrhepaedie Surge-ens
 Chapter 35: Current Cuneepts in Tendinepathy

L.‘

Figure 2 A. threugh C. Fhetegraphs shew eccentric heel drep exercises fer the treatment ef Achilles tendinepathy.
{Hepreduced with permissien frem Andres EM, Mu rrell EA: Treetrnent ef tendinepathy: What werlts, whet dues
net. and what is en the he risen. L'iin Drthep Heist Res IflDE;eEE:1539-1554.}

|Either Hensurgical lnterventiens

Humereus interventiens in addirien re exercise have been
used in an attempt te affect the imbalance ef regenerative
and degenerative changes in the tenden. The best means ef
intervening in the precess is still peerly understeed, hew-
ever. Traditienal treatment algerithms eften incerperate
the use ef NSflIDs and certicestereid injectiens. The lack
ef success ef these treatments may reflect the cemplexit].r
ef tendinepathy and the absence ef acute inflammatien.
NSAIDs treat tendinepathy by interrupting inflam ma—
tery signals threugh the cycleexygenase cascade, and they
are effective enly in the shert term. In a recent review,
14 ef I? placebe~centrelled studies ef patients with Achil—
les tendinepathy feund that NSAIDs previded substantial
pain relief.” Success has been limited in patients with
chronic cenditiens, and there is cencern abeut the effect
ef NSAIDs en tenden healing. Any petential benefit must “‘1-..“

:22»
be carefully balanced against patient-specific risks tn the i
gastreintestinal, cardievascular, and renal systems. Data
-
en lecal administratien delivery systems such as gels and
patches may be ferthceming. The use ef these metheds
is increasing. Figure 3 Phetegraph shewing decline squat fer patellar
Like NSAIDs, certicestereid injectiens are used te tendinepathy. Single-leg eccentric squats ere
perfermed en a decline beard fer treatment
interrupt the lecal cycle ef inflammatery signals. Several ef patellar tendinepathy. [Hepreduced with
studies feund shert—term but net icing—term benefit.11 The permissien frem 't'eung MA, Eeelt JL, Purdem
EFL Kiss ES. Alfredsen H: Eccentric decline squat
exact mechanism ef actien is unclear, and there is cencern pretecel effers superier results at 12 menths F!"
abeut the effect en the structural integrity ef the tenden. tempered with treditienal eccentric preteen-l
E
Shertrterm success has been documented, particularly in fer patellar tendinepathy,:r In velleyball players. i“:
Br} Sperts Med 3111153 5:1fl2—1fl5.) ‘1
the lateral elbew and retater cuff, but recurrence remains 11—!
:
a cencern.”+” The risk ef using certicestereid injectiens in -I'I'
e
1:
the lewer extremity and especially in the Achilles tenden but the effect size was estimated at 1.5%} Ultrasenegraphy H

sheuld be carefully censidered.
Only limited evidence supperts the use ef ether medal-
ities in tendinepathy. Seme medalities were feund te be
successful when used in cembinatien with a therapeutic
exercise pregram but net in iselatien. Ultraseuntl, the must
studied medality, had beneficial effects in patients with lat—
eral epicendylitis er calcific tendinitis ef the supraspinatus,
was not effective in Achilles tendinepathy er nencalcilic 5'
'9.
retater cuff tendinepathy.‘1 Lew-level laser treatment has iii
had little er ne benefit. Limited evidence supperts iente-
pheresis er deep frictien massage. Patients were feund te
have a pesitive respense te hyperthermia. 4
The use ef bleed, bleed preducts, and stem cells has
been investigated fer the treatment ef tendinepathy, and

El Idle American Academy ef flrdiepaedic Surgeens Drrhepaedic Knewledge Update: Sperrs Medicine 5
 Sectien ti: It'flscellaneeus Tepics
Figure 4 Phetegraph shews epen surgical debridement
ef the entenser carpi radialis hrevis at the
lateral epicendyle. {Hepreducee frern Maffulli
N, Lengn UG, Bahr Fl: Surgical therapy fer
tendinepathy, in Kibler WE, ed: flrthepaedic
Kne wledge Update: Sperts Medicine, ed
4. Easement. IL, American Academy at
firthepaedic Surgeens. 2009. pp 329-334.}
initial findings frem animal studies were premising. Seme
techniques require bene marrew biepsy and cell line ea:-
pansien, but these have net been widely incerperated
inte practice. A recent study ef autelegeus tenecyte injec~
tien feund enceuraging eutcemes in patients with lateral
epicendylitis.” Patients with Achilles tendinepathy whe
received injectien with skin-derived fibreblasts were feund
te have better results than centrel subjects.” The use ef
antegeneus bleed predncts such as platelet—rich plasma
{PEP} has been readily accepted. Early studies suggested
that grewth facters such as vascular endethelial grewth
facter {VEGF} and insulinulilce grewth facter l stimulate
tenden healing.If Small case centrel studies feund benefit
te using these grewth facters, but high-quality evidence
is scanning A level I study ef PEP fer the treatment ef
midsubstance Achilles tendinepathy did net find it sub—
stantially beneficial.“ Studies ef PRP are difficult te inter-
pret because cencentratiens, preparatiens, and injectien
pretecels vary widely.ll Research is centinuing, and the
LEI
indicatiens fer using PRP remain te be determined.”'15
.E
S Nitric ercide is a seluble melecnle that acts as a cel-
lular messenger. Glyceryl trinitrate has been used as a
'—
U'l
3
e
ei: delivery system in attempt te induce healing respenses
E in the tenden. In a rat medel, a decrease in nitric exicle
E
U was feund te be cerrelated with peer histelegic findings
and a lew lead te failure. Three randemieed centrelled
IE
E
studies fennd an appreaimately zen. pesitive treatment
a
effect when nitric estide er glyceryl trinitrate was used te
treat elbew, sheulder, er Achilles tendinepathy.“
Extracerpereal sheck wave therapy (ESWTJ uses
lew-energy sheck waves te treat tendinepathy. The mech—
anism ef actien is unclear. ESWT treatment pretecels
r193 flrdtepaeclic Knewledge Update: Sperrs Medicine 5
vary with respect te timing and intensity.“ Randemiened
centrelled studies feund that ESWT had efficacy in pa-
tients with calcific tendinitis ef the retater cuff but net in
patients with uencalcilied tendinitis.”*” Ne substantial
benefit was fennd in patients with lateral elbew tendinitis.
Scleretherapy invelves the injectien ef pelidecanel
er dextrese inte bleed vessels, eften under ultraseund
guidance”!31 The induced scleresis may inhibit the pre*
liferatien ef vascular cells and nerves, thus limiting pain
generatien. The effects ef scleretherapy en tenden struc-
tu re have net been elucidated, but available data appear te
suppert the safety and pain relief efficacy ef scleretherapy
fer use in the Achilles tenden.“ Additienal research frem
diverse seurces is needed.
Surgical Management ef Tendinepathy
Surgical interventien may be indicated fer the treatment
ef tendinepathy after extensive unsuccessful nensurgical
treatment. There is a striking lack ef evidence—based guid—
ance for surgical treatment, hewever. Few deuble-blinded
placebe-centrelled studies have been cenducted, and few
accepted indicatiens and techniques are available te guide
the surgical management ef tendinepathy. The literature
is diverse and net based en universal eutceme reels. Three
studies with a tetal ef mere than 40' patients feund that
vase te S'fl‘iri: had a successful eutceme, and a review ef
research inte surgery fer tendinepathy feund that studies
with peer methedelegy reperted better eutcemes than
studies with acceptable methedelegy.l
Surgical eutcemes are knewn te be unpredictable, and
cemplicatien rates are high. After clinically successful
surgery, the tenden may net heceme nermal and may
remain biemechanically weak. The purpeses ef the surgi-
cal precedure are te excise pathelegic tissue and premete
repair, but there is centreversy as re the mest successful
technique. The cemmen techniques expese the invelved
tenden, strip the paratenen, create lengitndinal tenete-
mies, and remeve abnermal tissue. Insertienal tendinep-
athies may require bursectemy, debridement, encisien ef
calcific depesits, and semetimes release and repair ef the
tenden {Figure 4}.
Achilles tendinepathy is asseciated with painful nee-
vascularizatien en the ventral aspect ef the tenden, which
can be treated with several ultrasenegraphically guid-
ed and percutaneeus techniques. The treatment may be
mest successful in the absence ef substantial paratenen
invelvement. Little infermatien is available fer cempar-
ing these techniques te epen surgery. Resectien ef mere
than 50% ef the tenden may require recenstrnctien in
an epen precedure. Several techniques can be used te
treat patellar tendinepathy, but research is limited. The
El ll] 16 American AcadMy ef Drrhnpaedic Surge-ens

primary procedures involve arthroscopically assisted or
open drilling and excision. Ultrasonograpbically guided
percutaneous techniques increasingly are used based on
limited evidence-‘-1
Recent Research on Tendinopathy
Research is revealing the limitations of current beliefs re—
garding the etiology of tendinopathy. In flammatory cells
such as macrophages and lymphocytes have been encoun-
tered in chronic tendinopathies, particularly in the para-
tenon and bursa. The predominant view of tendinopathy
may be shifting toward a paradigm consistent with that
of osteoarthritis. In osteoarthritis as well as the evolving
understanding of tendinopathy, mechanical overload is
the fundamental cause but ongoing active inflammation
contributes to the cellular pathology. This view of tendi—
nopathy has been clearly defined and is supported by the
presence of elevated levels of inflammatory mediators such
as substance P, the MMPs, VEGF, and cycloortygenase.
The classic cycloorcygenase pathway leads to elevated
levels of prostaglaudin El and E,, which have been found
in models of tendinopathy.1 Increased concentrations of
MMPs are linked to tendinopathy and are upregulated
in rotator cuff pathology. Injections of substance P into
the peritenon stimulated vascularity and tenocyte prolif—
eration with the altered ratios of type III collagen found
in tendinopathy.3L2 Novel interventions to attack these
inflammatory signals may lead to treatments that will be
more successful than the traditional treatments.“l
Tumor necrosis factor-a [TNF-n} is a proinflammatory
cytokine that stimulates ILHI, ILnt’S, MMPs, VEGF, and
prostaglandin E1. Higher-than-normal levels of TNF-a
are associated with cellular apoptosis. Synthetic monoclo-
nal biologic agents to inhibit TNFuu have been effective
in controlling inflammatory conditions such as rheumar
toid arthritis and ankylosing spondylitis.1 The use of a
diminished anti-TNF agent in tendinopathy has been
recommended.1L An investigation of adalimumab for use
in Achilles tendinopathy found pain improvement and
decreased blood flow at 12 weeks} Important questions
remain related to adalimtunab dosage, cost, and inunu-
nosuppression, and further study is necessary.
Tissue inhibitor of matrix metalloproteases and MMPs
are normal products of tenocytes for regulation of the
extracellular matrix of proteoglycans. Therefore, the
normal state of tendons involves a balance of synthesis
and degradation. Disruption of this balance was found in
messenger RNA profiles of chronically painful and rup-
tured tendons.2 The Ml'l ADA HTS-5 {A disintegrin and
metalloproteinase with thrombospondin motifs 5) is be—
ing investigated as a target of inhibition in osteoarthritis,
Er Ifllti American Academy of Urthopaedic Surgeons
Chapter 35: Current Concepts in Tendinopatby
and it may have value for the treatment of tendinopathy}
Substance P is known to be involved in nociception and
upregulated in tendinopathy. A rabbit model of Achilles
tendon overload found increased levels of substance P as
well as hypercellularity and angiogenesis.1 Substance P
may become a viable target for intervention. Glutamate,
a central nervous system signaling molecule, was found
in increased levels in pathologic Achilles tendon tissue.l
A histologic study of patellar tendinopathy found a
tenfold increase in glutamate and a ninefold increase
in N-methyl-D—aspartate receptor 1 {NMDAEI}, a glu-
tamate receptor, compared with control tissue.1 These
molecules also may become therapeutic targets. Specific
inhibition of neovasculariaation and neoinnervation has
generated interest. Inhibition of VEGF may reduce vascu-
larity. Nerve growth factor is involved in the maintenance
of sensory and sympathetic nerves and is believed to have
a role in neuropathic pain. Tanesumab was found to be
a monoclonal antibody against nerve growth factor in
clinical studies, and this finding may have clinical appli-
cation in treating chronic tendon pain.] The sclerar-cis gene
in teuocytes is upregulated in repair and remodeling and
also may become a target for gene therapy.
5 u m m a ry
Therapeutic interventions for tendinopathy are evolving
with increasing understanding of the condition. Some
basic information on the incidence, prevalence, and pre
vention of tendinopathy remains to be determined, but
progress is being made. Biochemical research is elucidat-
ing novel treatments and furthering the model of tissue
pathology as well as its interactions with the central ner-
vous system. It is critical to consider the tendon within
its place in the kinetic chain and the patient's overall
physiology. Continuing basic research and research into
methodology and outcome measures should translate into
improved clinical results.
Key Study Points
ff"
E
II Treatment of tendinopathy must take into account
l“:
the patient—specific pathology of the tendon as well ‘1
11—!
as its place in the kinetic chain. :
-I'I'
o
I Tendinopatby represents a disruption in the 1:
H
anabolicfcatabolic metabolic balance of the tendon. 5'
"E.
I Scant high—level evidence is available to guide treat- III
ment protocols.
1' Current research is targeting molecular and gene
therapies for tendinopathy.
Drthopaedic Knowledge Update: Sports Medicine 5
®
 Sectian E: Miscellaneaua Tapics
Annatated References
Rees JD, Stride M, Scntt A: Tendans: Time ta revisit in-
flammatian. Br J Sparta Med 2fl14:43[21]:1553-155 F.
Medline DUI
A review article examined hiataric and recent evidence
that chranic tendinnpathy incnrparates elements cf the
inflammatary precess and that this factar may affer pa-
tential therapeutic targets.
. Heviaser A, Andarawia-Puri N, Flataw E: Basic mecha-
nisms af tendan fatigue damage. I Sbaaider Elbaw Sarg
2012;21llifljfl-163.Medline DUI
Malecular and mechanical changes and animal model
research pertaining ta ratatar cuff tendau disease and
treatment were reviewed.
September AV, Nell EM, U’Cannell K, et al: A path-
way-based appraach investigating the genes encading
interleukin-1H, intedeukin-ci and the interleukin-1 re-
ceptnr antaganist pravides new insight iuta the genetic
susceptibility af Achilles tendinnpathy. Br I Sparta Med
2fl11:45{13J:1D4D—104T.Medline DUI
1iriariatians in the IL genes and the CULSAI EstLlI CC
genatypes were faund ta be callectively significantly as-
sa-ciated with the risk af Achilles tendinnpathy.
Scatt A, Daclting S, Viceneina E, et al: Sparta and cater-
cisearelated tendinnpathies: A review nf selected tapical
issues by participants cf the secand Internatiaual Scientific
Tendinapathy Sympasium {ISTS} Vancauver 2012. Br
1 Sparta Med 2013;4Ti9}:536-544. Medline DUI
Research and clinical practice issues were updated in a
summary af a 2011 canference.
Dirnitrias S, Pantelis M, Kallinpi S: Camparing the ef-
fects af eccentric training with eccentric training and
static stretching exercises in the treatment af patellar
tendinnpathy: A cantralled clinical trial. Effie Refs-chi!
2fl12;25{5}:423-43li.Medline DUI
The additinn af static stretching ta a pragram af eccentric
training far patellar tendinnpathy significantly reduced
pain and impraved functian. Level af evidence: II.
LEI
Ram 11, Meeuwisae W, Patel CI, Wiseman DA, Wiley JP:
.E The limited effectiveness af a heme-based eccentric train-
S ing far treatment af Achilles tendinapathy. Cffn Invest
Med ruraaaaperssssaa. Medline
'—
U'l
J lavage camhined with a subacramial bursa injectian had
a
al: Hame-based eccentric training was faund nnt tn meet pa-
E received the injectian alane. Level af evidence: I.
E tients” erpectatians far treatment af Achilles tendinnpathy.
U
Level af evidence: IV.
IE
E
a
. van der Plas A, de Jange 5, de Vas R], et al: A 5-year fal-
law-up study af Alfredsan’s heel-drap exercise pragramme
in cbranic midpnrtian Achilles tendinnpathy. Br ] Sparta
Med 2012;4fil3}:214—213. Medline DUI
At lung—term fallaw—up af a heel—drap exercise program for
Achilles tendinnpathy, patients had significant increases
Urdtapaedic Knawledge Update: Sparta Medicine 5
in autcame scares, but mild pain persisted and ane-half
af patients received aflrer therapies after the canclusian cf
the 3-mauth pragram. Level af evidence: IV.
Haratmann T, Jud HM, Friihlich 'v", Miindermanu A, Gran
S: 1|iiiihale—bady vibratian versus eccentric training er a
wait-and-see appraach far chranic Achilles tendinnpathy:
A randamiaed clinical trial. J Urtfsap Sparta Phys Ther
1fl13;43{11J:?fl4-3{}3. Medline DUI
Vibratian training was a successful camplemeut ar alter—
native ta eccentric training far ch ranic Achilles tendinnp-
athy, especially far patients with insertianal pain. Level
af evidence: I.
Stasinapaulas D, Stasinapaulas I, Pantelis M, Stasinn-
pnulau K: Camparisan af effects af a hame exercise pra-
gramme and a supervised exercise pragramme far the
management af lateral elbaw tendinapathy. Br I Sparta
Med ED1fl;44{S]:5?9-SSS. Medliue DUI
In '3’!) patients wha underwent a hame ar supervised err-
ercise pragram pragram far lateral elbaw tendinnpathy,
the supervised pragram had significantly better results at
12- and 24-week fallaw-up. Level af evidence: I].
Ii}. Maquirriain J, Kakalj A: Acute Achilles tendinnpathy:
Effect af pain cantral an leg stiffness. j Mascaiaakefet
Neuranaf Interact 2U14;I4{1}:131-136. Medline
Athletes with unilateral Achilles tendinnpathy had in-
creased leg stiffness after receiving aral anti—inflammatary
therapy. Level af evidence: III.
11. Karthilreyan 5, Kwang HT, Upahyay PK, Parsans hi, Drew
5], Griffin D: A dau hie-blind randamised cuntralled study
camps ring subacramial injectian af teuarticam ar methyl-
predniaalane in patients with subacramial impingement.
j Barre faint Sarg Br lfllflfllfllfilfil. Medline DUI
Carticasteraid injectian was fauud ta have significantly
better results than NSAID injectian far ahaulder funcn'an
after 6 weelrs in SS randamly assigned patients. Level af
evidence: I.
11'. cle Witte PE, Selten JW, Navas A, et al: Calcific tendinitis
cf the ratatar cuff: A randamiaed cuntralled trial af ul—
trasaund—guided needling and lavage versus subacramial
carticasteraids. Am] Sparta Med 3013:41{?]:I I565-16?3.
Medline DUI
At 1-year fallaw-up, patients with calcific tendinitis DI the
ratatar cuff wha received ultrasaund—guided needling and
better clinical and radiagraphic results than thnse wha
13. Mernlla G, Eianchi P, Parcellini G: Ultrasauud-guided
subacramial injectians af sndium hyaluranate far the
management af ratatar cuff tendinnpathy: A praspective
camparative study with rehabilitatian therapy. Maser-afa-
sirefet Surg 2013;??{Suppl 11:49-56. Medline DUI
Hyalnranic acid injectian was faund ta prnvide better pain
relief and autcame scares than rehabilitatian therapy at
weeks 4 and 12 but nat at week 24. Level af evidence: 11.
El 1016 American AcadMy af Urthapaedic Surge-ans

14. 1ii'i'u’ang A, Breidahl W, Mackie KE, et al: Autologous teno-
cyte injection for the treatment of severe, chronic resis-
tant lateral epicondylitis: A pilot study. Am ] Sports Med
2013;41{12}:1925-1931.Medline DUI
Twenty patients with lateral epicondylitis who were treated
with autologous tenocyte injection had significant func-
tional improvement and structural repair on MRI. Level
of evidence: IV.
1.5. Ubaid H, Clarke A, Rosenfeld P, Leach C, Connell D:
Skin-derived fibroblasts for the treatment of refractory
Achilles tendinosis: Preliminary short-term results. } Boise
joint Strrg Am 2012;94i3}:193 Jill]. Medline DUI
A randomised double-blind study of 32 patients {40
Achilles tendons} found significant differences in out-
come and pain scores and safety 5 weeks, 12 weeks, and
If months after injection of skinrderived fibroblasts. Level
of evidence: I.
is. Ereaney L, Wallace A, Curtis M, Donnell D: Growth
factor-based therapies provide additional benefit beyond
physical therapy in resistant elbow tendinopathy: A pro-
spective, single-blind, randomised trial of autologous
blood injections versus platelet-rich plasma injections.
Br ] Sports Med lfl11;45{12j:965-9?1. Medline DUI
PEP injections were found to be superior tn autologous
blood in the treatment of lateral epicondylitis. Level of
evidence: II.
1?. Mishra AK, Shrepnilt NV, Edwards SG, et al: Efficacy
of platelet-rich plasma for chronic tennis elbow: A dou-
hie-blind, prospective, multieenter, randomised controlled
trial of 130 patients. Am ] Sports MedI 2D14;42{2}:463-
4?]. Mcdline DUI
No significant difference was found at 12—week follow—up
based on whether patients with chronic tennis elbow had
received leukocyte-rich PEP injection, but there was sig-
nificant improvement at liluweelc follow-up. Level of
evidence: I.
13. Bell K], Fulcher ML, Rowlands DS, Kerse N: Impact of
autologous blood injections in treatment of mid-portion
Achilles tendinopathy: Double blind randomised con-
trolled trial. BM] 2D13;34E:f231fl. DUI
No additional benefit was found when two unguided peri-
tendinous injections were added to a standard eccentric
exercise program in patients with Achilles tendinopathy.
Level of evidence: I.
19. Eha DW, Park GT, Kim TE, Kim MT, Lee SC: Com-
parison of the therapeutic effects of ultrasound-guided
platelet-rich plasma injection and dry needling in rotator
cuff disease: A randomised controlled trial. Clio Rflfififlff
2D13;2T{2.]:113-122. Medline DUI
In patients with tendinopathy or a partial tendon tear, PEP
injection was found to be more effective than dry needliog
from 6-week to 5—month follow-up. Level of evidence: II.
Ill. de Jonge S, de Vos R], 1'illi'eir A, et al: Une-year follow-up
of platelet-rich plasma treatment in chronic Achilles
U Ifllti American Academy of Urthopaedie Surgeons
Chapter 35: Current Concepts in Tendinopathy
tendinopathy: A double—blind randomised placebo-eon-
trolled trial. Am I Sports MedI 2fl11;39{3}:1523-1629.
Medline DUI
A study of 54 patients did not find PEP injection to be su-
perior to placebo in combination with an eccentric exercise
program at 1-year follow-up, as determined by outcome
measures or ultrasound. Level of evidence: I.
2.1. Kesikburun 5, Tan AK, Tilmaa E, Yaear E, Yaeiciog-
lu K: Platelet-rich plasma injections in the treannent of
chronic rotator cuff tendinopathy: A randomized con-
trolled trial with 1-year follow—up. Am _,I Sports Med
2D13;41{11}:25fl9-2616.Medline DUI
In patients with chronic rotamr cuff tendinopathy, PRP
injection was not found to be more effective than place-
bo in combination with an exercise program. Level of
evidence: I.
11. Dragoo JL, Wastcrlain A5, Eraun H], Head KT: Plate-
let-rich plasma as a treatment for patellar tendinopathy:
A double-blind, randomized controlled trial. Am I Sports
Med 2fl14;41{3}:610a613. Medline DUI
Twenty-three patients with patellar tendinopathy who
were randomly assigned to standard eccentric exercises
with ultrasound-guided leukocyte rich PEP injection had
accelerated recovery compared with patients who received
exercises alone, but the results dissipated with time. Level
of evidence: I.
13. Vetrano M, lEastorina A, Vulpiani MC, Baldini R, Pavan
A, Ferretti A: Platelet-rich plasma versus focused shock
waves in the treatment of jumper’s knee in athletes. Am
1 Sports Med 2013;41(4}:?95-303. Medline DUI
Two PRP injections were found to be more effective than
ESWT at midterm clinical follow—up of patients with pa—
tellar tendinopathy. Level of evidence: II.
14. Gosens T, Den Uudsten EL, Fievea E, van ’t Spijlcer P,
Fieves A: Pain and activity levels before and after plate-
let-rich plasma injection treatment of patellar tendinop-
athy: A prospective cohort study and the influence of
previous treatments. Int Urtfiop 2012:36{9}:1941-1946.
Medline DUI
PEP was significantly beneficial in the treatment of patel-
lar tendinopathy, but patients who had undergone earlier
surgical or injection treatments did not have a response
to the treatment. Level of evidence: III. F!"
5
25. Moraes "UT, Lenea M, Tamaoki M], Faloppa F, Belloti iii
‘1
JU: Platelet—rich therapies for museuloslteletal soft tissue 11—:
injuries. Cochrene Database Syst Rev EMA-HEB DIUDTL :
I'D
Medline o
1:
H
5'
There was insufficient evidence to support the use of
"E.
platelet—rich therapies in patients with musculoslteletal ii
soft-tissue injury. Standardization of PRP preparation
methods was recommended.
26. Smunehrinlt M, Zwerver J, Brandsema R, Groenenhoom P,
van den Altker-Scheelt I, Weir A: Topical glyceryl trinitrate
treatment of chronic patellar tendinopathy: A randomised,
Urthopaedic Knowledge Update: Sports Medicine .5
 Sectiun E: Ii'fisceflaneuus Topics
duuhle-hlind, placehc-ccntrulled clinical trial. Br] Sports
Med 2D13;4?{1]:34 -3 9. Medline DUI
Tcpical glyceryl trinitrate in additicn tc an eccentric ea:-
ercise prugram did nut lead tu a superinr clinical cutcume
ccmpared with placebc patches in patients with chrnnic
patellar tendincpathy. Level of evidence: I.
2?. Zwerver J, Hartgens F, Verhagen E, van der Warp H, van
den Altlter-Scheelt I, Dierclts RL: Nu effect cf extraccrpc-
real shccltwave therapy cn patellar tendincpathy in jump-
ing athletes during the ccmpetitive seasun: A randcmized
clinical trial. Am I Sparta Meal 2011;39lfilfll 91-1199.
Medline DDI
In 62 randcmly assigned athletes with patellar tendincpa-
thy symptcms at less than 11 munths' duratiun, ESWT had
an significant benefit uver placeb-a. LEVEI cf evidence: II.
23. Kalle A, Tang KG, Tamminga R, van der Hueven H: Ea—
dial eatraccrpureal shack-wave therapy in patients with
chrcnic rctatcr cuff tendinitis: A prcspective randcmised
duuhle-hlind placehu-ccntrclled multicentre trial. Brine
faint } lfll 3:95—Ell 11:1521-1516. Medline DUI
Treatment with radial ESWT did nut reduce pain at im-
prc-ve functicn in patients with chrunic rutatcr cuff ten-
dinitis. Level cf evidence: I.
29. Galassc fl, Amelie E, Riceelli DA, Gasparini G: Shurt-
term cutccmes cf extraccrpureal shccle wave therapy fur
the treatment cf chrcnic ncn~calcific tendinnpathy cf the
supraspinatus: A duuble-blind, randumiaed, placebo-cun-
trclled trial. EMU Musculuskelet Discrd 1013;131:315.
Medline DUI
ESWT led tc hetter pain scores and range cf mutiun than
placebu in 20 patients with chrcnic nuncalcific tendincp—
athy cf the supraspinatus at 12-week fullcw-up. Level cf
evidence: I.
LEI
.E
3
'—
U'l
J
t:
e:l:
E
E
U
IE
E
a
flrdinpaedie Knnwledge Update: Sparta Medicine 5
3G. Telland M], Sweeting KR, Lyftcgt JA, Hg 5K, Scuffham
PA, Evans EA: Prclctherapy injecticns and eccentric lead-
ing exercises fur painful Achilles tendinnsis: A randumised
trial. Br] Spur-ts Med 2011;45{5}:421-423. Medline DUI
Prul-atherapy injeetiuns with eccentric-luading exercises
led tu mcrre rapid imprcvement in patients with Achilles
tendincsis than eccentric—luading exercises alcng, hut lung-
term results were similar. Level cf evidence: II.
31. Hchsrud A, Tcrgalsen T, Harstad H, et a1: Ultra-
suund—guided sclerusis cf necvessels in patellar tendinupa-
thy: A pruspective study ui 1U] patients. Am I Spurts Med
1012;4flt3}:541-541Medline DUI
Sclernsing treatment with pcliducancl resulted in mnder-
ate imprnvement in patients with patellar tendinc-pathy,
but must patients still were symptc-matic at Eel-munth
fulluw-up. Level cf evidence: IV.
32. Grass CE, Hsu AR, Chahal J, Hchnes GB Jr: Injectable
treatments fur ncninsertiunal Achilles tendincsis: A
systematic review. Fact Ankle Int ID13;34{5}:619-623.
Medline DUI
A literature review fcund that injectable therapies had
highly variable results in patients with nc-ninsertiunal
Achilles tendincsis. The evidence was inccnclusive.
33. Huh J5, Muhan PC, Huwe T5, et a1: Faseiutcmy and sur-
gical tenctumy fcr recalcitrant lateral elhnw tendincpathy:
Early clinical experience with a navel device fur minimally
invasive percutaneuus micruresectiun. Am I Sparta Med
2013;41{3}:636-644.Medline DO]
A pruprietary device was used fur minimally invasive ul-
trascrnic tissue resecticn. Nineteen cf ill patients with
recalcitrant lateral elbcw tendinnpathy had a gucd clinical
result at 1-year fullcw-up. Level uf evidence: IV.
El 1016 American AcadMy cf Drrhnpaerlie Surge-ans
Chapter 37
Current Applications of
Orthobiologic Agents
Ryan M. Degen, MD, Mfic, PECSC Scntt A. Enden. MD
Abstract
The effectiveness nf nrthnbinlngic agents, such as autn-
gtaft, allngra ft, and xenngra ft, in facilitating healing is
currently being studied. An understanding nf the science
behind tissue healing is impnrtant tn establish clinical
indicatinus for nrthnbinlngic agents.
Keywnrds: nrthnhinlngic agents; platelet-rich
plasma: stem cells: growth factors: scaffolds;
vitamin D deficiency; matrix metallnprnteinase
inhibitnrs
Intrnductinn
Despite recent impnrtant innnvatinns in nrthnpaedic sur-
gical techniques, implants, and devices, the time required
for healing remains a limiting factnr in restnring functinn
after injury. Heightened attentinn tn understanding the
basic binlngy nf tissue healing has led tn a cnncnmitant
interest in tissue regeneratinn. Sn-called nrthnbinlngic
agents have the pntential tn imprnve lncal binlngy and
expedite nr ntherwise imprnve the healing prncess. Avail-
able nrthnbinlngic agents include autngraft, allngraft,
and xenngraft binlngic substances that can be further
classified as having grnwth factnr, cellular, nr tissue ther—
apeutic actinn. An increasingly large number nf studies
have been published nn the available agents, but it can
be difficult tn use the literature tn determine the efficacy
and clinical usefulness nf these agents.
Dr. Hnden nran immediate famiiy memher serves as a paid
cnnsuitant tn Cyfflrf, Piuristem, and Hntatinh Medical and
has stncir er stncir nntinns heid in The Cayenne Cnmpany.
Neither Dc Degen nnr any immediate family member has
received anything at value frnm nr has stncir nr stncir np-
tinns heid in a cnmmerciai cnmpany nr institutinn reiated
directiy er indirectly in the suhject at this chapten
@ lfllfi American illcademyr nf Drthnpaedic Surgenns
Ernwth Factnr Therapy
Platelet-Rich Plasma
The first treatments using platelet-rich plasma {PEP} were
in maxillnfacial surgery.1 Pnsitive results led tn widespread
interest and use in cardinvascular and plastic surgery,
with mere recent applicatinu in nrthnpaedic surgery}-3
Several preclinical and clinical studies have investigated
the efficacy nf PEP in treating nrthnpaedic cnnditinns
including fracture nnnuninn, diabetic fracture, tendi-
nnpathy, tendnn-bnnc and ligament-bnne healing, heal-
ing after spinal fusinn, and cartilage repair.“ Currently,
there is nn cnnsensus en the use nf PEP in the treatment
nf spurt—related pathnlngy.
PEP is a cnncentrate nf autnlngnus blend with a higher
cnncentratinn nf platelets than whnle hlnnd. Eepnrted
studies have used variable platelet cnncentratinns. Clin-
ical efficacy has been fnund at values as lnw as 2Dfl,fli}fl
platelets per pL, whereas nther studies have defined PEP
as having a cnncentratinn nf at least 1 millinn platelets
per pL in 5 mL nf plasma.“ Either identified differencr
es in PEP fnrmulatinns include variability in leukncyte
cnncentratinn, the presence nf fibrin architecture, and the
need fnr an exngennus activating agent such as calcium
chlnride nr thrnmbin.Ii Each nf these factnrs affects the
activity nf PEP. The interpretatinn nf clinical data is lim-
ited by an inability tn determine the cnntributinn nf each
cnmpnnent tn the nverall efficacy nf PEP.
F!"
5
Preparatinn and |Izinmpnsitinn iii
‘1
future than 1.5 cnmmercial preparatinn systems are cur- 11—!
:
rently available fnr creating PR. P. Each system has its nwn -I'I'
n
1:
whnle blend vnhune requirement, centrifugatinn rate and H
time, platelet capture rate , and end vnlume [Table 1}. As 5'
'9.
a result, PEP samples have substantial qualitative differ- iii
ences in platelet, grnwth factnr, leukncyte, and neutrnphil
cnncentratinnsfi
The preparatinn nf PEP invnlves drawing whnle
blnnd, mixing it with an anticnagulant, and centrifuging
tn separate the specimen intn a red blnnd cell fractinn
Drrhnpaedic Ennwledge Update: Sparta Medicine 5
 El 1016 American Academ? uf Dnhnpaedj: Surge-ans
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 Chapter 3?: Eturent Applications of |lilrthobiologic Agents

Table 2

Functions of Selected Growth Factors Released From Platelet u-Granules

Growth Factor
Platelet—derived growth factor
1ll'ascular endothelial growth factor
Transforming growth factorvfll
Fibroblast growth factor
Epidermal growth factor
Insulin-like growth fa ctor-1
Function
Stimulates cell replication
Stimulates angiogeuesis
Stimulates mitogen for fibroblasts
Angiogenesis
Balances fibrosis and myocyte regeneration
Stimulates myoblasts
Stimulates angiogeuesis
Stimulates proliferation of mesenchymal and epithelial cells
Potentiates other growth factors
Stimulates chondrogenic proliferation of mesenchymal stem cells
Stimulates extra-cellular matrix production
Downregulates catabolic effects of MMPs and interleukin-1

and a plasma fraction containing platelets, white blood
cells iWBCs}, and clotting factors. The plasma is fur-
ther divided into platelet-poor plasma and PRP. The
PEP can be mixed with an activator to stimulate the
clotting and degranulation processes; if an activator
is not added, clotting and degranulation occur more
gradually after exposure to tissue~derived collagen} PEP
should be kept in an anticoagulated state until it is to
be used because as much as 90% of the growth factors
are released within the first 10 minutes after clotting,
and more than 95% is released within the first hour}
Platelets can remain viable in the anticoagulated state
for as long as 3 hours.1| A second centrifugation of the
plasma with calcium chloride converts the fibrinogen
to fibrin and traps the platelets in a dense fibrin matrix
{platelet-rich fibrin] to allow a gradual release of growth
factors over 5 to ? days.i3
Platelets contain u-grauules, in which proteins, cyto-
kines, and growth factors help regulate the healing prop
cess.H Among the commonly recognised growth factors,
each of which has a diffetent function, are platelet-derived
growth factor lPDGFl, vascular endothelial growth fac-
tor, transforming growth factor Bl {TGF-fll}, fibroblast
growth factor iFGFl, epidermal growth factor, and insu-
lin—like growth factor 1 {Table 2]. Platelets release these
Platelet concentration and the subsequent release of
growth factors initially were believed to represent the
primary mechanism of action of PR. P. Wh at app-cared to
be a dose—response relationship was found between the
concentration of platelets and the production of a cellular
response in treated tissues, although this relationship
was not always correlated with a measurable clinical ef-
fact.1 More recently, other important constituents were
identified as contributing to the healing activity of PEP;
these include red blood cells, neutrophils, and 1"'lliFPllZs
{leukocytes}, which are believed to propagate the local
inflammatory response.‘ The benefit of 1"iii’lillls in PRP is
controversial. Several studies supported the use of 1i'lil'Il,
arguing that they potentiate the release of cytokines from
platelets to improve healing and that, in vitro, they con fer
antimicrobial properties to reduce infection rates.13 Either
studies argued that the release of these cytokines causes
a highly inflammatory reaction that creates a predispo-
sition to fibrosis and structurally weaker tissue, without
confirmed in vitro antimicrobial effectsfil" The clinical
F!"
effect of WBCs and the other constituents of PEP remains 5
unclear, and further study is warranted to quantify each ill
‘1
substance and determine its specific clinical effects. 11—!
:
Uncertainty exists not only about the effects of individ- -I'I'
o
1:
ual PRP components but also about between—sample dis- H

substances during degranulation, and they aid in the heal-
ing process by stimulating cell proliferation, chemotaxis,
angiogeuesis, matrix production, and cell differentiation.1
In addition to growth factors, platelets release histamine
and serotonin, which increase local capillary perrueability
and thereby improve access for inflammatory cells to start
the reparative process}
parities in the concentration of the components. Concern 5'
"E.
over the heterogeneity of available PEP preparations and if
the generalisability of reported results led to a recent study
of the cellular composition of PRP produced from sever-
al commercially available separation systems." Marked
differences in cellular composition were identified. In ad-
dition, variable platelet capture and WEC concentration

Eb Ifllti American Academy of Urthopaedic Surgeons Drrhopaedic Knowledge Update: Sports Medicine 5
 Section ti: Miscellaneous Topics
were found when a single separation system was used to
process sequential blood draws from individual patients.
These findings should alert researchers and clinicians to
carefully quantify the individual PEP preparation char-
acteristics used in clinical studies, for the purpose of de—
termining the true clinical efficacy of PEP and improving
the applicability of reported results.
PEP in Tendinopathy
Tendon injuries can lead to substantial morbidity, interfer-
ing both with spurts participation and activities of daily
living. Healing tends to be slow because the injury often
is in a relatively avascular region, and a complex, gradual
process of inflammation, proliferation, and remodeling is
required to restore structural integrity.” The interaction
of several growth factors is important for generating the
inflammatory phase that initiates repair. There has been
significant interest in the potential ability of PEP to accel-
erate and improve healing by providing several requisite
growth factors to the injury site early in the process. in
addition, PEP may stimulate neovascularixation to facil-
itate regeneration of the injured tissue.4
The use of PEP in treating various forms of tendinop-
athy as well as tendon rupture has been widely studied in
recent years {Table 3). Rehabilitation coupled with PEP
has been studied in acute and chronic Achilles tendon
injuries, partial hamstring tears, lateral epicondylitis,
and patellar tendinitis. A randomized controlled inves-
tigation of chronic Achilles tendinopathy treated with
eccentric exercises and PEP or saline injection found no
benefit to the use of PEP.” A retrospective cohort review
of acute Achilles tendon rupture treated with functional
rehabilitation and PEP also found no benefit to the use
of PEP.” In contra st, partial hamstring tears were found
to respond to ultrasoundvguided PEP injection added to
eccentric exercises; patients in the treatment group had
better subjective pain scores and return-to-play timelines
than those in the control group.” in two separate ran-
domised controlled investigations, the use of PEP led to
LEI
better pain scores and functional outcomes in patients
.E
S with lateral epicondylitis, compared with dry needling
or corticosteroid injection and physical therapyfl'“? The
'—
U'l
J
o
a:l: utility of PEP in treating patellar tendinopathy is less
E clear, as two separate studies yielded mixed rcsults.”+”
E
U The success of PEP injections for tendinopathy is high—
ly variable and depends in part on the pathology. Further
IE
E
study is warranted on the treatment of tendinopathy with
a
PEP to more accurately quantify the administered PEP
concentrate. Because some studies found that the treat-
ment effect dissipated over timed”Er long-te:m follow-up
is needed to determine whether the treatment effect is
maintained.
flrrhopaedic Knowledge Update: Sports Medicine 5
PEP in Rotator Cuff Repair
The rotator cuff insertion consists of a specialized
area of organized tissue that makes a gradual transi-
tion from tendon to unmineraliaed fibrocartilage, then
to mineralised fibrocartilage, and finally to bone.11
Tendon-bone healing typically proceeds in a stepwise
fashion from an initial inflammatory phase to a repair
phase and a remodeling phase. The inflammatory and
repair phases occur within the first 14 days after in-
jury; both rely heavily on platelet aggregation, fibrin
deposition, and release of cytokines. These cytokines
include growth factors that attract inflammatory cells
as well as progenitor cells that rely on other signaling
molecules for differentiation and proliferation and con;
tribute to extracellular matrix synthesis.21 Typically,
the healing response after rupture or surgical repair
does not lead to replication of the original organized
structure but in stead results in formation of significant
fibrosis and scar tissue with weaker mechanical prop-
erties. PEP has been investigated in rotator cuff repair
for its potential to stimulate cellular proliferation and
differentiation leading to improved collagen orienta-
tion and structural integrity {Table 4}. A randomized
study of single—row repair of small rotator cuff tears
found no significant differences in patient-reported
outcomes {UCLA Shoulder Rating Scale, Constant
shoulder score] or retear rates based on whether PEP
was administered.“ A retrospective cohort review
found no measurable differences in patient-report-
ed outcomes (UCLA, Constant, Simple Shoulder Test
scores) based on whether PEP was used in double-row
repair of large to massive rotator cuff tears.” PL ran-
domized controlled study of a platelet-rich fibrin ma-
trix in the surgical repair construct of small to large
rotator cuff tears found no benefit in any treatment
group.“ Results were evaluated using a combination
of ultrasound-determined radiographic healing, dy-
namometer strength testing, and validated outcome
measures (American Shoulder and Elbow Surgeons
Shoulder Scale and L’Insalata Shoulder Questionnaire}.
In contrast, another study found improvement in radio-
graphic outcomes {retearing rates and cross—sectional
area} when PEP was added to a double-row suture
bridge repair construct for treatment of large to mas-
sive tears; these findings were not correlated with im-
proved clinical outcome scores, however.“
The currently available evidence appears to be insuf-
ficient to warrant the routine use of PEP in rotator cuff
repairs. Many early studies were flawed by poor meth-
odology and varying definitions of PEP composition.“
Further study is warranted to determine whether there
is a role for PEP in rotator cuff repair.
El 1016 American AcadMy of Drtbopaedic Surgeons
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Dnhnpaedic Knnwledge Update: Sparta Medicine 5

Chapter 3? Current Applicatiuns [If firthuhiul ': Agents

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PHP in Ehbndral Resurfacing
PEP has been studied for the treatment of ehbndral de-
fects because some of the released growth factors have
demonstrated anabolic effects in vitro by stimulating
chondrocyte proliferation. TGP-B has been found to en-
hance matrix production, cell proliferation, and osteo-
chondrogenic differentiation while it upregulates type II
collagen and aggrecan gene expression.2T PEP also has
been found to have a chemotactic effect, stimulating both
the migration of bone marrow stromal cells to the site
of injury and subsequent chondrogenic differentiation}?
In addition, PEP specifically increases the activity of
TGP-fll, which can stimulate extracellular matrix syn-
thesis, while downregulating the catabolic effects of in—
terleukin 1 [IL-1} and matrix metalloprotcinases {MMPs},
which are known to degrade articular cartilage.” Insu-
lin—like growth factor I has been found to have similar
anabolic effects; it increases production of extracellular
matrix, stimulates ehbndregenic differentiation of mes-
enchymal stem cells (MSCsl, down regulates the catabblic
effects of IL-1 and MMPs, and has a synergistic effect
when administered with TGP-[lld‘a
In the treatment bf ehbndral defects, PEP can be in-
jected locally to supply growth factors meant to stimulate
an inflammatory response and neovasculariaation {to
attract stem cells and fibroblasts), stimulate ehbndrb-
cyte differentiation and proliferation, and downregulate
catabblic enzyme activityr {to allow articular cartilage
regenerationldf'H A direct, intra—articular injection can
be administered, or a scaffold can be used to deliver PEP
to the intended site. The available polymer scaffolds are
protein based (fibrin, collagen}, carbohydrate based [by-
aluronic acid, alginate], or synthetic {polylactic acid,
polyglycolic acidlfis'
Animal studies found mixed results when osteochbn-
dral defects were treated with PEP, and few clinical stud-
ies exist. The effects bf intra-articular PEP and hyaluronic
acid injections were compared in treating talar osteo-
chondral defects.” No scaffold was used. The PEP was
activated with calcium chloride to allow a fibrin clot to
form within the joint. Patients in both treatment groups
had a decrease in visual analog scale {VAS} pain scores
and improvement in American Grthopaedic Foot and An-
kle Society ankle -hindfobt scores, but the outcomes were
substantially better in the patients treated with PEP.“ In
the treatment bf lcnee osteochondral defects, the use bf
a synthetic scaffold, in which PEP was combined with a
poly—gamma glutamic acid (PGAl—hyaluronan scaffold,
led to significant improvement in patient-reported out-
comes on the Knee Injury and lIlilsteoarthritis Outcome
Score {EGGS} and to histologic evidence of hyaline—like
repair tissue at the defect site at 1-year follow-up}1 Five
Eb Iflld American Academy of Urtlmpaedic Surgeons
Chapter 3?: Current Applications of Drthbbiblbgic Agents
patients treated for a patellar bstebchondral defect using
autolbgous matrix-induced chondrogenesis with added
PEP had improved clinical outcome scores (EGGS, Ku-
jala patellofemoral score, Tegner activity scale, VAS}, de-
spite laelc bf lesibnal filling on MEI at 1—year follow—up?2
These studies suggest that PEP can be useful in treating
bstebchbndral lesions, but further study is warranted to
determine the best method bf delivery and provide results.
PHP in fistebarthritis
The progress of osteoarthritis is largely driven by proteo-
lytie enzymes, with MMPs contributing to degradation
bf type II collagen and protebglycan. PEP is thought to
allow cartilage restbratibn by downregulating the ef—
fects bf these enzymes while stimulating chondrocyte
proliferation and extracellular matrix production}El Pre-
clinical in vitro studies found a positive effect bf PEP
on ehondroeyte metabolism and led to clinical studies.33
A randomized clinical study comparing PEP with hyal-
uronic acid injections in the treatment of knee gonar-
throsis found significantly better outcomes at 24-week
follow-up in the patients who had PEP injections, as
indicated by lower, maintained scores on the Western
Untario and McMa stcr Universities |I'Cllsteoarthritis Index
(WDMAC).34 Another comparison of PEP with hyal-
uronic acid for treating bstebarthritis found improved
International Knee Documentation Committee {IEDC}
Subjective Knee Evaluation Form and VAS scores in bath
groups at 2—month follow-up, but at 5—month follow-up
only the patients treated with PEP had maintained the
improvement in outcome scbres.” A double-blind, pro-
spective randomized controlled study compared the ef-
fects bf WEE-filtered PEP and normal saline iniectibns
in patients with osteoarthritis. Patients treated with one
or two PEP injections had better scores on the WDMAC
than those who received a saline iniection, but the effect
dissipated after 6 months.”I Although these studies show
a positive effect bf single or multiple PEP injections for
knee osteoarthritis, most of the results were limited to
15-month follow-up. Longer follow-up times are necessary
F!"
to determine whether the effect is maintained. E
l“:
‘1
PEP in Meniscal Repair 11—!
:i
The inner two-thirds bf the meniscus is a relatively avas- -I'I'
o
c
cular area with limited intrinsic healing capacity. Growth H
factor augmentation has the potential to stimulate neovas- 5'
'9.
cularieatibn and improve healing in this region. An early I'll
study found that an exogenous clot could stimulate heal-
ing, but more recent clinical studies are lacking.“ Animal
studies found improved meniscal healing in rabbits after
an introduced tear was repaired using PEP delivered with
a gelatin hydrogel or hyaluronic acid—collagen composite
Drthopaedic Knowledge Update: Sports Medicine 5
 Section ti: Miscellaneous Topics
matrirr..3"'~~"E A clinical study of meniscal healing after open
repair of a horizontal tear found Excellent healing regard—
less of whether PRP had been injected into the repair site,
but patients who received PRP had slightly better clinical
outcomes {IKDC, ED 05 scores] and radiographic menis—
cal appearance on postsurgical MRI.” Ongoing study
is required to determine the usefulness of PRP and the
optimal delivery method in meniscal injuries.
Isolated Growth Factors
Several active agents within PRP may be responsible
for its clinical effects. Platelet aggregation and degranu-
lation releases several different growth factors or cyto-
kines that may contribute to the overall effect. The most
commonly studied factors are PDGF, TGF-B, FGF, and
bone morphogenetic protein [BMPL which have been
shown to contribute to fibrosis and improved structur—
al properties at the repair site.“ The activity of several
of these growth factors was upregulated during normal
healing in an animal rotator cuff repair model.“1 It is not
entirely clear which factors are most active in stimulating
or contributing to soft-tissue or tendon-bone healing or
whether their effects are synergistic.
PDGF exists as two subunits (A, B) and three isoforms
(an, BB, AB}. PD GF—EB has been found to contribute to
tendon-bone healing by stimulating cell chemotaxis and
division as well as type I collagen synthesis.21 Preclini~
cal studies found that application of PDGF-EB in rabbit
medial collateral ligament injuries and in rat and sheep
rotator cuff injuries led to improvement in the histologic
appearance of the healing ligaments and tendons, with in-
creased tendonubone interdigitation and increased biomen
chanical strength at the bone—ligament and boneptendon
interfaces.“-““ Delivery of PDGF-BE in a collagen scaffold
improved the histologic appearance of the boneutendon
interface in a rat rotator cuff repair model, although it
appeared to have a detrimental effect on biomechanical
properties, as shown by increased retearing rates and
poor results on ultimate load—to—failure tests.“‘1 In addi—
LEI
tion to tendon-bone or ligament-bone healing, PDGF has
.E
e‘ been used in cartilage regeneration because it is a potent
chemotactic and mitogenic factor that attracts MSCs,
'—
U'l
J
o
a:l: Stimulates proliferation and differentiation (resulting in
E increased proteoglycan synthesis}, and antagonizes inter-
E
U leukin IB—mediated cartilage degradation.19
TGF-[i is secreted after platelet degranulation. Its three
IE
E
isoforms {TGF-fil, TGF-BZ, TGF-Bii} have different func-
a
tions. For example, TGF—fll activity is greatest with scar
tissue formation during wound healing, and TGF-B3 is
active during fetal tendon formation. Experimental stud-
ies that manipulated these growth factors with exogenous
application of TGF-fll and TSP-[53 in a rat rotator cuff
flrdtopaedic Knowledge Update: Sports Medicine 5
repair model found that administration of TGF-flS im-
proved the mechanical properties and histologic appear-
ance of the healing rotator cuff better than TGF-jill.“1
After TGP-Bl was administered, with suppression of
TGF—BE and ”HEP-[33, the cross-sectional thickness of
the rotator cuff increased. This thickness predominantly
represented mechanically inferior scar tissue, however. In
the same rat rotator cuff model, application of TGF—flfl
and an osteoconductive calcium-phosphate matrix led
to significant improvement in the strength of the repair
at 4 weeks, with favorable histologic appearance and an
improved ratio of type I to type III collagen.“
The FGF family of polypeptides has an affinity for hep-
arin-binding sites. The role of FGFs in soft—tissue healing
is primarily related to their contribution to angiogenesis,
in which they stimulate division of capillary endothelial
cells.11+“” FGF—1 and PEP—2 are prevalent in adult tissue.
Two studies of the effect of exogenous application of
FGF-2 in a rat rotator cuff model found better repair
strength in the treatment group than in the control group,
although in one study the effect was maintained for only 6
WEElCS.“'“ Similar results were found with the application
of basic FGF for the treatment of patellar tendon defects
in rats and flexor tendon injuries in chickensdft‘” FGF—Z
also has been used in cartilage regeneration. Exogenous
administration in a mouse model led to a reduction in
osteoarthritis, but administration in a mouse knockout
model led to accelerated osteoarthritis.” Caution was
recommended because large doses of exogenous FGF—Z
upregulated MMP activity and accelerated the progress
of arthritis.
The BMPs are a group of proteins constituting part
of the TGF superfamily that regulates bone, tendon, and
cartilage formation. The many BMP subtypes have been
widely studied because of their distinctly different regula-
tory effects. EMF—12 and EMF—13 have a regulatory effect
on new tendon formation. A study of the effects of EMP-
12 applied in a sheep rotator cuff repair model found
that treatment led to improved mechanical strength and
an improved histologic appearance at the tendon-bone
interface, with organized collagen fibrils. An investiga-
tion of the effect of EMF—13 in a rat rotator cuff model
found no notable differences in histologic appearance or
biomechanical testing.43 A more recent study, again using
a rat rotator cuff repair model, tested EMF—13 used in
isolation and with PEP. fin histologic analysis, EMF-13
was found to increase the ultimate load to failure as well
as the amount of type III collagen."
Despite preclinical evidence suggesting clinical efficacy
of growth factors in the treatment of various conditions,
clinical evidence is lacking, largely because of regulatory
restrictions. Further preclinical studies are necessary to
El 1016 American AcadMy of Cirrhopaedic Surgeons

irrefutably demonstrate the efficacy of growth factors and
establish a basis for approval of clinical studies.
Cellular Therapyr
In addition to the gradual process of inflammation, repair,
and remodeling, soft-tissue healing is often limited by
the inadequate availability of native differentiated cells
and tissues. The result can be an inflammatory process
that leaves reactive scar tissue at the site of injury. MSG
therapy is thought to have potential for improving the
process. MSCs are regenerative cells capable of reparative
healing; local paracrine activity, secrenon of necessary
growth factors, and attraction of additional cells lead to
improved healing and restoration of native tissue organi-
zation. lviSCs can be isolated from bone marrow, adipose
tissue, synovial tissue, or periosteum. MSCs are useful
in a multitude of areas; they maintain their multipotent
status and, depending on their environmental cues, are
able to differentiate into phenotypes including osteocytes,
adipocytes, and chondrocytes. Despite tremendous inter-
est and in vitro research activity, there is limited clinical
evidence to support the use of MSCs in spurts medicine.
Information is lacking on the number of cells required
for a positive treatment effect. One study found that a
relatively high concentration of progenitor cells produced
a correspondingly greater clinical effect, as shown by
improved healing rates when tibial nonunion was treated
with a relatively high concentration of l'IvISfls.ml The yield
of true pluripotent MSCs isolated from bone marrow
aspirate is low, although it varies depending on the site
from which the aspirate was drawn. A higher concentra-
tion was identified in iliac crest aspirates than in tibial or
calcaneal aspirates}l Commercial systems can produce
a bone marrow aspirate concentrate, but further study is
necessary to determine the cell concentrations required
to obtain a beneficial treatment effect in different tissues
before widespread use can be recommended.
Stem cell use is limited not only by the lack of clinical
evidence but also by the regulatory activity of the US FDA.
Despite significant interest in the possible usefulness of
stem cells in sports medicine, the US FDA allows only
homologous use and limits the physical manipulation
of stem cells. For example, isolated bone marrow-de-
rived cells cannot be expanded in culture before use. Cell
preconditioning is not allowed by the US FDA, despite
evidence from in vitro studies that preconditioned cells
confer a greater benefit than aspirate~concentrated cells.“
Stem Cells in Tendinopathy
Several preclinical studies found positive effects when
MSCs derived from multiple sources were used in the
El Ifllti American Academy of Drthopaedic Surgeons
Chapter 3?: Current Applications of Drthobiologic Agents
treatment of tendinopathies in animal models. The rel-
atively few clinical studies were done in Europe and
involved isolation and amplification of skin-derived
tenocytes, which are restricted in the United States?“
These studies found positive effects in pain reduction
and functional improvement when skin-derived fibroblast
cells were used for treating patellar tendinopathy, lateral
epicondylitis, or Achilles tendinosis. The stem cells were
administered in conjunction with a plasma centrifugate,
which may have affected interpretation of the clinical
results. The clinical evidence is insufficient to support the
routine use of stem cells in the treatment of tendinopathy.
Stem Cells in Rotator Cuff Repair
There is little clinical evidence to support the use of MSCs
in rotator cuff repairs. Stem cells can be aspirated from the
iliac crest or from the proximal humerus during arthro-
scopic rotator cuff repair, but only a few small studies
have found a beneficial effect from their use. Dne study
investigated the effect of adding autologous bone mar-
row—derived MSCs obtained from an iliac crest aspirate
to a standard rotator cuff repair involving one to three
tendons.” All 14 patients had MRI-demonstrated tendon
integrity at 11-month follow~up, with satisfactory clinical
outcomes {UCLA score}; there was no control group.
The researchers concluded that the use of bone marrow-
derived MSCs offered a potential beneficial effect. In
another study, all patients who received an iliac crest
aspirate concentrate of bone ma rrow-derived MSCs with
a standard repair of an isolated supraspinatus tear had
healing on ultrasound and MRI at 6-month follow-up,
compared with two-thirds of patients who received the
standard repair alone.5‘5 The treatment effect was main-
tained at 2-year follow-up, when 3?% of patients in the
treatment group and only 44% of patients in the control
group had an intact rotator cuff on ultrasound and MRI.
A relationship was identified between tendon healing and
the number of MSCs in the aspirate concentrate; higher
failure rates were correlated with lower concentrations of
MSCs.” This study did not report clinical outcome mea-
F!"
sures but did provide radiographic evidence to support 5
the use of MSCs in rotator cuff repair. Further study is iii
‘1
necessary to determine the associated clinical outcome. 11—!
:
-I'I'
o
1:
Stem Cells in |Itihondral Resurfacing H
It remains difficult to stimulate healing with appropri- 5'
'9.
ate tissue regeneration in chondral iniuries. Attention I'll
has focused on the use of stem cells to allow regenera-
tive cartilaginous healing as an expansion of the micro-
fracture theory first proposed by Steadman, in which
local growth factors and MSCs form a “super clot” that
allows regenerative healing-.1“i Early preclinical studies
Drthopaedic Knowledge Update: Sports Medicine .5
 Section ti: Miscellaneous Topics
and case reports found improvement in healing when
stem cells were used in chondral defects of rabbit knees
and human patellae.53'55' A clinical study investigated the
use of l'vISCs in treating chondral injuries of the medial
compartment of the knee, in conjunction with a high
tibial osteotomy.“ Stem cells were obtained from bone
marrow aspirate, cultured, and embedded in a collagen
gel that was delivered into the defect and secured with a
periosteal patch. At 42-week follow-up, arthroscopic and
histologic grading of the medial compartment in patients
who received an MSG injection showed complete filling
of the defects with metachromasia present. However,
the clinical outcomes showed nu statistically significant
differences based on treatment with MSC injection.“ A
clinical study of the treatment of osteochondral defects of
the distal femur compared the use of MSCs with the use
of autologous chondrocyte implantation, both of which
were inserted in a cell sheet secured under a periosteal
patch. Patients in both groups had improvement, with no
statistically significant differences. The researchers con—
cluded that the use of MSCs was efficacious for treating
chondral injuries, and that in comparison with autologous
choudrocyte implantation MSCs offered lower surgical
morbidity and a single~stage procedure!"1 Clinical and
radiographic results were reported 3 years after focal
osteochondtal defects were treated with a single—stage
knee arthroscopy with the use of iliac crest aspirate and
the subsequent concentration, preparation, and delivery
of a bone marrow-derived MSG—laden collagen mem—
brane.“ Improved IKDC scores and regenerative healing
on imaging studies led the researchers to conclude that
this procedure represented a viable option for treating
osteochondral lesions of the knee.
Although these preliminary results show potential for
using MSCs in the treatment of choud ral injuries, further
studies are required to determine the optimal delivery
method, and long-term clinical follow-up is needed to
ensure that the treatment effect is maintained.
Stem Cells in Dsteoarthr'rtis
LEI
.E
3 Unly limited clinical evidence is available to support stem
cell use in the treatment of osteoarthritis. The use of
'—
U'l
J
o
e:l: infrapatellar fat pad-derived MSCs was investigated in
E the treatment of knee osteoarth ritis.“ The fat pad sample
E
U was harvested during knee arthroscopy, and the MSCs
were concentrated, combined with ll} mL of PRP, and
IE
E
injected into the knee on the same day. Lysholm, VHS, and
a
WUMAC scores improved, as did the global MRI rating
for the knee. The study did not include a control group,
and the earlier arthroscopic débridement of the patients“
knees could have clouded the treatment effect. In addi—
tion, the administration of the MSCs with PEP creates
flrdiopaedie Knowledge Update: Sports Medicine 5
difficulty in discerning which agent led to the improve-
ment. A second study by the same researchers reported
on the second-look characteristics of isolated chondral
defects in arthritic knees treated with l'vISC injection us-
ing a different delivery method.“ Adipose—derived MSCs
from buttock tissue were delivered in a synovial MSG sus-
pension, which was injected onto the defect and allowed
to adhere for lllI minutes before the knee was moved. The
patients who underwent second-look arthroscopy had
significant improvement in outcome measures [IKDC,
Tegner scores}, but extensive irregularity remained in the
appearance of the regenerated cartilage, as determined
using the International Cartilage Repair Society clas-
sification. A subsequent study by the same researchers
added a group of patients treated using adipose-derived
MSCs with fibrin glue as a carrier. During subsequent
second-look arthroscopy, this method of delivery was
found to improve the intra-articular appearance of the de-
fect, compared with the earlier methodfi5 Although these
results are encouraging, ongoing study of the method of
delivery and long-term clinical outcomes is needed.
Stem Cells in Meniscal Repair
Despite an abundance of preclinical evidence showing the
positive effect of stem cells in the treatment of meniscal
lesions, there is minimal evidence to support its clinical
use. A novel clinical technique for meniscal repair used
a collagen matrix incorporated into a suture repair of
the meniscus, followed by injection of bone marrow-
derived stem cells; effectively, the collagen matrix was
used as a scaffold for delivering the stem cells to the
site of injury.lils This technique was used in 31'} patients
and, based on symptoms at 25-year follow-up, was
considered successful in I? [90%]. There was no imag-
ing to assess meniscal healing. Materials other than a
collagen matrix could be used as scaffolds for stem cells
in the treatment of meniscal lesions, but further study is
necessary.
Tissue Therapy: Scaffolds
Scaffolds are collagen-rich extracellular matrixes derived.
from human or animal dermis or submucosal intestinef‘in
scaffold often is required for delivery of PRP or stem cells
to the intended area of treatment. Scaffolds also can be
used independently to augment soft-tissue healing, with
the extracellular matrix providing immediate mechanical
strength in the transient period of weakness during the
healing phase after tendon or ligament repair. The use
of scaffolds is limited by the immune response they can
induce, their rate of degradation, and the overall biome-
chanical strength they confer to the local tissue.“
El ll] 16 American AcadMy of Urthopaedic Surgeons

Scaffolds are broadly classified as biologic or synthet-
ic. Biologic scaffolds are thought to offer greater benefit
than synthetic scaffolds because their natural composition
allows better remodeling.“ Animal-derived products are
regulated by the US FDA. The cellular response and host
response to the scaffold depends on its composition and
the extent of chemical cross-linking; non-cross-linked
scaffolds are rapidly remodeled, whereas cross-linked
scaffolds undergo slower remodeling and incorporation
into the host tissue!”I Degradation of the scaffold is opti-
mally balanced by local tissue regeneration to prevent any
transient periods of weakened structural integrity during
the healing process. Synthetic scaffolds are composed of
chemical compounds, and they attempt to simulate native
extracellular matrices to provide immediate mechanical
strength to the adjacent local tissue while allowing cellular
adhesion, differentiation, and proliferation.“ The advan—
tages of using a synthetic scaffold rather than a biologic
scaffold are a potentially lower infection rate, a lower
irnmu nogcnic response, a more consistent manufacturing
process, and greater availability. The rate of degradation
depends on the chemical composition of the scaffold, as
it does with a biologic scaffold. Poly—L—lactic acid and
polylactide-co-glycolide are among the more commonly
used synthetic scaffolds.
The two most common uses for scaffolds in sports
medicine are supported by preclinical and clinical evi-
dence. In rotator cuff repair augmentation, the scaffold
itself contributes mechanical strength during the healing
process. In cartilage regeneration with cellular engineer-
ing, the scaffold essentially is a carrier for chondrocytes,
MSCs, PEP, or other growth factors. Early clinical studies
of rotator cuff augmentation using porcine small intestine
mucosal patches had mixed results ranging from high
failure rates and inflammatory reactions to improved
outcomes on Constant and patient satisfaction scores with
correlated MRI findingsfiim More recent studies found
that the use of an acellular human dermal matrix allograft
to augment a two-tendon rotator cuff tear {larger than
3 cm} led to statistically significant improvements in Con—
stant and UCLA scores. There was a marked difference
in tendon continuity between patients in the treated and
control groups {35% or 4fl%, respectively)? A synthetic
scaffold {polycarbonate polyurethane patch] used to aug-
ment rotator cuff repairs led to significant improvements
in range of motion and patient—reported outcomes {Amer-
ican Shoulder and Elbow Surgeons, UCLA, Simple Shoul-
der Test scores}. The retear rate was only lfl’fféf-f"2
Synthetic biomimetic scaffolds with three layers sim-
ulating the chondral, tidemarlr, and subchondral layers
were used in the treatment of large defects in the knee.”
Patients had improved outcomes (IKDC, Tegner, VAS-
IE! Elllli American Academy of flrrhopaedic Surgeons
|IL'Zlilapter 3?: IIl'.'.'urreut Applications of |lillrthubiologic Agents
Figure 1 A. Chondral lesion of the medial femoral
condyle. B. Medial femoral condyle lesion
after clébridement and application of Neocart
scaffold. [Photos courtesy of Dr. Riley MlliamsJ
pain scores), with radiographically confirmed lesional
filling in ?0% of patients and an intact articular surface
in 53%.
Scaffolds also are used to carry regenerative cells in
cellular engineering. NeoCart {Histogenics} is one such
product that is administered as a collagen matrix scaffold
with autologous chondrocytes {Figure 1}. A randomised
clinical study found that the use of NeoCart led to ex-
cellent results in the treatment of osteochondral defects
of the distal femur, in comparison with microfracture.
Patients treated with NeoCart had significantly better
outcomes (IRENE, EDGE, VHS scores] than those who
were not treated with HeoCart.“
Although the studies appear to provide support for the
use of scaffolds in the treatment of rotator cuff injuries
and osteochondral defects, most are case control or case
studies. Larger, randomized prospective clinical studies
are necessary, with an appropriate-length follow-up.
Systemic Factors
Several systemic factors have been identified as contrib-
uting to the injury healing process, in addition to the
cellular response to injury and its contribution to healing.
The primary focus in recent years has been on the role
of vitamin D in soft-tissue and tendon-bone healing, the
role of MMP inhibitors in the treatment of osteoarthritis,
and the effect of diabetes on soft-tissue and tendon—bone F'."
healing. E
fir
n
E
Vitamin D Deficiency F
5
Vitamin D is a fat-soluble secosteroid that plays an inte- I'D
D
I:
gral part in the homeostasis of calcium and phosphate H'I
_.1
by affecting absorption and secretion in the intestine, El
"E.
kidneys, and skeletal systemJiT-J5 The primary source of
n
”I
vitamin D is ultraviolet light exposure of the skin, where
F—dehydrocholesterol is converted to previtamin D3. Pre-
vitamin D3 is slowly isomerised into vitamin D3, which
travels to the liver and is metabolized into 25—hyclroxy—
vitamin D, which travels to the kidney and is metabolized
Drtbopaedic Knowledge Update: Sports Medicine 5
 Section 5: Miscellaneous Topics
into 1,25-dihydroxyvitamin D; this represents the biologi-
cally active form. Dietary vitamin D is a minor, secondary
component of the daily requirement. Skin production of
vitamin D is affected by geographic location, age, and
skin pigmentation. The process of hydroxylation in the
liver and kidney is regulated by a complex interaction
among calcium, phosphate, and parathyroid hormone.
In addition to regulation of calcium and phosphate ho-
meostasis, vitamin D affects neuromuscular junctions,
inflammatory and immune responses, and gene expres-
sion and regulation of apoptosis.“
Most experts define vitamin D deficiency as a 1,25 —di-
hydroxyvitamin D level of less than 10 ng per mL.”
1ifitamiu D deficiency, or hypovitaminosis D, has been
associated with cardiovascular disease, cancer, diabetes,
and bone fragility. In sports medicine, it has been associ-
ated with decreased athletic performance and muscle
function. Vitamin D is capable of stimulating muscle
metabolism and growth through vitamin D receptors
within muscle. The decrease in the number of these recep-
tors with natural aging, in conjunction with decreasing
muscular function, suggests that a vitamin D deficiency
can contribute to decreasing muscle function and sub—
sequent athletic performancef'f In addition, vitamin D
deficiency is correlated with increasing muscular atrophy,
fatty infiltration, and muscle fibrosis, although most of
these effects are reversible with vitamin D supplementa-
tion. Results from an observational study suggested that
vitamin D deficiency may contribute to the progression
of osteoarthritis, although the causal relationship has not
been well defined.”
A recent study using a rat model investigated the effect
of vitamin D deficiency on rotator cuff healing.” Com-
pared with control rats, vitamin III—deficient rats had
lower load-to-failure rates in early biomechanical testing
and less structural integrity at the bone-tendon interface
on histologic analysis. These results suggest that low vita—
min D levels may adversely affect soft-tissue healing. This
study represents the only preclinical evidence suggesting a
deleterious effect of vitamin D deficiency on tendon-bone
E?
IE
healing, but it should lead to increased attention to the
I—
In effects of vitamin D on soft-tissue healing.
:5
D
IIll
E
J! Matrix Metalloproteinases
E The MMPs are a complex set of sincudependent enzymes
.E
5
LE
that are responsible for maintenance and remodeling of
the extracellular matrix. The l'vil'viPs are involved in nor-
mal activities including embryonal development, soft—
tissue healing after ininry, and remodeling after surgery.
MMPs also are involved in pathologic activities including
tumor growth and development of vascular aneurysmal
disease. In sports medicine, excessive MMP activity has
firthupaedic Knowledge Update: Sports Medicine 5
been related to osteoarthritis, tendinopathy, and rotator
cuff diseasesii'f'Iil
In native tissue, the activity of MMPs is primarily
regulated by tissue inhibitors that control the balance
between degradative and reparative processes. Evidence
exists that in certain pathologic processes, such as rotator
cuff degeneration or tearing, this balance is lost, with a
resulting increase in MMP activity and decrease in levels
of tissue inhibitors of MMPs.” Agents that act as MMP
inhibitors may be able to reverse some of these effects
or slow the degradative processes driven by the Ml'vIPs.
PRP and EMF—T are some of the substances that have
been shown to inhibit MMP activity in the treatment
of osteoarthritis or chondral defects.” In two separate
rat-model studies, local administration of the MMP in-
hibitors n-l-macroglobulin and doxycycline after surgi-
cal rotator cuff detachment and repair led to significant
improvement in collagen organisation at the tendon-bone
interface. However, biomechanical testing did not detect
a significant maintained effect on failure strength at 4
weeks.i'9*3f'
The use of MMP inhibitors represents a potential
means of restoring the native inhibitory processes to
prevent ongoing degradative changes, but further study
is necessary to determine the benefits beyond histologic
improvement in the healing response. Preclinical and clin-
ical studies are needed to define the indications for 141t
inhibitors in the treatment of sports medicine pathology.
Diabetes Mellitus
Diabetes mellitus causes metabolic changes including
glycosylation of proteins, microvascular abnormalities,
and abnormal collagen accumulation, and it is strongly
associated with vascular and neuropathic disease. In
addition, the disease is related to mnscnloskeletal con-
ditions such as adhesive capsulitis, tendinopathy, and
rotator cuff tearing.“ An observational study of rotator
cuff characteristics and injury patterns in patients with
diabetes and age-matched control subjects found that
those with diabetes had significant tendon thickening as
well as significantly higher rates of degenerative change
in the rotator cuff {43% compared with 2fl%} and biceps
tendon (RTE: compared with 3%).“
A review of outcomes of arthroscopic rotator cuff re-
pair in patients with and without diabetes found less
Constant score improvement in those with diabetes {from
49.2 to 60.3] than in those without diabetes [from 46.4
to 55.2}.33 Further analysis of the Constant score revealed
that the patients with diabetes had more limitation in
postsurgical range of motion, specifically forward flexion
{15'3“ compared with 15?“) and external rotation {40“
compared with 51"}, than those without diabetes.
fl ants American Academy of Orthopaedic Surgeons

A rat study found that a persistent state of hyper-
glycemia has a negative effect on tendon-bone healing
in rotator cuff repairs.1t Diabetes was induced with an
intraperitoneal injection of streptoaotocin and confirmed
by two glucose tolerance tests and hemoglobin Ale lev-
els. In comparison with the control animals, those with
diabetes were found to have less fibrocartilage and less
well-organized collagen at the repair site, and they had
a significantly reduced ultimate load to failure at 1 and
2 weeks.
These studies show the adverse effect that diabetes has
on soft—tissue healing and surgical outcomes, particularly
for tendon-bone healing. Patients should be encouraged to
achieve appropriate glycemic control both as a preventive
health measure and a potential factor in postsurgical re-
covery. Clinical study is necessary to determine whether
glycemic control can improve outcomes after treatment
of sports-related iniuries.
flrthobiologic agents offer the potential to improve or
expedite healing and improve outcomes after nonsurgical
or surgical treatment of a variety of musculosleeletal inju-
ries. A significant amount of preclinical research has been
conducted, but clinical research with improved meth—
odology, including standardization of biologic adjuvant
preparation and method of delivEry, is required before
appropriate clinical indications can be established.
Key Study Points
1* Drthohiologics, including PRP, mesenchymal
stem cells, and tissue scaffolds, represent an est-
citing potential adjunct to traditional treatment of
musculoskeletal injuries and sport—related pathol~
ogy, although clinical data are currently lacking.
l Careful review of available literature, with ongoing
clinical studies to further assess the efficacy of these
agents should be performed prior to widespread
utilisation.
Annotated References
1. Mars: RE: Platelet-rich plasma: Evidence to support
its use. } Dre! Mexiffofec San-g 2flfl4;62{4}:439-496.
Medline D01
2. Sheth Li, Simunovic bl, Klein G, et al: Efficacy of autolo-
gous platelet-rich plasma use for orthopaedic indications:
IE! tots American Academy of flrthopaedic Surgeons
|lilltapter 3?: lIl'Jurrent Applications of |lillrtllobiologie Agents
A meta-analysis. ,' Bone joint Snrg Arts 2fl11;94{4}:193-
30?. Medline DUI
This meta—analysis reviewed the usefulness of autologous
blood concentrates in the treatment of orthopaedic bone
and soft-tissue injuries. There are no clear indications for
use because of variability in study protocols and concen-
trate preparation. Level of evidence: IL
. Poster TE, Puskas EL, Mandelbaum ER, Gerhardt MB,
Rodeo SA: Platelet-rich plasma: From basic science to
clinical applications. Arts} Sports Med lflfl9;3?{11}:2259-
EITE. Medline D0]
The basic science of PEP was reviewed, with clinical ap-
plications in orthopaedic sports medicine, human studies
using PEP, the use of PRP in sports, and its regulation by
antidoping agencies.
. Hsu WK, Mishra A, Rodeo SR, et al: Platelet-rich
plasma in orthopaedic applications: Evidence-based rec-
ommendations for treatment. I Am Aced tbop 5mg
2fl13;21{12}:?39-?4E.Medline DUI
The preparation and composition of PEP was reviewed
with its current clinical applications and supporting
evidence.
. Hall lP, Band PA, Meislin lit], Jasrawi LM, Cardone
DA: Platelet-rich plasma: ICurrent concepts and appli-
cation in sports medicine. ,7 Ans Aco‘d' Grtbop Strrg
ZIJ fl951?{lflj:fifl2—Eflfl. Medline
The composition and clinical applications of PEP with
available evidence were reviewed.
Derwin FLA, Hovacevic D, Kim lid-S, Ricchetti ET: Biologic
augmentation of rotator cuff healing, in Nicholson GP, ed:
UKU: Sboufrfer and Efbottr 4. Rosemont, IL, American
Academy of Drthopaedic Surgeons, 2fl13, pp 31—44.
Available tissue-engineering strategies were reviewed as
applied in the treatment of rotator cuff injuries. PEP,
growth factors, and scaffolds were discussed with rele-
vant clinical evidence.
. Li G-Y, Yin J-M, Ding H, Jia Willi-T, Zhang C- Q: Efficacy
of leukocyte- and platelet-rich plasma gel {L-PRP gel} in
treating osteomyelitis in a rabbit model. I Drabop Res
2fl13:31[6}:949-956.Medline BID]
The usefulness of leukocyte-rich PEP was reviewed in the
treatment of osteomyelitis using an animal model.
F'."
E
fir
n
E
. Moojen D], Everts PA, Schure R-M, et al: Antimicrobial F
activity of platelet-leukocyte gel against Staphylococcus 5
I'D
aureus. I Urtbop Res 200 S:26{3}:4fl4 41 0'. Medline DUI D
I:
H'I
_.1
El
. Lopes-Vidriero E, Goulding EA, Simon DA, Sanchez M, "E.
Johnson DH: The use of platelet-rich plasma in arthros-
n
”I
copy and sports medicine: Uptimiaiug the healing environ-
ment. Arthroscopy lfllfl;26[2}:169-1?S. Medline DUI
The composition, contribution to healing, and clinical
application of PEP were reviewed.
Drthopaedic Knowledge Update: Sports Medichie 5
 Sectien 5: Miscellaneous Tepics
ll]. Anitua E, Zalduende MM, Prade E, Alkhraisat MH,
|iCZ'Irive G: Merphegen and preinflammater}r cvteltine re-
lease kinetics frem PEGF-Enderet fibrin scaffelds: Evalu-
atien ef the effect ef leultecvte inclusien. J Biemerf Mater
Res A lfl]5;1fl3l3}:lflll-1UEU. Medline DUI
An in vitre studv analvaed grewth facter—release ltine-
matics frem leultec'vte-free and lenltecvte-rich PEP fi-
brin scaffelds. An increased release ef grewth facters and
preinfla mmater}r cvteltines was identified with inclusien
ef lenlcecvtes.
11. Massecca AD, McCarthy MB, |Ebewaniec DM, et al:
Platelet-rich plasma differs accerding te preparatien
methed and human variabilitv. }' Hens fen-rt Surg Am
2fl12:94l{4}:303-316.Medline 13-01
The differences in qualitative cempesitien ef PEP derived
frem cemmerciallv available separatien svstems were re-
viewed, with identificatien ef significant differences in
cempenent cencentratiens between samples.
12. Ateselt K, Fu FH, Welf ME, et al: Augmentatien ef tenden-
te—bene healing. j Bees jer‘et Serg Am 2D14;96{6}:513-
521. Medline DUI
This review cevers challenges in achieving tenden-bene
healing and related basic science research strategies.
13. de 1Fvies E], 1|lll'eir A, van fichie HT, et al: Platelet-rich plas-
ma iniectien fer chrenic Achilles tendinepathv: A ran—
demieed centrelled trial. IAMA 2P1fl;3fl3{2}:144r149.
Medline DUI
A. randemized centrelled stud}r cempared PEP injectien
and saline injectien in patients whe alse perfermed eccen-
tric exercises fer the treatment ef chrenic Achilles tendi—
nepathv. He significant imprevement in pain and functien
was identified after PEP injectien. Level ef evidence: I.
14. Eanilti N, Willits E, Mehtadi HG, Fung V, Bryant D: A
retrnspective cnmparative studv with histerical centre] te
determine the effectiveness ef platelet-rich plasma as part
ef neneperative treatment ef acute Achilles tenden rup-
ture. .A:1?famaster's-j,r 1314;30i91fll39-1145. Medline DUI
A. retrnspective study.r cempared the effectiveness ef PEP
in the treatment ef nensurgicallv managed acute Achilles
tenden ruptures. Ne significant benefit ef PEP injectien
was identified. Level ef evidence: III.
15. A Hamid M5, l'viehamed Ali ME, 1i’usef A, l|.'.3‘reerge J,
E?
IE
l— Lee LP: Platelet-rich plasma injectiens fer the treatment
u:
:l ef hamstring injuries: A randemised centrelled trial. Am
D
IIll ] Spa-rte MedI 2fl14t4lflfl'lfl4lfl—Z413. Medline DUI
E
J!
E A randemised centrelled stud},r investigated the effect ef
.E a single PEP injectien ceupled with rehabilitatien fer the
5 treatment ef grade 1 hamstring injuries, cempared with
LE
rehabilitatien alene. The additien ef PEP injectien led te
signifies ntl},r lewer pain sceres and earlier return te play.
Level ef evidence: II.
16. Mishra AK, filtrepnilt NV, Edwards SC, et al: Efficacy,r
ef platelet-rich plasma fer chrenic tennis elbew: A deu-
ble—blind, prespective, multicentet, randernired centrelled
firthepaedic Knewledge Update: Sperts Medicine 5
trial ef 230 patients. Ass: 1 Sperts Med 2014;433:463-
4?1. Medline DUI
A randemieed centrelled study evaluated the efficacy,r ef
PEP cembined with drv needling fer the treatment ef
lateral epicendvlitis. There was significant imprevement
en the eutcemes measure in patients treated with PEP at
14-week fellew-up. Level ef evidence: II.
1?. Peerbeems JC, Sluimer J, Eruijn D], Iflesens T: Pesitive
effect ef an autelegens platelet cencentrate in lateral epi-
cendvlitis in a deuble-blind randerniaed centrelled trial:
Platelet-rich plasma versus certicestereid injectien with a
1-year fellew-up. Am ] Sperrs Med 2010;33i2}:255-262.
Medline [II-DI
A randemised centrelled stud}.r cempared the effectiveness
ef PEP and certicestereid injectien in the treatment ef
chrenic lateral epicendvlitis. Patients in the PEP greup had
significantlv better pain sceres and functien than these in
the certicestereid greup. Level ef evidence: I.
13. Chareusset C, Eaeui A, Bellaiche L, Beaver B: Are mul-
tiple platelet—rich plasma injectiens useful fer treatment
ef chrenic patellar tendinepathv in athletes? A pre-
spective studv. Am ] Sperts Med 2fl14;42{4]l:9i}E-911.
Medline DUI
A case stud}F ef PEP in the nensurgical treatment ef
chrenic patellar tendinepathv found that patients had
significant imprevement in svmptems and functien after
three ultraseund-guided injectiens ef PEP, in cempari-
sen with these whe received enlv rehabilitatien. Level ef
evidence: IV.
19. Dragee JL, Wasterlain A5, Braun H], Head KT: Plate-
let-rich plasma as a treatment fer patellar tendinepathv:
A deuble-blind, randemiaed centre] led trial. Arr: ,l .9m
Med Zfll4g4li3}:filfl-filfl. Mcdlinc DUI
A randemised centrelled studv ef eutcemes when patellar
tendinepathv was treated with drv needling, with er with-
eut PEP injectien feund imprevement in eutcemes with
dry needling hut ne apparent benefit ef PEP injectien.
Leml ef evidence: I.
20. Patel 5, Dhillen M5, Aggarwal 5, Marwaha N, Jain
A: Treatment with platelet-rich plasma is mere effec-
tive than placebe fer knee esteearthritis: A prespec-
tive, deuble-blind, randemised trial. Am I Sperts Med
2013:4H2}:35I5-364.Medline DUI
A randemised centrelled Study evaluated the effect ef
PEP in the treatment ef esteearthritis. A single dese ef
1"Illi'fi'f."J-iiltered PEP previded transient imprevement in pain
and eutceme sceres, with dissipatien ef the treatment
effect at 6 menths. Level ef evidence: 1.
21. Weeks KI} III, Dines J5, Eedee 5A, Bedi A: The basic
science behind bielegic augmentatien ef tenden-hene heal-
ing: A scientific review. Instr Cearse Lest 2614;63:443-
450. Medline
A review ef the basic science behind tenden-hene heal-
ing included the relevant grewth facters, hie-engineering
fl lfllfi American Academy ef Cirrhepaedic Surge-ens

strategies used tn augment rntatnr cuff repair, and sup-
pnrting evidence.
21. Malavnlta EA, Gracitelli ME, Ferreira Hetn AA, Assuncan
JH, Bnrdaln-Iindrigues M, de Camargn UP: Platelet-rich
plasma in rntatnr cuff repair: A prnspective randnm-
ized study. Am I Sparta Med 2fl14;42{1fl}:2445a2454.
Medline DUI
A randnmised cnntrnlled study investigated the effect nf
PRP in rntatnr cuff repair. Ne demnustrable benefit was
fnund when PRP was added tn the existing cuff repair
cnnstruct. Level nf evidence: I.
23. Chatnusset C, Zanui A, Bellai'che L, Piterman M: Dnes
autnlngnus leukncyte-platelet—rich plasma imprnve ten-
dnn healing in arthrnscnpic repair nf large nr massive
rntatnr cuff tears? Artbrnsenpy 2DI4;3fl{4l:423-435.
Medline DUI
A case cnntrnl study reviewed the effect ef leukncyte—rich
PRP injectinns in the treatment nf rntatnr cuff repairs,
cnmpared with rehabilitatinn alcl-ne. Ne: benefit was fnund
in quality nf tendnn repair, tetearing rates, nr functinnal
nutcnme. Level nf evidence: III.
14. Rnden SA, Delns D, Williams R], Adler ES, Pearle A,
Warren RF: The effect nf platelet-rich fibrin matrix en
rntatnr cuff tendnn healing: A prnspective, randc-mised
clinical study. Am I Spurts Med lfl]2;4fl{6]:1234-1141.
Medline DUI
A randnmised clinical study assessed the efficacy nf plate—
let-rich fibrin matrix en rntatnr cuff repair, cnmpared
with rehabilitatinn alnne. Ne demc-nstrable effect nf PILF
applicatinn was fnund nn tendnn healing, vascularity, nr
functinn. Level nf evidence: II.
25. In CH, Shin J5, Lee TU, et al: Platelet-rich plasma fnr
arthrnscnpie repair nf large tn massive rntatnr cuff tears: A
randnmiaed, single-blind, parallel-grnup trial. An: I Spurts
Med ID13:41{101:224D—124fi. Medline DUI
A randnmised cnntrnlled study assessed the efficacy nf
PRP in the treatment nf rntatnr cuff repairs. PRP applica-
tinn was found tn significantly imprnve structural prnper-
ties, with lnwer tetearing rates and a larger crnss-sectinnal
area, althnugh nn clinical imprnvement was nnted. Level
nf evidence: I.
26. Ehahal J, Van Thiel GS, Mall N, et al: The rnle nf plate-
let-rich plasma in arthrnscnpic rntatnr cuff repair: A sys-
tematic review with quantitative synthesis. Arthrnscnpy
lflll;l${11}:1?13—1?2?.Medline no:
A system atie review nf the efficacy nf PEP in rntatnr cuff
healing cnneluded that PEP dnes nnt appear tn have an
effect nn tetearing rates nr patient-reperted nutcnmes
when added tn arthrnscnpic rntatnr cuff repair. Level nf
evidence: III.
3?. Zhu Y, Yuan M, Meng HY, et al: Basic science and clinical
applicatinn nf platelet-rich plasma fnr cartilage defects
and nstenarthritis: A review. Ustenartfrrftis Cartilage
1013;11{11}:161?—163?.Medline DUI
IE: Eillfi American Academy nf Urthnpaedic Surgenns
|IL'ilIapter 3?: Uiureut Applicalinns nf Urtllnbinlngic Agents
A review nf the basic science behind PRP preparatinn
as well as the binlngic mechanism nf actinn and clinical
applicatinn fnr its use in treating cartilage defects and
nstenarthritis.
23. Fnrtier LA, Barker JU, Strauss E], McCatrel TM, Unle E]:
The rule nf grnwth factnrs in cartilage repair. Elie: Urtfanp
Reins Res 1-31 1;459[Ifl}:1?fl6-2T15. Medline DUI
A systematic review nf the effect nf grnwth factnrs nn
cartilage repair fnund prnmising results, but further re-
search is needed befnte rnutine use can be recnmmended.
25'. Tuan RS, Chen AF, Klatt EA: Cartilage regeneratinn. I An:
Acnd Urtfrnp 3mg 1013:21f5}:3fl3-311. Medline DUI
The basic science nf cartilage regeneratinn and bin-engi-
neering strategies aimed at imprnving this prncess were
reviewed.
30. Mei-Dan U, Carmnnt MR, Laver L, Mann G, Maffulli
N, Nyslta M: Platelet-rich plasma nr hyalurnnate in the
management nf nstenchnndral lesinns nf the talus. An:
} Spnrts Med 1012;4D{3}:534—541. Medline DUI
A randnmised cnntrnlled study cnmpared PRP and hyal-
urnnie acid injectinns fer the treatment nf nstenchnnd ral
lesinns nf the talus. Enth injectinns led tn imprnvement in
pain and functinn, but PEP nutcnmes were significantly
better. Level nf evidence: II.
31. Siclari A, Mascarn U, lGentili C, Cancedda R, Enux E: A
sell-free scaffnld-based cartilage repair prnvides imprnved
functinn hyaline-like repair at nne year. Elie: Urtfrnp Refat
Res lOIl;4?D{3}:91fl—919. Medline DUI
A case study reperted the nutcnmes nf patients with artic-
ular cartilage defects treated with pnly-gamma glutamic
acid—hyalurnnic acid scaffnld immersed in PEP. Clinical
nutcnmes and histnlngic analysis nf the regenerative tissue
reflected treatment benefit. Level nf evidence: IV.
31. Dhnllander AA, De Heve F, Almqvist KP, et al: Autnln—
gnus matrix-induced chnndrngenesis cnmbined with plate-
let-rich plasma gel: Technical descriptinn and a five pilnt
patients repntt. Knee Snrg Sports Tranmatnl Artbrnsc
EDIIflEHIfiSfi-Sdl. Medlinc DUI
A pilnt study was repnrted with a technical descriptinn
nf autnlngnus matrix-induced chnndrngenesis in the treat-
ment nf chnndral patellar lesinns nf the knee. Level nf
evidence: IV. F'."
E
fir
33. Filardn G, Knn E, Ruff-i A, Di Matter: B, Merli ML, n
E
Marcacei M: Platelet—rich plasma: Why intra—articulari' F
A systematic review nf preclinical studies and clinical
5
I'D
D
evidence nn PEP fnr jnint degeneratinn. Knee Snrg Spnrts I:
H'I
Traumatic-f Arternsc [published nnline Nnvember 26, _.1
U
2fl13]. Medline DUI "E.
n
”I
A systematic review nf intra-articular PRP injectinns fnr
the treatment nf arthritis suggested nverall suppnrt, al-
thnugh the duratinn nf the pnsttreatment clinical imprnve-
ment was limited. Level nf evidence: IV.
Urtbnpaedic Knnwledge Update: Spnrts Medicine 5
 Seetien 5: Miseellaneeus Tepics
34. Cerea F, Carni S, Careangiu A, et al: IL'Ieniparisen between
hyalurenic acid and platelet-rich plasma, infra-articular
infiltratien in the treatment ef genarthresis. Am I Spur-ts
Med2fl11;4fl{12}:2322-1321Medline ner
A randeniised centrelled study cempared intra—articular
PEP and hyalurenic aeid injectinns in the treatment ef
genarthresis. Patients treated with PEP had significantly
better eutcemes than these treated with hyalurenic acid.
Level ef evidence: I.
35. Ken E, Mandelbauni B, Euda E, et al: Platelet-rich
plasma intra-articular injectien versus hyalurenic
acid viscesupplementatien as treatments fer cartilage
pathelngy: Frem early degeneratinn te nsteearthritis.
Artbrescepy 2011;E?{11}:149fl-15fl1. Medline DUI
A case centrel study reperted en eutcemes ef PEP and
hyalurenic acid injectiens fer esteearthritis. PEP iniec-
tiens had mere and lenger efficacy than hyalurenic acid
inieetiens, with reduced pain and impreved functien. Level
ef evidence: II.
3h". Henning CE, Lynch MA, Yeareut HM, Vequist 5W, Stall-
baumer E], Decker EA: Arthrescepic meniscal repair
using an exegeneus fibrin clet. Effie Un‘ibep Eel'at Res
1990;252:6431. Medline
3?. Zellner J, Mueller I'vi, Berner A, et al: Eele ef mesenchymal
stem cells in tissue engineering ef meniscus. I Biemed
Mater Res A 2010:94i4ifllifl-1 161. Medline
An in vitre study {if the effect ef stem cells in the repair
nf meniscal defects feund fibrecartilageulike repair tissue
14 days after applicatien, suggesting a centributien te
repair quality.
33. Ishida K, Kureda E, Miwa M, et al: The regenerative ef-
fects ef platelet-rich plasma en meniscal cells in vitre and
its in vive applicatien with biedegradab-le gelatin hydregel.
Tissue Eng 200?;13I5lflli33-1111. Medline DUI
39. Pujel N, Salle De Chen E, Eeisreneult P, Beaufils P:
Platelet-rich plasma fer epen meniscal repair in yeung
patients: Any benefit? Knee Sari-g Spur-ts Tianmatel Ar-
trflSE 2fl15;23{1]:51-53. Medline DUI
A case centrel study ef the efficacy ef PEP in meniscal
repair healing cencluded that epen repair ef the meniscal
injury impreved eutcemes and that PEP added tn the
repair site did net significantly alter the nutceme. Level
3 nf evidence: III.
IE
I—
us
:5
U
IIll
4U. Gulntta LV, Enden 5A: Grnwth factnrs fer retater cuff
E
J!
repair. Clive Sperts Med 2U09flfli1}:13—23. l'viedline DUI
E
The grewth facters centributing te the healing precess
.E
5 after repair ef a tern retater cuff were described.
LE
41. Kevacevic D, Guletta LV, Ting L, Ehteshami JR, Deng
E—H, Eedee 5A: tDGF-BB premetes early healing in
a rat retater cuff repair medel. Cfffl Uri‘bep Refer Ees
[published enline ahead ef print Ucteber 23, 1014].
Medline DU]
Urthnpaedic Knewledge Update: Sperts Main 5
An in vitre study ef the efficacy ef tDGF-EB in the treat-
ment ef retater cuff tears in a rat medel feund impreved
cellular preliferatien and angiegenesis brut ne biemechan-
ical imprevement in the healing tissue.
41. Eedi A, I'viaalt T, Walsh C, et al: Uytekines in retater
cuff degeneratien and repair. 1 Shenider Effiew Sang
lflllgliiliflifl-EEEMEdIinE DUI
The cytekines invelved in retater cuff degeneratien and
repair were described.
43. Kevacevic D, Fee: A], Hedi A, et al: Calcium-phesphate
matrix with er witheut TGF—Bd impreves tenden-bene
healing after retater cuff repair. Am J" Sperts Med
2011:39{4}:311-319.Med|ine DUI
A centrelled laberatery study investigated the effect {if
TGFufld applicatien in a rat retater cuff repair medel.
Tepical applicatien led te increased fibrecartilage ferma—
rim with impreved cellagen erganiaatien and tenden-bene
healing, with impreved biemechanical strength.
44. Ide J, Kikultawa E, Hirese J, Iyarna K, Sakamnte H,
Miauta H: The effects ef fibreblast grewth facter-l en
retater cuff recenstructien with acellular dermal matrix
grafts. Artbrescepy lflflflrlfi{61:6 IDS-616. Medline DUI
A centrelled laberatery study investigated the effect ef
FGF applicatien in a rat retater cuff repair medel. Tepical
applicatien led te accelerated tenden remedeling with
impreved biemechanical strength.
45. Ide J, Kikultawa K, Hirese J, et al: The effect ef a le—
cal applicatien ef fibreblast grewth facter-l en tenden-
te-bene remedeling in rats with acute injury and repair
ef the supraspinatus tenden. ] Sbenfder Elbert: Sang
lflflflflflldlflfill-SSS.Medliue DUI
A centrelled laberatery study ef the effect ef tepical FGF
applicatien in a rat retater cuff repair medel feund accel-
erated tenden remedeling and impreved hinmechanical
strength.
46. Chan HP, Fu 5, Qin L, Lee K, Eelf CG, Chan K: Effects
ef basic fibreblast grewth facter [bFGF] en early stages ef
tenden healing: A rat patellar tenden medel. Acre Urtbep
Strand lflflflfilfi 1:513-5 13. Medline DUI
4?. Tang JH, Can ‘1', Ehu B, Kin Iii-Q, Wang ET, Lin PT: Ade-
ne—asseciated virus-l-mediated bFGF gene transfer te dig-
ital fleiter tendens significantly increases healing strength:
an in vive study. I Hens Inner 3mg Am 2003:5905 }:1fl?3-
11339. Medline DUI
43. Guletta LV, Kevacevic D, Packer JD, EhteshamiJE, Eedee
5A: Adennviral—mediated gene transfer ef human bene
merphegenetic pretein-IEI dees net impreve retater cuff
healing in a rat medel. Am I Sperrs Med lflll:39i1l:lflfl-
13?. Medline DUI
A centrelled laberatery study ef EMF-13 en rat retater
cuff repair feund ne effect en cartilage fermatien er cel—
lagen fiber erganisatien with tepical applicatien.
U lfllfi American Academy ef Urthepaedic Surge-ens

49'. Lamplot JD, Angeline M, Angeles J, et al: Distinct ef-
fects of platelet-rich plasma and EMP13 on rotator cuff
tendon injury healing in a rat model. Arr: I Sports Med
2D14:41{12]:23T?-233T.Medline DUI
A controlled laboratory study of the effect of EMF-13 on
rat rotator cuff repair found enha nced fihronectin expres—
sion with increased load-to-failure strength. Histologic
improvement was found in retrieved samples.
5D. Hernigou P, Poignard A, Beaujean F, Rouard H: Percuta-
neous autologous hone-marrow grafting for nonunions:
Influence of the number and concentration of progeni-
tor cells. ] Horse Joint Sarg Arr: ZUDS:ST{?}:143fl-l431
Medline DUI
51. Hyer CF, Berle: GE, Bussewitr 3W, Hankins T, Eiegler
HL, Philhin TM: Quantitative assessment of the yield of
ostcohlastic connective tissue progenitors in bone marrow
aspirate from the iliac crest, tibia, and calcaneus. } Barre
joint Sarg Am 2613;95{141:1312-1 316. Medline [ll-DI
Bone marrow aspirates from different locations were
collected and centrifuged to concentrate nucleated cells,
which were plated and grown in culture to identify ostoov
hlastic progenitor cells. Progenitor cells were found tn he
most concentrated in iliac crest aspirates.
52. Clarice AW, Alyas F, Morris T, Robertson C], Bell J, I«Eon-
nell DA: Skin-derived tenocyte-lilte cells for the treatment
of patellar tendinopathy. Arr: j Sports Med lflll:39l[3}:614-
633. Medline DUI
A randomised controlled study of the efficacy of autolo-
gous tenocy te-lilte cells in the treatment of patellar tendi-
nopathy found that patients had significant improvement
in pain and function compared with patients who received
autologous plasma injection. Level of evidence: I.
.53. Connell D, Datir A, Alyas F, Curtis M: Treatment of lat-
eral epicondylin's using shin-derived tenocyte-lilce cells.
Br} Sports Med. 2Ufi9;43{4]:293-293. Medline DUI
A randomised controlled study of the efficacy of autolo-
gous tenocyte-lilte cells in the treatment of lateral epicon-
dylitis found improvement in patient-reported outcome
measures as well as number of tears, neovasculariaation,
and tendon thickness.
54. Dhaid H, Clarke A, Rosenfeld P, Leach C, Connell D:
Skin-derived fihrohlasts for the treatment of refractory
Achilles tendinosis: Preliminary short-term results. I Horse
,l'ofrrt 3mg Arr: 2fl12;94{3}:193-lflfl. Medline DUI
A randomised controlled study of the efficacy of autoloe
gous tenocyte-like cells in the treatment of chronic Achil-
les tendinosis found significant improvement in pain and
function. Level of evidence: I.
5.5. Ellera Gomes JL, da Silva RC, Silla LM, Abreu MR, Pel-
landa R: Conventional. rotator cuff repair complemented
by the aid of mononuclear autologous stem cells. Knee
Surg Sports Traumutof Arthrosc 2612:20f2}:3?3-3T?.
Medline DUI
IE: 2fl16 American Academy of flrthopaedic Surgeons
|IL'IlIaptcr 3?: Current Applications of |lliillrtllcllhiolclgic Agents
A case studyr of arthroscopic rotator cuff repair aug-
mented with autologous hone marrow mononuclear cells
found generally positive radiographic and clinical out-
comes and supported the safety of this technique. Level
of evidence: IV.
.56. Hernigou P, Flouaat Lachaniette CH, Delamhre J, et al:
Biologic augmentation of rotator cuff repair with mesen-
chymal stem cells during arthroscopy improves healing
and prevents further tears: A case-controlled study. Irrt
Drtlrop 2fl14;33[9}:1311—1313. Medline no:
A cohort study comparing the results of rotator cuff repair
augmented with Mfr-Es found significant improvement in
healing outcomes with hone marrow concentrate injection,
as determined using follow-up MRI.
5?. Steadman JR, Rodi-toy WG, Rodrigo J]: Microfracture:
Surgical technique and rehabilitation to treat chondral de-
fects. Clin- Drtbop Relat Res lflflldfifi'l, 5uppl}:53 62-5369.
Medline DUI
53. 1|illi'altitani 5, Goto T, Pineda 5], et al: Mesenchymal cell-
hased repair of large, full-thickness defects of articular
cartilage. ] Horre jofrrt 3mg Arr: 1994:?6H}:5?9-591.
Medline
.59. 1|liti'altitani 5, Mitsuolta T, Nahamura N, Toritsulta 1', Na-
kamura Y, Horihe 5: Autologous hone marrow stromal
cell transplantation for repair of full-thickness articular
cartilage defects in human patellae: Two case reports. Ceff
Transplant Eflfl4;13{5 ltfififi—fiflfl. Medline DUI
6G. Wahitani 5, lmoto K, Yamamoto T, Saito M, Murata N,
Yoneda M: Human autologous culture expanded hone
marrow mesenchymal cell transplantation for repair of
cartilage defects in osteoarthritic knees. Osteoarthritis
Cartffrtge lflfllflflfilflfifi-Eflfi. Medline DUI
61. hleiadnilt H, Hui JH, Feng Choong EP, Tai B-C, Lee EH:
Autologous hone marrow-derived mesenchymal stem cells
versus autologous chondrocyte implantation: An observa-
tional cohort study. Arr: I Sports Med 2910;33ffilflllfl-
1116. Medline DUI
A cohort study of chondral lesions treated with autologous
chondrocyte implantation or hone marrow-derived MSG-s
found improvements after both treatments. Augmentation
with bone marrow—derived MSCs may represent a safe
alternative to autologous chondrocyte implantation. Level
F'."
of evidence: II I.
E
fir
n
62.. Euda R, T'v'annini F, IIaallo M, et a1: Due-step arthro- E
F
scopic technique for the treatment of osteochondral le- 5
HI
sions of the knee with hone-marrow-dcrivcd cells: Three ID
I:
years results. Maseafoskefet Sa-rg lfl]3:9?{2]:14§ -151, H'I
_.1
Medline DDI El
"E.
n
A case study of osteochondral lesions of the ltnee treated ”I
with hone marrow—derived MfiCs delivered to the in-
jury site with a scaffold found significant improvements
in patient outcomes and radiographic appearance of the
lesions. Level of evidence: IV.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 5: Miscellanemls Tupics
1‘53. Keh Y—G, In 5—3, Kwan D—R, et al: I'vlesenchymal stem
cell injectinns imprcve symptums cf knee eaten-arthritis.
Artfrrflacapy 1013;19{4}:?43-?55. Medline DUI
A case study uf cateuchundral lesiuns [if the knee treated
with fat pad—derived MSEs delivered thraugh intra-artic—
ular injectic-n ftmnd significant imprevements in patient
nutccmes and radicgraphic appearance cf the lesicns.
Level c-f evidence: I‘v‘.
64. Kuh YE, Cheri Y], Kwnn DH, Kim Y5: Secund-lccrk
arthrnscapic evaluatian cf cartilage lesians after mesen-
chymal stem cell impla ntatinn in estecarthritic knees. An:
J Sports Med ED14;41{?]:1623-163T. Medline DUI
A case study uf cateuchundral lesiuns cf the knee treated
with fat—derived MSCs iniected intu the defect faund sig—
nifica nt imprc-vements in patient antcnmes and arthrn-
sccpic appearance cf the lesicns. Level uf evidence: IV.
65. Kim T5, Ehei ‘1'], Huh D5, et al: Mesenchymal stem cell
impiantaticn in cstenarthritic knees: Is fibrin glue effec-
tive as a scaffcld? Am } Sparta Med 2fl15g43{1}:1?fi—135.
Medline DD]
A cahurt study cf the efficacy ef MSCs delivered in fi-
hrin glue far the treatment cf chundral defects in arthritic
knees faund significant impruvement in patient-repented
uutccme scares and arthrc-scc-pic grading cf the chundral
lesic-ns. Level of evidence: III.
66. Jacahi M, Jakah RP: Meniscal repair: Enhancement cf-
heaiing pracess, in Beaufils P, 1Fv’erdunk R: The Meniscus.
New Turk, HY, Springer-Verlag, lfllfl , pp 119-135.
Bic-engineering strategies far treatment [if meniscal injuries
were reviewed.
6?. Hussuv S, Dines JS, Ivlurrell GA, Rudeu 5A, Bedi A: Bin—
Iagic augmentatinn cf tenden—terhnne healing: Scaffnlds,
mechanical luad, vitamin D, and diabetes. Instr Ccnrae
Leer 1014;63:451-452. Medline
Biulugic augmentatiun aptiuns fur tendun—hcrne healing
were reviewed.
6'3. Ricchetti ET, Aurara A, Iannutti JP, Derwin EA: Scaffald
devices far ratate-r cuff repair. I Shanider Elbert: Snrg
2fl12;21{2}:251-255.Medline DDI
Scaffold devices for rctatnr cuff repair augmlltatiun and
the hiulugic respcnse and incnrpuratiun nf these devices
3
IE
I— were reviewed.
In
:5
D
Ilil 69. Iannctti JP, Cudsi M], Ewen TW, Derwin K, Cicccnc J,
E
J! Brems J]: Percine small intestine suhmuccsa augmenta-
E titm nf surgical repair uf chrtmic twu-tendcn rctatnr cuff
.E tears: A randumired, cuntrulled trial. ] Bane faint Snrg
5 was correlated with ustenarthritia.
LE Arn Efifl6:33{6}:1233-1244. Medline DUI
F'fl. Eadhe 5P, Lawrence TIvl, Smith FD, Lunn PG: An assess-
ment cf purcine dermal :cenugraft as an augmentaticn graft
in the treatment c-f extensive rctatnr cuff tears. I Shcnfder
Effaunr Snrg 2Dfl3;17[1, Suppllflfifi-SES. Medline DUI
Drthnpaedic Knawledge Update: Sparta Ivledich'ie 5
T1. Barber FA, Burns JP, Deutsch A, Lahhe MR, Litchfield RE:
A prcspective, randcmieed evaluatic-n uf acellular human
dermal matrix augmentaticm fcr arthrcscupic rutatur cuff
repair. Arthraacapy lflllglflflhfi-I 5. Medline DID]
A raudnmiaed centralled study cf the safety and efficacy
cf an acellular human dermal matrix augmentatic-n device
for rutatur cuff repairs fcund imprcved patient-repnrted
cutcumes and luwer retearing rates in treated patients.
Level nf evidence: II.
T2. Encalada-Diaa I, Cale E], IvIacgillivrayJD, et al: Ratatur
cuff repair augmentatinn using a navel pnlycarhcnate
pulyurethane patch: Preliminary results at 12 malnths1r
fullcw-up. } Shunfder Eifratn Snrg 1011;2flf5}:?33-T94.
Medline DC."
A case study cf the efficacy cf a palycarhenate pnlyure-
thane patch fur augmentaticn cf a retatcr cuff repair in
10 patients fuund significant imprcvements in pain and
functinnal nutcame scares. Level nf evidence: IV.
T3. Eerrutu M, Delccrgliana M, de Cara F, et a]: Treatment
cf large knee eaten-chundral lesiens with a hiamimetic
scaffcld: Results nf a multicenter study cf 49 patients at
11-year fclicw-up. Arn I Sparta Med 2014;42{?}:16flT-161?.
Medline DD!
A case study nf treatment nf aster-chundral leainns cf the
knee with a hicmimetic scaffnld faund significant im-
prcvements in patient-reparted c-utccme measures and
high rates uf lesic-nal filling an MRI. Level cf evidence: IV.
T4. Crawfcrd DC, DeBetardinu TM, Williams E] III: Nea-
Cart, an autalngaus cartilage tissue implant, campared
with micrnfracture fer treatment cf distal femaral car-
tilage lesicns: An FDA phase-II prcspective, rand-am-
iaed clinical trial after twc: years. } Bane joint Snrg Ant
2013;54{111:9?9-939. Mcdline DUI
A randc-miaed centre-lied study campared an autnlagaus
cartilage tissue implant with micrcfracture fer the treat-
ment uf chundral lesiuns cf the distal femur. Patients
treated with the implant had superinr clinical autccme
scares at 2-year fullew-up. Leml nf evidence: I.
75. Angeline ME, Gee AD, Shindle M, Warren RF, Radea
SA: The effects crf vitamin D deficiency in athletes. Arn-
Jf Sparta Med lfllS;41(2}:4EI-4Ifi4. Mediinc DUI
The physic-lugic rule uf vitamin D and the patential adverse
effects nf vitamin D deficiency in athletes were reviewed.
T6. Zhang FF, Drihan JB, Ln GH, et al: 1'v'itamin D deficiency
is assaciated with pragressian af knee eatenarthritis.
J Nntr 1D14:144{12}:EDOE-2l]fl3. Medline DDI
An nhservatiunal study fcund that vitamin D deficiency
TT. Angeline ME, Ma Ii, Pascual-Garridc C, et al: Effect uf
diet—induced vitamin D deficiency an rutatc-r cuff heal—
ing in a rat madel. An: I Sparta Med 2D14:42{1}:2?-34.
Medline DD]
D lfllfi American Academy af Drthnpaedic Surge-ans

A cnntrnlled laberatnry study nf the effect ef vitamin D
deficiency in a rat rutatnr cuff repair nindel feund a de-
crease in hie-mechanical strength. with less hene fermatinn
and cullagen fiber crrganisatinn en bistelegic analysis.
7’3. Del Bunnn A, I[Zilliira F, Usti L, Maffulli N: Metallnprci-
teases and tendinepathy. Muscles Ligaments Tendnfls
,7 2013;3{1}:51-5?. Medlinc
The rele af MMPs in the pathephysinlegy ef tendinnpathy
was reviewed.
?9. Eedi A, Fee A], Hnyaceyic D, Deng Iii-H. 1Warren RF, Re-
den SA: Dmtycycline-mediated inhibiticIn nf matrix metal-
lepreteinases imprnyes healing after retater cuff repair.
Am ] Spam Med 2G1fl;33{2}:3l}3-31?. Mcdline DUI
A centrelled labntatary study ef the effect (if lncally ad-
ministered deaycycline in a rat rnratnr cuff repair mndel
fnund imprnyed cellagen fnrmatinn and fiber erganizatinn
crn histcnlcngic analysis, with impreyed lead—te—failure test-
ing at 2 weeks.
3B. Eedi A, Knyaceyic D, Hettrich C, et al: The effect c-f matrix
metallepreteinase inhibitinn en tenden-te-hene healing
in a rntatnr cuff repair model. }' Sbnufder Elbe-w 3mg
lfllfl;19{3l:334-391.Medline D01
a centrcrfled laberatery study ef the effect uf a lecally
delivered MMP inhibiter in a rat retater cuff repair nuidel
IE! lfllfi American Academy bf flrthnpaedic Surgeens
Chapter 3?: lII'Jurreult Applicafinns uf flrthubinlegic Agents
fc-und imprcwed cnllagen fiber formatien and erganitatinn
c-n histe-le-gic analysis.
31. Abate M. Schiayene C, Saliui V: Sane-graphic evalua-
tien ef the sheulder in asymptematic elderly subjects
with diabetes. .3i Muscufnskefet Disnrrf lfllfl;11:2?3.
Medline DD]
An ebseryatienal study compared rntater cuff and biceps
pathelegy in patients with diabetes and central subjects.
The patients with diaberes had higher rates ef degenerative
changes in the rntatnr cuff and biceps.
BE. Clement ND, Hallert A, Macmald I}, Howie C, Mc-
Birnie J: Dcres diabetes affect nutcerne after arthrci-
scepic repair ef the retatar cuff? j Bane faint Surg Br
lfllflflllflhllll-llllMedline DUI
A case centre] study cempa red nutcnrnes after retatnr cuff
repair in patients with at witheut diabetes. These with
diabetes had lewer uutceme scures and physical functiun.
33. Hedi A, Fm: A], Harris PE, er al: Diabetes mellitus impairs
tenden—bc-ne healing after retatnr cuff repair. I Sbnafder'
Elbert: 3mg 201D;19f?}:9?E-933. Medline DID]
A centre-[led laheratnry study ef the effect ef induced di-
abetes in a rat rntatnr cuff repair mndel feund a decrease
in biemechanical strength, with less bane fermatinn and
cellagen fiber c-rganieatien c-n histelegic analysis.
F'."
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n
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n
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Drthepaedic Knnwledge Update: Sperrs Medicine 5
Chapter 33

The Biology and Biomechanics

of Grafts and Implants
F. Alan Barber. MD. FACS

Bielegic grafts are available fer a number ef applicatiens. They are cemmenlg.r used fer ligament recenstructien
and tendnn augmentatien. Allegrafts have a better clinical track recerd with better eutcnmes and fewer adverse
events cempared te senegraft and svnthetic materials. Fer anterier cruciate ligament recnnstructien allegrafts
have preved effective, previding cemparable results te autegrafts witheut the issues ef dener site mnrbiditv and
mere difficult rehabilitatien. Fer patients whe are net aggressive piveting er centact athletes, and whe are elder
than 25 veers, there is nn cencern abnut allegraft use. Allegrafts that are chemically precessed er irradiated de
net perferm as well as deep-freaen, chemical-free, nenirradiated grafts. Acellular dermal matrix allegrafts can
augnent retater cuff tenden healing, especially in tears greater than 3 cm in length and these with the petential
fer peer healing.
As suture ancher designs centinue te develep, the trend is tewa rd biedegradable and plastic anchers centaining
several (usuallyF up tn 3} ultra-high-melecular-weight pnlvethvlene (UHMWPfll-centaining sutures. Evelcts are
cemmenl},r feund at the insertien end ef the ancher facilitating sliding, leaking knet—tving. Screw tvpe anchers
are stranger than ether designs. Gleneid anchers are smaller than retater cuff repair anchers te mere easil'jlr fit
inte the denser smaller gleneid bene. These smaller gleneid anchers de net previde the higher failure leads ef the
larger anchers but are clinicallv apprepriate fer the designed envirenment. Knetless anchers are primarilyr used
fer the lateral rew ef a deuble rew retater cuff repair.
Altheugh several implants are available te assist in arthrescepic meniscal repair, the kev te meniscal repair
healing is a geed bleed supply, the absence ef meniscal degeneratien, and a stable knee. The current all-inside
techniques use a suture—based, self-adjusting meniscal repair device with nenahserbable UHhiIWPE—centaiuiug
suture attached tn pelvether ether keteue anchers and cennected by a pretied, sliding, and self-lacking knet.

Keywerds: binlugy: biemechanics; grafts; implants
mtrndugtifln
lGrafts and implants are cemmenlv used in sperts med-
icine te repair, recenstruct, er augment ligaments, ten-
and characteristics. The surgeen sheuld understand the
bielegv and biemechanics nf grafts and implants as well
as the strengths and weaknesses asseciated with their
surgical applicatiens. This infermatien sheuld affect F'."
preeperative discussiens with the patient, the cheice ef E
surgical applicatien, and the pesteperative rehabilitatien
fir

n
E
dens, and cartilage. The eptiens include autegrafts, pregram. Several grafts and implants are available fer F
5
allegrafts, and devices having different materials, designs, use in the United States as related te treatment ef the an- I'D
D
E
terier cruciate ligament (ACLl, the retater cuff tendens, H'I
.4
sheulder instability, and the meniscus. D
"E.
Dr. Barber er an immediate famiiy member has received
n

”I

reyaities frem DePuy-Miteir; is a member ef a speakers“ hu-

reau er has made paid presentatiens en behaif ef {Seemed Grafts in ACL Hecenstructien
Linvatec and DePuy—Miteit; serves as a paid censuitant te Recenstructien ef the ACL is a cemmen precedure that
CenMed Linvatec and DePuy-Mitek; and has stack er stack censists ef replacing the tern ligament with a graft. Al-
eptiens heici in Jehnsen s Jehnsen. theugh different autegrafts have been used in the past,

fl lflld American Academy ef Drrhepaedic Surgeens Drthepaeclic Knewledge Update: Sperts Medicine 5
 Section 6: Miscellaneous Topics

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Figure 1 Fhotog ra ph sh ovvs a quadriceps ten don graft II-I'I INLllgllllllllllilllllllIllllIIIIIEIIIIIIIIIII'

with a bone plug taken from the patella. Figure 2 Photograph shows a bone—patellar tendon-
bone graft. Cine bone plug {shown on the left}
will be trimmed. flipped back onto the tendon.
and secured by circumferential sutures.
bone-patellar tendon—bone IBPTB), hamstring tendon,
and quadriceps tendon autogra fts currently are the most
commonly used. Allografts from the same sources or ultimate load to failure of 2,352 N {Figure 1}. A BPTB
from other tendons, such as the Achilles tendon, also graft of appropriate size {113' mm long and 4 mm thick]
are often used. has an ultimate load to failure of 2,??? N. In contrast,
Substantially delaying or not performing an ACL re- the ultimate load to failure of a strand of semitendinosus
construction can have consequences, especially in rela- or gracilis tendon is 1,216 hi or 333 M, respectively. The
tively young patients. Although nonsurgical treatment of practice of looping the hamstring tendon creates a dou-
a complete ACL injury should be considered, it is associ— ble—strand, triple—strand, or quadruple—strand graft with
ated with risks, especially in young patients. A risk of strengths of 2,422bl to 4,590 N.
additional intra-articular damage was associated with The manner of inserting the graft into the knee can
nonsurgical treatment or delayed ACL reconstruction in affect how it is secured. Cine concern in using a BPTB
29 patients [mean age at time of injury, 15 years].1 BPTB graft is that excessive length of the tendon portion can
or hamstring tendon autograft reconstruction was per- lead to tunnel-graft mismatch. Rotating the graft 90* can
formed an average 11.6 months after injury. At a mean shorten the graft and increase its strength. If the length of
14.6-year follow-up (range, 10 to 20' years after surgery), the tendon section of a EPTE graft exceeds 50 mm, one
the treated knees were more likely to have osteoarthritic bone plug can be trimmed, flipped back onto the tendon,
changes than the contralateral knees. However, patients’ and secured by circumferential sutures {Figure 2]. This
clinical outcomes and health-related quality-of-lifc scores technique creates a shorter graft that allows outlet fixation
did not differ significantly from those of control subjects. at both the femoral and tibial tunnels.1 Although looping
The Multicenter Orthopaedic Clutcomes Network study a hamstring tendon graft to create a construct with two to
reported that ACL reconstruction is the most cost-effec- four strands will increase the ultimate load to failure, it is
tive treatment of an ACL tear and that it has less societal important that these separate strands be tensioned equally
cost than nonsurgical rehabilitation, especially when the to maximize the graft strength and reduce stretching at
cost of work limitations and reduction in earning ability nonisometric points in the joint range of motion.
are included.I
3
IE

Autografts
p.
In IGraft Biomechanics The type of graft is selected based on the patient‘s age and
:5
DI
U3
The biomechanical properties of graft materials are influ- activity level as well as the preferences of the patient, fam-
E:
J! enced by graft size, graft preparation, donor age, and fix- ily, and surgeon. The calculation of comparative costs is
E ation method. To avoid damage during the healing phase, not straightforward. Although short—term or day-of-sur-
.E
5
d5
the rehabilitation program may be affected by the choice gery costs may decrease if an autograft is used, a complete
of graft. Graft strength should exceed the load-to-failure cost analysis must consider the entire course of treatment.
strength of the native ACL as reported in tests of relatively If the focus is on the insurance provider within the first
young cadaver specimens (average, 2,160 :I: 15? N). The year, the calculation may favor the use of an autograft. If
grafts commonly used for ACL reconstruction exceed the analysis is patient focused and includes out-of-pocket
this target. The average quadriceps tendon graft is 10 mm costs for all physical therapy sessions, medications, and
long {maximum length, 11 cm} and 2 mm thick, with an transportation as well as the cost of time lost from work,

flrdiopaedic Knowledge Update: Sports Mediehte 5 fl 2fl1I5 American Academy of Orthopaedic Surgeons

the use ef an. autegraft may be mere expensive than an
allegraft. If lung-term cests are included in the analysis,
the incidence ef revisien surgery must be censidered. Must
published discussiens de net include these cest censid-
eratiens, hewever.
Grafts harvested frem the patient are the mest cem—
men type ef graft fer ACL recenstructien in high-per-
fermance athletes. The disadvantages ef using autegrafts
include lenger surgical times; dener site merbidity, such
as anterier knee pain, kneeling pain, patellefemeral crep-
itus, anterier knee numbness, patellar fracture, tenden
rupture, er muscle weakness; cesmetic cencerns; and time
lest frem werk er scheel.
Dpiniens differ as re whether a EPTE graft, multi—
ple-strand hamstring tenden graft, er quadriceps tenden
graft is superier. Several systematic reviews ef ra udemited
centrelled studies have attempted te answer this questien.
A Cechrane Database review ef 19 studies evaluated
results in 1,59? yeuug te middle-aged adults and feund
ne statistically significant differences between BPTE and
hamstring tenden grafts in funcrienal assessments ef
return te activity, subjective eutceme measures {Tegner
activity level and Lyshelm knee questiennaire sceres],
and the need fer revisien ACL recenstructien} Stability
tests {the KT-lflflfl [MEDmetric], Lachman, and pivet
shift tests} censistently shewed BPTB recenstructien te
be mere stable than hamstring tenden recenstructien.
The leng-term develepment ef esteearthritis was net an-
alyzed, but a greater incidence ef anterier knee pain was
feund in patients with a BPTE autegraft.
Anether systematic review alse reperted that ham—
string renden autegrafts were inferier re BPTB autegrafts
fer restering knee jeint stability but that patients whe
received a hamstring tenden autegraft had less anterier
knee and kneeling pain.‘ These findings were supperred
by a separate meta-analysis, which reperted that alrheugh
hamstring autegrafts resulted in less anterier knee pain,
kneeling pain, and extensien less, the BPTB autegrafts
resulted in lewer KT—lflflflr arthremeter sceres, and fewer
pesitive Lachman er pivet shift tests.5 Anether meta-anal—
ysis alse reperted that patients whe underwent EPTB
recenstructien were mere likely te have a stable knee
{measured using the KT—lflflfl test} and had an almest
20% greater chance ef returning re preinjury activity
levels than these whe underwent a semitendinesus er
gracilis tenden recenstructien};
Substantial knee flexien weakness and a statistically
significant knee flexer deficit were reperted with the use
ef hamstring tenden auregraft.’ Hamstring tenden aute-
graft was reperted te be mere likely te lead te infectien
cempared with BPTE autegraft er allegraft {P c 0.05],
with a trend reward a greater likeliheed ef graft remeval.“
IE! lfllfi American Academy ef flrrhepaeclic Surgeens
Chapter 33: The flielegy and Biemechanics ef Grafts and Inplants
In summary, the BPTB autegra fr prevides a very secure
fixatieu because ef the presence ef bene plugs at betb
ends ef the tenden. BPTB autegrafts have a lew failure
rate and a high rate ef patient satisfactien, especially in
patients whe want a rapid return te sperts. Hewever, the
BPTB graft is asseciated with an increased incidence ef
anterier knee pain and extensien less, especially if the
patient dees net underge an accelerated rehabilitatien
pregram immediately after surgery, with an emphasis en
regaining full extensien. Quadrupled hamstring tenden
grafts alse are asseciated with excellent eutcemes, and
there is less anterier knee pain and numbness than with
ether types ef grafts. A slewer return re full-pivering
sperts is required, hewever. Quadruplecl hamstring tend
den grafts are mere lax than BPTB grafts, especially in
wemen. The hamstring tenden harvest leads te decreased
knee flexien strength and can be a facter in graft failure.
Quadriceps tenden grafting is unlikely re cause anterier
knee pain er numbness, and it leads te excellent clinical
eutcemes. There is ne mere knee laxity after quadriceps
tenden grafting than BPTB grafting, with ne less ef knee
extensien.
Allegrafts
The use ef an allegraft decreases surgical time by elimi-
nating the need fer graft harvesting. Dener site merbidity
and cesmetic cencerns are eliminated. It is impertant re
recegniae that the rehabilitatien pregram after allegraft
use must be substantially slewer than the pregram after
autegraft use.
The availability ef allegrafts semetimes is limited, and
the quality can vary. The preparatien ef the allegraft can
have a significant effect en its quality and the subsequent
surgical eutceme. Irradiatic-n er chemical precessing
significantly increases the likeliheed ef graft rupture.iil
ACL recenstructiens using sterilized allegraft had a 45 '34:-
failure rate at 6—year fellew—up, in sharp centrast te a
6% failure rate after autegraft recenstructien.” Irradi-
ated allegrafts were feund te have greater laxity than
autegrafts.“ A meta—analysis cemparing BPTB allegrafts F'."
re autegrafts rep-erred ne impertant eutceme differenc- E
es unless the allegrafts were irradiated er chemically
fir
n
E
precessed.‘ll F
5
Eliminating data related re chemically pre-cessed er I'D
D
I:
irradiated grafts can be difficult and requires careful read- H'I
_.1
ing ef the research. A recent study ef primary ACL recen- El
"E.
structiens in patients an elder than 13 years reperted that
n
”I
the failure rate was 15 times greater after an allegraft was
used than after an autegraft was used.'1 Revisien surgery
was required after 1 cf the 59 autegraft precedures and
T ef the 2D allegraft precedures. Five ef the allegraft
failures eccurred appreximarely 6 menrhs after surgery,
Drrbepaedic Knewledge Update: Sperrs lvledichte 5
 Section 5: Miscellaneous Topics
and all involved irradiated or chemically processed grafts.
The postsurgical motion of these allografts was not re-
stricted, and a continuous passive motion device was used
immediately after surgery. The delay in beginning an
exercise program was only 1 to 2 weelts compared with
the autografts. Sport—specific training began IS months
after surgery, at which point five of the seven allograft
failures occurred. This study shows the need to avoid
irradiated or chemically processed allografts as well as
an overly aggressive rehabilitation program after allograft
use. Compared with the use of autografts, successful use
of allograft tissue requires the avoidance of any chemi-
cally processed grafts, avoiding grafts with any level of
irradiation, and a delayed rehabilitation program.”I
Comparison of Autografis and Allogra'l'ts
Allogrsft reconstruction was found to allow an earlier
return to sport than autograft reconstruction in patients
older than 4i] years.” A study of AOL reconstruction
with BPTB allograft found no difference in subjective or
objective outcomes based on whether patients were older
or younger than 4U years.” A systematic review found
that the choice of autograft or allograft did not affect
ACL reconstruction outcomes but that those treated with
an allograft had less laxity than those treated with an
autograft {using the KT—lflfifl test] and that more patients
with an allograft achieved a normal International Knee
Documentation Committee {IKDC} Subjective Knee Eval-
uation Form score.“5 There was no statistical difference
between allograft and autograft use in rates of ruptures
or postoperative complications.
In contrast, a matched case-control study used uni-
variate logistic regression models to find that ACL graft
reconstruction was less likely to succeed in patients with
a high activity level than in those with a low activity level
and that ACL reconstruction was less likely to be success-
ful if an allograft was used rather than an autograft.”
The potential for ACL reconstruction failure in young or
high-performance athletes has been a concern.” However,
a recent prospective comparison of BPTB allograft or
E
IE
autograft ACL reconstruction in patients younger than
I—
In 26 years found that patients who selected a graft type
:5
D
IIll
and followed the appropriate rehabilitation protocol had
E
J! no unsuccessful procedures, no differences in functional
E outcome scores, and no revision procedures at an over
.E
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age 3—year follow-up.IEI Similar subjective and objective
outcome measures were reported at an average .9 to 10
years follow—up for patients who participated in strenuous
sports after undergoing autograft or fresh-frozen allograft
patellar tendon AC]. reconstruction.”
The Multicenter Orthopaedic Outcomes Network
study also evaluated the effect of graft choice in ACL
firthopaodic Knowledge Update: Sports Medicine 5
reconstruction.“ Patients age If} to 19 years were most
likely to experience graft failure, irrespective of graft type,
but an allograft was four times more likely to fail than
an autograft. The types of allograft included anterior
and posterior tibial tendon and Achilles tendon as well
as BPTB, and different graft fixation techniques were
used. The report did not specify whether the grafts were
irradiated or chemically processed.
Considerable attention has been focused on whether
the outcomes of autograft and allograft reconstructions
are equivalent. A meta-analysis of HS studies with 5,132
patients compared the use of BPTB autografts and al-
lografts in ACL reconstr uction.11 Patients who received an
autograft were found to have better outcomes {su bjective
IKDC, Lysholm, and Teguer scores; single-leg hop and
KT-lilflil tests} than those who received an allograft, but
allograft use was found to lead to better rates of return to
the preiujury activity level, higher overall IKDC scores,
better performance on the pivot shift test, and less anterior
knee pain. The allografts had a 12.??3 rate of rerupture,
compared with a 4.3% rate for autogra fts. Unfortunately,
the W5 studies were not selected to eliminate irradiated or
chemically processed grafts or be comparative in nature,
compromising the conclusions.21
A systematic review found level I, II, or III evidence
in nine studies that compared the use of autografts with
that of nonirradiated allografts.22 Six of the studies com-
pared BPTE autografts and allografts, two compared
hamstring tendon autografts to allografts, and one com~
pared hamstring tendon autografts to tibialis anterior
tendon allografts. No significant difference was found
between the use of autografts and nonirradiated allografts
in any outcome measure, including the graft failure rate.11
Another systematic review and meta-analysis found no
differences in clinical failure rates after EPTB autograft
or fresh-frozen EPTB allograft was used.23L
A systematic review and meta-analysis of five studies
with a total of 504 patients compared ACL reconstruc-
tions using hamstring tendon autograft or soft-tissue
allograft.24 Some of the allografts were irradiated and
chemically processed. Cine study reported greater laxity
at follow-up in irradiated allografts than in autografts,
but the meta-analysis found no significant differences
between hamstring tendon autografts and soft-tissue al-
lografts for any outcome measure, including graft laxity.“
Tunnel enlargement does not affect clinical outcome
scores or laxity data. but it can affect graft placement
and fixation in revision surgery and necessitate a two-
stage procedure to allow bone grafting. The cause of
tunnel enlargement after ACL reconstruction is unclear,
but it usually occurs during the first few months. Tun—
nel enlargement can be explained by mechanical factors
fl lflld American Academy of Orthopaedic Surgeons

I‘-
'—I. _______
I I
Images nf a human dermal allngraft patch fnr arthrnscnpic augmentatinn nf rntatnr cuff tendnn tissue that is
attenuated nr dnes nut cnmpletely cnver the attachment site. A. Ph ntngra ph shnws a prnperly sized patch is
prepared by passing sutures thrc ugh its periphery as well as the te ndnn. B. Arth rnsccpic view shcws the graft
passed intn the jnint. The sutures are tied tn reinfnrce and augment the tendnn repair. The nnlay adds strength tn
the repair and can binlngically enhance healing.
including imprnper graft placement, the chnice nf fixatinn
methnd, the graft length nr type, single—bundle nr dnu—
hie-bundle recnnstructinn, and the effect nf synnvial fluid
mnving intn the graft—tunnel wall interface. Secure fix-
atinn is impnrta nt tn prevent graft mnvement within the
tunnel and allnw gnnd healing nf the graft tn the tunnel
wall. Many types nf graft fixatinn devices are available,
and an understanding nf their material prnperties as well
as the cnrrect technique fnr using them is essential.
The type nf graft appears tn have an effect an the
develnpment nf tunnel enlargement. Hamstring tendnn
recnnstructinn can lead tn substantially greater tunnel
enlargement than BPTE recnnstructinn. A prnspective
cnmparisnn study fnund greater tunnel widening after
hamstring tendnn grafting than BPTB grafting as early
as 4 mnnths after recnnstructinn.“ Patients with BPTB
graft recnnstructinn had a 15% decrease in femnral tun-
nel size and a 2% decrease in tibial tunnel size. The graft
tunnels in thnse with a hamstring graft were statistically
larger and had increased in size; the largest increase was
3.9% in the tibial tunnel. A recent study fnund that
at a mean 5 -year fnllnw—up after quadrupled hamstring
tendnn autngraft recnnstt uctinn, the crnss- sectinnal area
nf tunnels had mnre than dnubled at all levels except the
femnral nntch level."m Cnncerns exist abnut the prnspect
nf tunnel enlargement with the use nf a dnuble-bundle,
dnuble—tunnel technique, but up difference in the risk nf
enlargement was fnund based nn whether a dnuble-bun-
dle nr single-bundle technique was used.“ The methnd
nf fixatinn alsn is impnrtant. Cnrtical suspensinn fixa—
tinn allnws graft mntinn within the tunnel and leads tn
IE! ants American Academy nf flrthnpaedic Surgenns
Chapter 33: The Einlugy and Eiumechanics nf Grafts and Implants
significant enlargement. A crnss-pin fixatinn prnvides
rigid intramedullary fixatinn and substantially decreases
the amnunt nf tunnel enlargement.”
Implants
The gual nf any repair is tn attach the tissue and held it in
place lnng ennugh tn achieve tissue healing. A variety nf
implants can be used tn facilitate tissue healing, including
tendnn patches, suture anchnrs, sutures, and meniscus
repair devices. Rntatnr cuff repair is being dnne mnre
frequently with the increase in the number nf aging but
active patients and with increasing recngnitinn nf the
lnng-term adverse results nf rntatnr cuff arthrnpathy.
The nnrmal rntatnr cuff tendnn has a fibrncartilage
transitinn snue that canunt be exactly replicated by sur-
gical repair. The best that currently can be achieved is a
fibrnvascular scar. Several factnrs affect tendnn-tn-bnne
healing, snme nf which are beynnd the surgenn‘s cnn- F'."
trnl; these include the patient’s age, smnking histnry, and E
wnrkers' cnmpensatinn status as well as the presence nf
fir
n
E
fatty infiltratinn. The surgenn can cnntrnl surgical aspects F
5
including tissue augmentatinn with patches, anchnr and I'll
D
I:
suture selectinn, repair technique, and pnstnperative re- HI
_.1
habilitatinn prntncnl. El
"E.
Rntatnr cuff tendnn repair nften invnlves a cnmplete
n
”I
nr chrnnic tear nf degenerative, frayed, nr retracted tis-
sue. Dvertensinning a tendnn tear must be avnided. Aug-
menting the repair nf a damaged tendnn with an nnlay
graft may prnvide additinnal strength and imprnve the
likelihnnd nf binlngic healing {Figure 3]. This applicatinn
Drthnpaedic Knnwledge Update: Spnrts Medichse 5
 Section 5: Miscellaneous Topics
is approved by the US FDA and is used for large tendon
tears. The postrepair gap should be no larger than 1 cm.
At 12— or 24—month follow—up, a prospective random—
ized controlled study found significantly decreased rates
of retearing after an acellular dermal matrix allograft
patch was used for augmentation of tears that involved
two rotator cuff tendons and were larger than 3 cm (as
documented by gadolinium-enhanced MRI}? The repair
was intact in 35% of patients who underwent augmented
repair, compared with 4D% of those who did not receive
augmentation (P c 0.01}.
Several types of implant patches are available. Some
allograft material is derived from human skin or tendon.
Xenografts are made from animal dermis, pericardium, or
small intestine submucosa. Implants made from synthetic
polymers also are available. Considerations in selecting an
implant patch should include tissue origin, graft source,
graft processing, cross-linking, physical properties, and
clinical experience.
Dermal and Tendon Allografts
Graftjacltet (Wright Medical Technology) is an acellu-
lar dermal matrix allograft produced from human skin
obtained from a tissue bank approved by the American
Association of Tissue Banks. The skin is processed to
remove epidermal and dermal cells with preservation
of collagen types I, III, IV, and VII as well as elastin,
chondroitin sulfate, hyaluronic acid, laminin, tenascin,
proteoglycans, and fibroblast growth factor. Graftjacket
allografts are available in 5 s 5 cm and 5 a 1D cm sheets
with several average thicknesses. ManForce (Wright Med—
ical Technology} allograft is an average 1.4 mm thick
(range, 1.2? to 1.?3 mm}, and Graftjacket ManFnrce
Extreme allograft is an average 2.1] mm thick (range, 1.?3
to 2.15 mm}. Graftjacket allografts must be hydrated for
1.5 to 30 minutes before implantation.
Allopatch HD (Musculoskeletal Transplant Founda—
tion} is derived from human skin obtained from a tissue
banlr approved by the American Association of Tissue
Ba nks and is an acellular human collagen matrix dermal
E
IE
allograft for augmentation of soft-tissue repairs. Allo-
I—
In patch HD is processed to preserve the biomechanical,
:5
D
IIII
biochemical, and matrix properties of the dermal graft.
E
J! Several thicknesses are available: thin (range, [1.4 to (L?
E mm}, thick (range, [1.3 to 1.? mm}, ultrathick (range, 1.3
.E
5
LE
to 3.9 mm}, and extra-ultrathick (range, 4.fl to 5.0 mm).
The sheets measure 2 cm s 5 cm, 5 cm s 5 cm, 4 cm s:
3 cm, or 1 cm x 12 cm. Hydration is not needed, but
the material must be rinsed to remove the 7D% ethanol
packing liquid.
RC Allograft (Arthreitl is a freeze—dried human rotator
cuff tendon allograft. After donor screening, the tissue
firthnpaedic Knowledge Update: Sports Medicine 5
is aseptically recovered and cleaned using the AlloWash
process (Lifehlet Health}, which includes terminal steril-
isation on dry ice to reduce or eliminate bacteria, marrow
elements, and lipids. Some but not all forms are gamma
irradiated. The thickness of the material ranges from 2
to 3 nun, and it is supplied in 2 :s' 3—cm sheets.
xenografts
The available xenograft patches are made from porcine,
bovine, or equine material. These products are mechan-
ically tested under tension. In general, allograft derived
from human skin is the strongest material, followed by
bovine and porcine skin; porcine small intestine submu-
cosa is the weakest patch material?”1 These mechanical
differences can affect the durability of the patch during
implantation and its effectiveness in augmenting the me-
chanical strength of the tendon repair.
The Restore Clrthobiologic soft-tissue implant (Depuyl
and CuffPatch (Arthroteltl are derived from porcine small
intestine submucosa. Permacol ('EovidienlI and Tissue—
I'vIend (Strykerl are derived from porcine dermis or fetal
bovine dermis, respectively. firthAdapt (Synnvisl is made
from equine pericardium.
Restore, the first implant material approved by the
US FDA for tendon repair, consists of more than 90%
collagen with 5% to 1fl% lipids and a small amount of
carbohydrate. The Restore implant is a circular patch
63 mm in diameter, consisting of 10 layers of porcine
small intestine submucosa that are not cross—linked. It is
provided dried and requires soaking for 5 to 1!] minutes
before use. The CuffPatch is 9?% collagen and 2% class
tin. Its eight layers of porcine small intestine submucosa
are cross-linked using carbodiimide and sterilized using
25 kGy of gamma radiation. The material is provided as a
6.5 :u: 9-cm sheet that is supplied prehydrated but should
be rinsed before use.
Permacol, a porcine dermal implant, is a single—layer
xenograft supplied in a sterile, off-white 5 a 10 cm flat
sheet of acellular cross-linked collagen and its constituent
elastin fibers. The sheet is 1.13 mm thick. Cross-linking,
accomplished using hesamethylene diisocyanate, increas-
es the strength but substantially extends the degradation
time of the implant. Permacol is sterilised using ganuna
irradiation, and it is supplied prehydrated in saline.
At Sumonth followuup, only 1 of 11 patients (5 women
and ti men, age range 52 to 7’3 years} who had undergone
a large rotator cuff repair augmented with the Restore im-
plant had a successful repair.” A study of rotator cuff red
pairs with or without Restore patch augmentation found
a higher rate of retearing and significantly more weakness
at 2—year follow—up in patients with the Restore patch.“
The patients who received the Restore patch augmentation
fl 211115 American Academy of Orthopaedic Surgeons

also had more impingement and a lower level of sports
participation than those who did not receive augmenta-
tion. At a mean 13 days after surgery, 4 of 25 patients
with Restore patch augmentation of a rotator cuff repair
had an acute nonspecific inflammatory response requiring
implant removal." The Restore patch is no longer recom-
mended for rotator cuff repair augmentation.
Tissuel'vlend is derived from fetal bovine dermis and
is a single-layer graft decellulariaed through a series of
chemical processes in which all cells, lipids, and carbohy-
drates are removed to reduce the risk of an inflammatory
response. The result is 99% —nondenatured collagen that is
not artificially cross-linked. Tissuelvlend is manufact ured
as a rectangular 5 a 6 cm sheet 1.1 to 1.2 mm thick. The
product is aseptically processed and sterilized in ethylene
oxide, and 1 minute of hydration is required before use.
flrthAdapt, no longer on the market, was an equine
pericardium :cenograft cross-linked to add strength and
contained 90% type I collagen and 10% type III colla-
gen. The processed acellnlar pericardial tissue was not
irradiated. The sheets used were 3 1r 3.- cm or 4 :r 5 cm
and approximately {1.5 mm thick.
Synthetic Grafts
The SportMesh graft {Artimplanu Biomet] is a knitted,
degradable, polyurethane urea fabric constructed from
Artelon scaffold fibers {Artimplant} and sterilized with
25 kGy electron beam radiation. The sheets are 4 cm a 6
cm and [LB mm thick [Figure 4]. This synthetic material is
soaked in saline at room temperature for 5 minutes before
use. SportMesb is elastic and highly porous.
The X'Repair {Synthasome} is a woven poly-L-lactic
acid {PLLA} material available in sheets measuring 12 :c
‘l-fl mm with thickness of 0.3 mm. This material is elastic
and was found not to contribute stiffness in an in vitro
model. Human cadaver rotator cuff repairs augmented
with this implant demonstrate significantly higher yield
loads and ultimate failure loads.m
Implant Biomechanics
Biomechanical testing has been reported for several im-
plantsfifl'“ Load elongation after cyclic loading revealed
that the Sportlvfesh synthetic-material patch had signifi-
cantly greater displacement during cyclic loading than
any other tested graft material.“ RC Allograft, the tested
human rotator cuff tendon implant, had the least elasticity
and was the most resistant to elongation. Although great
elongation raises concern as to whether a graft can pro—
vide sufficient mechanical support, resistance to elonga-
tion raises concern about the potential for stress shielding
during healing. Testing of ultimate load to failure found
that the tested acellnlar human dermal allografts were
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 33:: The Biology and Biomechanies of Grafts and EnplaJIts
Photograph shows a SportMesh synthetic
graft constructed from knitted. degradable.
polyurethane urea fabric.
stronger than the xenograft or synthetic implants.“‘” The
acellnlar human dermal allografts also were stiffer than
the tested equine pericardium and synthetic patches. A
single vertical simple stitch was used in suture retention
testing that found acellnlar human dermal allografts to
have greamr suture retention strength than xenograft and
synthetic allografts.”1 The thickness of dermal grafts was
related to suture retention, with a thick graft providing
more strength than a thin graft.
In general, dermal allograft implants add strength to a
tendon repair without stress shielding. The implants are
incorporated into the repair over time, and their use was
found to lead to lower rates of retearingF" Unlike :ceno-
graft implants, human dermal allograft implants have
not been associated with inflammatory adverse events.
Equally effective synthetic or tissue-engineered grafts
may become available in the future, but their clinical
effectiveness has not yet been established.
Suture Anchors
F'."
The primary function of a suture anchor is to securely E
attach suture into bone, which attaches tissue to the ap-
fir
n
E
propriate site and holds it in place until healing occurs, F
5
without excessive tension or loosening. The ideal suture I'D
D
I:
anchor does not react to the surrounding tissue, per- H'I
_.1
forms its designed function for as long as needed, and El
"E.
disappears without a trace. Biodegradable anchors for
n
”I
the most part accomplish these goals and do not create
difficulties related to postoperative imaging or revision
procedures. Both biodegradable and nonbiodegradable
{metal or plastic} anchors are subiect to anchor loosening
and migration, however.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 5: h'liscellaoeous Topics
5uture Anchor Materials
Suture anchors were previously made from metal, but
during the past 2|] years biodegradable suture anchors
made from other materials have become available. The
initial biodegradable material was PLLA, which was fol-
lowed by polymer combinations that combine lactic acid
with another polymer, which usually is polyglycolic acid
[PEA]. The resulting copolymer, called PLLA-co-PGA,
has mechanical properties comparable to those of PLLA
but with more rapid degradation. A more amorphous
lactide polymer can be engineered by combining different
amounts of dextro {D} and levo {L} lactide monomer to
create a stereoisomer. A greater percentage of the dextro
component leads to a more rapid degradation and the
potential for an increased inflammatory response. Several
combinations of dentro and levo lactide are available.
Sometimes a stereoisomer of PLLA {PDLLA} is combined
with a copolymer [PLLA-co-PGA] to create an even more
complex polymer with different characteristics.
Some authors have reported the development of an
inflammatory synovitis associated with the use of biode-
gradable suture anchors resulting in the need for subse-
quent surgery.39""" An analysis of biodegradable implants
without regard to the polymer type or the presence of a
copolymer or stereoisomer does not con sider the material
characteristics of entirely different polymers. The use of
the term PLLA to genericallyr describe this group of ma-
terials ignores the substantial differences in degradation
profiles, and the conclusions drawn from such analyses
are inaccurate. A study of 44 shoulders requiring surgery
for complications after repair of the labrum or rotator
cuff stated that “gross, histologic, and MRI-visualized
pathology was observed in patients in whom PLLA im-
plants“ were used.” In reality, the anchors in 39 shoulders
were composed of levo {L}- deI-ttro {D} lactide stereoiso-
mers {poly—levo [?fl%]fdestro [mm—lactic acid {PUT}!
DSHLAD. The stereoisomers or copolymers of PLLA vary
in biodegradable characteristics and behave differently.
Only 3 of the 44 shoulders were rcported to have actual
PLLA anchors.
E?
IE
Degradation time differs among the polymers.‘““”5 An
l—
us inflammatory response does not develop until the long
:5
D
IIII
polymer chains begin to break down and release mono-
E
J! mers. Most PLLA implants were macroscopically intact
E at BDumonth followbup, with no apparent inflammatory
.E
5
LE
response, in contrast to the stereoisomers and copolymers
of PLLA, which have markedly more rapid reabsorp-
tion patterns.“*“ Degradation begins as these polymer
chains break down and the crystalline implant becomes
amorphous. Implant fragmentation releases monomers,
which are phagocytosed primarily by macrophages and
polymorphonuclear leukocytes. In the final degradation
firthopaedic Knowledge Update: Sports Medicine 5
m.“ =_-.. ' . '--.I'4~l-'-'.—"
Figure 5 Photograph shows several biodegradable
suture anch ors constructed of biocom posite
material. From left to rig ht: the TwinFiit HA 5.5
{Smith Sr Nephew Endoscopy}r TvvinFt HA 4.5
{Smith a Nephew]. CrossFT BC 5.5 {Confined-
Linvatec}, Healt EH. 5.5 {DePuy lvlitekl.
Gryphon BR {De Puy l'v'l'rteki. and Double Flay 5.1]
{Arthrotarel
step, the lactic acid monomer enters the Krebs cycle and
is released as carbon dioxide and water.
Inflammation is an inherent part of the degradation
process. PGA is an example of a rapidly degrading poly-
mer. The breakdown of PGA can be so rapid that acidic
breakdown products incite a symptomatic local infla mma-
tory tissue reaction within 11 weeks of impla ntationfi“5 A
sinus that discharges implant remnants sometimes devel—
ops and can persist as long as s months.“ Inflammatory
responses with intracapsular synovitis and granulomatous
reactions in the shoulder have been reported after PEA
tacks were used.”
Suture anchors and other implants for arthroscopic in-
sertion are composed of different biodegradable polymers,
most of which are unlikely to cause an inflammatory
reaction. A recent study of are shoulder procedures found
that an anchor-specific adverse event occurred only in 2
procedures (0.5%).” Only one of these adverse events
was polymer related, and it occurred in a PLTGIDSGLA
anchor that was reabsorbed too quickly, thus loosening
the eyelet suture and allowing it to migrate into the joint
and cause articular cartilage erosion.
The use of biocomposite materials is a recent develop-
ment in biodegradable implants {Figure 5}. A biocompos-
ite combines a biodegradable polymer with a bioceramic
material. Beta-tricalcium phosphate {fl-TCP) is currently
the most commonly used bioceramic. The other bioce-
ramics include hydrostyapatite (CamiPGgifiiDHill, cal-
cium sulfate {$50,}, and calcium carbonate iCaCDQ.
Combining PLLA with fi—TCP blends the compressive
strength and stiffness of B-TCP with the degradation
fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 33: The Biology and Biomechanics of Grafts and EuplaJIts

profile of PLLA. The resulting hiocomposite degrades

more rapidly than pure PLLA, and it encourages osten-
conductive ingrowth of bone into the anchor location.
Usteoconductive ingrowth into the area of the implant
occurs during absorption when the bioceramic releases
a base that buffers the acidic monomer, thus raising the
local pH toward neutral. A sclerotic bone wall is less
likely to develop if the environment around the degrad-
ing implant is not acidic. The released calcium ions also
encourage osteoconductive ingrowth. Biocomposite im-
plants are replaced by a material with the radiographic
.I' I. I. .._":I.f: .- I, "

Ti * '- ' . l .
appearance and density of cancellous hone.“"3'*"'9 .: . :1. . _.
Suture-based anchors represent a new type of anchor-
ing device. As with most shoulder anchors, one or more ':."!i"'- .
sutures containing No. 2 ultra-high—molecular-weight . lbw-1LT: I. I-' -'
Z .‘fi'f'w-lfil I ' '
polyethylene fUl-IMWPE] are used. The anchor is creat-
i3] 7 'I-Ii'. .

Figure E- Photograph showing several l-tl'l otless suture

ed hy adding a 1— to 3—mm—wide sleeve with a length of
UHMWPE or braided polyester. The suture or sutures are
woven though this sleeve. Methods of passing the suture
through the sleeve create different patterns in the anchor
when tension is applied.
anchors. From left to right: Footprint Pls'. {Smith
a Nephew Endoscopy}. FopLok (Conlv'lecl-
Linvatec), Pu sh Lock [Arth rex). These anchors
have an internal locking mechanism or use
pressure between the anchor body and the
adjacent bone to secure the sutures.

Biomechanical Considerations
A suture anchor in the shoulder can he a medial-row
rotator cuff anchor, a lateral-row rotator cuff anchor,
or a glenoid instability anchor. The design that is ap—
propriate for a rotator cuff anchor will differ from the
design appropriate for a glenoid anchor, which should be
smaller, suitable for insertion into denser cortical bone,
and hold fewer sutures. In contrast, a rotator cuff anchor
will be larger, suitable for less dense cancellous bone, and
routinely accommodate two or three sutures. Recently re-
leased suture anchors are more likely than earlier anchors
to he made from a radiolucent material such as a plastic
{polyether ether ketone, PEEK}, a biodegradable material,
or a hiocomposite material. hiocomposite anchors most
commonly contain [S-TCP. The sutures for most anchors
now contain UHMWPE, are fully threaded, and have a
distal or internal eyelet.
Knotless anchors have been developed to accommodate
the increasingly common use of dual-row constructs. To
secure the sutures, these so-called knotless designs use
stability of a dual-row repair, probably because the knot-
less medial-row anchor is effective in sharing the load
with the lateral row. This factor is important because
lateral-row anchors receive less stress than medial-row
anchors. The lateral anchors of a dual-row repair take
only 33% of the overall load?“1 This 2:1 loading ratio
can cause the medial anchors to fail before the lateral-row
fixation, both clinically and biomechanically, and conse-
quently protects the lateral-row fixationfiih54
Medial-row anchors usually have a strong screw-in
design requiring knot tying and having a higher failure
load than lateral-row or glenoid anchors. These anchors
also are appropriate for biceps tenodesis. Lateral-row
anchors usually are a knotless design and can accom-
modate sutures from a medial row for a suture-bridge or
transosseous technique.
Glenoid anchors for labral and shoulder instability F'."
procedures are designed to he used in relatively young E
patients with good-quality bone. The restricted working
fir

n
E
an internal locking mechanism or pressure between the space and narrow glenoid contour require the use of a F
5
anchor body and the adjacent bone {Figure ti}. Threaded small anchor. Consequently, the available glenoid anchors I'D
D
I:
{screw-in]I and nonthreaded {push-din} knotless anchors range in diameter from less than 2 mm to 3.5 mm. Toggle H'I
_.1
are available. Threaded hiocomposite lateral~row knotless anchor designs are less effective than screw—in designs El
"E.
anchors can withstand higher loads than nonthreaded in the osteoporotic bone of the greater tuberosity, but
n

”I

knotless anchors because of the efficiency of the screw
fixation design.m
Biomechanical studies have evaluated the effect of
knots in medial-row sutures before creation of a suture
bridge. Medial-row knots increase the stiffness and
they can be used effectively in the glenoid. A relatively
short anchor and shallow drilling depth are preferable
in the glenoid to avoid overpenetration. If the drill is
too long or the anchor penetrates into the axilla, the
axillary nerve is at risk. However, a small anchor has a

IE! lfllfi American Academy of flrthopaedic Surgeons Drthopaedic Knowledge Update: Sports lvledichse 5
 Sectien 5: Miscellaneous Tepics

lewer lead-te-failure strength and cannet accemmedate

as many sutures as a larger ancher.
Few new metal anchers are being released. Instead, the
current trend is teward radielucent anchers made frem
PEEK, biedegradable materials including PLLA and PDL- ! {'I'. .:

LA, and biecempesites centaining fl-TCP er hydrexyap—

atite. Biecempesite anchers, especially these with [S-TCP,
are esteecenductive. Many currently available anchers
were intreduced several years age er are miner variatiens
ef previeus designs. The newest ancher designs typically
are fully threaded, centain multiple UHMWPE sutures,
and have a central er distal cressbar eyelet.
The first whelly suture-based ancher was the 1.4-mm
JuggerK net {Biemet}. In the bene, the suture and sleeve are
drawn up inte a W shape by tractien en the sutures; this
fill-shaped suture acts much like the teggle anchers that
preceded suture—based anchers {such as ReterleC, Smith
3C Nephew; UltraSerb RC, Linvatec; Panalek, DePuy
Mitch}. As with the use ef a teggle ancher, the cempressed
mass ef suture engages the everlying certical bene, and
a space is created belew the bene. Because the suture has
ne screw threads, ribs, fins, er expanding wings te secure
itself in the cancelleus bene, any slack in the suture—tissue
interface can cause a pisten effect against the everlying
cermx, pessibly leading te subcertical cavitatien.
The 1.4—mm Juggcrlinet had lewer failure leads than
ether gleneid anchers; suture breaking and ancher pulleut
eccurred with alrnest equal frequency.” The subsequently
intreduced 1.5- and 2.9-111111 Juggerlinets have a Eli—nun
sleeve and significantly higher failure leads. Nene ef the
test samples failed by device pulleut. In a destructive
test, all ef the newer Juggc net anchers failed by suture
breaking after cyclic leading.-“5
Several ether suture-based anchers are available, in-
cluding the Icenix {Stryker}, Y-Knet iCenMed Linvatec),
SutureFix {Smith 5: Nephew}, and Draw Tight {Parcus
Medical]. The three versiens ef the Icenix have ene, twe,
er three He. 2 UI-IMWPE sutures, which are weven three
times threugh a flat, flexible tube ef braided pelyester that
when tensiened cellapses inte a cleverleaf cenfiguratien
E
IE
Figure ii Fhetegraph shews nenabserbable suture‘basecl
anchers. Frem left te right: Icenix 1 ancher
depleyed inte a 'cleverleaf' term, the Icenix
1 ancher net depleye-d, the deubIe-Ieaded
Icenix 2 ancher. and the triple-leaded Itenix 3
ancher. Acres: the helium is the lcenix 2 ancher
witheut a felcl.
suture breakage is cemmen. In biedegradable anchers,
the distal cressbar eyelet fails and the suture pulls eut.
PEEK anchers have a tendency te fail by ancher pulleut.
1"iii'ithin the suture ancher censtruct, the suture er the
suture eyelet is mere likely te fail than the ancher itself.
Ancher placement is an impertant censideratien. Sub-
certical placement fer the ancher is preferable te burying
the ancher deeper inte the bene. With cyclic leading a
deeply buried ancher will shift within the cancelleus bene
and migrate reward the surface, thereby intreducing dis-
placement inte the repair. In additien, the sutures frem a
deeply buried ancher will cut threugh the bene. In vitre
testing feund that this ancher metien centributed as much
as ene third ef the tetal displacement ef the suture ancher
censtruct.” Altheugh sutures frem a deep ancher can cut
a channel threugh the adjacent bene, the suture itself can
fail as the result ef abrasien by the dense certical bene.
The design and size ef the ancher have an effect en

te create the ancher {Figure 7}. The Y—Knet is available in its lead-te-failure strength. Several single-pull and cyclic
I—
us 1.3- and 1.3mm sizes fer gleneid use and in a deuble- er leading lead-te-failure tests feund that the relatively large,
:5
D
IIll
triple-leaded 2.3-mm size fer retater cuff applicatiens. fully threaded screw anchers apprepriate fer retater cuff
E
J! The suture sleeve is cempressed te ferm a ball cenfigura- tenden repair have statistically higher failure strengths
E tien. In a recent laberatery test at the institutien ef this than anchers designed fer gleneid placement?“ Hewev-
.E
5
LE
chapter’s anther, the 2.3—mm Y-Knet failed by suture er, there was ne statistical difference in failure lead tests
breaking twice as eften as by ancher pulling eut ef the ef 5.5- and 6.5-mm anchers ef the same design.
bene; the mean resistance te failure was 50‘!) te EODN.
Suture anchers ef several sizes and designs have been Clinical Censideratiens
mechanically evaluated. The failure mede eften is relat- Ancher Failure
ed te the ancher material. Fer example, metal anchers Ancher failure can eccur during the surgical precedure
are likely te be strenger than the asseciated suture, se er shertly thereafter [immediate failure] er after clinical

firthepaedic Knewledge Update: Sperts Medicine 5 fl lfllfi American Academy ef Orthepaedic Surge-ens

healing [late failure}. Different failure issues exist fnr bin-
degradable anchnrs and fnr metal and PEEK anchnrs.
Immediate failure can nccur at the anchnr itself, as with
imprnper insertinn, breaking during insertinn, pulling
nut frnm the bnne, nr eyelet failure; at the suture, as with
breaking during suture passing nr knnt tying nr with knnt
failure; nr at the tissue, as with suture cutnut. Late mndes
nf failure include anchnr lnnsening nr breaking, anchnr
migratinn, and reactive changes. Inflammatnry reactinns
related tn bindegradable anchnrs are uncnmmnn and tend
tn be pnlymer specific.
Imprnper insertinn can lead tn extranssenus place—
ment nf the anchnr, which can cause immediate articular
cartilage damage nr neurnvascular impingement nr later
damage frnm anchnr migratinn. Anchnr breakage during
insertinn can be related tn the depth nr angle nf insertinn
and in snme anchnr designs can be related tn rntatinn nf
the anchnr sn that the exiting sutures have an incnrtect
nrientatinn.
Changing the angle nf the insertinn cannula while
impacting an anchnr can result in insertinn failure. It is
impnrtant tn maintain an accurate alignment with the
drilled hnle and tn avnid tnn much fnrce when impacting
the anchnr intn place. After advancing the anchnr dnwn
intn the cannula, it is nften helpful tn use finger pressure
tn manually seat the anchnr as far as pnssible intn the
bnne befnre using the mallet. Impacting the anchnr tnn
far dnwn the drill hnle can place it belnw the cnrteit and
create difficulties related tn anchnr mntinn, suture cutting
thrnugh bnne, and anchnr angulatinn with cyclic lnading.
In additinn, remnving the insertinn cannula frnm the bnne
hecnmes mnre difficult.
Anchnr pullnut after rntatnr cuff repair was repnrted tn
nccur in 2.4% nf patients, including 0.5% nf thnse with a
tear nf 3 cm nr less and 11.fl% nf thnse with a tear larger
than 3 cm? Anchnr pullnut resistance is a functinn nf the
amnunt nf cnntact surface at the bnne—anchnr interface
and the frictinn generated. The anchnr failure lnad increas-
es with screw thread depth and the number nf threads,
which create anchnr surface area. Screw-in anchnrs gener—
ally have a higher failure lnad than nnn—screw-in anchnrs.
Fully threaded anchnrs hnld better than anchnrs that are
net fully threaded, and if deplnyed flush with the cnrtical
surface, fully threaded anchnrs dn nnt migrate as much.
The risk nf anchnr eyelet breakage has been significantb
ly reduced by the change frnm ptnminent prnzsimal pnst
eyelets tn distal crnssbar eyelets. Althnugh snme anchnrs
have independent suture-based eyelets, a distal crnssbar
eyelet at the end nf a hnllnw central anchnr cure is nnw
a cnmmnn design. The distal crnssbar breaks befnre the
anchnr bndy can be pulled frnm the bnne, and this feature
serves as a prntective measure. Recent in vitrn studies
IE! Elllfi American Academy nf flrthnpaedic Surgenns
Chapter 33: The Binlngy and Binmechanics nf Grafts and [unplants
rep-nrt anchnr eyelet breakage as the principal mechanism
nf failure fnr many anchnrs, prnbably because nf the use
nf multiple UHMWI’E—cnntaining sutures.
The causes nf late failure include anchnr migratinn and
the develnpment nf inflammatnry reactinns. There is cnn-
cern abnut pnssible anchnr migratinn related tn technical
issues in arthrnscnpic insertinn. Hnwever, npen anchnr
insertinn was assnciated with anchnr migratinn as late as
T years after insertinn.ff Bnth metal and bindegradable
anchnrs have been assnciated with this cnmplicatinn. The
inflammatnry reactinns include nstenlytic changes, cyst
fnrmatinn, and inflammatnry synnvitis.“
Sutures
The suture has a key rnle in the integrity nf a tissue repair.
As all-arthrnscnpic repairs nf the glennid labrum, biceps
tendnn, and rntatnr cuff have becnme the standard, the
impnttance nf the suture has increased. The surgenn’s
challenge is tn cnnsistently apprnximate and hnld the re-
paired tissue by secu rely tying the knnt thrnugh a cannula
in an aquenus envirnnment, using knnt pushers rather
than the fingers. Sutures that dn nnt hnld the knnt, be-
cnme frayed, nr are likely tn break cnmplicate this prn—
cess. The sutures initially used in arthrnscnpic surgery
were unnabsnrbable braided pnlyester {Mersilenm Ethi-
bnnd} nr absnrba ble mnnnfilament pnlydinitannnc {PBS}.
Ethibnnd, a braided pnlyester suture, was the preferred
arthrnscnpic suture because it was cnated with pnlybu-
tilate tn achieve a lnw-frictinn surface with imprnved
handling characteristics. P135 is cnmpletely reabsnrbable,
but the rigid mnnnfilament imparted a memnry tn the
suture, thus decreasing the ability tn create a secure knnt.
PDS begins tn lnse breaking strength 3 weeks after im-
plantatinn, retains nnly 4fl'% nf its nriginal strength at
6 weeks, and has nn measurable strength at 5" weeks.f5
In cnmparisnn, pnlyglycnnate {Maann} sutures retain
nn significant strength at 5 weeks, and pnlyglactin—El'lllI
Wicryl} and PGA {Derrnn} sutures retain nnly minimal
breaking strength 3 weeks.EIE
These sutures were manufactured tn a standard de- F'."
fined by the United States Pharmacnpeia based nn suture E
diameter and cnmparative suture-breaking strength. This
fir
n
E
system was nverturned with the intrnductinn nf FiberWire F
5
[ArthreJ-t]. In this revnlutinnary suture, the traditinnal I'D
D
I:
braided pnlyester was wnveu arnund a cnre nf UHM‘WPE H'I
_.1
fibers. The cnmbinatinn nf materials made the FiberWire El
"E.
suture much strnnger than all nthers with a similar size
n
”I
rating. In lnad—tn-failu re testing, Mn. 2. FiberWire prnved
tn be as strnng as Mn. 5 braided pnlyester suture, and
therefnre it was much less likely tn break during tying with
an arthrnscnpic knnt pusher.” Fiber‘Wire quickly became
the suture nf preference fnr arthrnscnpic applicatinns.
Drtbnpaedic Knnwledge Update: Spnrts Medicine 5
 Sectinn 5: Miscellanenus Tnpics
Tn becnme cnmpetitive, nther manufacturers intrn-
duced their nwn high-strength sutures, many nf which
were made with braided UHMWPE. The UHMWPE in
all nf these sutures was prnvided by Dyneema {DEM}.
Despite varied prnprietary names, the braided UHM‘W PE
suture and braided pnlyester suture were made nf the
same materials. Suture strength was further increased by
eliminatinn cf the surrnu nding braided pnlyester in favnr
nf pure braided UHMWPE. Cnnsequently, FiberWire is
substantially strnnger than the earlier braided pnlyester
sutures, but braided UHMWPE suture is substantially
strnnger than FiberWire.“
|Elrthnllflnrd (Depuy Mitek}, the must recently intrn-
duced suture, is a cnmbinatinn nf braided UHMWPE with
many small strands nf absnrbable mnnnl'ilament pnlydinat-
annne; it is cnated with pnlyglactin-E'li} tn imprnve its
handling characteristics. DrthnCnrd and FiberWire are
equivalent in strength but statistically weaker than pure
braided UHMWPEF‘MFJE All nf the new sutures far ex-
ceed the lnad-tn—failure requirements fnr a secure tendnn-
tn-bnne repair.
The handling and feel nf these new sutures differ frnm
nne annther. Pure braided UHMWPE is mnre abrasive
than FiberWire nr UrthnCnrd, bnth nf which have a snfter
feel that facilitates suture handling. Althnugh these new
sutures are strung in testing mndels, knnts tied using them
behave differently. Arthrnscnpic knnts begin with a slip
nr lncking knnt that is fnllnwed by a series nf half-hitches.
Apprnpriately placed half—hitches shnuld be alternated by
asymmetrically applying tensinn tn the strands with the
hunt pusher. The result shnuld be a tight lnnp hnlding the
tissue with a secure knnt. Any clinical failure nf the tied
knnt shnuld be by material failure {suture breaking} rather
than lnnp failure (knnt slippage]. Using a sliding ln-cking
hitch tn increase intenial suture resistance increases the
knnt cnmplexity and can result in greater knnt security.
Backing up an arthrnscnpic knnt with reverse half—hitches
and pnst switching alsn is essential.
Knnt slippage befnre material failure creates laxity in
the repair. liEyclic displacement nf as little as 3 tn 5 mm
E
IE
is undesirable fnr healing. UH MWPE-cnntaining sutures
I—
us are mere likely tn slip at submasimal lnads than braided
:5
D
IIll
pnlyester sutures; therefnre, creating the right type nf knnt
E
J! is especially impnrtantfiirfifl Suture surface characteristics
E and cnnstructinn were fnund tn affect the likelihnnd nf
.E
5
LE
knnt slippage, and slippage was fnund tn nccur at very lnw
tensinn levels. Twn studies fnund that, althnugh FiberWire
was substantially strnnger than braided pnlyester suture,
mnre than half cf the knnts tied using FiberWire slipped
at submaximal lnadsfiii‘i'E The Duncan lnnp, which dnes
nnt have an internal Inciting lnnp, slipped befnre maximal
failure 915% cf the time. The Westnn knnt slipped 36%
firthnpaedic Knnwledge Update: Spnrts Medicine 5
nf the time. Hnwever the SMC, Tennessee slider, Revn,
and San Diegn knnts resisted slipping in mere than 90%
nf the tests.“ The cnnclusinn was that the Duncan lnnp
nr any nther knnt withnut an internal lncking lnnp shnuld
nnt be used with UHMWPE-cnntaining suture.
Meniscus Repair
The meniscus efficiently disperses lnads acrnss the surface
cf the knee articular cartilage by deepening the tibial
articular surface, thus increasing the weight-bea ring sur-
face area and lnwering cnntact stresses during weight
hearing. The meniscus alsn cnntributes tn knee jnint
lubricatinn, stability, cnngrueuce, prnprinceptinn, and
articular cartilage nutritinn. An intact meniscus changes
vertically nriented cnmpressinn stresses intn radial hnnp
stresses, and it serves as a secnndary stabilizer fnr transla-
tinn and rntatinn. The intact meniscus plays an impnrtant
rnle in prntecting an ACL-deficient knee frnm arthritic
changes.
These impnrtant rnles underscnre the impnrtance nf
attempting tn preserve a turn meniscus. Meniscus repair
is preferable if there is a gnnd blnnd supply and a reasnn-
able estpectatinn nf meniscal healing. The best candidates
fnr meniscus repair are relatively ynung patients with a
traumatic tear and nn apparent degenerative meniscal
changes, especially if they are undergning cnncurrent ACL
recnnstructinn. In general, the indicatinns fnr repair are
the presence nf a vertical nnndegenerative peripheral tear
rather than a displaced bucket-handle tear, in the red-red
nr red-white reginn nf the meniscus.
Fnur techniques have been used fnr meniscus repair:
npen, inside nut, nutside in, and all inside. Cnmbinatinns
nf twn nf these techniques snmetimes are called hybrid
repairs. Inside-nut and nutside-in suture-based repairs
are dnne less frequently than all-inside repairs. All-inside
repairs are quicker, dn nnt require additinnal incisinns,
and are less likely tn result in neurnvascular injury.
Meniscus Repair Devices
The current all-inside techniques use suture-based,
self-adjusting meniscus repair devices with nnnabsnrb-
able UHMWPE-cnntaining suture. The UHMWPE
suture is much strnnger than braided pnlyester suture
and represents an impnrtant advance in the repair nf
meniscus tears. The suture usually is attached tn nnnab-
snrbable PEEK anchnrs cnnnected by a pretied, sliding,
and self—lncking knnt {Figure 3}. These devices are in-
serted thrnugh an anterinr arthrnscnpic pnrtal, and they
are passed thrnugh the meniscal fragment and intn the
peripheral rim. The deplnyed anchnr is lncated extra-ar—
ticularly en the capsule. The suture is tensinned, and
fl lflld American Academy nf Drrhnpaedic Surge-ans
 Chapter 33: The Elie]legitr and Eiemechanics pf Grafts and implant:

“3-1,:- aJ-ri" vF-Pi'sls . l?“- 25":-

‘ fl"? "Fl-7'19 ':' - "Iii-- I

Figure 3 Pheteeraph shews the Dmnifipan. a self-

adjusting meniscus repair device used in an
all-inside technique. The nnna bsnrba ble
ultra-high-melecular weight pelvethvlene—
cn ntaining suture is attached tn pelyether ether
hetene anthers tnnnected by a pretied. sliding. , _ .L-I"
_':-I:_".HI:r'IL_I .'.,i"
-';--LII1 ':.-:-.:.~r-'
psi-II "'
l..--l‘-.I.

and self-Inciting ltnet.

an“ r".‘*
3.23..- fill'J-QFIFfi‘r
':lt' in: a
l_'Iii:1'lf£
*rdl'‘:‘-31;:*1":
#1135“ {ht-i
E" .‘hl.

Figure 9 Phntngraph shnws the Mai-{Fire meniscus

the sliding lecking knet secures the tear and maintains
cnmpressinn fnr meniscal healing.
Altheugh elder repair devices have net been remeved
frnm the market, the relative new suture—based, self—ad—
justing meniscus repair devices are mere nften used. The
available devices ef this type include the Fast-Fix 360
{Smith be Nephew}, Dmnifipan Il'Il'lePu}.r Mitelc], Me—
niscal Cinch {Arthresc}, the MascFire {Einmet}, Sequent
{Cenlvled Linvatec}, and CressFis-c II {Cayenne Medical].
The Fast—Fist 36D has twn arrnw—shaped PEEK an—
chers cennected bv braided Ne. l—fl UHM‘WPE suture
centaining a sliding le-cking knet. The reunded—handle
insertien device advances the 1?—gauge needle (straight,
25“ curved. er 15° reverse curved} with twe separate
passes. The preceding versien ef this device {the Ultra
FasT-Fisc} cnntained a larger He. 0 UHMWPE suture.
An adjustable depth limiter is en the handle as a safety
feature.
The IE'lmniSpan uses a needle (straight, 12“ curved, nr
2?“ curved } fitted ente a dispesable gun. The device has a
strand nf Ne. 2-D UrthnCerd dnubled between twe PEEK
anchers, inserted by the gun in twn passes. A silicnne
tube en the needle prevides a seft step te limit ancher
re pair device. The twe anthers tnnsist nf Mn.
5 pelvethvlene sleeves that bunch up en the
peripheral meniscus capsule te create the
anthers.
dewnward and clicked inte pesitien, and the secend de-
vice is inserted in the same fashinn as the first.
The MascFire is a UH MWPE suture with twn anchers
censisting ef bin. 5 pelvethvlene sleeves that are similar tn
the anchers in the JuggetKnnt suture ancher [Figure 9}.
The twe anchers are inserted inte the meniscus with
a trigger—gun device that deplevs a curved er straight
needle. With tractien, the depleted sleeves bunch up tn
create anchers en the peripheral capsule. A pretied sliding
lncking knnt is part cf the repair.
The Sequent device uses a curved needle tn insert a
braided He. 0 UHMWPE suture centaining three. feet.
er seven PEEK anchers. The technique allews centinueus
stitching, and the anchers can be used tn create a V—, W—,
er best-shaped repair. The beers are created after insertien
nf each ancher by retating and tensiening the insertien F'."
device tn leek the suture inte sluts in the PEEK ancher. E
The CressFia II is an all-suture censtruct with ne im-
fir

n
E
insertien at 13 mm. The sliding lncking knnt is ln-cated plant. The dual-prnnged deliver}? device has twn hellew, F
5
en the nutside nf the first PEEK anchnr tn be inserted, parallel 15-gauge needles {straight nr 12“ curved}. The I'D
D
I:
and it creates a repair with twe sutures cressing cm the device has a lt’iumm depth limiter. Te allew the internal H'I
_.1
meniscal surface between the rwn anchers withnnt a hunt. nitinel shuttling needle tn clear the plastic sheath, 3 mm El
"E.
The Meniscal Cinch uses a 15" curved gun leaded ef tissue penetratien is required. When eapesed, the twe
n

”I

with twe separate trecar needles. Each needle is leaded
with a hellew tubular PEEK ancher cnnnected by He.
2-0 Fiber‘illr'ire with a pretied sliding leclting knet. After
insertien ef the first device, the needle asseciated with it
is retnnved and handed eff. The secnnd needle is pushed
parallel needles extend eutside the plastic sheath, and a
small needle shuttles a braided He. {II UHMWPE suture
with a pretied sliding Westin lrnet between them, creat-
ing a 3—mm mattress stitch. This system uses ne suture
ancher.

IE! Ellie American Academy nt' flrtbepaedic Sergenns Drtbnpaedic Knewledge Update: Spnrts Medicbse 5
 Seefien 6: hfiseellaneeus Tepics
Biemechanical Censideratiens
During the pesteperative rehabilitatien and healing phase,
meniscal repairs experience cempressien and shear leads
but prebably little if any distractien. l'vluch higher shear
leads than distractien leads can be anticipated in a su-
ture—based repair device.“ A cemparisen study ef human
meniscal tissue feund that seme suture-based, self-adjust-
ing devices with UHM‘WPE-centaining suture previde
repair strengths cemparable te these ef an inside-eut
repair using a braided pelyester er UHMWPE-centain-
ing suture.TEI The MaxFire device had substantially lew-
er mean failure leads, cempleted fewer lead cycles, and
demenstrated greater displacement during cyclic leading.
The MaxFire had a 1?% failure rate related te final de—
vice tensiening during arthrescepic insertien in human
cadaver meniscif1 A meta-analysis ef the biemechanical
preperties ef meniscus repair devices and sutures feund
that a yertically eriented mattress suture was strenger
than a herizental mattress suture and that repairs with
seme meniscal devices had biemechanical preperties sim—
ilar te these ef suture repairs.fl
Clinical Censideratiens
Arthrescepic meniscus repair is a successful technique
when used in apprepriately selected patients. The healing
rate after an iselated meniscus repair witheut ligament
surgery is appreximately seem In early results {witheut
revisien surgery}, the repair was successful in apprexi-
mately 90% ef patients when dene in cenjunctien with an
ACL recenstructien.“ This rate may decline ever time, but
an 36% healing rate was reperted at 6-year fellew-up. In
patients with a histery ef ACL recenstructien predating
the meniscus injury, the success rate was lewer {apprexi-
mately 60%] and suggested a degenerative precess.
A peripheral vertical tear is ideal fer repair, but seme
success has been reperted with ether tear types. A sys-
tematic review ef heriaental meniscus tear repairs feund
a 73% success rate when reeperatien was the principal
criterienfj Several types ef tears are unlikely te heal in-
cluding white-white aene tears, degenerative tears, irre—
3
IE
ducible tears, tears with relied edges, and tears in which it
I—
In is net pessible te achieve a seund fixatien. Chrenic buck-
:5
D
IAil
ct-handle medial meniscus tears are difficult te repair, but
E
J! a retrespective review ef suture repairs reperted enceur-
E aging results?E Df 24 repairs ef chrenic bucket—handle
.E
5
LE
tears with a minimum length ef 2 cm, 20 {83%} had
healed at an average ef 1i] menths after injury, based en
clinical eutceme sceres and pesteperative MRI. All ef
the unsuccessful repairs were iselated meniscus repairs
witheut an asseciated ACL recenstructien.
Few leng—term reperts exist, but it appears that menis—
cus healing rates may deterierate with time. The success
firthepaedic Knewledge Update: Sperts Medicine 5
rate ef meniscus repairs using a first-generatien device
{Meniscus Arrew, Bienx) was fmnd te deterierate frem
appreximately 91% at 2—year fellew—up te T1551”: at GAS—year
fellew—up.” There are few reperts ef secend-leek arthres-
cepy. Secend-leelc arthrescepy was dene an average ’14
menths after 52 all—inside meniscal repairs ef red—red and
red-white aene lengitudinal tears using the FasT-Fix device
and dene at the time ef ACL recenstructien.” The heal-
ing rate was ?4%; an additienal 15% were incempletely
healed, and 11% had net healed. Clinical success was net
equivalent te healing; enly ene ef the unhealed repairs had
mechanical symptems at the time ef the secend surgery.
Bielegic grafts are available fer a number ef applicatiens.
They are cemmenly used fer ligament recenstructien
and tenden augmentatien. Allegrafts have a better clini-
cal traclc recerd with better eutcemes and fewer adverse
events cempared te xenegraft and synthetic materials.
ACL recenstructien allegrafts have preyen effective,
previding cemparable results te autegrafts witheut the
issues ef dener site merbidity and mere difficult rehabil—
itatien. Fer patients whe are net aggressive piyeting er
centact athletes and whe are elder than 25 years, there
is ne cencern abeut allegraft use. Allegrafts that are
chemically precessed er irradiated de net perferm as
well as deep-freaen, chemical-free, nenirradiated grafts.
Acellular dermal matrix allegrafts can augment retater
cuff tenden healing, especially in tears greater than 3 cm
in length and these with the petential fer peer healing.
As suture ancher designs centinue te deyelep, the trend
is teward biedegradable and plastic anchers centaining
several {usually up te 3} UHMWPE—centaining sutures.
Eyelets are cemmenly feund at the insertien end ef the
ancher facilitating sliding, leclting [met-tying. Screw type
anchers are strenger than ether designs. Gleneid anchers
are smaller than retater cuff repair anchers te mere easily
fit inte the denser smaller gleneid bene. These smaller
gleneid anchers de net effer the higher failure leads ef
the larger anchers but are clinically apprepriate fer the
designed envirenment. Knetless anchers centinue te be
intreduced and are principally designed fer the lateral
rew ef a deuhle-rew retater cuff repair.
Altheugh several implants are available te assist in
arthrescepic meniscal repair, the key te meniscal repair
healing is a geed bleed supply, the absence ef meniscal
degeneratien, and a stable knee. The current all—inside
techniques use a suture-based, self-adjusting meniscus
repair device with nenabserbable UHMWPE-centahiing
suture attached te PEEK anchers and cennected by a
pretied, sliding, and self-lecking knet.
fl lflld American Academy ef Urthepaedic Surge-ens
 Chapter 33: The Biology and Biomechanics of Grafts and Innplants
Key Study Points
' BPTB allograft ACL reconstruction is an effective
technique in most patients. The issue arises for the
younger aggressive, noncompliant athlete who is
unwilling or unable to follow a slow recovery plan.
I: The use of chemically processed or irradiated al-
lografts is associated with higher failure rates.
I Several biodegradable suture anchors made from
different materials are available. More rapid poly-
mers are more likely to develop inflammatory re-
actions. An appreciation that different materials
behave differently is essential to the proper selection
of an anchor.
Annotated References
1. Mansson fl, Sernert H, Rostgard- Christensen L, Kartus J:
Long-term clinical and radiographic results after delayed
anterior cruciate ligament reconstruction in adolescents.
Am J Sports Med 2015:43i1‘JflBE-145. Medline DD]
ACL reconstruction in adolescents led to more osteo-
arthritic changes in the treated knee than in the nonin-
volved knee at long-term follow-up. Clinical outcomes and
health-related quality of life were comparable to those of
healthy control subjects. Level of evidence: IV.
2.. Mather RC III, Hoenig L, Kocher MS, et al: MD DH Knee
Group: Societal and economic impact of anterior cruciate
ligament tears. } Bone joint Sarg Am 2013:95{19]:1?51—
1159. Medline DD]
AEL reconstruction was found to be cost-effective and to
reduce societal costs relative to rehabilitation if indirect
cost factors, including work status and earnings, were
considered.
3. Mohtadi HG, Chan D5, Dainty FIN, Whelan DE: Patellat
tendon versus hamstring tendon autograft for anterior
cruciate ligament rupture in adults. Cochrane Database
Syst Rev 201 1:9:CDDDSHSD. Medline
it}. Gorschewsky C}, Klakow A, Riechert K, Pita] M, Becker
There was insufficient evidence to draw conclusions as
to the differences in long~term functional outcome after
patellar and hamstring tendon autografts were used. After
patellar tendon reconstruction, knees were more likely to
be stable but had more anterior issues. Medline D01
4. Li S, Chen Y, Lin 2, l[Sui W, Ehao J, Su W: A systematic
11.
review of randomised controlled clinical trials comparing
hamstring autografts versus bone-patellar tendon-hone au-
tografts for the reconstruction of the anterior cruciate liga-
ment. Arch flrthop Trotters Stir-g 201 2,11 SllfllflEST—IEHT.
Hamstring tendon and EPTE autograft ACL reconstruc-
tions similarly restored postoperative knee joint func-
tion. Hamstring tendon autografts were inferior to BPTB
ID EDIE American Academy of Drthopaedic Surgeons
autografts for restoring knee joint stability but were associ-
ated with fewer postoperative complications.
Li S, Su W, Zhao J, et al: A meta—analysis of hamstring
autografts versus bone~patellar tendon-bone autografts
for reconstruction of the anterior cruciate ligament. Knee
2011,1136 }:23?-293. Medline DUI
EPTE autografts led to better knee stability on the KT-
lflflfl, Lachman, and pivot tests. Hamstring tendon au-
togra fts led to fewer postoperative complications, such as
anterior knee pain, kneeling pain, and extension loss. No
differences were found in graft failure rates.
Tunes l'vi, Richmond JC, Engels EA, Pincaewski LA:
Patellar versus hamstring tendons in anterior cruciate
ligament reconstruction: A meta-analysis. Arthroscopy
2Ufl1;l?{3}:243-25?.Mcdlinc DDI
KimJG, 1fang S], Lee TS, Shim JC, Ra H], ChoiJY: The ef-
fects of hamstring harvesting on outcomes in anterior cru-
ciate ligament-reconstructed patients: A comparative study
between hamstring-harvested and -u nharvested patients.
Arthroscopy 2fl11;2?{9}:1226-1234. Medline DUI
ACL reconstruction led to substantial knee flexion weak-
ness in comparison with the unaffected knee, irrespective
of hamstring tendon harvesting. The increase in knee
flexor deficit in patients who underwent hamstring tendon
harvest was significant in comparison with those who
received an allograft. Level of evidence: III.
Barker JU, Drakos MC, i'viaak TE, Warren RF, Williams
RJ III, Allen AA: Effect of graft selection on the incidence
of postoperative infection in anterior cruciate ligament
reconstruction. Am I Sports Med lfllfl;SS{2}:ZSI-ZSE.
Medline DUI
Hamstring tendon autografts have a higher incidence of
infection than EPTE autografts or allografts. The use of
allograft material in ACL reconstruction does not increase
the risk of infection or the need for graft removal with
infection. Level of evidence: III.
Krych A], Jackson JD, Hoskin TL, Dahm DL: A me-
ta'analysis of patellar tendon autograft versus patellar
tendon allograft in anterior cruciate ligament reconstruc-
tion. Arthroscop-y 2GflS;14{3}:291—193. Medline Dfll
It: Clinical comparison of the Tutoplast allograft and F'."
autologous patellar tendon {bone-patellar tendon-bone} E
fir
for the reconstruction of the anterior cruciate ligament: n
E
2- and 6—year results. Am J Sports Med lflflSfiSiSJfllfll— F
12.69. Medline DUI 5
I'D
D
I:
H'I
Sun If, Ehang J, 1|Ifang Y, et al: Arthroscopic anterior _.1
D
cruciate ligament reconstruction with at least 2.5 years’ "E.
n
follow-up comparing hamstring tendon autograft and ”I
irradiated allograft. Arthroscopy lfllltlflfilfllfifi-1 21111.
Mcdline DUI
The use of irradiated hamstring tendon allografts led to
significantly more instability and joint laxity than the
use of hamstring tendon autografts. However, IKDC
Drthopoedic Knowledge Update: Sports Medicine 5
 Sectiun 5: Miscellaneous Tupics
functinnal and subjective scnres nr activity levels did nnt
differ. Level uf evidence: II.
12. Ellis HB, Matheny Ll‘vf, Briggs Eli, Pennnclt AT, Steadman
JR: Dutcumes and revisiun rate after hune-patellar ten-
dun—bune allugraft versus autugraft anteriur cruciate lig-
ament recunstructiun in patients aged 13 years nr ynunger
with clnsed physes. Arthrnscnpy lflll:lB{12]:1319-1325.
Medline DUI
Nu significant differences in functiun, activity, ur satisfac-
tinn were fnund after allngra ft nt autugraft recunstructiun
in patients ynunger than 19 years. The allngrafts were
unsuccessful 15 times mute uften than the autugrafts. All
failures ucc urred during the first year after recunstructiun.
Level uf evidence: III.
13. Barber FA, Cuwdcn CH III, Sanders E]: Bevisinn rates after
anterinr cruciate ligament recunstructiun using hnne-pa-
tellar tendun-hune allngraft ur autugraft in a pupulatiun
25 years uld and yuunger. Arthrusenpy 2fl14;3fl{4}:4fl'3-
491. Mcdline DUI
Becnnstructinns using BPTB allngrafts that were nnt ir—
radiated ur chemically prucessed were nu mure successful
than thuse using BPTB autugrafts in patients nu ulder
than 25 years. Rehabilitatinn prngrams varied. Clinical
nutcnme scnres did nnt differ. Level nf evidence: III.
14. Barrett (3, Stnltes D, 1|I'lii'l'iite M: Anterinr cruciate ligav
ment recnnstructinn in patients nlder than 4i] years: fil-
lugraft versus autugraft patellar tendun. An: I Spurts Med
1fl05;33{1flj:1505—1512.Mndline nu:
15. Barber FA, Asia-Jacuhu J, Dru FE: Anteriur cruciate
ligament recunstructiun using patellar tendnn allngraft:
An age-dependent nutcnme evaluatinn. Arthrnscnpy
2fl10;26{4}:433-493.Medline DID]
llil'utcumes uf BPTB allngraft ACL recunstructiun did nut
subjectively nr uhjectively differ based nu whether pa-
tients were ynu nger than 4i] years nr nlder than 40 years.
Patients in h-uth age gruups had cunsistent results. Level
uf evidence: III.
16. Fuster TE, Wulfe BL, Ryan 5, Silvestri L, Kaye EH: Dues
the graft snurce really matter in the nutcnme nf patients
undergning anterinr cruciate ligament recunstructiun?
An evaluatiun uf autugraft versus allngraft recunstruc-
tiun results: A systematic review. Ann I Spurts Med
lfllflgfifliliflflfl—ISB.Medline nut
E allngraft. Patients were in their late Ills and early Sills.
IE
I—
In Nu specific graft snurce was fnund tn be clearly superiur
:5
D tn nthers. This finding led tn the cnnclusinn that the graft
IBil
E suurue has a minimal effect cm the nutcnme uf patients
J! undergning ACL recunstructiun.
E 23. Yan LW, Wang Q, Zhang L, et al: Patellar tendnn autugraft
.E
5 1?. Butchers JR, Pedruza A, Kaeding C: Activity level and
LE
graft type as risk factnrs fnt anterinr cruciate ligament
graft failure: A case-cnntrnl study. Am ] Spur-ts Med
2fl09;3?{12}:1362-236?.Medline DUI
Stratum-specific udds ratius revealed a multiplicative
interactiun between higher activity level after ACL
firthnpaedic Knnwledge Update: Spnrts Medicine 5
recunstructiun and allngraft use, such that the ndds nf BEL
graft failure were greatly increased. Level uf evidence: III.
13. Barrett GR, Luher K, Replngle TH, Manley JL: Allngraft
anteriur cruciate ligament recunstructiun in the yuung,
active patient: Tegner activity level and failure rate. Ar-
thtnscnpy Zfllfltlfiillltljflfi-lfifll. Medline Dfll
Fresh—frnsen BPTB allngrafts shnuld nnt be used fnr ACL
recunstructiun in yuung patients whu will return tu a high
activity level. The failure rate in such recunstructiuns was
1.6 tn 4.2. times higher than if patients returned tn a lnw
activity level. Level nf evidence: III.
15'. Mascarenhas B, Trannvich M, Karpie JG, Irrgang J], Fu
FH, Ha met CD: Patellar tendnn anterinr cruciate ligament
recunstructiun in the high-demand patient: Evaluatiun uf
autugraft versus allngraft recunstructiun. A-rternsccpy
lfllfl:2fii9, Suppl}:553-Sfin. Medline DUI
In patients with high physical demands at 3- tn 14-year
fulluw-up, autugraft and fresh-frusen allngraft BPTB ACL
recunstructiuns had similar patient-repurted and uhjective
nutcnmes. Level nf evidence: III.
ID. Kaeding CC, Arcs B, Pedrnaa A, et al: Allegraft 1hier—
sus Autngraft Anterinr Cruciate Ligament Recnnstruc-
tiun: Predicturs uf Failure Frum a MDGN Pruspective
Lungitudinal Cuhurt. Spurrs Herrftb 2fl11;3{11:?3-31.
Medline DUI
11. Kracutler M], Bravman JT, McCarty EC: Bnne-patellar
tendnn-bnne autugraft versus allngraft in nutcnmes nf an-
teriur cruciate ligament recunstructiun: A meta-analysis uf
5131 patients. An: ] Sports Med lfllB;41{1fl}:2439-2443.
Medlinc DUI
ACL recnn structinn with BPTB autugra ft led tn less graft
rupture nr lrnee laxity, better results nn single-leg hnp
tests, and greater patient satisfactiun than ACL recun-
structicn with BPTB allngrafts.
21. Mariscalcu MW, Magnussen RA, l'viehta D, Hewett
TE, Flanigan DC, Handing CC: Autngraft versus nun-
irradiated allngraft tissue fnr anterinr cruciate ligament
recunstructiun: A systematic review. Arr: ,7 Spurts Med
1014;42{2}:491—499.Medline nu:
A systematic review fnund nn differences in graft failure,
pnstnperative laxity, nr nutcnme scnres in a cnmparisnn
uf ACL recunstructiuns using autugraft ur nunirradiated
These findings shnuld nut be extrapnlated tn ynunger,
mnre active patients.
versus patellar tendnn allngraft in anteriur cruciate liga-
ment recunstructiun: A systematic review and meta—anal-
ysis. Eur ] flrrhnp Snrg Trannrarnf 21315;}! 5iEJ:355-365.
Medline DD]
a meta-analysis fnund nn clinical differences after BPTB
autugraft ur allugraft was used in primary ACL recun-
structiun. Overall, mute clinical failures were ubscrvcd
when allngraft was used. Fresh-frnsen allngrafts had
fl lfllfi American Academy nf Drrhnpaedic Surge-ens

results equivalent te these ef autegrafts excePt in Tegner
sceres.
24. Cvetanevich UL, l'viascarenhas R, Saccemanne MP, et al:
Hamstring autegraft versus seftwtissue allegraft in anterier
cruciate ligament recenstructien: A systematic review and
meta-analysis ef randemieed centrelled trials. Arthresce-
py aeia;3enr}:1sis-1saa. Medliue DUI
A review ef randemiaed centrelled studies cemparing
hamstring tenden auregraft and seft-tissue allegra ft ACL
receustructiens feund ne significant eutceme differences.
Level ef evidence: II.
2.5. Clatwerthy MG, Annear P, Bulew JU, Bartlett R]: Tun-
nel widening in anterier cruciate ligament recenstrue-
tien: A prespective evaluatien ef hamstring and patella
tenden grafts. Knee See-g Sperts Trexmefei Arthresc
1999;?{3l:133-145.Medliue DUI
26. Nebelung 5, Deitmer U, Gebing R, Reichwein F, Nehelung
W: High incidence ef tunnel widening after anterier cruci-
ate ligament recenstructien with transtibial femeral tunnel
placement. Arch Urtfrep Trauma Surg EBI 2;]31i11}:1553-
1663. Medline D-UI
Clinical and MRI exa miuatien ef 55" primary ACL recen—
structiens with quadrupled hamstring tenden autegraft
at a mean 61-menth fellew-up feund that tunnel cress-
sectienal areas had mere than deubled. I-Iewever, ltnee sta-
bility er fu nctien was net affected. Level ef evidence: IV.
1?. Achtnich A, Stiepani H, Ferltel P, Metelaff S, Hiinninen EL,
Petersen W: Tunnel widening after anatemic deuble-bun-
tile and mid-pesitien single-bu ndle anterier cruciate liga-
ment recenstructien. Arthrescepy' Zfil3;29{9}:1514-1524.
Medline DUI
Pesteperative tunnel widening was evaluated after ham-
string tenden feur-tunnel deuble-bundle and hamstring
tenden [we-tunnel single-bundle ACL recenstructiens. At
H-menth fellew-up, MRI revealed significant widening in
all bene tunnels, with en difference between the types ef
recenstructien. Level ef evidence: III.
23. Sabat D, Kundu K, Arera 5, Humar V: Tunnel widening
after anterier cruciate ligament recenstructien: A prespec-
tive randemixed cemputed temegraphy—based study cem—
paring 2 different femeral fixatien metheds fer hamstring
graft. Arthrescepy lfllI;l?{ti}:??E-T33. Medline DUI
After quadrupled hamstring tenden ACL recenstructiens
with femeral fixatien using the EndeButten er Transfix,
tunnel widening was measured en UT at intervals tn 6
menths. Tunnel widening was significantly less with the
Transfix than the EndeButten. Level ef evidence: II.
29. Barber FA, Burns JP, Deutsch A, Labbf: ME, Litchfield RB:
A prespective, randemieed evaluatien ef acellular human
dermal matrix augmentatien fer arthrescepic retater cuff
repair. Arrhrescepy 2012:23i1}:3-15. Medline DUI
Repair ef large retater cuff tears augmented using acel-
lular human dermal matrix led te higher eutceme sceres
than uenaugtnented repairs. Un MRI, 35% cf augmented
IE! Eillii American Academy ef Urthepaeclic Surgeena
Chapter 33: The lilielegy and Eiemechanics ef Grafts and Inaplants
repairs and 40% ef nenaugmented repairs were intact [P
e [LEI]. Level ef evidence: II.
30. Barber FA, Herbert MA, Ueens DA: Tenden augmentatien
grafts: Biemechanical failure leads and failure patterns.
Artbrescepy 2006;32{5}:334-533. Medline DUI
31. Barber FA, Arie-Jacebe J: Biemechanical testing ef cem-
mercially available seft-tissue augmentatien materials.
Arthrescep'y EDU9;15{11}:1233-1139. Mcdlinc DUI
Acellular human cellagen matrix grafts {Graftiacltet er Al-
lepatch] were strenger with cyclic leading and had greater
suture retentien strength than synthetic er xenegraft mate-
rials {Spertbiesh er UrdiAdapt} as well as greater stiffness.
32. Derwin KA, Baker AR, Spragg BK, Leigh DR, Iannetti JP:
Cnmmercial extracellular matrix scaffelds fer retater cuff
tenden repair: Eiemechanical, biechemical, and cellular
preperties. J Renee feint 5mg Am Zflflfitflflfllltlfit'iS-EEFE.
Medline DUI
33. Aurera A, McCarren J, Iannetti JP, Derwin K: Cemrner-
cially available extracellular matrix materials fer retater
cuff repairs: State ef the art and future trends. J Sheeider
tere Stir-g lflflfilfiii, Suppll:51?1-SI?3. Medliue DUI
34. Derwin HA, Eadylalt SF, Steinmann 5P, Iannetti JP:
Extracellular matrix scaffeld devices fer retater cuff
repair. I Sherrider Effrere Sarg 1B1fl;19{3}:467a4?6.
Medline DUI
A review ef the basic science and clinical understanding ef
extracellular matrix scaffelds fer retater cuff repair em-
phasized the best immune respense, scaffeld remedeling,
mechanical and suture retentien preperties, and clinical
studies. Level ef evidence: IV.
35. Sclamberg EU, Tibene JE, Itamura JM, Kasraeian 5: Six-
menth magnetic resenance imaging fellew-up ef large
and massive retater cuff repairs reinferced with pet-
cine small intestinal submucesa. J Sheaftier Eihew Sin-g
lflfl4:13[5}:533-54LMedline DUI
36. Walten JR, Eewman NH, Khatib ‘r, Linldater J, Murrell
lGA: Restere erthebielegic implant: Net recemmeuded fer
augmentatien ef retater cuff repairs. ] Eerie Jefrtt Surg
Am. lflfl?:39{4}:?35—?91. Medline DUI
3?. Malcarney HL, Benar F, Murrell GA: Early inflammamry F'."
teactieu after retater cuff repair with a percine small E
intestine submucesal implant: A repert ef 4 cases. An:
fir
n
I Sperfs Med 10fl5t33ffiltfifl 1911. Medline DUI E
F
5
I'D
U
33. Evie-Barren JA, l'illcs RA, Chen K, Iannetti JP, Der- I:
H'I
win KA: Impreved time-aere biemechanical preperties _.1
using pely—L-lactic acid graft augmentatien in a cadav-
U
"E.
eric retater cuff repair medel. J Sheaidsr Elbert: 3mg
n
”I
2fl1fl;19{5}:633-696.Medline DUI
39. lcCa rry LP III, Buss DD, Datta MW, Freehill MU,
Giveans MR: |Cemplicatiens ebserved fellewing labral er
retater cuff repair with use ef pely-L-lactic acid implants.
J Benejefflt Surg Am EDI awareness-511. Medline DUI
Urthepaedic Knuwledge Update: Sperts Medichie 3
 Sectien 5: Miscellaneous Tepics
Ferty-feur patients had macrescepic hiedegradahle ancher
debris after sheulder débridement. IIGress and histelegic
examinatien shewed giant cell reactiens (34%], pelarizing
crystalline material {100%}. papillary synevitis {T9 ‘34:}, and
grade 3 er 4 chendral damage {Tfl‘ie's}. Level ef evidence: N.
4D. Park M], Hsu J E, Harper (3, Sennctt B], Huffman
GR: Pely-LiD-lactic acid anchers are asseciated with
reeperatieu and failure ef SLAP repairs. Artfrrescepy
1fl11,1?{1i}}:1335-134fi.Mcdline eel
Eieabserbahle PLPEID4LA suture anchers were feund
mere eften than nenahserhahle anchnrs in unsuccessful
superier labrum anterier and pesterier repairs and sec-
eud surgeries. The use ef these suture anchers sheuld he
aveided. Level ef evidence: IV.
41. Barber FA, Deckery WU, lL'Iewden CH III: The degrada-
tien eutceme ef hiecempesite suture anchers made frem
pely L-lactide-ce-glycelide and B-tricalcium phesphate.
Artfrrescepy 1fl13;19{11}:1334-1339. Medline DUI
A PLLAfPGA—fl—TCP suture ancher {Healisr BR, Depuy
Synthesj was feund te he cempletely degraded and fully
reahserhed 3 years after implantatien. IElsteecenduct‘ivity
was ehserved at Tlfff: ef ancher sites and was cemplete er
almest cemplete in 50%. Level ef evidence: I‘v".
41. Barb-er FA, Deckery WD, Hrnaclc SA: Leng—term degra-
datien ef a pely-lactide ce-glycelidcffl-tricalcium phes-
phate hiecempesite interference screw. Artbrescepy
2fl11;2?{5j:63?-643.Medline DD]
A FLLAfPGAffi-TCP interference screw {Milagre, Depuy
SynthesJ was feund te he cempletely degraded and fully
reahserhed 3 years after implantatien. Dsteecenductivity
was cenfirmed in 31% ef patients, and the screvvr cemplete-
ly filled the prier screw site in 19%. Level ef evidence: IV.
43. Barber FA, Deckery WU: Lung-term abserptieu ef he-
ta—tricalcium phesphatc pely—L—lactic acid interference
screws. Artfrrescepy lflfl3:24{4]:441-44?. Medline Dfll
Martinek V, Scil R, Lattcrmann C, Watkins 5C, Fu FH:
The fate ef the pely—L-lactic acid interference screw after
anterier cruciate ligament recenstructien. Arthrescepy
2fl01;1v{1}:vs—vs.sssaliae net
45. Stiihelin AC, Weiler A, Riifenacht H, Heffmanu FL, Geiss-
mann A, Feinstein R: lElinical degradatien and hiecem—
patihility ef different hinahserhable interference screws:
3
IE
I— A repert ef six cases. Afifrrescepy 199?;13{2]:233-144.
us
:5 Medline DID]
D
IBil
E
J! 45. Biistman GM, Fihlajamiilti HE: Adverse tissue reactiens
E expesed lcnets en the heny surface ef the retater cuff
.E te hieahserhahlc fixatien devices. Efisr Osiris-rip Refat Res
5 lflflfltdflflld-EZEMedline DUI
LE
4?. Edwards DJ, Hey G, Saies AD, Hayes MG: Adverse reac-
tiens te an ahserhahle sheulder fixatien device. } Shut-rider
Effsetrr Surg 1994;3[4h13fl-133. Medline DUI
4B. |lEelzlaleda Aristiaahal AF, Sanders E], Barber FA:
Adverse events asseciated with hiedegradahle
firthnpaedic Knewledge Update: Sperrs Medicine 5
lactide—centaining suture anchers. Artbrescepy
lfl14;3fl{5}:555-560.Medline DUI
Ancher-specific adverse events eccurred in 1 cf 36f} pre-
cedures (I15%}. The enly material—related event eccurred
when a PmDSflLA ancher released the eyelet suture,
which migrated intn the jnint and caused chendral dam-
age. He events eccurred with the use ef hie-cemp-esite
PLLAi'fl-TCP auchers. Level ef evidence: I‘v'.
49. Barber FA, Deckery WD: Leng-term ahserptien ef
pely—L—lactic Acid interference screws. Artistescepy
2Bflfi;22{3}:BZG-Eld.Medline DUI
5D. Barber FA, Bava ED, Spenciner DB, Piccirille J: Cyclic
hiemechanical testing ef hiecempesite lateral rew ltnnt-
less anchers in a human cadaveric medel. Arrfrmscepy
1s13,ss:s}:1n12—1ms. Mcdliue net
The use ef th readed hiecempesite lrnetless anchnrs {Healitt
and Bie-SwiveLeclt, Arthres} led te less displacement and
higher failure leads than the use ef nenthreaded hie-cem-
pesite anchers {PushLeclc}. Healis: knetless anchers had
the lewest rate ef displacement.
51. Vaishnav 5, Millett P]: Arthrescepic retater cuff repair:
Scientific ratienale, surgical technique, and early clinical
and functienal results ef a ltnetless self-reinfercirlg deu-
hle-rew retater cuff repair system. I Sfretrfder Effaetrr 3mg
release, 5uppl]:33-9{l. Medline Den
The knetless self-reinfercing dual-rew repair system
previded impreved centact area and restered the native
feetprint ef the retater cuff tendee, leading te impreved
eutcemes. Level ef evidence: I‘v'.
51. Kheury LU, Ewen YW, Hummer F]: A nevel methed te
determine suture ancher leading after retater cuff repair:
A study ef twe deuhle-rew techniques. Ball NYU Heap
y: es summarises-as. Medline
Medial anchers withsteed greater leads than lateral
anchnrs in dual-raw censtructs {revs versus 21%} and
suture-bridge censtructs [dT‘f’s versus 33%]. Abductien
{45‘ re ET] had little effect en ancher tensiens. Internal
and external retatien increased anterier er pesterier an—
cher leads in heth rews.
53. ‘r'amaltade K, Katsue S, Miaune K, Araltawa H, Ha—
yashi S: Medial-rew failure after arthrescepic deuhle-rew
retater cuff repair. Arrhrescepy 2B1fl;2fi{3}:43l}-435.
Medline [ll-DI
Medial-rew mattress suture pulleut eccurred in feur pa—
tients after dual—raw arthrescepic retater cuff repair. The
tenden was avulsed at the medial rew, and there were
feetprint. Level ef evidence: 11".
54. Schneeherger AG, veu Rel] A, Kalherer F, jaceh HA,
Gerber {3: Mechanical strength ef arthrescepic retater
cuff repair techniques: An in vitre study. ] Herr-s Jeiirt
Surg Am 1Dfl2;E4 -A{12}:1151-116l}. Medline
fl lflld American Academy ef Urrhepaedic Surge-ens

5.5. Barber FA, Herbert MA, Hapa U, et al: Biemecbanical
analysis nf pulleut strengths ef retater cuff and gleneid
anchers: 2011 update. Arthreseepy Zfl11:2?{?}:395-905.
Medline DUI
Lnad tn failure was fnund tn depend nnt en anchnr inca-
tien {cancelleus er certical bene} but en anchnr type {cuff
ancher er gleneid ancher]. Relatively large, fully-threaded
screw-in rntatnr cuff anchers had higher failure strengths
than smaller, nenscrew glennid anchnrs.
55. Mahar A, Allred DW, Wedemeyer M, Abbi U, Pedewita
R: A biemechanical and radiegraphic analysis ef stan-
dard and intracertical suture anchers fer arthrescepic
rntatnr cuff repair. Arthrescnpy 20U6;12{1}:13Il-135.
Medline DUI
5?. Barber FA, Herbert MA, Cnnns DA, Bnnthby MH: Su-
tures and suture anchnrs: Update 2006. A-rthreseepy
Zflflfiglll’lfllflflffl.e1-1fl63.e5.Medline DUI
53. Barber FA, Herbert M, Click JIM: Recent suture aneher
develepments. Arthrnseepy 1996;12:361-362. DUI
59. Barber FA, Herbert MA: Suture anchers—update 1959.
Arrhreseepy 1999:15iflfl19-TES. Medline DUI
BB. Barber FA, Herbert MA, Hapa U, et al: Biemechanical
analysis uf pullnut strengths nf rntatnr cuff and gleneid
anchnrs: lflll update. Artbrfl-Sflflpji 2fl11;2?{?}:395‘905.
Medline DUI
61. Barber FA, Herbert MA, Richards DP: Sutures and suture
anchers: Update Zfiflfi. Arthreseepy 2Bfl3:19[9]:935-990.
Medline DUI
62. Bensnn EC, MaeDermid JC, Dresdnwech D5, Athwal
US: The incidence nf early metallic suture anchnr pull-
nut after arthrnscnpic rntatnr cuff repair. Arthrescepy
lfllfl;26{3]:31fl—315. Medline DUI
There was a minimal risk ef suture ancher pulleut in
small- tn medium-size tears, but the risk increased with
tear siae. Rnutine radingraphic fnllnw—up after the use nf
metallic anchnrs was recemmended te identify anchnr
pulleut. Level nf evidence: III.
63. Uneminne S, Debeer P: Delayed migratien ef a metal
suture anchnr intn the glennhumeral jnint. Acte Urthep
Belg 1B1fl;?fi{6}:334-33?. Medline
Intra-articular migratinn ef a metallic suture anchnr nc-
curred T years after epen labral recenstruetien. Surgeens
sheuld be aware ef pessible aneher migratien in patients
with sharp nr persistent pain, catching sensatiens, nr lnss
ef mebility. Level ef evidence: IV.
E4. Dhawan A, Uhedadra N, Karas V, Salata M], Cele B]:
Cnmplicatiens ef binabsnrbable suture anchnrs in the
shnulder. Am I Sperts Med 2912;4fll61fl424-143I}.
Medline DUI
Ten binabsnrhable anchnr—related cemplicatinns were
rcperted te the US Feed and Drug Administratien in
2003, representing a small fractien ef bieabserbable
IE! EBIE American Academy ef firthepaedic Surgeries
Chapter 33: The Bielegy and Binnieehanies ef Grafts and Implants
anchnr implantatiens. The use nf bieabsnrbable suture
anchers remains safe, repreducible, and censistent. Level
nf evidence: IV.
65. Barber FA, Click JH: The effect ef inflammatery syne-
vial fluid en the breaking strength nf new i“lung lasting”
absnrbable sutures. Arthrnseepy 1991;3{4}:43T—441.
Medline DUI
66. Barber FA, lGurwita US: Inflammatnry synnvial fluid and
abserbable suture strength. Arthrescepy IEBB;4HI:2?2-
27'7. Medline DUI
5?. Barber FA, Herbert MA, Beavis RC: Cyclic lead and
failure behavinr nf arthrescepic knets and high strength
sutures. Arthrescepy lflfl?:25{1}:192-199. Medline DUI
Knet security and lead-te—failure strength was studied in
several types ef sutures.
63. Abbi I3, Espinesa L, Udell T, Mahar A, Pedewita R: Eval-
uatien ef 5 hunts and 2 suture materials fer arthrescepic
rntatnr cuff repair: Very strung sutures can still slip. Ar-
thrnscepy 10B6;12[1]:33-43. Medline DUI
69. Fisher MB, Jung H], McMahnn P], 1illl'nn 5L: Suture aug-
mentatien fellewing AUL injury te restere the funetien
ef the ACL, MEL, and medial meniscus in the gear stifle
jnint. ,7 Hines-reel: lflll;44{3}:153D-1535. Medline DUI
Suture augmentatinn may be helpful in ACL healing in
cnmbinatinn with functienal tissue-engineering apprnach-
es by previding initial jeint stability while lewering leads
en the medial meniscus.
TU. Barber FA, Herbert MA, Bava ED, Drew UR: Bieme-
chanical testing nf suture-based meniscal repair devices
centaining ultrahigh-mnlecular-weight pnlyethylene su-
ture: Update 213-11. Arthreseepy EGIE;EE{EJ:32?—334.
Medline DUI
All-inside meniscal repair devices use UHMWPE suture
with fixatinn cemparable tn that nf vertical mattress suture
repairs. The Umflispflfl, (flinch, Sequeut, and FasT—Fiir 315i]
were frmnd te be equivalent tn suture repair. The MairFire
device had significantly lewer leads tn failure and survived
less cyclic leading than nther devices.
TI. Likes RL, jullca A, Arns BC, et al: Meniscal repair with
the MasFire device: A cadaveric study. Urtfeep Burg
2011:3{4}:259'264.Medline DUI F'."
E
[if 54 MaxFire devices placed in cadaver knees, I?%
fir
n
failed during device tensiening. Three sutures brnke, ene E
F
cnnld nnt he reduced, and twn pulled nut nf the meniscus. 5
I'D
D
I:
H'I
11. M Buckland D, Sadeghi P, Wimmer MD, et al: Meta-anal- _.1
U
ysis en biemechanical preperties ef meniscus repairs: Are "E.
devices better than sutures? Hesse Snag Sperts Tmnmetel
n
”I
firth-rest: 2015;23l1}:33-39. Medline DUI
A meta-analysis nf 41 studies feund that the leads tn fail-
ure ef vertically nriented meniscus repair sutures were su-
perier te these ef herizental sutures. Seme meniscal repair
devices have biemechanical preperties similar tn these ef
Drthepnedic Knnwledge Update: Sperrs Medicine 5
 Section 5: Miscellaneous Tupics
suture repairs. Seccrnd-generaticrn devices are significantly
stranger and stiffer than first-generatinn devices.
F3. 1ilii'estermann R'ilii’1r Wright RW. Spindler KP, Hustcn L],
1Wnlf ER; MD UN Knee IErnup: l'vIeniscal repair with cun-
cnrrent anteriur cruciate ligament reccrnstructiun: Dpera-
tive success and patient nutccrnes at 5-year fullc-w—up. Am
1 Sparta Med lfll4:42[9]:2134-2193. Medline DUI
|[Zinncurrent meniscal repair-REL reccrnstructiun was
assnciated with an apprnrcin'rately 14% rate nf failure at
6-year fullcw-up. Imprnvement in patient—nriented cut—
cnme sccres was sustained at 6-year fullnw-up. and gnnd
clinical nutccrmes were present. Level cf evidence: III.
7’4. Walter RP, Dhadwal A5, Schrana P. Mandalia V: The
nutccrnre cf all-inside meniscal repair with relatinn tn
previnus anterinr cruciate ligament recunstructicrn. Knee
2fl14;21{6}:1156-1159.Medline Dfll
Retruspective review of all-inside meniscal repairs with
cc-ncc-mitant REL recnnstructinn fnund a 9% meniscal
tenperatinn rate. The rate was 3?% after all-inside repair
with previc-us ACL reccm structinn. Level cf evidence: IV.
5'5. Kuraweil PR1 Lynch NM, Cnleman 5, Kearney R: Repair
cf hnriscntal meniscus tears: A systematic review. Ar-
tbrnscnpy 2014:3fli11}:1513-1519. Medline DUI
A systematic literature review did nut suppnrt the hypnth-
csis that surgical repair cf meniscal heriauutal cleave tears
has an unacceptably lnw success rate. When renperaticn
E?
IE
I—
hl'r
:5
D
IIII
E
J!
E
.E
5
LE
firthnpaedic Knnwledge Update: Sparta Medicine 5
was used tn define failure, If? cf 93 repairs 913%] were
successful. Level cf evidence: IV.
'?6. Espejc-Reina A. Serrann-Fernandea ll, Martin-Cas-
tilla B, Estades-Rubiu F], Briggs KK, Espejn -Baena A:
Clutccrmes after repair c-f chrnnic bucket-handle tears crf
medial meniscus. Arthrnscnpy Eflldgfiflfllflflldfifi. Med-
line D-DlRepairs cf chrc-nic bucket-handle meniscal tears
had gun-0d clinical nutcnnres and a relatively lnw failure rate
(ITEM. Repairs cf isulatcd meniscal tears were significantly
less likely tn succeed than repairs dune in cnnjunctinn with
REL recnnstrncticI-n. Level nf evidence: IV.
3'1 Lee GP. Diduch DR: Dietetic-rating nutcnmes after menis-
cal repair using the Meniscus Arr-aw in knees undergning
cnncurrent anteriur cruciate ligament rccnnstructinn: In—
creased failure rate with lung-term fullnw—up. Am 1 Sparta
Med 2fl05;33{31:1138-1141. Medline DD]
T3. Tachihana Y, Sakaguchi R. Gutt- T. |Elda H, ‘r'amasa-
lci K, Iida 3: Repair integrity evaluated by seccrnd-lnult
arthroscnpy after arthrnsccrpic meniscal repair with the
FasT—Fia: during anteric-r cruciate ligament recc-nstructicn.
Am. I Spurts Med Zfllfl;33{5]:955-9?l. Medline DUI
Secnnd-lnnlt arthrcrscc-py was used tn evaluate 55 FasT-Firr
meniscal repairs with cnncnrnitant REL reccnnstructinn;
74% were cnmpletely healed, 15% were incumpletely
healed, and 11% had not healed. Regardless cf meniscal
integrity, 33% {If menisci were symptnm free. Level c-f
evidence: W.
fl lfllfi American Academy crf Urrhnpaedic Surge-ens
Medical Issues
Chapter 39
Sports Nutrition
Iacqueline R. Berning, PhD. RD. CSSD Kelly L. Neville. M5
Diet is a factor in human performance. bio amount of
training or natural ability ensures peak performance
without the proper fuel for the exercising muscles.
A knowledge of carbohydrate, protein, and fat con-
sumption for athletes is imperative for sports medicine
professionals who work in athletic environments. Ad-
ditionally, providing science-based information and
recommendations regarding hydration before, during,
and after exercise can help athletes perform at their peak.
Keywords: diet and sports performance:
hydration: pregame meals: recovery nutrition:
competition eating
Introduction
Athletes invest a lot of time and effort in training to gain a
competitive edge. Many only need to look to their diet to
enhance performance; however, no amount of motivation,
training, or natural ability will ensure peak performance
without the proper fuel for exercising muscles. Although
good eating habits cannot substitute for training and
genetic aptitude, a diet focused on essential nutrients can
provide energy for training, competition, recovery, and
health {Figure 1}. Much misinformation exists about the
effects of diet and nutrients on athletic performance. A
good working knowledge and understanding of sports
nutrition can help team physicians and sports medicine
profeasionals recommend diets and eating patterns that
can enable their athletes to reach their athletic potential.
Ms. Neviii'e or an immediate famiiy member is an empioyee
offliogen idec and has stock or stock options heid in Amyen
andI Eiogen. Neither Dr. Earning nor any immediate famiiy
member has received anything of vaiue from or has stock or
stock options heid in a commerciai company or institution
reiated directiy or indirectiy to the subject of this chapter.
fl lflld American Academy of Drthopaedic Surgeons
Adenosine triphosphate {ATP} is the high—energy com—
pound derived from the oxidation of macronutrients such
as carbohydrates, fats, and proteins that supplies the body
and the cells with energy. Muscle cells store a limited
sanssl leaipaw :,1;
amount of ATP and depend on metabolic pathways to
provide sufficient ATP for exercise and training. A rest-
ing muscle cell contains only a small amount of ATP,
just enough to keep the muscles working maximally for
about 2 to 4 seconds. To produce more ATP for muscle
contraction over extended periods, the body uses phos-
phocreatine. Additionally, dietary carbohydrates and fats
are used as energy sources. The breakdown of these com-
pounds releases energy to make more ATP. The amount of
ATP that is needed depends on the intensity and duration
of the exercise, thus determining which energy systems
become the predominant source of ATP {Table 1}.
Dietary Recommendations for Athletes
Energy Availability
The number of calories needed by athletes depends on
body size, body composition, and the type and length of
training. Additionally, energy needs can change in season
as well as out of season. To maximize health and training,
athletes need to consume adequate energy to maintain or
modify body weight. Many dietetic professionals now
use the concept of energy availability to monitor caloric
requirements. Researchers argue that this concept is more
useful than that of energy balance for the athletic pop-
ulation.1 Energy availability is the amount of energy left
for bodily functions after the energy costs of training and
competition have been calculated. Table 2 gives an exam-
ple of calculations that show adequate energy availability
for an athlete. It is generally agreed that athletes with
an energy availability lower than 3D kcal per kg of lean
body mass have a greater risk of metabolic and hormonal
disruptions, including that of reproductive function. Re-
gardless of the technique used to monitor caloric require-
ments, an excessive or inadequate intake of calories can
result in fatigue, an increased risk of injury, a prolonged
recovery period, and poor athletic performance overall.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 7’: Medical Issues

Athletes Plates

EASY THHIHIHE I WEIGHT MANAGEMENT:

=
E
E

Lhivel'fiiti' of Cola-ado
.E M Conrad: Eprlnge
'U
'11 A Sports Hutfitiflr'l Pl’flgI'EI'l'i
E
ri-l

HIIIIEIIA'I'E 'I'IIIIIHIHE:

filth; l_! I
Tea

Figure 1 The athlete's plates have been designed as a food guide for athletes to follow based on the physical demands of
the clay. {111e Athlete's Plates are a collaboration between the United States fllympic Eommittee Sport Dietitians
and the University of Colorado [UEE] Sport Nutrition Graduate Program, Colorado Springs, til}

Carbohydrates availability and attempts to match increased carbohydrate

Carbohydrates are the primary energy source for the
exercising muscle. Any athlete who engages in a vig-
orous workout for more than 1 hour a clay or works
out for several hours per day may need as much as T to
9 g of carbohydrates per kg of body weight to maintain
and replenish muscle and liver glycogen. In the past, car-
bohydrate recommendations often were expressed as a
percentage of total calories. This percentage is poorly
correlated to the amount of carbohydrate actually eaten
and the fuel needed to support an athlete’s training and
competition; for athletes, it is important to match their
carbohydrate intake to their fuel needs for training and
recovery. This concept has been defined as carbohydrate
intake to specific training and competition needs.2
Eating a variety of whole grains, fruits, and vegetables
provides not only the carbohydrates that athletes need
but also a range of essential vitamins, trace minerals,
and fiber. Too often, athletes choose carbohydrates with
high amounts of fats and sugars. Because the body has
limited glycogen stores, unlimited fat stores, and typically
does not use protein as an energy source during exercise,
active athletes can afford to consume more caloric-dense
foods from carbohydrates. Sports drinks, gels, and other
foods high in sugar should be reserved for pregame and
postgame refueling rather than be included in a daily
meal pattern.

firthnpaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons
 Chapter 35': Sports Nutrition

Table 1

Energy Systems Used in the Body to Create Adenosine Triphosphate

Energy System Main Storage Site 1When Used Activity
stored adenosine All tissues All the time Sprinting Iii-4 s
triphophosphate
Phosphocreatine All Tissues Short bursts of activity Shot put, high jumpt bench
press
Carbohydrate Muscles High-intensity activity lasting 3i] IUD-m sprint
[anaerobic] 5 ti? 3 "1'"
Carbohydrate Muscles and liver Exercise lasting 2 min to 3 h or logging. soccer. basketball,
{aerabic} more swimming
Fat Muscles and fat cells Exercise lasting more than a few Long-distance running,
{aerobic} rninutes; greater amounts are marathons. ultra-

sanssl leagpaw :1
used at lower—intensity exercise endurance events, cycling
that is of long duration

-—
Sample Calculation of Adequate
minimize saturated fat intake. Vegetarian athletes appear
to meet or exceed their protein requirements, but because
plant proteins tend to be less hioavailable, vegetarians
Energy Availability should increase their protein intake by approximately
lflfh's.‘ An athlete following a vegetarian diet may have
Athlete's weight 53 kg
lower levels of muscle creatine, a nitrogenous compound
Workout EDD Itcalr'd found in the muscles, where it becomes phosphorylated,
expenditure
producing phosphocreatine. Phosphocreatine can then
Energy intake 25% ltcali'd supply a phosphate to adenosine diphosphate to become
Percent body fat 13% ATP, a readily available cellular energy source. Studies
Lean body mass 53 ltg-Tr' kg = 45 ltg have shown that elevated levels of muscle creatine increase
Energy asoo ltcal-BDD ltcal = 1soo Itcallllfi the rate at which phosphocreatine is resynthesixed and
availability ltg lean mass = 34.8 Itcalr'lean may enhance exercise performance and recovery time for
mass short bouts of repeated maximal exercise. Several studies
have shown that vegetarian athletes tend to have lower
levels of muscle creatine compared with their omnivore
Protein counterparts and that vegetarians who took creatine sup-
Protein recommendations for athletes range from 1.1 plements had a higher increase in resistance training and
to 1.? g of protein per kg of body weight. This amount lean body mass than those in a placebo groupf”
is more than double the requirement for the sedentary 1Fsiegetarian athletes gain some nutritional benefits.
adult. Protein is important for the athlete because it facil- They consume a higher percentage of energy from car-
itates muscle synthesis and repair. Although most athletes bohydrates in a diet that typically includes more fruits
exceed their protein requirement because of the added and vegetables compared with nonvegeta rians. This may
protein shakes and powders in their diets, protein require- minimise the risk of free-radical damage in 1regetarian
ments can be met easily through a well—planned diet. Re- athletes, offering advantages to training and health.
cent research supports the consumption of approximately Potential nutritional concerns for vegetarian athletes
25 to 30 g of protein in multiple meals throughout the day include deficits in vitamin Bu, iron, zinc, and calcium.
during training and off—season conditioning.“ Consum— Deficiencies in any of these nutrients can result in poor
ing more than 40 g of protein in a single meal confers no athletic performance. Because of the potential risk of
additional benefits in boosting lean muscle mass. Protein specific dietary deficiencies of a vegetarian diet, a sports
consumption in excess of need may actually inhibit the dietitian can play a key role in educating vegetarian
body's ability to increase lean muscle mass? athletes about menu planning, cooking, and food prepa-
Athletes are encouraged to choose leaner sources of ration to maximize their nutrient intake and athletic
animal protein and to include plant sources of protein to potential.

IE! Elilli American Academy of flrthopaedic Surgeons Drthopaedic Knowledge Update: Sports lvledichse S
 Section 7’: Medical Issues
Fat
Fat supplies another source of energy during exercise
as well as essential fatty acids and fat—soluble vitamins
that are important in an athlete’s diet. Most athletes fall
within the range of recommended fat intake or exceed
it. Athletes who consume a high—fat diet not only have
adverse health effects but also may see diminished per-
formance. Conversely, athletes who eat a very low-fat
diet—less than 15% of total calories from fat—do not
gain any additional performance benefits. Athletes should
be encouraged to consume more heart-healthy fats, which
include plant—based oils that contain monounsaturated
and polyunsaturated fatty acids, and lower amounts of
animal fats, which contain higher amounts of saturated
= fatty acids such as butter, lard, and animal fat. Trans fat
E
E intake should be kept to a minimum by limiting fried
.E
'U [especially deep fat—fried} foods, pastries, crackers, tor—
E
'11
tillas, croissants, biscuits, and cookies as well as stick
I:
margarine or shortening.“
Sufficient fluid intake is important for everyone, but it is
particularly critical for athletes, especially those train-
ing in hot and humid weather. Thirst is a late sign of
dehydration. If an athlete waits to drink until thirsty,
then he or she will start training in a dehydrated state.
Additionally, if an athlete drinks to satisfy thirst, gener-
ally only one—half to two—thirds of fluid loss is replaced.
During exercise, the goal is a loss of no more than 2%
of body weight. For every pound lost during exercise, 3
cups of fluid {24 ounces} should be consumed. Athletes
who are even mildly [1% to 1%} dehydrated may present
with fatigue, confusion, and irritability? During repeat-
ed training bouts throughout the day, weight should be
monitored as a marker for hydration. In many cases, urine
color charts are used as another method to determine
hydration status. The rate of fluid replacement depends
on the athlete‘s sweat rate, the duration of exercise or
training, and the opportunities to consume fluids. Ta-
ble 3 lists the guidelines for fluid intake before, during,
and after training periods. Oral rehydration appears to
be the best way to hydrate athletes, and no additional
benefit appears to be conferred from intravenous fluid
rehydration. Intravenous administration of fluid may be
beneficial if the athlete is unable to hydrate orally.”
Sports Drinks
Several professional organizations, including the Amer-
ican College of Sports Medicine, the Academy of Nutri-
tion and Dietetics, and the National Athletic Training
Association, suggest that the consumption of a sports
firthopaedic Knowledge Update: Sports Medichie 5
-—
Guidelines for Recommended Fluid Intake
Before, During, and After Exercise
Before Exercise
At least 2 to 4 hours before the start of exercise.
drink 12 to 20 ounces of water or sports drink.
During Exercise
Consume E to 12 ounces of water or sports drink
every 15 to 2|] minutes during exercise.
After Exercise
For every pound lost, drink 16 to 24 ounces of fluid.
Generally. the volume of replacement should be 1.5
times the amount of fluid lost during exercise.
drink that contains electrolytes and carbohydrates can
be beneficial to athletes who train or compete for longer
than 1 hour. This is especially true if the athlete has not
consumed a preexercise meal, is participating in back-
to-back tournament play, or has multiple workouts in 1
day. The electrolytes in these beverages aim to replace
those lost in sweat, and the carbohydrates are crucial for
maintaining blood glucose levels and supplying energy to
the muscles as glycogen becomes depleted. Additionally,
researchers have found that the consumption of sports
drinks delays fatigue and maintains hydration in high-in-
tensity activities and stop—andrgo sports, such as soccer
and basketball, that last less than 1 hour." An ideal sports
drink contains 6% to 3% carbohydrates and l’llii| to 165
mg of sodium and should be consumed during periods
of training and competition instead of at mealtime and
during other non—active times throughout the day.
Rehydrating with only water during prolonged eu-
durance events may lead to hyponatremia. Consuming
a beverage with at least 100 mg of sodium per 3 ounces
will help prevent hyponatremia.
Eating During Competition and Training
The foods consumed before, during, and after competi-
tion and training can affect performance and the speed
at which the body can recover. Specific guidelines are
available that provide athletes with the best recommen-
dations to ensure optimum performance}-m
Before Exercise
To keep an athlete from feeling hungry before or during
an athletic event, a preexercise meal should be consumed.
In addition to warding off hunger, the preexercise meal
maintains blood glucose levels and provides fluids for
fl lflld American Academy of Orthopaedic Surgeons

hydration. Research has shown that eating before exer-
cise, rather than exercising in the fasted state, can improve
performance.“ Guidelines for the preexercise meal include
the following strategies:
It The meal should be composed primarily of carbohy-
drates. This recommendation is based on digestion
rates. Carbohydrates are digested in about 2 hours,
with liquid emptying the fastest. Proteins take about
3 to 4 hours, and fats take 4 to 6 hours to digest and
absorb. A high-fat preexercise meal may still be in the
stomach of an athlete as he or she takes the field to play.
i The precompetition meal should be consumed 3 to 4
hours before play to avoid stomach distress during the
event. A mixed meal of carbohydrate, protein, and fat
will take longer to digest. Generally, a carbohydrate
feeding of l g of carbohydrate per kg of body weight
is appropriate 1 hour before exercise, whereas 3 to 4 g
per kg of body weight can be consumed 3 to 4 hours
before competition.
* Although fiber is necessary for good digestive health,
it is not reconnnended that athletes consume high-fi-
ber foods before competition or training because these
foods may cause bloating and gastrointestinal upset.
' In the 15 to so minutes before competition or training,
athletes may benefit from consuming a liquid ca rbohy-
drate such as a preexercise beverage or gel that contains
approximately 15 g of carbohydrate. Carbohydrate
sources that are high in fructose should be avoided
because they slow absorption and can cause gastroin-
testinal upset.
' Each athlete has individual preferences, and what works
for one athlete may not work for another. Personal pref-
erences and tolerance need to be considered. If an athlete
is willing to try new and unfamiliar foods, he or she
should experiment with them in training sessions first.
During Exercise
Consuming carbohydrates during exercise is especially
important for athletes who exercise after an overnight
fast and for those who compete or train in longer events.
Consuming 3!] to 6121' g of carbohydrates per hour can help
prevent fatigue and prolong optimal endurance perfor-
mance. Carbohydrates can be consumed in the form of
a sports drink, energy gel, or other simple carbohydrate
that is easy to digest and tolerated well by the athlete.
The following guidelines for food and fluid consumption
during exercise are recommended:
' Carbohydrate consmnption should begin shortly after
the start of exercise.
* Solid carbohydrates can be consumed during exercise;
IE! lfllfi American Academy of Drthopaedic Surgeons
Chapter 35': Sports Nutrition
Determining the Hourly Sweat Rate
1. Determine body weight {in kg] before exercise
2. Determine body weight [in kg} after exercise
3. Determine fluid intake [in L} during exercise
4. Exercise duration, recorded in hours {40 min I DEE
h}
Calculation: Sweat rate = Body weight {kg}
preexercise — body weight [kg] postexercise + fluid
intakefexercise time in h
Example: 125 kg — 121 kg + {2 L15 h = 2 Li'h
however, they are digested more slowly than are liquid
sanssl leaipaw :,1;
forms of carbohydrates. During sports such as cycling,
in which less movement of the gastrointestinal tract
takes place, it is easier to consume solid foods. In other
sports such as running and swimming, athletes may
find it easier to consume carbohydrates in liquid form.
I To maximize the absorption of carbohydrates during
exercise, a combination of different sugars such as
glucose, sucrose, maltodextrins, or dextrose is con-
tained in most sports drinks. Research has shown that
if an athlete needs a large amount of carbohydrates in
a prolonged activity, then the combination of differ-
ent sugars results in faster gastric emptying time and
absorption.”~”
I Athletes should focus on consuming enough fluid to
prevent weight loss during exercise. They should also
avoid consuming too much fluid, which may result in
weight gain during exercise. To consume the proper
amount of fluid during exercise, an athlete should know
his or her individual sweat rate. Table 4 describes how
to calculate an athlete’s sweat rate.
After Exercise
Proper refueling begins within 30 to 60 minutes after
exercise. Refueling is more critical during a competition
in which the athlete competes in multiple heats or events
that occur within several hours. A postexercise recovery
snack and meal promote muscle glycogen and protein
synthesis. Researchers have found that glycogen synthesis
is greatest immediately after exercise because the mus-
cles tend to be insulin sensitive. Thus, consuming U] to
1.5 g of carbohydrate per kg of body weight within 3i]
minutes after exercise and at 1-hour intervals up to 6
hours will reload the muscles with glycogen for the next
day’s competition or training." Likewise, consuming a
small amount {Ell g} of protein 31} minutes after exercise
stimulates protein synthesis and muscle repair.“*11 Protein
sources that have been recommended include meat, pork,
Drthopaedic Knowledge Update: Sports Medicbie .‘i
 Section 7’: Medical Issues
chicken, turkey, egg, and dairy products. These sources
appear to contain the essential amino acids, which are
incorporated more readily into muscle tissue. Further—
more, research shows that leucine, an essential amino
acid, is a major stimulator for the mammalian target of
rape mycin pathway, which is responsible for stimulating
muscle protein synthesis. Because protein and carbohy-
drates play a role in muscle recovery, it is important to
consume both of these nutrients in a postexercise meal. In
many cases, athletes consume a sports bar after exercising
that is composed of only protein, but they fail to reload
muscle glycogen. Similarly, an athlete who consumes a
bar containing only carbohydrate fails to stimulate pro-
tein synthesis and muscle recovery. Therefore, consuming
n foods having a combination of carbohydrates and protein
A"
E is extremely important after training. The following food
.E
'U combinations are examples of recovery meals and snacks
E
'11
recommended 3!] to SD minutes after exercise:
I:
I A medium-size whole-grain bagel with 2 tablespoons
of peanut butter and a sports drink
I An energy bar containing carbohydrates and protein
and a sports drink
I A commercial recovery beverage
”Within a few hours, the athlete should continue recov-
ery by eating a meal such as:
I Two cups of whole-grain pasta with tomato sauce and
3 ounces of chicken, fish, or meat
I A turkey sandwich on wheat bread with 1 cup of fruited
yogurt and a large banana
A few hours later, the athlete should eat another small
snack such as:
I Two cups of whole-grain cereal with 1 cup of low-fat
milk
I l[fine piece of fruit with 2 ounces of low-fat string cheese
The recovery period is also a time to rehydrate and
rcplace fluids and electrolytes that were lost during ex-
ercise. A simple guideline, replacing 15 to 24 ounces of
fluid for every pound lost during exercise,wi1l help start
the rehydration process. In addition, consuming fluids and
foods that contain electrolytes speeds the recovery rate
threefold and may help prevent muscle cramps in those
who are salty sweaters. It is best to consume both foods
and fluids, because the combination provides nutrients
that restore hydration status and the substrates for gly-
cogen and protein synthesis.
Although recovery nutrition is highly recommended
for athletes, those who will not compete or train the
next day do not necessarily need to follow an optimal
recovery plan. For example, a high school soccer player
firthnpaedic Knowledge Update: Sports Medicine 5
in the offseason who is refining his or her soccer skills
in a 1-hour practice consumes a meal a flaw hours af-
ter exercise along with regular eating and drinking; this
is sufficient to replenish glycogen and protein synthesis
before the next practice session in 3 days. Similarly, a
cross—county runner who will be competing at the end of
the week and goes for an easy run during the beginning of
the week does not need to follow a strict recovery nutri-
tion plan because he or she has plenty of time during the
remainder of the week to restore glycogen and optimize
hydration Status by consuming a normal diet.
Supplements
Most athletes and consumers take supplements. 1Whether
the benefit is real or perceived, many athletes believe that
supplements will give them the winning edge. As a result,
many athletes experiment with the dose and timing of
supplements, hoping to gain an ergogenic benefit. Many
of these dietary supplements, such as bee pollen, ginseng,
artichoke hearts, and gelatin, are ineffective, whereas
a few supplements, such as creatine and caffeine, may
be effective only in certain scenarios. In fact, scientific
support for ergogenic effectiveness exists for only a few
dietary substances, including adequate fluid and electro-
lyte intake, carbohydrate availability, and the consump-
tion of a variety of fruits and vegetables. From a dietary
perspective, most athletes consume two to three times the
amount of protein needed for optimal performance; thus
protein and amino acid supplementation generally is not
necessary as a means of enhancing performance. Most
athletes can meet their protein requirement and all their
other nutrient needs easily by consuming a healthy and
varied diet. Vitamin and mineral supplementation should
be used only to meet specific dietary shortcomings, such
as inadequate iron or calcium intake. A risk-benefit ratio
for any ergogenic aid should be calculated before the
supplement is taken.
Health professionals working with athletes must ap-
proach supplement use with caution until the efficacy and
safety of the supplement have been verified scientifically.
The Dietary Supplement Health and Education Act of
1994 has allowed supplement manufacturers to produce
a variety of supplements that do not have proven safety or
efficacy without much oversight from the Food and Drug
Administration. As a result, some supplements do not
contain the actual substance or the amount that is listed
on the label and may contain ingredients that could cause
an athlete to test positive on a screen for banned drugs.
Caution should be used even if the supplement has proven
scientific efficacy because good manufacturing practices
may not be in place, and the substance could easily be
fl lflld American Academy of Orthopaedic Surgeons

contaminated. Finally, rather than relying cm a magic
bullet tn enhance perfnrmance, athletes shnuld fncus nn
nptimiaing their diet, training, and sleep quality. It is
prudent, hnwever, tn keep npen lines nf cnmmunicatinn
with athletes whn may be interested in taking supplements
sn the spnrts medicine practitinner can give cnunsel nn
their safety and efficacy.
Summary
A bndy nf evidence shnws that fnnd eaten befnre, during,
and after cntnpetitinn affects perfnrmance and the speed
at which the athlete can recnver frnm training er a perfnr-
mance. Mnst athletes dn nnt have the nutritinn knnwledge
tn attain the prnper balance nf nutrients and energy fnr
nptimal perfnrmance. ivlany athletes dn nnt eat befnre,
during, nr after exercise and then rely nn supplements
tn meet their nutritinnal requirements nr mistakenly use
them tn nbtain a cnmpetitive edge.
A spnrts dietitian whn is a registered dietitian, pref-
erably nne whn is a bnard certified specialist in spnrts
dietetics, can he a valuable member at the spnrts medicine
team and can help cnunsel athletes nn the apprnpriate rec—
nmmendatinns fnr nptimiaing nutritinn fnr perfnrmance.
Hey Study Pnints
1* Carbnhydrates are the main fuel snurce fnr exp
ercising muscle and the central nervnus system.
Athletes need tn cnnsume ca rbnhydrates; hnwever,
they need nnly tn cnnsume ennugh fnr training and
cnmpetitinn [carbnhydrate availability} rather than
cnnsuming a certain percentage nf tntal calnries.
The cnncept nf matching carbnhydrate intake tn
training and cnmpetitinn has been defined as car-
bnhydrate availability.
I Athletes need tn cnnsu me fnnd thrnughnut the day,
rather than in nne large meal. This is alsn true
fnr prntein cnnsumptinn. Eating smaller amnunts
nf prntein {2D tn 25 g} thrnughnut the day stim-
ulates the pathway that turns nn muscle prntein
synthesis. Cnnsuming large amnunts nf prntein in
nne meal may cnmprise the amnunt nf new muscle
that can be made.
i A registered dietitian whn is hnard certified in
spnrts dietetics can be a valuable member cf the
spnrts medicine team because nf his nr her knnwl-
edge and skills tn teach athletes the prnper diet fnr
performance that will allnw athletes tn perfnrm at
their genetic pntential.
IE! lfllfi American Academy nf flrthnpaedic Surgenns
Chapter 39: 511a Nutrition
Annotated References
1. Lnucks AB, Kiens B, Wright HH: Energy availabil-
ity in athletes. } Spnrts Sci 2011;19isuppl 1}:5?—515.
Medline DID]
This article argues that the cnncept nf energy availability
is mere useful fnr managing the diets nf athletes than is
the idea nf energy balance and summarizes its use and the
clinical cnnsequences nf lnw energy availability.
Burke Livi, Hawley JA, Wnng 5H, Jeukendrup AE: Ear-
bnhydrates fnr training and cnmpetitinn. ] Spnrts Sci
lflllelflisuppl 1}:SlT-SET. Medline DUI
This review article defines carbnhydrate availability and
examines the carbnhydrate intake nf athletes and the tim-
ing nf ca tbnhydrate cnnsu mptinn in relatinn tn exercise tn
sanssl lestpew :1
maintain adequate carbnhydrate substrate fnr the muscles
and central nervnus system.
. Phillips 5M: A brief review nf critical prncesses in ex-
ercise-induced muscular hypertrnphy. Spnrts Med
2fl14;44{supp1 11:5T1-STT. Medline DUI
This review article examines practices nf different amnunts
nf prntein ingestinn and its influence nn the stimulatinn nf
muscle prntein synthesis {MP5}. Higher prntein ingestinn
is needed tn stimulate MP5, but nther factnrs invnlved are
prnteins that prnvide essential aminn acids and high levels
nf leucine fur the maximal stimulatinn nf the mammalian
target nf rapamycin pathway.
. Tiptnn ED, 1‘illl'itard DC: Prntein requirements and recnm-
mendatinns fnr athletes: Relevance nf ivnry tnwer argu-
ments fnr practical recnmmendatinns. Elite Spnrss Med
lflfl?;2ti{1}:1?-3EI.Medline DD]
. Mnnre DR. Enbinsnn M], Fry ]L, et al: Ingested prntein
dnse respnnse nf muscle and albumin prntein synthesis
after resistance exercise in ynung men. Am ] Ciin Nate
2fl09;39[1}:161-153.Medline DUI
This article describes a randnmired study designed tn yield
a dnse respnnse fnr ingested prntein in the stimulatinn nf
muscle and albumin prntein synthesis. Entb muscle and
albumin prntein syntehsis were stimulated maximally at
EU g nf ingested prntein.
. Craig W], Mangels AR; American Dietetic Assnciatinn:
Pnsitinn nf the American Dietetic Assnciatinn: Vege-
tarian diets. I Am Diet Assnc 2dfl9;1fl9{?}:1266—1231.
Medline D0]
This pnsitinn paper reviewed studies pertaining tn veg-
etarianism, gave nutritinnal recnmmendatinns frnm
evidence-based science, and reviewed the benefits and
disadvantages nf a vegetarian diet.
. Burke DE, Chilibeck PD, Parise G, Candnw DE, l'vlabnney
D, Tarnnpnlsky M: Effect nf creati ne and weight training
nn muscle creatine and perfnrmance in vegetarians. Med
Sci Spnrt‘s Exerc Ell [13;35{11}:194E-1 955. Medline DUI
Drtbnpaedic Knnwledge Update: Spnrts Medichte .‘i
 Seeders 7’: Medical Issues
Rodriguez HR, DiMarca NM, Langley S: American Di-
etetic Assaciatinn; Dietitians nf Canada: American |Cniiege
nf Sparta Medicine: Nutritinn and Athletic Perfarmance:
Pasitian af the American Dietetic Assnciatian, Dietitians
af |Canada, and the American Callege af Sparta Medicine:
Nutritian and athletic perfnrmance. I Am Diet Assnc
lflfl951fl9{3}:509-521Medline DUI
This pasitien paper, cempascd in assaciatian with the
American Callege ef Sparta Medicine and Dietitians af
Canada, reviewed studies pertaining tn the tale nf nutri-
tinn in exercise and spurts. The review prnvides recum-
mendatians far the nutritianal intake ef athletes ftam
evidence-based science.
D'Anci KE, 1|Ii'ilzihal-tar A, Kanter JH, Mahaney CR,
Taylnr HA: Valuntary dehydratinn and cngnitive per-
fnrmance in trained caliege athletes. Percept Mat Skiiis
= Efl095109{1}:251—259.Medline DUI
A"
This study investigated the cagnitive and mead changes
E
.E
'U resulting fram mild dehydratian and glucaae cansump-
'11
E than in male and female caliege athletes. Dehydratinn was
t: assaciated with higher thirst and negative maeds. Subjects
shewed better attentian with hydratian.
1i}. American Callege af Sparta Medicine: Selected issues fer
nutritian and the athlete: A team physician canaenaus
statement. Med Sci Spnrts Exer'c Efll 3;4S{12]:13TS 41335.
Medline DUI
This canaenaus statement pravides an everview af and
guide ta selected issues in aparta nutritian that are impat-
tant tn team physicians wha are respansible far the care
and treatment nf athletes.
Drthapaedic Knawledge Update: Sparta Medicine 5
11. Phillips SM, Tamer AP, Gray 5, Sanderaan MF, Spraule J:
Ingesting a 6% carb-ahydrate-electraiyte salutinn impraves
endurance capacity, but nnt sprint perfarmance, during
intermittent, high-intensity shuttle running in atlalescent
team games players aged 12-14 yea rs. Ear ] App! Physic!
lfllfl;109[5}:311-321.Medline DUI
This dnuhle-hlind randamiaed study investigated the influ-
ence af canauming a 6% carhahydrate {CI-ID}-electrelyte
drink an intermittent high-intensity perfarmance cam-
pared with a nan-CHE} placehn drink. Subjects fallawed
the Laughbntaugh Intermittent Shuttle prntncnl. The time
ta fatigue and the valume af warlt perfarmed significantly
increased when CHD was ingested. Na difference was
seen between sprint times, hawever.
12. Jenltendrup AE, Mnseiey L: Multiple transpnrtable carbn-
hydrates enhance gastric emptying and fluid delivery. Scar-rd
} Med Sci Sparta lfllflglflflltl 11—121. Medline DUI
This study cempared the effects ef ingesting water, a
glucase salutian, and a glucese plus fructaae salutian an
gastric emptying and absnrptinn during maderate-inten-
sity exercise. Results shawed that glucese plus fructaae
cansumptian resulted in faster emptying time and fluid
delivery than glucnse alane.
13. Jentjena RL, Jeultendrup AE: High rates af exegenaua
carbahydrate nxidatian frnm a mixture nf glucnse and
fructaae ingested dating prninnged cycling exercise. Br
I Naif lflflS;93{4l:4SS—492. Medline DUI
14. Ivy jL, Kata AL, Cutler CL, Sherman WM, lL'Jnyle
EF: Muscle glycagen synthesis after exercise: Effect ef
time nf carhnhydrate ingestinn. I Appi Physini (1935}
19Sfl;64{4}:14Sfl-1435. Medline
D lfllfi American Academy af Drrhapaedic Surge-ans
Chapter 40
Sport Psychology
l[Ihristupher l'vl. Eader, PhD, LP, CC—AASP
Abstract
Spurt psychulugy principles are used with a wide variety
uf clients ur patients, frum yuuth spurt participants
thruugh the Olympic and prufessiunal tanks. Orga-
nizatiun uf the field, uppurtunities fur cullabutatiun,
and clinical tupics for further discussiun with patients
warrant review.
Keywurds: spurt psychulugy; athletes and mental
health; injury recuvery
lntruductiun
Spurt psychulugy has its histurical ruuts in the late 19th
and early 2(lth centuries, and is a dynamic field uf study
cuncerned with endeavurs that reach acruss clinical, edv
ucatiunal, and research spectra. Sume challenges exist
within the field uf spurt psychulugy that make defining it
difficult. Fur example, nu universal definitiun uf a “spurt
psychulugist“ exists, research typically is nut widely read
ur understuud by thuse uutside the field, and training
within the field is still debated extensively.‘ '3
Twu cf the majur urganizatiuns fucused specifically
un spurt psychulugy (as well as individuals within and
uutside thuse urganisatiuns} have attempted tu address the
identificatiun ui spurt psychulugists. The American Psy-
chulugical Assuciatiun {APA} includes a divisiun {Divisiun
4?) cuncerned with spurt and exercise psychulugy. This
divisiun established a pruficiency fur the practice uf spurt
psychulugy and has stated its pusitiun that a spurt psy-
chulugist shuuld first be a licensed psychulugist in his ur
her respective stateis) ut pruvinceis}. The Assuciatiun fur
Applied Spurt Psycbulugy {AASP} has a different audience
Neither Dr. Easier nur any immediate family member has
received anything at value from ur has stuck ur stuck up-
tiuns held in a cummerciai cumpany ur institutiun reiateu'
directlyr ur indirectly tu the subject uf this chapter.
fl lflld American Academy uf Drthupaedic Surgeuns
in terms uf membership, generally appealing tu thuse
with backgruunds in psychulugy andi'ur exercise science.
AASP has established a distinctiun uf Certified Cunsul-
tant [indicated as “CC—AASP“) within its ranks as a way
tu identify thuse in the urge nisatiun whu have cumpleted
sanssl leaipaw :,1;
specific educatiunal requirements and mentured applied
experiences.“ As a member uf APA andiur AASP, a spurt
psychulugist is held tu the ethical standards put furth in
the ethical cudes uf the respective assuciatiun. Each uf
thuse cudes was created In demunstrate respunsible prac-
tice by practitiuners. By extensiun, membership in thuse
urganizatiuns and adherence tu their ethical standards
shuuld pruvide sume prutectiun tu individuals seeking
spurt psychulugy services.
The title uf spurt psychulugist can be sumewhat cun-
fusing and misleading, depending un a petsun’s back-
gruund and use uf terminulugy. Fur example, a state- ur
pruvince-licensed psychulugist with advanced training
and supervisiun in the area uf spurts ur athletics might
be designated a spurt psychulugist. At the same time,
sume individuals hulding the distinctiun uf CC—AASP
but nut having a license tu practice psychulugy alsu may
use the term spurt psychulugist. Still uthers—licensed
andi'ur certified ur nut—may use terms such as “spurt
psychulugy cunsultant,“ “spurt psychulugy cuach,“ “spurt
cunsultant,“ ur “mental cuach.“ Althuugh a title may be
impurta at, the backgruund, training, and expertise uf an
individual with whum a patient might chuuse tu wurk is
much mute impurtant.
The principles established in the practice uf spurt
psychulugy can be beneficial in many fields, including
surgery and medicine. Presurgica] andiur pustsurgical
cunsultatiun with spurt psychulugists is being explured
by physicians in many practices because uf the putential
tu address clinical cuncerns befure they becume majur
clinical issues. As the understanding uf preventive, as
uppused tu reactive, care and treatment increases, the
mutually beneficial relatiunship between physicians and
spurt psychulugists may pruve tu nut unly save time and
muney, but mure unpertantly, alsu pruvide patients with
peace uf mind abuut their care and treatment.
Drthupaedie Knuwledge Update: Spurts Medicine 5
 Section 7’: Medical Issues
Roles and Specialization of a Sport Psychologist
The evolving relationship between the fields of sport
psychology and medicine has been well documented, as
seen in the Team Physician lEonsensus Statement5 that
was produced by an alliance of the foremost professional
medical associations and the National Coflegiate Ath—
letic Association (NCAA) Sport Science Institute {SSIF‘
publications.
In the 2014 publication, Mind, Body and Sport,F a
guide to student athlete mental health from the NCAA,
three prevailing models of mental health services to
student athletes were discussed. Those models include
the full-time employment of a sport psychologist within
the athletics department, part-time use of a consultant
= to the athletics department, and a referral model with
A"
E on-campus counseling services.“ Each of the proposed
.E
'U models has advantages and disadvantages, and although
E
'11
these models are discussed in the context of an NCAA
ri-l
institution, each can be adapted for use across several
settings. For example, an orthopaedic practice may have
a referral-based model for its patients, in which patients
are provided names and contact information for local
sport psychologists before and irmnediately following a
surgical procedure. Similarly, a hospital system may have
a part-time or full-time relationship with a sport psychol-
ogist to provide services to its patients. In each of these
models, the relationship between the various providers
is extremely important. Trust, demonstrated knowledge,
and expertise need to be present.
As the field of sport psychology continues to grow and
evolve, individual providers are developing subspecialties
within the field. For example, certain individuals are con-
sidered experts in the field of sport psychology and eating
disorders. Additionally, emerging treatment programs
specifically designed for athletes in whom eating disor-
ders have been diagnosed and programs developed for
athletes with process and chemical addiction diagnoses
are now available. The areas of youth sport psychology,
collegiate sport psychology, and professional or Olympic
sport psychology also could be considered concentrations
within the field of sport psychology, given the unique
opportunities and challenges in each of those areas.
1'I"outh Sports
Participation in youth sports has a wide range of benefits,
including peer socialization, the development of self~es~
teem, the establishment of leadership qualifies, and the
promotion of health and fitness? As tens of millions of
young people participate in sports, meeting the needs of
those athletes through sport psychology interventions
[for example, workshops on various topics within the
realm of sport psychologyfperformance enhancement} is
firthopaedic Knowledge Update: Sports Medicine 5
increasingly important. It is important to encourage simi-
lar interventions to their coaches and parents or guardians
as well. Approaching each group with ideas about having
a positive influence on sports participation will ensure
maximum benefit for youth sports participants.IEI Parents
and coaches can have a great influence on their young
athletes. After athletes reach a certain age, however, their
parents and coaches take a backseat to their peers in terms
of influential input into continued sports participation.
Cine way the benefits of youth sports participation can
be jeopardized is by compromising the health of the young
athlete through sports specialization at an early age. A
direct linlt between early specialization and burnout is
not yet clear in the research, but several risk factors are
thought to be associated with that linlt. Through edu-
cation and awareness of these potential problems, it is
thought that long-term injury and burnout can be prevents
ed.” Parents, coaches, physicians, and young athletes have
a responsibility to participate in the prevention, treatment,
and recovery from injury when it occurs. Although the
clinical concerns discussed later in this chapter are seen in
younger individuals, most of these problems do not fully
develop until later in life. In dealing with young athletes
who are injured, awareness of the possible presence of
conceming symptoms is important. Additionally, resourc-
es {iu the form of a handout or informational flyer, or
contact information for a sport psychology professional]
for the athletes and their parents are essential.
Collegiate Sports
Recently, the NCAA SSI has designated the mental health
of student athletes as the main challenge to their health
and safety? Based on that designation, the 551 has been
instrumental in publishing and disseminating information
to the NCAA membership on mental health issues for
student athletes.
Many schools are beginning to address the mental and
physical health of collegiate student athletes before they
even step onto campus. The initial transition to college
encompasses several areas: academic, social, and ath—
letic. The athletic transition can include changing roles
on a team, modifying the amount of participation, or
dealing with injury.“ The academic shift can be quite
an awakening as well, with some underprepared student
athletes finding themselves behind before they are fully
established in the academic term. Because of this potential
lag, schools have begun to develop special coursework for
student athletes to ease the transition.” The social transi-
tion can include issues surrounding relationships, social
events including parties, the separation from parents or
guardians, and simply fitting in on a college campus.
A student’s level of athletic identity can be a major
fl lflld American Academy of Orthopaedic Surgeons

factnr during times nf transitinn. Several recent studies
relate athletic identity tn career develnpment and career
maturity (nne's readiness tn make infnrmed, age—apprn—
priate career decisinns and cnpe with career develnp-
meut tasksj.” Athletic identity can be threatened when
an athlete is injured. This threat tn the athlete’s nvcrall
identity can cause psychnlngical issues that can impede
physical recnvery. 1|When assisting a student athlete whn
is injured, cnllabnratinn with medical and psychnlngical
persnnnel can be nf great benefit. It is impnrtant tn invnlve
rnnmmates, teammates, cnaches, and pa rents tn create a
pnsitive suppnrt system thrnughnut the prncess. The med—
ical persnnnel {'eg, physicians, athletic trainers} invnlved
are cm the frnnt lines nf mnnitnring pntential changes in
a student athlete’s mental state fnllnwing injury.
In additinn tn bndily injury, head injury, specifically
cnncussinn, has been researched and studied widely in
recent years. Althnugh deciphering the natural bistnry nf
cnncussinn remains a wnrk in prngress, there has been
cnnsiderable advancement in the understanding and
management nf spnrts-related cnncussinn. Established
signs and symptnms nf cnncussinn have been develnped,
and guidelines are nnw available fnr cnaches and athletic
trainers tn fnllnw if a cnncussinn is suspected. It is impnrt-
ant fnr medical persnnnel tn be aware hi this infnrmatinn
tn minimise ptnlnnged symptnmatnlngy. Clue frequently
discussed psychnlngic symptnm nf cnncussinn is depres-
sinn nr depressed mend, which nften accnmpanies many
nf the physical symptnms nf cnncussinn.”
Psychnlngic injury, such as a severe mental health is-
sue, nften is seen fnr the first time during the cnllegc
years. Anecdntally, an increase in the use nf cnunseling
services and in the severity nf mental health issues in
cnllegc students has been seen cnmpared with years past.
Fnr example, cnllege students, including student athletes,
may experience a first bnut with majnr depressinn nr
even a first psychntic break nr episnde in cnllegc. Again,
medical persnnnel are cm the frnnt lines in detecting these
issues, and festering a pnsitive wnrking relatinnship with
a clinically trained, licensed mental health prnvider can
assist in early treatment effnrts.
As mentinned previnusly, parents and guardians play a
significant rnle in the lives nf their student athletes. Mnst
parents and student athletes maintain healthy bnundar-
ies during the cnllegc years; hnwever, snme situatinns
require special cnnsideratinns fnr the inclusinn nf pa rents
nr guardians. Fnr example, when physically injured, a
student athlete, whn is an adult in chrnnnlngical age,
may still desire tn have his nr her parents present tn help
make surgical decisinns and during the subsequent reha-
bilitatinn prncess. This prnvides medical and psychnlngic
persnnnel annther avenue nf access tn pnstsurgical student
IE! lfllfi American Academy nf flrthnpaedic Surgenns
Chapter 4|]: fipnrt Psycbnlngy
athletes, because many parents see the benefit nf having
a spnrt psychnlngist available, and many will encnurage
their student athletes tn seek these services.
Underlying the transitinn issues and injury cnncerns
during cnllegc are the general mental health and well-
ness nf student athletes. Depending cm the mental health
status nf student athletes upnn entry intn cnllege, their
transitinn andi'nr injury rehabilitatinn may be easier nr
mnre difficult.
Prefessinnal and Olympic Sperts
At this develnpmental level nf spnrts, the rnle nf the spnrt
psychnlngist is snmewhat different. He nr she may be
hired by an individual player nr petfnrmer nr by the larger
nrganieatinn. Within prnfessinnal spnrts, mnre nrganisa-
sanssl jeajpaw :,1;
tinns seem willing tn hire such a previder tn address the
clinical and perfnrmance needs nf their athletes.
Fnr Ifillympic-level athletes in the United States, the US
Olympic Cnmmittee [USUCJ maintains a team ni spnrt
psychnlngists assigned tn wnrk at the varinus Olympic
training centers and with the teams acrnss the cnuntry.
Additinnally, the US Hatinnal Gnverning Endies may
hire a spnrt psychnlngist tn wnrk specifically with their
teams. The structure nf the suppnrt teams within the
USDC includes a spnrt psychnlngist as an integral cnm-
pnnent. Again, this arrangement is seen as useful, and
when cnaches help the cnnsultant becnme integrated with
the team, can serve tn lessen the stigma assnciated with
psychnlngical services.”
Given the elite level nf cnmpetitinu, it may be even mnre
impnrtant tn have access tn a spnrt psychnlngist when
cnnsidering surgery fnr an l[llympic-level athlete. The
previnusly mentinned intersectinn nf injury and identity
cnuld be even mnre impnrtant, cnnsidering the lnnger and
mnre intense invnlvement in the given spnrt.
Clinical Psychnlngic Cnncerns
Clinical cnncerns exist acrnss develnpmental levels in
spnrts. One cf the mnst cnnsistent psychnlngic factnrs
assnciated with the risk nf athletic injury is stress.5 Psy-
chnlngic suppnrt is a factnr that repeatedly has been
demnnstrated in recent research tn assist in injury reha-
bilitatinn and stress reductinn."‘~” In additinn tn stress,
snme cf the mnst significant cnncerns fnt spnrt psychnln-
gists tend tn be alcnhn] and nther drugs, eating disnrders,
n1nnd disnrders, and anxiety disnrders. These cnncerns
can lead tn higher incidences nf injury and can becnme
mnre prnnnunced in respnnse tn an injury. In addressing
andi'nr treating clinically significant psychnlngic cnncerns,
it is impnrtant tn realize the benefits nf having at least a
cnnsultative relatinnship with a psychnlngical care prnu
vider well versed in the culture nf spnrts.
Drthnpaedic Knnwledge Update: Spnrts Medichie 5
 Sectiun 7’: Medical Issues
Alruhul and Either Drugs
Althuugh alcuhul and uther substance use sumetimes is
accepted by the general public, athletes tend tu be held
tu different standards because uf the putential fur lust
eligibility ur participatiun in spurts.” Must cf the majur
spurts leagues in the United States have begun tu address
substance use and abuse in their persunal cunduct and
drug policies. When addressing student athlete use at
nunprufessiunal levels, must uf the guverning urganiaa—
tiuns adupt the laws uf the given cuuntry, especially fur
underage athletes.
Several facturs—biulugic, psychulugic, and sucial—en-
ter intu an individual’s putential fur abuse uf ur depen-
dence un a particular substance.“g A genetic predispusitiun
= fur use wuuld represent a biulugic factur influencing use.
E
E Thuughts, feelings, and behaviurs surruunding use are
.E
'U examples uf psychulugic facturs [fur example, “One is
E
'11
guud, twu is better, and three’s a party!”}. Peuple, places,
ri-l
and things are cunsidered sucial facturs influencing use.
The twu must pruminent substances used and abused
in cullege are alcuhul and marijuana. The current state
uf marijuana legalizatiun is a cumplicating factur in ad-
dressing the larger issue uf use ur abuse, because sume
states have legalized marijuana fur medicinal andi'ur rec-
reatiunal purpuses. flue cf the majnr cumplicating fac-
turs is the cuncentratiun uf tetra hydrucaunabinul {THC}
in marijuana and marijuana edibles when cumpared tu
similar pruducts in past decades. Fur example, in sume
areas, a marijuana bruwnie may cuntain 16 servings uf
THC. This example illustrates the need fur educatiun
abuut purtiun cuntrul when it cumes tu legal and illegal
substances. A lung histury exists uf athletes binging un
substances, given their time in training and the biupsycbu-
sucial facturs mentiuned previuusly. Additiunally, sume
teams have rules pruhibiting use during a certain periud
befure cumpetitiun leg, the “43- huur rule”) rather than
educating athletes abuut respunsible decisiun making.
Asking specific questiuns abuut use, misuse, and abuse
is beneficial in putentially curbing an abuse issue befure it
becumes a dependence issue. It alsu may alert a prescriber
tn the putential fur the abuse uf prescriptiun medicatiun
fulluwing injury ur surgical prucedures.
Eating Dr'surdurs
The main diagnused eating disurders are anurexia nervu-
sa, bulimia nervusa, and binge eating disurder. Cunditiuns
alsu ucc ur that du nut qualify as eating disurders but are
cunsidered disurdered eating; these include anurexia ath—
letica, muscle dysmurphiaireverse anurexia, urthurexia
nervusa, and ubesity ur being uverweight.”
Like substance abuse, eating disurders and disurdered
eating have ruuts in genetic and suciucultural facturs.
firthupaedic Knuwledge Update: Spurts Medicine 5
Genetics are thuught tu predispuse tu an eating disurder,
but they du nut tell the whule stury. Suciucultural facturs
such as the media, the family, the peer gruup, and sucial
cumparisun alsu heavily influence the develupment uf an
eating disurder. In spurts, a bust uf additiunal cuntribut—
ing facturs exist, including injury, depressive and muud
disurders, weight and budy—fat reductiun, and perfur-
mance increases. Uthers include the ideal cf cumpetitive
thinness, wearing revealing spurts attire, a cuntagiun
effect (in which an individual begins disurdered eating
behaviur based en the perceptiun ur reality that uthers are
duing it}, subcultural expectatiuns, and spurts in which
the budy is seen as being judged (cg, gymnastics, diving,
figure sltatingl.“J
Asking questiuns uf the individual being studied seems
tu be key in determining the risk uf ur engagement in
eating behaviurs that cuuld be detrimental ur dangeruus.
A suitable time fur such an evaluatiun is before participa-
tiun in spurts ur befure a surgical interventiun. An injury
that requires surgery, thus making spurts participatiun
unavailable, cuuld trigger unhealthy ur disurdered eat-
ing.” The same scenariu alsu cuuld trigger a depressive
ur muud disurder.
Depressive and Muud Disuru'ers
Depressiuu is multifaceted and can affect athletic per-
furmance, academic ur wurk perfurmance, and sucial
activity.m Majur depressive disurder is in a categury
uf muud—based disurders that alsu includes persistent
depressive disurder {dysthymia} and premenstrual dys-
phuric disurder, alung with uther less well—knuwn de‘
pressive disurders. Althuugh nunathletes are affected by
the symptums uf depressiun leg, depressed muud, luss uf
interest ur pleasure in activities}, certain symptums seem
tu be mure prublematic fur athletes. Sume indicaturs uf
depressed muud in athletes are missed rehabilitatiun ap-
puintments, vague ur specific physical symptums, sluw ur
sluggish perfurmance, andl'ur withdrawal frum athletic
participatiun and sucial uppurtunities.” Additiunally,
this cunstellatiun uf symptums can lead tu a decline in
health ur perfurmance and an increased risk uf injury ur
suicide. At times, athletic status can be a prutecrive factur
against the develupment uf muud disurders, insumuch
as the demands un their time du nut alluw fur extended
periuds uf isulatiun. At the same time, thuse time demands
can exacerbate an already depressed muud}u
When addressing depressed muud, medical and psy-
chulugic prufessiunals shuuld make sure tu inquire abuut
the presence uf suicidal ideatiun. Priur tu inquiry, the
medical practice shuuld ensure that it has a referral suurce
and treatment plan in place fur individuals experiencing
suicidal thuughts.11
fl lfllfi American Academy uf Urthupaedic Surge-uns

Anxiety Disorders
Like depressive and mood disorders, anxiety disorders in-
clude a range of diagnoses, including generalized anxiety
disorder, panic attacksipanic disorder, obsessive compul-
sive disorder, specific phobias, and posttraumatic stress
disorder. Certain symptoms are common among all of
these disorders, including feelings of apprehension, a sense
of impending danger or doom, increased heart rate, rap-
id breathing, sweating, trembling, and fatigue andior
weakness. Although some of these symptoms also can
result from a hard workout, in individuals with anxiety
disorders, such symptoms have a negative effect on the
ability to function}3
Athletic performance may place demands on athletes
that challenge their natural reaction to an anxious presen-
cations“:3 For example, a skier who experiences a hard fall
that results in substantial injury may experience several
anxiety-based symptoms when attempting to return to the
mountain. If these symptoms interfere with performance,
they may then meet the criteria for an anxiety disorder.
Psychiatric issues
The presentation of these clinical concerns may call for
consultation with a psychiatrist. Incorporating psychia-
try into an interdisciplinary treatment plan can hasten
recovery and return athletes to play with improved per—
formance and a greater understanding of the complex
nature of their presenting concerns. The early recognition
of problematic symptoms is key because it shortens the
time between onset and treatment, allowing a quicker
resolution to the presenting concern.14
If clinical concerns go unaddressed, poor performance
may result, thus increasing stress and potentially leading
to injury. This illustrates the importance of sport psychol—
ogy and the integration of service providers. Cine way to
screen for clinical issues is to query patients about each
area when they fill out the initial or preperformance phys—
ical examination paperwork. Having a qualified mental
health practitioner review the answers could go a long way
toward identifying and preventing additional psychiatric
issues in the patient.
Summary
A brief overview of the field of sport psychology has been
presented and the athlete groups that would benefit most
from its principles described. It is important to consider
several factors described in this chapter when treating
athletes at any developmental level. Aligning the interests
of those in the medical community with those of the sport
psychology community can help maximize the benefit to
athletes.
IE! Eillfi American Academy of flrthopaedic Surgeons
Chapter 40: Sport Psychology
Key Study Points
1' Several comorhid psychological factors should he
considered when assessing a patient’s injury or the
potential for surgery.
I Consultation with a sport psychologist enhances
the patient experience.
Annotated References
1. Brewer E, 1|Ii'an Raalte J: Introduction to sport and exercise
psychology, in Brewer E, 1|Ii'an llaalte J, eds: Exploring
senssl jeajpew :g
Sport 6' Exercise Psychology, ed 2. Washington, DC,
American Psychological Association, .1001, p 3-9. DD]
2. Murphy S: Preface, in Murphy S, ed: The Sport .Psycl:I
l-l'nntfhook. Champaign, IL, Human Kinetics, 10135, pp
vn-vm.
3. Association for Applied Sport Psychology Abstract: Co-
alition for the Arleancernent of Gradnate Edncation and
Training in the Practice of Sport Psychology: Voluntary
Prograrn Recognition for Sport Psychology Practice Grad-
nate Programs. https:iiwww.appliedsportpsych.orgian-
nual-conferenceiabstractsilfl143335. Accessed June 16,
2015.
The goal of the coalition referenced is to promote
high-quality graduate training programs within the field
of sport psychology.
4. Association for Applied Sport Psychology: About Cer-
tified Consultants. http:iiwww.appliedsportpsych.orgl
certified-consultants. Accessed June lei, 101.5.
The information referenced is a site aimed at explaining
the requirements and rigor involved in becoming certified
through AASP.
5. American College of Sports Medicine; American AcadMy
of Family Physicians; American Academy of |[l'rthopaedic
Surgeons; American Medical Society for Sports Medi-
cine: American flrthopaedic Society for Sports Medicine;
American llD'steopathic Academy of Sports Medicine: Psy-
chological issues related to injury in athletes and the team
physician: A consensus statement. Med Sci Sports Exerc
lflflfitfifiilllflfldfl-ZDS4.Medline DUI
6. National Collegiate Athletic Association: Sport Science in-
stitnte. hrtp:iiwww.ncaa.orgihealth-and-saferyisport-sci-
ence-institute. Accessed June 26, 2015.
NCAA SSI is a relatively new development within the
NCAA. This group is devoted to activities that benefit the
overall safety and wellness of the student-athletes within
the NCAA.
Drrhopoedic Knowledge Update: Sports Medicine 5
 Section 7’: Medical Issues
?. Hainline B: Introduction, in Brown ('3, ed: Mind, Body,
and Sport: Understanding uru‘l Supporting Student-A tlr-
lete Mental 1|Wellness. Indianapolis, IN, National Culle-
giate Athletic Association, .1014. DD!
This recent publication of the NCAA is aimed at educating
professionals within NCAA member institutions.
Carr C, Davidson J: The psychologist perspective, in
Brown Cr, ed: Mincl, Body, and Sport: Understanding
and Supporting Student-Athlete Mental Wellness. Indi-
anapolis, IN, National Collegiate Athletic Association,
21] 14! PP 211-13,
This recent publication of the NCAA is aimed at educating
professionals within NCAA member institutions. The
roles of a psychologist within an athletic department and
a brief history of those roles are discussed.
n influence hiring the right person hoping to ensure success
A" DiFiurijP, Benjamin H], Brenner JS, et al: Dveruse injuries
and burnout in youth sports: A position statement from
E
.E
'U the American Medical Society for Sports Medicine. Br
} Sports Med aursusmesv—ass. Medline not
'11
E
I:
This consensus statement was offered as a systematic and
evidence-based review of the literature on youth spurt
overuse injuries. The authors offer their summary to a
wide range of possible readers including parents, athletes,
coaches, and other sport scientists.
ll]. Smith R, Smell F: Psychological interventions in youth
spurt, in Brewer B, Van Baalte J, eds: Exploring Sport
El" Exercise Psychology ,ed 3. Washington, DC, American
Psychological Association, 2111'14, pp SSS-STE. DCII
The relevant literature regarding youth spurt participation
is reviewed. The authors also suggest interventions at var—
ious levels within the youth spurt culture — interventions
for parents, coaches, and athletes.
11. Petitpas A, Brewer E, Van Raalte J: Transitions of the
student-athlete: Theoretical, empirical, and practical per-
spectives, in Etael E, ed: Counseling and Psychological
Services for College Student-Athletes. Morgantuwn, WV,
Fitness Information Technology, 2U U9, pp 233-31312.
The authors have taken the opportunity to outline the
multifaceted idea of transition. They explore the various
ways that student athletes can experience transition and
they offer practical, research-based suggestions on how
to he an effective help-er to those in need.
11. Piultney J, Tehhe C: The college student-athlete experience
and academics, in Ettcl E, ed: Counseling until Psycholog—
icel Services for College Student-Athletes. Morgantown,
WV, Fitness Information Technology, 2009, pp EST-231.
The impact of the ‘student‘ part of student athlete is stud-
ied by exploring the research around academic success
in student athletes. Study strategies and tips to use when
working with student athletes in the area of academics
are presented.
13. Savickas ML: Career maturity: The construct and its mea-
surement. Vocat Guiti Q 1934;31:222-231. DUI
Clrthupaedic Knowledge Update: Sports Medich'ie S
14. Coppell D: Post—concussion syndrome, in Brown C, ed:
Mind, Body, and Sport: Understanding and Supporting
Student-Athlete Mental 1Wellness. Indianapolis, IN, Na-
tional Collegiate Athletic Association, Bill-4, pp iii-"i9.
This recent publication of the NCAA is aimed at educating
professionals within NCAA member institutions. The
nuances and difficulties associated with concussion and
postconcussion including symptoms and strategies for
improvement, are discussed.
15. McCann 5: So you’d like a sport psychology consultant
to work with your team? Three key lessons learned from
Cllympic teams. Diyrnpic Couch 2fl14;25{3}:15-3il
The author draws on his knowledge of working within
the USDC and offers practical tools for individuals look—
ing to bireiwurk with a sport psychologist. Factors that
are explored.
16. Petrie T, Deiters J, Harmison R: Mental toughness, so-
cial support, and athletic identity: moderators of the life
stress-injury relationship in collegiate football players.
Sport Exerc Perform Psychol 2G14;Sl1]:13-27. DE“
The findings herein suggest that mental toughness moder-
ates the relationship hetween positive life stress {ITS} and
injury outcome. Student athletes with low levels of mental
mughness and family social support miss more days to
injury when experiencing high levels of PLS.
1?. Ruddock-Hudsun M, O’Hallorau P, Murphy (3: The psy-
chological impact of long-term injury on Australian Fuut-
ball League. 1 Appl Sport Psychol 2014;26j4]:3??-394.
This study looks qualitatively and longitudinally at ath—
letes” psychological responses to injury. The authors report
the practical implications of their findings in a way that is
useful for practitioners in order to benefit the athlete and
their return to competition. DDI
IS. Brewer B, Petrie T: Psychopathology in sport and exer—
cise, in Brewer B, 1iian Ba alte J, eds: Exploring Sport s-
Exercise Psyclaology, ed 3. Washington, DC, American
Psychological Association, lflfll, pp 311-335.
19. Thompson E, Sherman R: Eating disorders: clinical and
subclinical conditions, in Thompson E, Sherman F1, eds:
Eating Disorders in Sport. New York, NY, Boutledge,
lfllfl, pp T-BB.
This book provides a complete examination of eating
disorders in collegiate student-athletes. Research of the
disorders is reviewed and treatment suggestions and prac-
tical advice offered for individuals with disordered eating.
20. Maniar S, Summers-Flanagan J: Clinical depression and
college student-athletes, in Etael E, ed: Counseling and
Psychological Services for College Student-A tlrletes. Mor-
gantown, WV, Fitness Information Technology, 2009, pp
323-343.
The presentation of depression in student athletes is dis-
cussed. Causes, symptoms, a litany of treatment options,
and guidance for individuals who may be in a position
D lflld American Academy of Drthupaedic Surgeons

to assist a student athlete struggling with depression are
outlined.
21. Bade: C: Mood disorders and depression, in Brown C, ed:
Mind, Body, end Sport.- Undetstnnding and Supporting
Student-Athlete Mental Wellness. Indianapolis, IN, Na-
tional Collegiate Athletic Association, 2fl14, pp 33-43.
The goal of this recent publication of the NCAA is to
educate professionals within NCAA member institutions.
New developments, signs, symptoms, and treatment op-
tions for mood disorders, which can interfere with athletes’
performance, are presented.
22. Lester D: Suicidal tendencies, in Brown C, ed: Mind,
Body, nnd Sport.- Undetstnnding end Supporting Stit-
dent-Athlete Mentnl Wellness. Indianapolis, IN, National
Collegiate Athletic Association, 2014, pp fiE-t'iS.
The goal of this recent publication of the NCAA is to
educate professionals within NCAA member institutions.
Information, warning signs, and myths about suicide are
discussed, along with possible risk factors seen in profes-
sional and student athletes.
IE! Eillii American Academy of flrthopaedic Surgeons
Chapter 4|]: Sport Psychology
13. Goldman 5: Anxiety disorders, in Brown G, ed: Mind,
Body, end Sport.- Understnnding end Snppotting Etn-
dent-Athlete Mentnl Wellness. Indianapolis, IN, National
Collegiate Athletic Association, 2014, pp 34-31
The goal of this recent publication of the NCAA is to
educate professionals within NCAA member institutions.
The signsisymptoms and treatment options for anxiety
disorders are discussed, the disorders are described, and
suggestions on how to help are offered.
24. Stull T: The psychiatrist perspective, in Brown C, ed:
Mind. Body, end Sport; Understanding and Supporting
Stndent-Atltlete Mental Wellness. Indianapolis, IN, Na-
tional Collegiate Athletic Association, 2014, pp 24-26.
The goal of this recent publication of the NCAA is aimed
at educating professionals within NCAA member insti-
tutions. A psychiatric perspective is provided on some
sanssl lesgpaw :,1;
of the more commonly seen psychological disorders in
student athletes.
Drtbopaedic Knowledge Update: Sports Medicine 5
Chapter 41
Cardiac Issues in Athletes
Kimberly G. Harmnn, MD Innathan A. Dreaner, MD
Sudden cardiac death (SUD) is the leading cause nf
medical death in athletes with an estimated rate bf l in
513,000, with higher risk in same subgrnups including
males, African Americans, and male basketball ath-
letes. A thnrnugh understanding nf the epideminlngy
nf sudden cardiac arrest and SEE in athletes is imper-
tant as well as familiarity with screening methc-ds and
debate regarding detectinn nf underlying cardinvaseular
disease. Recngnitinn nf the types nf cardiac pathnlngy
in athletes as well as differentiatinn nf disease item
the benign changes nften seen with intense training in
athletes (“athlete’s heart") are essential. Cnmprehen-
sinn bf issues related tn return te- play and restrictinn
guidelines after diagnnsis nf cardinvascular disease is
cr1t1cal fer the team physician making these decislens.
Keywords: spurts cardinlngy: sudden cardiac
death; sudden cardiac arrest: athlete
IntrndUttic-n
Physical activity can have many pnsitivc physical and
mental health benefits; hnwever, in snme individuals,
vignrnus activity can increase the risk bf sudden cardiac
arrest {SBA} and death. Sudden cardiac death {5CD} is
the leading medical cause nf death in athletes and typi-
cally is the result nf undiagnnsed structural nr electrical
Dr. Harman c-r an immediate family member has received
nnnincnme suppnrt [such as equipment er services}, cem—
mercially derived hnnnraria, nr ether nen-research-related
hindingI (such as paid travel} from Snncdite and serves as
a beard member, nwner; nfficei; er cnmmittee member at
the American Medical Snciety fnr Spnrts Medicine. Neither
Dr. Dreaner nor any immediate family member has received
anything at value from or has steel: er stnclc nptiens held
in a cnmmercial cnmpany nr institution related directly or
indirectly to the subject at this chapter:
fl lflld American Academy at Drthnpaedic Surgenns
cardinvascular disease.‘ The ultimate nbiectiye at the
preparticipatinn screening nf athletes is the detectinn nf
“silent“ cardinvascular abnnrmalities that can lead tn
SCH"- Distinguishing nnrma] physinlngic adaptatinns tn
exercise, cnllectively knnwn as “athlete’s heart,” frnm pa-
sanssl leaipaw :,1;
thnlegy can be challenging. Electrecardingraphic criteria
have been develnped that attempt tn accnunt far these
changes and reduce the number nf false-pnsitive results
while maintaining specificity.3 A thereugh understanding
cf the issues invnlved in the preparticipatinn eaaminatinn
and screening is required nf spurts medicine physicians.
in additinn, knnwledge regarding the incidence bf SCA
in athletes, the grnups at high risk fnr SEA, the causes nf
SCD in athletes, and return-te-play issues is impnrtant.
Prepartitipatien Examinatifln
Twelve millinn cnmpetitive high schnel and cellegiate
athletes live in the United States, and must are required
be have a preparticipatien eaarninatinn befnre participat-
ing in spurts. The American Heart Assnciatinn {AHA}
recnmmends a 14-pnint screening histnry and physical
examinatinn“ {Table 1}, whereas the Eurepean Seciety
nf Cardinlngy,‘ the Internatinnal lDlympic Cnmmitteefi
the Federatinn Internatinnale de atball Assnciatinn,
and mast US prefessinnal assnciatinns recommend the
additinn nf a Ill—lead electrncardingram {ECG}, based an
Italian data shnwing a 90% reductinn in the rate nf SCD
with the inclusinn nf E'IIIG.T lEither studies have questinned
this result, hnwever.fl The primary cnncerns cited regard-
ing the additinn cf the 12-lead ECG include its cast and
additinnal wnrkup, high false-pnsitiye results, and the
unavailability nf adequate physician infrastructure fer
the widespread implementatinn nf screening with ECG.
Althnugh these cnncerns have been lnng held, a recent
meta—analysis examining the histnry, physical examina-
tinn, and electrc-cardiegraphy feund that the sensitivity
nf a 12—lead ECG was much higher than both histnry
and physical erraminatinn, with similar specificity.” In
additinn, the false-pnsitive rate nf electrneardingraphy
{6%} was less than that cf the histnry {3%}, er the physical
examinatinn {10%}. Electrneardingraphy had the highest
Drthnpaedic Knnwledge Update: Sparta Medicine 5
 Sectien 1': Medical Issues
_—_
The H—Element American Heart
Asseciatien Recemrnendatiens for
Preparticipatien Cardievascnlar
Screening fer |L'Jempetitive Athletes
Medical Histery
Persenal histery
1. Chest painfdiscemfertftightnesslpressure related
te exertien
2. Unexplained syncepelnear syncepe
Excessive and unexplained dyspneal'fatigue er
5-”
palpitatiens asseciated with exercise
= Prier recegnitien ef a heart murmur
HF‘l-"P
E Except: QHS veltage criteria fer LvH eccurring with
Elevated systemic bleed pressure
E
.E
'U
'11
Frier restrictien frem participatien in sperts
E depressien, T-wave inversien, er pathelegic E}
Frier testing fer the heart erdered by a physician
I:
Family histery
B. Premature death {sudden and unexpected er
ethervvise} befere age 5D y attributable te heart
disease in a 1 relative
9. Disability frem heart disease in clese relative
yeunger than 50 y
10. Hypertrephic er dilated cardiemyepathy, leng QT
syndreme, er ether ien channelepathy, Marfan
syndreme. er clinically significant arrhythmias;
specific knewledge ef genetic cardiac cenditlens
in family members
Physical examinatlen
11. Heart murmur
12. Femeral pulses te exclude aertic cearctatien
13. Physical stigmata ef Marfan syndreme
14. Brachial artery bleed pressure {sitting pesitien}
Data frem Maren BJ. Frled man FlA. ltllngfleld P. et al: Assessment ef
the 12-Iead ecg as a screening test fer detectien ef cardievascular
disease in healthy general pepulatiens ef yeu ng peeple {12—25 years
crl‘ age}: A sclentlflc statement frem the Amerlcan Heart Asseclatlen
and the American lIllellege ef Cardielegy. Circulatien Ifl14:l3tl:13flil-
1334.
positive likeliheed raties and the lewcst negative likeli-
heed raties fer the detectien ef underlying cardievascular
abnermalities, suggesting that electrecardiegraphy was
the mest effective strategy—and that the histery and
physical examinatien were relatively ineffective scrat-
egies—fer the detectien ef underlying carclievascular
disease? Te minimize the false-pesitive rate, the interpre-
tatien ef the ECG must take inte acceunt the physielegic
adaptatiens ef the heart te exercise. The Seattle Criteria
were develeped by an internatienal greup ef experts in
firthepaedic Knewledge Update: Sperts lvledich'le 5
Electrecardiegraphic Interpretatien in
Athletes: The “Seattle Criteria”
Hermal EEG Findings in AthletesI
1} Sinus bradycardia {EBB bpm}
2] Sinus arrhythmia
3] Ectepic atrial rhythm
4] Junctienal escape rhythm
5} 1" AV hleclt [PH interval :- Eflt'l ms]
5} Mebitz type | {Wencltebachl 2” AV bleclc
T} lncemplete HERE
5] lselatecl QRS veltage criteria fer LVH
any nenveltage criteria fer L‘v'H such as left atrial
enlargement, left axis deviatien, ST segment
WHVES
9] Early repelariaatien {5T elevatien. l-peint
elevatien, J waves. er terminal QHS slurring}
1E] Eenvex ["demed"] ST segment elevatien
cembined with T-vvave inversien in leads V1 -‘v'4 in
African American er African athletes
EEG = electrecardlegram. mm = mllllmeter. av = atrleventrlcular.
ms = millisecends. HEIBB = right bundle branch ble-clt. Lil'H = left
ventricular hypertrephy.
II'l'hese cemmen tralnlng—related ECG alteratlens are physleleglc
ada ptatiens te regular exercise. are censidered nerrnal variants in
athletes, and dc net require further evaluatien in asym ptematic
athletes.
llepreducecl with permissien frem Drexner JA. Acherman MJ'.
Andersen J, at al: Elactrecardieg ra phic interpretatien in athletes:
The "Seattle crlterla‘. ErJ Sperts Med 2e13:w[a]:1 22-124.
sperts cardielegy and have been shewn te reduce the
false-pesitive rate ef ECGs in athletes te appreximately
4%, while maintaining specificity3 {Table 2}.
Ne study has demenstrated the effectiveness ef the his-
tery and physical examinatien alene in preventing 5CD.
Cine study examining 115 athletes with SCI) revealed
that enly ene athlete had been cerrectly identified at the
pceparticipatien examinatien, demenstratieg the relative
inability ef the histery and physical examinatien te detect
underlying cardievascular disease.” Indeed, cest-effec-
tiveness analysis cemparing screening with ECG alene,
histery and physical examinatien alene, er electrecardi~
egraphy cembined with histery and physical examina-
tien cencluded chat electrecardiegraphy alene is the [nest
cest-effective strategy, fellewed by electrecardiegraphy
cembined with the histery and physical examinatien."
In many places, the infrastructure te perfern: and
preperly interpret EEGs in athletes dees net exist.
fl lflld American Academy ef Cirrhepaedic Surge-ens
 Chapter 41: Cardiac Issues in Adfletes

Electrocardiographic Interpretation in Athletes: The “Seattle Criteria”

Abnormal Electrocardiogram Findings in Athletes' Definition
T-wave inversion :- 1 mm in depth in two or more leads vr-vs. II and a’v'F.
or I and a'v'L [excludes Ill. a‘vlfl, and vi)
ST segment depression 2 I05 mm in depth in two or more leads
Pathologic Q waves :- 3 mm in depth or :- 4l'i ms in duration in two or more
leads {except Ill and aVl-‘tl
Complete left bundle branch blocl: QRS a 12:: ms. predominantly negative QRS complex in
lead V1 [05 or r5]. and Upright monophasic R wave in
leads I and VE
Intraventricular conduction delay Any QRS duration 2 14B ms
Left axis deviation as: to —9I:I"

sanssl leagpaw :,1;

Left atrial enlargement Prolonged F wave duration of :- 1.1"lilI ms in leads I or II
with negative portion of the F wave 2 1 mm in depth
and a All} ms in duration in lead v1
Right ventricular hypertrophy pattern it-"v'1 + S-"v'5 :- 1lIi.5 mm AND right axis deviation or 12D“
lv'entricular PH interval e 120 ms with a delta wave [slurred upstroke
preexcitation in the QRS complex) and wide 0R5 ll:- 12:: ms}
Long QT interval“ lQTc a are ms {male}
42c e 430 ms {female}
QTc a EDD ms {marked QT prolongation]
Short QT intervalh QTc 5 32B ms
Brugacla-lilte ECG pattern High take-off and downsloping ST segment elevation
followed by a negative T wave in a 2 leads in v1-vs
I'vlobitz type II 2" av block Intermittently nonconducted P waves not preceded by
PR prolongation and not followed by PR shortening
3" av block Complete heart block
Profound sinus bradycardia «a so bpm or sinus pauses ‘e 3 s
Atrial tachyarrhythmias Supraventricular tachycardia, atrial fibrillation, atrial
flutter
Premature ventricular contractions a 2 P'v'Cs per 10 s tracing
Ventricular arrhythmias Couplets, triplets, and nonsustained ventricular
tachycardia
ECG = electrocardiogram. mm = millimeter. bpm = beats per minute. A‘v' = atrloventrlcular. ms = milliseconds. PM": = premature ventricular
contraction, RHEIB = right bundle branch block, L‘Iu'H = left ventricular hypertrophy.

' These ECG findings are unrelated to reg ulartraining or expected physiologic adaptation to Exercise, may suggest the presence of pathologic
cardiovascular disease. and require further diagnostic evaluatlon.

" The QT interval corrected for heart rate lEcl ideally is measured with heart rates of EU to Eltl bpm. Consider repeating the EEG after mild
aerobic activity for borderline or abnormal QTc values with a heart rate -c 5111 bpm.

lteprod uced with permission from Dremer .lA. Aciterman lvl.l. Anderson .I. et al: Electrocardiographlc interpretation in athletes: The 'Seattle
criteria'. EHr Sports Med 2o: EIHTIEIIHIE-‘lle.

Several efforts are underway to educate providers in Currently, the standard of care in the United States
the interpretation of ECG in athletes, including free on- is the AHA 14-point screening guideline, although a
line training modules, available at http:fflearning.htnj. ll—lead ECG can he considered for patients in high
coml'learningl'course-introl.html?course[d=1l]042239. risk groups.

IE! lfllli American Academy of flrrhopaedic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Section. 2: Medical Iasues

-—
Incidence ef Sudden llilardiac Death
He. nf Age Iiange
Aether ‘I'aar Enuntry Marilee Papnlatlnn Incidence 5H“ lil'flfll'

. Retrpspectiue Callegei'high _ _
1lul'an I‘Eal'r'lpl5 1990 U5 cehert ache-0| athletea 1.300.000 10 12 24

Hetrnspectiee High schnnl .

Maren“ 1990 U5 cnhnrt athletes 1.212.000 were“ 11 HA.

. 1:4? 000 athlete

Prnspectwe Athleteafynung _ '
Eprrade“ 2005 Italy c-hnrt study people 1.142.900 wrung 20 12-55
people

Eckart” 2004 us “w'flfiflw Military recruits 1:10am 25 1035

IZIIrezneriiI 2005 05 Rflrgflifltwe {allege athlete: 1:01.000 5.5 NA.

=
E Gunnaraeni‘ 2000 Iceland “Etrfnfifr‘:”e mung penple 1:ea.aea an 12-35
E

.E U5 and Prnspectiee _ _
'U Atkins“ 2009 Eanada [uhart study 'fcung peaple 1.49.000 5 12 19
02
E Prcspectl'ue
r: Ehugh“ 2009 05 pcpulatlan— cng peaple 1:55.520 5 1—15
based

Creas-eactianal High schaal 1:25.000 50A + 500

IZIIreznerl‘El 2009 05 survey anilatae 1:40.000 500 HA HA.

Maren" anus us “Wuipmw'i

cnhn rt
Athletes 1:15:35: :7 sea
. ,, Hetraspectiee _
Fepedalns 2009 UK cahcrt ‘I’pu ng pecple 1-55.000 4 1-55

1.. Retreepectiue A01Ieteefypung 1:02.045 athlete _

Halat 2010 Denmark cehcrt pecple 1:20.595 general pep T 12 35

Heist" 2010 Denmark “atriflifltwe ‘fcung peaple 1:55.000 1' 1-55

Enlherg” 2010 Hemay “Etrlflmfitlue Ten ng penple 1:111.111 20 15-54

camper- 2011 05 "fliiifilfrttm '1'cung pecple 1:32.25a HA 2-24

4: 20 yr — 1:29. 025;
1 Retrospective I'I.Iii|i|:ar:n.|I 20-24 51 - 1:00.955.“
Eckart' 2011 ”5 cahcrt perscnnel 25-29 yr - 1:50.120; 10 "5-3"
30-55 3.! — 1:2 5.000

Hanrmn‘ 2011 us “wuipmm

cehcrt
{allege athletes 1:43am: 5 mac
Hetrnspectiee _
llnllargeyl'i‘I 2011 Ireland who,” ‘fcung peaple 1.55.000 5 15-55

.. . Ecmpetltiee .
Mal] Ian'i1 2011 France Prnspectwe athletes 1.102.015 HA 10-55

. Retrespectiue 151439.520 2nd- ,

51elmrille 2011 Israel cehert Athletes 131.553 1244

Hat-respective High achaal

Marenfl 2012 05 cnhc rt athletes -
1-150.000 12_10

Prpspective
. 10.24 11' - 1:09.000
I'lnlleyerl'“l 2012 U5 papflsfllen- ‘fcung peaple 25,35 _ 1:22.?00 HA HA

Hetrnspectiee (allege! high 1:11.235?! cclllege 1:

Baden“ 2013 ”5 cnhn rt ache-ell fnnthall 312.500 high schnnl "A "A

Filmer“ 2010 Canada ““ruipmwe

cahcrt
mung penple 1:129.000 5 1-1a
.. Hetespectiue High schenl 1:410.000 last decade
“we”: 2°13 ”5 cehert athletes 1:91am "0 "‘2

flrdinpaedic Kncwledge Update: Sparta Medicine 5 fl 2010 American Academy cf Drrhnpaedic Surge-ens
 Chapter 41: Cardiac Issues in fldfletes

Table 3 {re —
Incidence of Sudden Cardiac Death
Htlnher of Age Range
Author ‘t'ear Country method Population Incidence
1steers lyeers}

were“ can Denmark ““‘ficfifitfl ‘r'oung people teases :- 1-1s

Retrospective teatime—confirmed
Me run" It'll-II U5 cohort I:ollegle athletes 1:52!flflt‘l—pre5"med in ‘lT-EE

Prospective High sd'loal _ _

Tomsdahl" 2M4 US observational athletes 1.S?,?1'El SEA+SED 3 14 15

HA - not available, US - United States. SEA - sudden cardiac arrest. 5CD - sudden cardiac death, Ult - United Kingdom.

Normal Hseerimehie nerd interstellar

sanssl lesipaw :,1;

+f of sorts
Smell left
ventricle

Left eentri e

1tul'entricular 'l'hioltened
septum ventricular septum

fl MA‘I’D FD UHflATIflH FUR MEDICAL EWD'LTI'DH AHD FIE-SEARCH. ALL liliGHTfi RESERVED.

Drawings show a normal heart and a heart with hypertrophic cardiomyopathy. [Reproduced with permission from
the Mayo Foundation for Medical Education and Research, flocl‘lester, MN.)

Incidence of SCD in Athletes or use unreliable population estimates. In studies using

The incidence of SCD in athletes is debated, with esti—
mates ranging from 1:3,{JDCI in some high-risk groups' to
1:91?!) GB.” The cause of this discrepancy.r relates largelyr to
the populations studied and the methods used for case iden-
tification.” Mandatory reporting of death is required in few
athlete populations; thus, many studies rel'f.r on media re—
ports, registries, and insurance claims for case identification
data from the mandatoryr reporting of death and a reliable
ascertainment of the population studied, higher incidence
numbers tend to be reported compared with studies relying
on media reports or insurance claims for case identifica-
tionL'E'J'i-M'i"r {Table 3]. A reasonable estimate for the rate
of SCD in athletes is 1:50,!)0fl, with African Americans,
males, and basketball players at higher risk. The reasons for
the increased risk of these subgroups are not clear.

IE! lfllfi American Academy of flrthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medichse .‘i
 Seeders 7’: Medical Issues

T _ E [trawl-lg). Gymnastics, Martial -“ - - . m'arding.

1, arts, Sailing, Spa-rt elimb'ng, Wraatling
Eg Water skiing, Weight Lifting,
-- Windsurfing _fl

E '-_'s ary, suite racing, Diving. American feetball, Field events Basketball, lee heekey,
_, gE UT uasb'ian, Mehtcyellng {iumping}, Figura skating, li".'.irciss-cciuntry skiing [skating
g g 3;! i Fledeeing, Ftugby, Ftunning technique), Laeresse, Flum'
E ,‘ {sprint}, Surfing, Eynehrenizad middle distance}, Swimmine'
g- _. g l swimming Team handball
El“.- _ m,
‘3 _ ,Bewllng, Brisket, i saaasairsaebau, Fencing, Badminten, Cress-eeuntry

-
'fi ~ . Gall, Hillary Table tennis. 1illsIllaiyilastl skiing {classic technique],
a E Field heekey, Orienteering,

5 a
g g5 Ftace walking, FitacquutstlitlililluIr I
a . _' é Squash, Running {Ieng
E
E
.- distancs}, Seeear, Tennis
.E
'U
'11
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r: A. Law E. Madurai! B. High
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Causes cf SEC! in Athletes
The Inc st cerc men cause cf 5CD in athletes in the United
States typically is hypertrephic cardiemycpathy {HEMltl‘
hewever, this assumptien has been called inte questien
recently.“ In a frequently queted 2009 analysis ef EEO
SCDs, 36% were attributed te HEM, whereas ablyr 3%
cf cases were attributed ta autcpsy-negative sudden unex-
plained death {AN—SUDl.” In that study, 359 deaths that
were censidered cardiac, but for which as specific cause
ceuld he identified, were remcved tram this analysis with
little estplanatien.M In centrast te this study, in studies
ef athletes frem ether ceuntries‘imfldfl in age-matched
ncnccmpetitive athlete pcpulatiens such as these in the
U5 military‘iv‘“ and in general pepulatiens ef yeung peeple
in the United States and abread, AN-SUD represented a
larger prepertien cf deaths and HCM a relatively smaller
prepertien ef deaths.”"“-‘“-“1 A recent study ef U5 cellcgc
athletes alse feund Ali-SUD te he must ccmmen and
HCM te be mere infrequent than previeusly ]_::u'edicted,3fl
altheugh a different study ef the same pepulatien and
examining the same autcpsies, reparted a higher incidence
ef HCl'irl.fl These incensistencies highlight the need fer
standardised pathelegic definitiens, autepsies dene by
these with expertise in sudden cardiac death, and me-
lecular autcpsies.
Whatever the distributien ef causes, it is impertant te
have an understanding ef cardievascular diseases that
can predispese athletes te ECU and the cemmen findings
related te these diseases. These cenditiens typically are
categerised inte structural and functienal greups. The
structural greup includes hypertrephic cardiemyepathy,
cerenary artery anemalies, aertic rupture andi'er Mar—
fan syndreme, dilated cardiemyepathy, myecarditis and
arrythmegenic right ventricular cardiemyepathy. The
electrical greup includes leng QT syndreme {LQTS},
1'L'Iii'elff-13'srltirtsen-‘lflihite {WP‘W} syndreme, Brugada
syndreme, catechelaminergic pclymerphic ventricular
tachycardia {CPVT}, and shert QT syndretne. Cerutue—
tie cerdis is a well-described cause ef SCI} in athletes,
eccurring fellewing impact tn the chest wall during a
narrew windew ef repelarisatien, leading te ventricular
fibrillatien,
Hypertrephic Eardiemyepathy
The prevalence cf HCM is 1:500 in the general pepulatieu
but is feund less frequently threugh screening in cem—
petitive athletes, appresimately 1:1,[ICICI te 1:5,flDfl.5"43'*5

firthepaedic Knewledge Update: Sperts Medicine 5 fl lflld American Academy ef Urthepaedic Surge-ens

The characteristic morphologic features of HCM include
asymmetric left ventricular {LV} hypertrophy {usually
involving the ventricular septum}, LV wall thickness of
16 mm or more {normal is less than 12 mm; borderline
is 13 to 15 mm}, a ratio between the septum and free
wall thickness of more than 1:3, and a nondilated left
ventricle, with impaired diastolic function.“ Histologic
analysis shows a disorganized cellular architecture with
cardiac myocyte disarray. An ECG will be abnormal in
up to 95% of patients with HEMP“ Echocardiography
remains the standard to confirm the diagnosis of HCM
by identifying pathologic LV wall thickness {greater than
16 mm} and a nondilated left ventricle with impaired
diastolic function {Figure 1}. If the diagnosis of HCM
is uncertain {borderline LV wall thickness of 13 to 15
mm}, MRI with gadolinium, genetic testing, or repeat
echocardiography after IE to 12 weeks of deconditioning
can help distinguish HEM from athletic heart syndrome.
8CD will be the presenting symptom in 30% of HEM
cases, making identification through screening a priority,
although some athletes may experience prodromal synco-
pe or chest pain,” and some may have the characteristic
murmur of HEM.” It is recommended that athletes with
HEM compete in low-intensity sports only” {Figure 2}.
Coronary Artery Anomalies
Athletes with coronary artery anomalies may present with
symptoms of chest pain during exercise, syncope, or sud-
den death.“ The most common coronary anomaly is an
abnormal origin of the left coronary artery arising from
the right sinus of Valsalva. Impingement of the anomalous
artery with an intramural course {within the wall of the
aorta} during exercise may lead to ischemia and a subse-
quent arrhythmia. Dther features that can contribute to
ischemia during exercise include an acute angled takeoff
and hypoplastic ostium of the anomalous artery.
If an anomaly is suspected, transthoracic echocar—
diography can identify the coronary artery origins in
approximately 30% to 9.7% of patients.52 Advanced car-
diac imaging such as CT angiography, cardiac MRI, or
coronary angiography may be needed to detect coronary
anomalies in some instances. Coronary artery anoma-
lies rarely are identified through ECG. Coronary artery
anomalies often can be corrected surgically, with return
to play following surgical recovery.ml
Aortic Rupture and Marian Syndrome
Marfan syndrome is the most common inherited disorder
of connective tissue that affects multiple organ systems,
with a reported incidence of l to 3 in 10,0130 individu-
als.53 Marfan syndrome causes a progressive dilatation
and weakness (cystic medial necrosis} of the proximal
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 41: Cardiac Issues in Athletes
aorta that can lead to rupture and sudden death. Myxo-
matous degeneration of the mitral and aortic valves also
can lead to valvular dysfunction. Marfan syndrome is
caused by mutations in the fibrillin-l gene, with ?5% of
cases inherited through autosomal dominant transmission
with variable expression and 25% of cases from de novo
mutationssfl Athletes with Marfan syndrome who have
nondilated aortas may participate in moderate dynamic
and low static competitive sports; those with aortic root
dilatation {greater than 4 cm} or prior aortic root repair
should participate in low-intensity competitive sports
only” {Figure 2}.
Myocarditis
Myocarditis is another important cause of SCD. Acute
sanssl leagpaw :,1;
inflammation of the myocardium can lead to an arrhyth-
mogenic focus and sudden death. Coxsackie B virus is
implicated in more than 5{1% of cases, but echovirus, ade-
novirus, influenza, and Chlamydophr’lia pneumoniae also
have been associated with myocarditis. The acute phase
of myocarditis presents with a flu-like illness, which can
lead to dilated cardiomyopathy and signs and symptoms
of congestive heart failure. Histologic analysis shows a
lymphocytic infiltrate of the myocardium with necrosis or
degeneration of adjacent myocytes. Myocardial scarring
or fibrosis also can develop and can act as an arrhyth-
mogenic focus.
Characteristic symptoms of myocarditis include a
prodromal viral illness followed by progressive exercise
intolerance and congestive symptoms of dyspnea, cough,
and orthopnea. If myocarditis is suspected, the ECG may
show diffuse low voltage, ST—T wave changes, heart block,
or ventricular arrhythmias. Serologic testing may show
leukocytosis, eosinophilia, an elevated erythrocyte sedi-
mentation rate or C-reactive protein level, and increased
myocardial enzymes. Echocardiographyr will confirm the
diagnosis within the right clinical context, showing a
dilated left ventricle, global hypokinesis or segmental
wall abnormalities, and decreased LV ejection fraction.
Cardiac MRI may demonstrate regional wall motion ab-
normalities and areas of late gadolinium enhancement.
Athletes should be restricted from all competitive sports
for 6 months following diagnosis. Return to sport may
be considered after ECG, Holter monitoring, graded ex-
ercise test, enzymes, and echocatdiogram have returned
to normal.m
Arrhythmogenic flight Ventricular Cardiomyopatl'ny
Arrhythmogenic right ventricular cardiomyopathy
[ARVfl was reported as the leading cause of SCI)
{22%} in the 1F«Veneto region of northeastern Italy but is
less commonly reported in the United States.“ ARVC is
Drthopaedic Knowledge Update: Sports Medichie 5
 Section 7’: Medical Issues
characterised by a progressive fibrofatty replacement of
the right ventricular myocardium, causing wall thinning
and right ventricular dilatation. The estimated prevalence
is 1 in 5,l]l}i] in the general population, and the disorder
results from mutations in genes encoding for desmosomal
{cell adhesion} proteins.“
ARVC can present with myocardial electrical instabil-
ity, leading to ventricular arrhythmias, which precipitate
cardiac arrest, especially during physical activity. Au EEG
may show right precordial T-wave inversion [beyond V1),
an epsilon wave {a small terminal notch seen just beyond
the QRS in V1 or V2}, prolongation of QRS duration
longer than 110 ms, or right bundle branch block pattern.
Echocardiogram, cardiac MRI, or CT may demonstrate
n right ventricular dilatation and wall thinning, reduced
E
E right ventricular ejection fraction, focal right ventricular
.E
'U wall motion abnormalities, or right ventricular aneu—
E
'11
rysms. Fibrofatty infiltration of the right ventricle is seen
ri-l
best on cardiac MRI or by histologic analysis in selected
cases. It is recommended that athletes with ARVC be
excluded from competitive sports-‘1lfll
Ion Channel Disorders
Ion channel disorders are primary electrical diseases of
the heart predisposing to potentially lethal ventricular
arrhythmias. They are characterised by mutations in
ion channel proteins, leading to dysfunctional sodium,
potassium, calcium, and other ion transport across cell
membranes. They include disorders such as LQTS, short
QT syndrome, Erugada syndrome, or familial CP‘VT.”
Long QT Syndrome
LQTS is the most common ion channelopathy and is
characterised by prolongation of ventricular rcpolarisa-
tion, as measured by the QT interval corrected for heart
rate [QTcL In an asymptomatic athlete without a family
history of 5CD, current cutoff values for a prolonged QTc
are 4TB ms and 430 ms in males and females, respective-
ly.” Ten gene abnormalities are recognized for LQTS
involving potassium and sodium ion channels impor—
tant in cardiac repolarisation.” Most arrhythmias from
LQTS are triggered by emotional or physical stress and
present with syncope or near—syncope, seizures, or sud-
den death. Syncope is usually due to torsades de pointes,
a specific form of polymorphic ventricular tachycardia.
Up to 2D% of patients who have LQTS and present with
syncope, but in whom the diagnosis is not made and who
are not treated, will experience 5CD in the first year after
syncope, and 50% will have 5CD by 5 years.” lCurrent
guidelines recommend restriction from all but low-inten-
sity competitive sports for those who have experienced
an out-of-bospital cardiac arrest or syncope precipitated
firthopaedic Knowledge Update: Sports Medicine 5
by LQTS,” although some authors contend this guideline
is too restrictive, arguing that patients should have more
autonomy in decision making and that those who do
return to play are unlikely to have adverse outcomes.”
Catechoiaminergic Poiyventricuiar Tachycardia
CPVT is a familial disorder characterized by stress-
induced ventricular arrhythmias that result in SEE in
children and young adults and most commonly involves
a cardiac ryanodine receptorfcalcium release channel
mutation. CPVT can present with syncope, drowning
or near drowning, seizure, or sudden death triggered by
vigorous physical exertion or acute emotion. Syncope is
the presenting symptom in most patients with CPVT,
with the first syncopal event occurring at approximately
3 years of age.“ A family history of syncope or sudden
death is also present in 313% of cases.” It is recommended
that athletes with CPVT be restricted from competitive
sports.”
Wolff-Parkinson-White Syndrome
Ventricular preexcitation occurs when an accessory path-
way of electrical activation bypasses the atrioveutricular
node. As a result, abnormal innervation of the ventricle
ipreexcitation} occurs, with shortening of the PR. interval
{less than 120 ms}, slurring of the initial QRS {delta wave],
and widening of the QRS {longer than 1113 ms}. This is
evident on the ECG as the WPW syndrome patternfi‘h“
The WP‘W syndrome pattern occurs in approximately
1 in lflflfl athletesfli'1 The presence of an accessory path-
way can predispose an athlete to sudden death if the
athlete also experiences atrial fibrillation. Rapid conduc-
tion of atrial fibrillation across the accessory pathway
can result in ventricular fibrillation. The risk of sudden
death associated with asymptomatic WPW syndrome
in most population-based studies is 0.1% per year in
adults.“ Evidence suggests a higher risk of sudden death
in asymptomatic children and younger adults with WP‘W
syndrome?” Athletes with WPW should undergo fur-
ther testing to stratify high—risk and low—risk pathways.
High-risk pathways can be ablated with return to play
after several days.”
Commotio Cordis
Commotio cordis is an important cause of 5GB in ath-
letes. It occurs in a structurally normal heart after the
chest wall is struck with a blunt object. If the blow is
sustained during a specific, narrow window of repolar-
isation, it can lead to ventricular fibrillation.“ In sports,
commotio cordis is described most often in baseball, la-
crosse, and combat sports such as karate. Biologic char—
acteristics such as male sex, pliability of the chest wall,
fl lflld American Academy of Orthopaedic Surgeons

and genetic susceptibility play a rnle in cnmmntin cnrdis.I545
Attempts tn prevent cnmmntin cnrdis include using snfter
“safety balls” in ynuth baseball. Chest prntectnrs seem
tn have limited efficacy in the preventinn nf SEA. Early
recngnitinn and defibrillatinn are the keys tn survival.
Afliletic Heart Syndrnme
Snmetimes athletes are identified with larger-than-nnrmal
hearts. This finding can be secnndary tn pathnlngy such as
HCM nr tn “athlete’s heart”, which nccurs with intensive
athletic training, leading tn physinlngic adaptive changes
including enlargement nf the heart. Differentiating be—
tween the twn cnnditinns snmetimes can be difficult,
with serinus implicatinns and pntential disqualificatinn
fnr thnse with a diagnnsis nf HEM. LV wall thickness
is less than 13 mm in mnst hearts; hnwever, between 13
and 15 mm, a physinlngic “gray snne" exists, which may
represent HEM nr physinlngic remndeling. In the past,
a perind nf decnnditinning nften vvas recnmmended tn
assess fnr the regressinn nf wall thickness. Research has
demnnstrated impnrtant differences between “athlete’s
heart“ and HCl. The mnst reliable differentiatnr is the
LV cavity size, which enlarges in athletes secnndary tn
hemndynamic and neurnhnrmnnal stimuli but dnes nnt
dn sn in HEM.” (Figure 1] In additinn, T-vvave inversinn
in the lateral leads is highly suggestive nf HCl'vl.
Summary
5CD is the leading cause nf death in exercising athletes,
nccurring abnut 'l in every SELDU'D athlete-years, althnugh
males, African Americans, and basketball players are at
higher risk. Preparticipatinn esaminatinns are required
nf mnst cnmpetitive athletes, and the primary nbjective
is tn screen fnr pntentially lethal cardinvascular disnr-
ders. The AHA currently recnmmends a 14-pnint histnry
and physical esaminatinn, althnugh nther nrganisatinns
suppnrt the additinn nf a ill-lead ECG, particularly in
high-risk grnups. I-ICl'vi traditinnallyr has been thnught tn
be the mnst cnmmnn cause nf 5CD in athletes, althnugh
mnre recent studies have suggested Ali-SUD may be a
mnre frequent finding. Either cnnditinns such as cnrnnary
artery abnnrmalities, ARVC, Marfan syndrnme, and inn
channel disnrders are alsn impnrtant causes nf 5CD. A
thnrnugh knnwledge nf cardinvascular screening and
pathnlngy is impnrtant fnr spnrts physicians invnlvcd in
preparticipatinn esaminatinns and the care nf athletes.
IE! lfllfi American Academy nf Drehnpaedic Surgenns
Chapter 41: Cardiac Issues in Athletes
Hey Study F'nints
' 3CD is the leading medical cause nf death in ath-
letes with a rate nf apprnsimately 1 in 50,flflfl and
higher risk in males, African Americans, and male
basketball athletes.
I HEM is frequently cited as the mnst cnmmnn cause
nf SCD; hnwever, Ali-SUD may be mnre cnmmnn
in athletes than previnusly thnught.
1' The primary nbjective nf the PPE is the identificatinn
nf previnusly unknnwn cardinvascular disnrders.
A standardised histnry and physical enaminatinn
is the minimum recnmmended evaluatinu. The ad-
ditinn nf a screening ECG significantly imprnves
the ability tn detect cardiac disnrders at risk nf
sanssl lesgpew :,1;
sudden death and cnuld be cnnsidered if prnper
interpretatinn and adequate cardinlngy resnurces
are available.
I Management nf many cardinvascular cnnditinns
had evnlved frnm “identify and restrict” tn identify,
infnrm and a mnclel nf shared decisinn making.
Annntated References
1. Harmnn KG, Asif IM, Klnssnet D, Dresner JA: Incidence
nf sudden cardiac death in Hatinnal Cnllegiate Athletic As-
snciatinn athletes. Circulatinn 2fl11;123{15}:1594w16i}fl.
Medline DGI
The incidence nf 5CD is higher than previnusly repnrted,
at 1 in 43,fli}l'l athlete years fnr all Natinnal IEnllegiate
Athletic Assnciatinn athletes. There are snme subgrnups
nf athletes that appear tn be at higher risk including males,
African Americans and male basketball athletes. Level nf
evidence: III.
2. Marnn E], Dnuglas PS, |Graham TP, Nishimura RA,
Thnmpsnn PD: Task Fnrce 1: Preparticipatinu screening
and diagnnsis nf cardinvascular disease in athletes. I An:
Cull Cardinl2Ufl5;45{3]:1322-1326. Medline DUI
3. Dreamer JA, Ackerman M], Andersnn J, et al: Electrncar-
dingraphic interpretatinn in athletes: The ‘Seattle criteria’.
Br I Spurts Med 2013;4?{3l:122-124. Medline DD]
The use nf standardised criteria fnr interpretatinn nf ECGs
that accnunt fnr the physinlngic changes nf training can
imprnve sensitivity and specificity and decrease false-
pnsitive rate. Level nf evidence: V.
4. Marnn E], Friedman RA, Kligfield P, et al; American
Heart Assnciatinn |Elnuncil nn Clinical Gardinlngy, Advn-
cacy Cnnrdinating Cnmmittee, |IEnuncil nn Cardinvascular
Disease in the 'I'nung, Cnuncil nn |Cardinvascular Surgery
and Anesthesia, Cnuncil nn Epideminlngy and Preventinn,
Cnuncil nn Functinnal Gennmics and Translatinnal Binln-
gy, |IEnuncil nu Quality nf Care and IC'n'utcnmes Research,
Drthnpaedic Knnwledge Update: Spnrts Medicine 5
 Seetinn 7’: Medical Issues
and American IL'lnllege nf Cardinlngy: Assessment cf the
12-iead ECG as a screening test fnr detectinn nf cardin-
vascular disease in healthy general pnpulatinns nf ynung
penple {11-25 Years nf Age}: A scientific statement from
the American Heart Assnciatinn and the American Cni-
lege nf Ca rdinlngy. Circniatinn 20 14:1 3111115l:13l}3-1 33 4.
Medline DUI
The primary purpnse nf cardinvascular screening is the
detectinn nf underlying disease, and this screening is rec-
nmmended fnr athletes. A 14-pnint histnry and physical
examinatinn is recnmmended and where prnper resnurces
are available, ECG can be cnnsidered. Level nf evidence: V.
Cnrradn D, Pelliccia A, Einrnstad HH, et al; Study Grnup
nf Spnrt |Cardinlngy nf the Werking |E'irnup nf Cardiac
Rehabilitatinn and Exercise Physinlngy and the Wed-ting
|l'iirnup nf Myncardial and Pericardial Diseases nf the Eu-
n repean Seciety nf Cardinlegy: Cnnsensus Statement cf the
A" Study Grnup nf Spnrt Cardinlngy cf the 1|illinrlting Crnup
E
.E nf Cardiac Rehabilitatinn and Exercise Physinlngy and the
'U
'11 1'bllli'nrlsing Grnnp nf Myncardial and Pericardial Diseases
E cf the Eurnpean Snciety nf Cardinlngy: Cardinvascular
t: pre-participatinn screening nf ynung cnmpetitive athletes
fnr preventinn nf sudden death: Prnpnsal for a cnmmnn
Eurnpean preteen]. Ear Heart I lflfl5;26{51:516-524.
Medline DD]
Eille K, Figueiras D, Schamasch P, et al: Sudden cardi-
ac death in athletes: The Lausanne Recnmmendatinns.
Eur I Cardintrasc Presr Rebabii 1006;13i6]:359-3T5.
Medline DUI
|Cnrradn D, Eassn C, Pavei A, Michieli P, Schiavnn M,
Thiene G: Trends in sudden cardinvasculat death in ynung
cnmpetitive athletes after implementatinn nf a prepartic-
ipatinn screening prngram. IAMA lflflfi;296[13}:1593-
1601. Medline DUI
Steinvil A, Chundadae T, Zeltser D, et a]: Mandatnry
electrncardingraphic screening of athletes tn reduce their
risk fnr sudden death prnven fact nr wishful thinking?
I Am Cell Cardinf2fl11;5?{11}:1291-1196. Medline [II-DI
In a retrnspective review using twn Israeli newspapers tn
identify athletes with sudden cardiac arrest, there was nn
difference nnted between the time befnre and after the
use nf electrncardingraphy fnr screening. Enth case iden-
tificatinn and defining the athletic cnhnrt by estimatinn
temper cnnclusinns that can be drawn frnm this study.
Level nf evidence: III.
Harmnn KG, Zigman M, Dreaner JA: The effectiveness nf
screening histnry, physical exam, and ECG tn detect pn-
tentially lethal cardiac disnrders in athletes: A systematic
reviewimeta-analysis. j Eiectrncardini lfl15543{3}:319—
333. Medliue DCI'I
ECG is significantly mnre sensitive with a similar specific-
ity tn histnry and physical examinatinn, with the lnwest
false—pesitive rate fer the detectinn nf cardinvascular dis—
ease in athletes. Level nf evidence: III.
If}. Maren E], Shitani J, Pnliac LC, Matheuge R, Rnberts WC,
Mueller FD: Sudden death in ynung cnmpetitive athletes.
Drthnpaedic Knnwledge Update: Spnrts Medicine S
Clinical, demngraphic, and pathnlngical prnfiles. IAMA
1996;2T5i3lfliiS-lfl4.Medline D-CII
11. Schnenbaum M, Denchev P, Vitielln B, Kaltman JR: Ecn-
nnmic evaluatinn nf strategies tn reduce sudden cardiac
death in ynung athletes. Pediatrics 1fl12;13fl{1]:e33D-e339.
Medline DUI
The additinn nf ECG screening tn current PPE is net cnst
effective. An ECG-nnly screening strategy is mnre cnst
effective. Level nf evidence: III.
12. Rnberts WU, Stnvits SD: Incidence nf sudden cardiac death
in Minnesnta high schnnl athletes 1993-2012 screened
with a standardised pre-participatinn evaluatinn. } Am
Cnii Cardin;l lfllhfililfltllflfl-ISDL Medliue DDI
In this retrnspective review nf insurance claims fnr 5CD
in Minnesnta high schnnl athletes whn died while playing
a schnnl spnrt, it was reperted fnund that the rate nf SCD
was apprnximately l in 4flfl,{lflfl. Level nf evidence: III.
13. Harmnn KG, Dresser JA, 1i'li’ilsnn MG, Sharma S: Inci-
dence nf sudden cardiac death in athletes: A state-nf-the-art
review. Heart 2014;10fll161:122?—1234. Medline DCl'I
The incidence nf SCD in high schnnl athletes is between
1:5fl,flflfl and 1 in Sfl,flflfl athlete years. The incidence is
cnllege athletes is apprnximately 1:5fl,{iflfl, with high-risk
grnups cnmprising males, African Americans, and male
basketball athletes. Level nf evidence: ‘v'.
14. Marnn B], Dnerer J], Haas TS, Tierney DM, Mueller FCl:
Sudden deaths in ynung cnmpetitive athletes: Analysis nf
1366 deaths in the United States, HEB-EGGS. Circaiatinn
1009:119{3}:1035-1fl92.Medline DUI
The mnst cnmmnn cause nf death in a registry was HCM
{36%}, fnllnwed by cnrnnary artery annrnalies [1?%].
Level nf evidence: III.
15. Cnrradn D, Eassn C, Riaanli Ci, Schiavnn M, Thiene G:
Dnes spnrts activity enhance the risk nf sudden death
in adnlescents and ynung adultsi‘ I Am Cnif Cardinf
lflflS:41{11}:1959-1963.Medline DflI
16. Hnlst AG, Winkel EC, Theilade J, et a]: Incidence and
etinlngy nf spnrts-related sudden cardiac death in Deu—
marlt—implicatinns fer preparticipatinn screening. Heart
Rhythm 2010;7{1fl}:1365-13?1. Medline DUI
The incidence nf 5CD in Danish athletes during exercise
was lnw. The mnst cnmmnn autnpsy findings at death
were arrythmngenic right ventricular cardinmynpathy,
sudden unexplained death, and cnrnnary artery disease.
Level nf evidence: III.
1?. Ecltart RE, Scnville SL, Campbell CL, et al: Sudden death
in ynung adults: A 15-year review nf autnpsies in mili-
tary recruits. Ann Intern Med Zflfl4;141[11}:329v334.
Medline Dfll
13. Ecltart RE, Shry EA, Burke AP, et al; Department nf
Defense Cardinvascular Death REgistry Grnup: Sud-
den death in ynung adults: An autnpsy-based series nf
Q 211115 American Academy nf Urthnpaedic Surge-ens

a pepulatien undergeing active surveillance. I Am Cell!
Cardin! 20] I;SS{I2}:I2S4—12EI. Mcdline DUI
The incidence uf sudden unexplained death in military
persennel yeunger than 35 years was [1.2 per Iflflflflfi.
The Inest cemrnen cause ef death in these yeunger
than 35 years was sudden unexplained death. Level uf
evidence: III.
IS. Papadaltis M, Shanna S, Cux S, She ,n ,nard MN, Panuulas
VF, Behr ER: The magnitude uf an en cardiac death in
the yuung: A death certificate-based review in England and
Wales. Exrupece 2Gfl9;11{1i}}:1353—1353. Medline DUI
The number ef cardiac and sudden deaths in the yuung is
sufficiently high tu cemmand attentiun. Awareness uf such
deaths atneng primary care physicians, pathelegists, and
cereners sheuId he raised. Level ef evidence: III.
2!}. Selherg EE, Gjertsen F, Haugstad E, Kelsrud L: Sudden
death in spurts amung yuung adults in Hurway. Eur] Cer—
dt'ueesc Fret: Refined 2fl10;12{3}:332-341. Medline
Myucardial infarctiun was the leading cause uf death in
Nerwegian athletes age 15m 34 years. Level ef evidence: III.
21. Margey R, Rey A, Tuhin S, et al: Sudden cardiac death
in 14- tn SS-year elds in Ireland fretn 201115 te 2DII'2: A
retruspective registry. Eurupece 2011;13i1mfl411-1413.
Medline DUI
The incidence ef SUD in individuals age 14 te 35 years
in Ireland was 4.96 per Iflfl,fli}fl fer males and 2.56 per
1!] [hi] [it] fur Females. Sudden arrhythmic death syndrurne
was the must cummun cause ef SUD in these individuals.
Level ef evidence: III.
22. Maren B], Haas TS, Murphy C], Ahluwalia A, flatten-Ila-
mes S: Incidence and causes ef sudden death in [1.5. cel-
lege athletes. ] Arr: Cuff Curdfe! 2014;63(IS}:1636-Ifi43.
Medline DUI
The incidence ef SUD in cellege athletes, accurding tu a
review ef registry and Natienal Cellegiate Athletic As-
seciatien data, was 1 in 52,0133. Level ef evidence: III.
23. Van Camp SP, EIeer CM, Mueller FU, Cantu RC, Ulsen
HG: Nentrautnatic sperts death in high scheel and cel-
lege athletes. Med Sci Sparta Exerc ISSS;2?{S]I:64LE42.
Medline DUI
24. Maren B], lUuhman TE, Aeppli D: Prevalence uf sud-
den cardiac death during cempetitive sperts activities
in Minneseta high scheel athletes. ,I Art: Ce!! Cardin!
1993;32f2}:ISSI—1334.Medline DUI
2.5. Dreaner JA, Rugers K], Zimmer RR, Sennett E]: Use nf
autumated external defibrillaters at NCAA Divisiun I
universities. Med Sci Sperrs Eaters 2GDS;32[9}:1432-1492.
MedIine DUI
26. Gunnarssen C: Sudden death in the yuung: a SCI-year
natienwide study in Iceland. Eur Sec Cardin! 2flfl‘ti.
2'2. Atkins DL, Eversen-Stewart S, Sears CK, et a1; Resusci-
tatiun Uutcumes Cunsurtium Investigaters: Epidemiulugy
IE: 2fl1ii American Academy ef Urthupaedic Surgeens
Chapter 41: Cardiac Issues in Athletes
and eutcemes frem eut—ef—hespital cardiac arrest in chil-
dren: The Resuscitatiun Uutcumes IClunsurtium Epist-
ry-Cardiac Arrest. Circufetiuu 2fifl9:119{11]:1434-1491.
Medline DUI
Age-stratified incidence and eutcemes ef eut-ef-hespita]
cardiac arrest in children were studied; the incidence ef
this cunditiun in infants is clese tu that in adults but is
lewer in children and adelescents. Survival te discharge
was repertedly mere liltely in children and adelescents.
23. Chugh SS, Reinier I'I, Balaji S, et al: Pepulatien-hased
analysis uf sudden death in children: The Uregun Sudden
Unexpected Death Study. Heart Rhythm 2DD?:E[11}:1613-
1622. Medline DUI
Sudden cardiac arrest in children was studies ever a 3-year,
cenlmunity—wide study. Ninety percent ef deaths eccurred
in children yuu nger than 1 year; must ef these patients
sanssl leugpaw :1
received a diagnesis ef sudden infant death syndrenle.
Educatien en preventien ef sudden infant death syndrerne
and early diaguusis uf uccult heart disease will play a rule
in preventien uf sudden death in children.
29. Drezuer JA. Rae AL, Heistand], Eluemingdale MK, Har-
mun KG: Effectiveness uf emergency respunse planning
fer sudden cardiac arrest in United States high scheels
with autumated external defibrillaters. Circuiutier:
2flfl9;12fl{fi}:SIS-525. MedIine DUI
The availability and use ef autumated external defibrilla-
ters is asseciated with high survival rates in student ath-
letes and ethers whe experience SCA en scheel greunds.
3D. Ceeper WU, Hahel LA, Sex CM, et al: ADI-ID drugs and
serieus cardiuvascular events in children and yuung adults.
N Eng! j’ Med 2fl11:365{2 01:1396 -I Elfld. Medline DE“
The authurs feund an evidence that drugs used te treat
attentien deficit hyperactivity diserder centrihuted te an
increase in serieus cardievascular events.
31. Marijen E, Tafflet M, Celerniajer DS, et al: Sperts-relat-
ed sudden death in the general pupulatiun. Circuiatiur:
2flII;124(fi}:fi?2-ESI.MedIine DUI
The authurs reperted that the general pupulatiun expe-
riences spurts-related sudden death tnere eften than ini-
tially suspected:I prernpt interventien is asseciated with
impruved survival rates.
32. Maren E], Haas TS, Ahluwalia A, Rutten—Ramus SC:
Incidence uf cardievascular sudden deaths in Minnesuta
high scheel athletes. Heart Rhythm 2fl13;1fl{3}:324-322.
Medline DUI
The risk uf cardievascular sudden death in the high schuul
athlete pupulatiun studied was small: accurding tu autepsy
data, apprexilnately 30% ef these deaths were caused by
disease that ceuld be detected during preparticipatien
screening.
33. Meyer L, Stuhhs B, Fahrenhruch C, et al: Incidence, caus-
es, and survival trends frum cardievascula r-related sudden
cardiac arrest in children and yuung adults [I tu 35 years
ef age: A Sill-year review. Cfrcnfntier: 2G12;12IS{11]:1363-
1322. Medline DUI
Urthepaedic Knuwledge Update: Sperts Medicine S
 Seeders 1': Medical Issues
Uut—ef—hespital cardiac arrest eccurs mere eften in chil-
dren and yeung adults than previeusly reperted; future
preventien pregrams sheuld be guided by a thereugh un-
derstanding ef the causes ef this eccu rrence.
34. Eeden HP, Ereit I, Beachlet JA, 1lillll'illia ms A, Mueller FD:
Fatalities in high scheel and cellege feethall players. Art:
I Sperts Med 2013;41{5}:11flE-1116. Medliee DUI
The mest cemmen causes ef fatalities in high scheel and
cellege feetball players are cardiac failure, brain injury,
and heat illness, with the incidence ei Fatalities being
higher at the cellege level.
35. Filmer CM, Kirsh JA, Hildebrandt D, Krahn AD,
lflew RM: Sudden cardiac death in children and ade-
Iescents between 1 and 19 years ef age. Heart Rhythm
Efl14;11{21:139-245.Medline DUI
=
E Underlying causes ef 5CD in children and adelescents are
E
presumed primary arrhythmia syndreme and structur-
.E
'U al heart disease. Age-specific diagnestic and preventien
E
'11
strategies are needed.
ri-l
35. Winkel EC, Risgaard B, Sadjadieh Cr, Bundgaard H,
Haunse S, Tfelt-Hansen J: Sudden cardiac death in chil-
dren [1-13 years}: Symptems and causes ef death in a
natienwide setting. Ear Heart ] 2U14;35{13]:363-S?5.
Medline DUI
In a natienwide study ef deaths in children ever a ?—year
peried, mete than half ef these whe experienced 5CD
had antecedent andl'er predremal symptems. Subsequent
familial screening sheuld include diagnesis and treatrneut
ei petential inherited cardiac diseases.
3?. Teresdahl EC, Rae AL, Harmen KG, Dresner JA: Incidence
ef sudden cardiac arrest in high scheel student athletes
en scheel campus. Heart Rhythm 2D14:11{T}:1190-1194.
Medline DUI
Because the incidence ef sudden cardiac arrest is higher
than previeusly estimated, additienal advanced cardiac
screening and enhanced emergency planning in scheels
is required.
38. Harmen KG, Dresner JA, Malesaewski J], et a1: Pathe-
geneses ef sudden cardiac death in natienal cullegiate ath-
letic asseciatien athletes. Ctr-r Arrhytbm Electrephyst'el
2fl14;?{21:193-204. Medliue DUI
The mest cemmen cause ef death in Natienal ICellegiate
Athletic Asseciatien athletes was AH-SUD (31%]. HCM
represented enly 3% ef deaths. Level ef evidence: III.
39. de bierenha 5V, Sharma S, Papadalcis M, Desai S, Whyte
G, Sheppard MN: Aetielegy ef sudden cardiac death in
athletes in the United Kingdem: A pathelegical study.
Heart Elli} 9:9.Sl 1?}:1409-1414. Medliue DUI
l SCDs evaluated at the Natienal Heart and Lung In-
stitute and Reyal Brempten Hespital, mest male, 31% ef
deaths were exertienal, and the mest cemmen pathelegic
finding at death was a structurally nermal heart. Level ef
evidence: III.
Drthepaedic Knewledge Update: Sperts Medicine 5
41']. Suarez-Mier MP, Aguilera E, Mesquera RM, Sancheevde-
Let'm MS: Pathelegy ef sudden death during recreatienal
spurts in Spain. Fererrsic Sci Int 1U13;226{1-3}:133-196.
Medline DUI
In a study ei sudden death during spurts participatien iu
the Irish pepulatien berween the ages ef 9 and 69 years,
the must cemmen cause ef death was cerenary artery dis-
ease. Death mest eften eccurred during cycling fellewed
by seccer. Level ef evidence: III.
41. Cerrade D, Easse C, Thiene G: Sudden cardiac death in
yeung peeple with apparently uermal heart. Cardt'eeasc
Res 1Dfl1;SD{2}:399-4US. Medlirte DID]
42. Puranil-z R, Chew CK, Dufleu JA, Hilbern M], Mc-
Guire MA: Sudden death in the yuung. Heart Rhythm.
lflflSflflEJflETT-IZSZ.Medline DC'II
43. Currade D, Basse C, Schiaven M, Thiene Cr: Screening fer
hypertrephic cardiemyepathy in yeung athletes. N Eng!
I Med 1993;339l6]:364-369. Medline DUI
44. Stefani L, Galanti G, Tencelli L, et al: Bicuspid aertic valve
in cempetitive athletes. Br I Sparta Med EDD 3,1421:1):.31-35,
discussien 3S. Medliue DCIII
45. Basavarajaiah S, 1|ilililsern M, 1|ilil'hyte G, Shah A, McKenna
W, Sharma 5: Prevalence ef hypertrephic cardiemyepathy
in highly trained athletes: Relevance te preparticipatien
screening. I Am Cell Cardiel 2fl03;51{1U]:1fl33 -1 U39.
Medline DUI
46. Maren B], Pelliccia A, Spirite P: Cardiac disease in yeung
trained athletes. Insights inte metheds fer distinguishing
athlete’s heart frem structural heart disease, with particu-
lar emphasis en hypertrephic card iemyepathy. Circulatiea
1995;91{S}:1596-1Efl1.Medline DUI
4?. Maren B], Reberts WC, Epstein SE: Sudden death in
hypertrephic cardiemyepathy: A prefile ef TS patients.
Circalatt'ea 1932;65{T}:1333-1394. Medline DID]
4E. Melacini P, Cianfrecca C, Calere C, Eevelate F, Paele F,
Quattrini F, Pelliccia F, Sha tma S, McKenea W, Maren E,
Pelliccia A, Cerrade D: Abstract 339i}: Marginal everlap
between electrecardiegraphic abnermalities in patients
with hypertrephic cardiemyepathy and trained athletes:
Implicatiens fer preparticipatien screening. Cirealaa'ea
1Dfl?;115:II-?ES.
49. Maren B], Friedman RA, Kligfield P, et a]; American
Heart Asse-ciatien Ceuncil en Clinical Cardielegy; Ad-
vecacy Ceerdinating Cemmittee; Ceuncil en Cardievas—
cular Disease in the Yeuug: Ceuncil en Cardievasculat
Surgery and Anesthesia; Ceuncil en Epidemielegy and
Preventien; Ceuncil en Functienal Genemics and Transla-
tieual Bielegy; Ceuncil en Quality er' ISate and Dutcemes
Research, and American Cellege ef Cardielegy: Assess-
ment ef the 12-lead electrecardiegram as a screening test
fer detectien et cardievascular disease in healthy general
pepulatieus ef yeuug peeple [12-35 years ef age}: A scien-
tific statement frem the American Heart Asseciatien and
fl 211115 American Academy ef Urrhepaedic Surge-ens

the American Cellege ef Cardinlngy. ]' Am Uni! Cardin!
3014;E4{I4]:I4?9-1514. Mfidlinfi DUI
The primary purpese ef cardievascular screening is the
detectinn nf underlying disease and is recnmmended fur
athletes. A 14-pnint histnry and physical examinatinn is
recemmended and where preper resources are available,
ECG can be censidered. Level ef evidence: V
5'1}. Maren E], Zipes DP: Intrnductien: Eligibility recnm-
mendatinns fer cempetitive athletes with cardievascular
abnnrmalities-general cnnsideratinns. I Am Cnfi Cardin!
2005,45[3}:1313—1311. Medline DUI
51. Eassn C, Maren E], Cnrradn D, Thiene G: Clinical prnl'iie
ef cengenital cerenary artery anemalies with erigin frem
the wreng aertic sinus leading te sudden death in yeung
cnmpetitive athletes. ] Am Cuff Cardin! lfiflfifiS{E}:1493-
1501. Medline DUI
52. Pelliccia A, Spatarn A, Maren B]: Prnspective echncardin-
graphic screening fer cerenary artery annmalies in 1,360
elite cempetitive athletes. Am I Cardin! 1993;?!“ 21:9?3-
PPS. Medline DDI
.53. Ammash NM, Sundt TM, Cennelly HM: Marfan syn-
drnme-diagnnsis and management. Carr Pref?! Cardin!
lflflfl;33{1l:?—39.Medline DUI
54. Bassn C, Cnrradn D, Thiene G: Arrhythmngenic right
ventricular cardiemyepathy in athletes: Diagnesis, man-
agement, and recnmmendatinns fer spert activity. Cardin!
Ciin 2007;25i3}:415-422, vi. Medline DDI
5.5. Maren II]: Sudden death in yeung athletes. N Engf] Mad
lflfl3;349{11}:1fl64—10?5.Medline DUI
56. Dreaner JA, Ackerman M], Cannnn EC, et al: Abner-
mal electrncardingraphic findings in athletes: Recngnis-
ing changes suggestive ef primary electrical disease. Br
1 Spurs: Med 2613:4?{3]:153-Ie?. Medline DDI
This article is a review nf ECG findings in athletes that
are suggestive nf disease. Level nf evidence: If.
5?. Lehnart SE, Aclterman M], Eensnn DW Jr, et al: Inherited
arrhythmias: A Natinnal Heart, Lung, and Bin-ed Institute
and lDffice ef Rare Diseases werkshep censensus repert
abnut the diagnesis, phenntyping, mnlecular mechanisms,
and therapeutic apprnaches fnr primary cardinmynpathies
ef gene mutatiens affecting ien channel functien. Circa-
!aiinfl 200?;1'16flfll:2325-234S. Medline DUI
53. Hebbs JB, Petersen DR, Mess AJ, et al: Risk ef abetted
cardiac arrest er sudden cardiac death during adelescence
in the leng-QT syndrnme. ]AMA 2Dflfi;196{1[l}:1249-
1254. Medline D-DI
59. ]nhnsnn ]l'~I, Ackerman M]: Return tn playi| Athletes
with cengenital leng QT syndrnme. Br I Sperts Med
Zfll3t4?{1}:23-33.Medline DUI
Athletes with LQTS and their families sheuld discuss
risks and benefits when faced with participatinn decisinns.
In 650 athlete years of fellew—up ef athletes with LQTS
ID EDIE American Academy ef Drthepaeclic Surgeens
Chapter 41: Cardiac Issues in Athletes
whn chnse tn participate, there were ne deaths. Level nf
evidence: III.
60. Leenhardt A, Lucet 1'v", Denjey I, Gran F, Ngec DD, Ceumel
P: Catechelaminergic pelymerphic ventricular tachycardia
in children. A T-year fellew—up nf 21 patients. Circufafinr:
1995;91{5}:1512-1519. Medline DUI
51. Surawica E, Childers R, Deal E], et al; American Heart
Assnciatinn Electrncardingraphy and Arrhythmias lCum-
mittee, Ceuncil en Clinical Cardielngy; American Cellege
nf ICardinlngy Fnundatinn; Heart Rhythm Snciety: AHAJr
ACCFIHRS recnmmendatinns fer the standardizatinn and
interpretatien ef the electrecardiegram: Part III: Intraven-
tricular cenductien disturbances: A scientific statement
Item the American Heart Assnciatinn Electrncardingra-
phy and Arrhythmias Cnmmittee, Ceuncil nn Clinical
Cardielegy; the American Cellege ef Cardielegy Fenn-
sanssl lesgpaw :,1;
datinn; and the Heart Rhythm Snciety: Endnrsed by the
Internatinnal Seciety fer Cemputeriaed Electrncardinlngy.
Circaiaiinr: 20139511 9i1fi}:e235-e24i}. Medline DUI
61. Pelliccia A, Culassn F, Di Panln PM, et al: Prevalence nf
abnermal electrecardiegrams in a large, unselected pepu-
latinn undergeing pre-participatien cardievascular screen-
ing. Ear Heart ] IDUTQBEIEIQD DE 401 0. Medline DUI
63. Munger TM, Packer DL, Hammill SC, et al: A pepulatinn
study nf the natural histnryr nf Welff—Parkinsnn-White
syndreme in ICIlmsted Ceunty, Minneseta, 1553-1939.
Circaiarinr: 1993;E?{3}:SEE-S?3. Medline DUI
64. Klein C], Eashere TM, Sellers TD, Pritchett EL,
Smith WM, Gallagher ]]: Ventricular fibrillatinn in
the Welff—I’arltinsnn-White syndrnme. N Eng! ] Med
19?9;3fl1[2fl}:IDSII—IGSS. Medline DUI
ES. Deal E], Beerman L, Silica M, 1'Ii'i'l'alsh EP, Klitener T,
Kugler J: Cardiac arrest in yeung patients with 1'iiii'elffvPar-
kinsen-White syndrnme. Pacing Cilia Efectrepfrysin!
1995;13:315.
66. Linit MS: Pathnphysinlngy, preventinn, and treatment
nf cnmmntin cnrdis. Carr Cardin! Rep 2fl14;15{6]:495.
Medline DUI
Cemmetie cerdis is increasing as a cause ef 5CD en the
playing field. Preventien ef cnmmntin cerdis is pessible.
Imprnved recngnitinn and resuscitatinn have led tn im-
preved eutcemes. Level ef evidence: V.
5?. Caselli S, Maren MS, Urbann—Meral JA, Pandian HG,
Maren E], Pelliccia A: Differentiating left ventricular
hypertrnphy in athletes frem that in patients with hyper-
trnphic cardinmynpathy. Ans ] Cardin! 2fl14;114{9}:1333-
1339. Medline DUI
Identificatien ef HCM in yeung athletes is challenging
when L"vr wall thickness is between 13 and 15 mm. In
athletes with Us!r hypertrnphy in the "gray anne" with
HEM, LV cavity site appears tn be the mnst reliable cri-
terien te help in diagnesis, with a cuteff value ef «:54 mm
fer differentiatien frem athlete's heart. Dther criteria,
including LV diastnlic dysfunctinn, absence nf T-wave
inversien en ECG, and negative family histnry, further aid
in the differential diagnesis. Lavel ef evidence: V.
Drthepaedic Knewledge Update: Sperts Medicine 5
Chapter 42
Female Athlete Triad
Marissa M. Smith, MD Marci ii... ll'iirfllolshy, MD
Abstract
The female athlete triad [the Triad] is a syndrome describ—
ing the relationship between three components: energy
availability, menstrual function, and bone health. The
Triad can exist along a spectrum from healthy states to
the severe diagnoses of eating disorder, amenorrhea, and
osteoporosis. Short-term and long-term consequences of
the Triad include stress fractures, infertility, and osteo-
porosis. These consequences can be prevented with early
recognition and treatment by a multidisciplinary team.
Screening for the components of the Triad is critical, and
a series of questions about menstrual function, weight
changes, eating behaviors, and bone injuries can help
identify patients at risk. The Triad can be seen in any
athlete but is more common in athletes participating in
endurance, esthetic, and weight—class spurts. The best
treatment is prevention, but nutrition counseling and
exercise modifications are the mainstays of treatment.
A cumulative risk score can help guide clinicians on
return to play and clearance of athletes with the Triad.
Keywords: female athlete triad: amenorrhea:
oligomenorrhea: disordered eating; eating
disorder; female athlete;r low bone density:
osteoporosis: IDW energy availability
Introduction
Since the enactment of Title IX of the Education Amend-
ments of '1 9'32, the participation of girls and women in
competitive athletic endeavors has increased dramatically.
Dr. Gooisby or an immediate famiiy member serves as a
board member; owner; officer; or committee member of
the American Medicai Society for Sports Medicine. Neither
Dr. Smith nor any immediate famiiy member has received
anything of vaiue from or has stock or stock options heid
in a commerciai company or institution reiated directiy or
indirectiy to the subject of this chapter.
fl lflld American Academy of Drrhopaedic Surgeons
The number of high school girls involved in sports in-
creased from less than 3fl0,fl0fl in 197'? to more than 3
million in 2fl13.1-’-
It is well established that involvement in sports and
exercise has benefits for physical and mental health, and
sanssl leagpaw :y;
all girls and women should be encouraged to participate
in active endeavors. Participation also carries potential
risk to these involved, however. Due of the unique risks
to the active female is the medical condition first termed
the female athlete triad {the Triad} in 1992.
The Triad was originally described as the interrelation-
ship of disordered eating, amenorrhea, and osteoporosis.
Since that time, this definition has been broadened to
refer to a medical condition that can involve a spectrum
of disease severity {Figure 1} that includes low energy
availability {BA} with or without disordered eating, a
variety of menstrual irregularities, and diminished bone
mineral density {EMU}. It has further been established
that, not only do the individual components of the Triad
present along a spectrum, but only one or two of the
components of the Triad may be present at any given
time, an occurrence that still can have potential adverse
health consequences. Understanding the range of signs
and symptoms of the Triad allows early recognition and
intervention for this significant medical condition.
Determining the number of women affected by the
Triad is difficult because of the variability of the disease.
Those with the most severe form of the Triad {eating
disorder, amenorrhea, and osteoporosis} have been esti-
mated to be between zero and 15.9%. 1iii'hen evaluating
these with less severe components or those with only one
or two components, however, the prevalence increases.
Estimates are zero to 60% for menstrual disturbance,
zero to 39.2% for eating disorderidisordered eating, and
zero to 39.3% for low BMDP
The Triad can affect women of all ages, often starting
in adolescence, before or after menarche. More com-
monly, the Triad affects athletes involved in sports and
activities that value leanness, endurance, weight class, and
esthetics, such as running, gymnastics, and dancing, but
it may affect any active female, making this an important
topic for all health professionals to understand.
Drthnpaedic Knowledge Update: Sports Medich'ie S
 Section T: Medical Issues

Uplimal energy
availability

1%s
Fleduoed energy 1
with or without
disordered saling
Low energy availability /

an eating disorder Subdinieal/ health

n'lanstiual /
dist] I'ElETE Law
EMU
Functional /
hypothalamic ___}.
amanorrhea Dateopo roaia

n Figure 1 Diagram depicts the female athlete triad, defined as the spectrums of energy availability, menstrual function, and
E bone mineral density {EMU}. The athlete can move along the spectrum from healthy to unhealthy states of each
component. Law en ergy availability affects menstrual function and bone health, and menstrual dysfunction also
E

.E leads to poor bone health. {Reproduced from Goolsby M, Lister I: Medical considerations and risk management:
'U
'11 The ie male athlete, in Limpisvasti D, ltrabalt Ell, Albohm M]. ads, at al: The Sports Medicine Field Manual.
E
ri-l Hose mont, IL, American Academy of Drthopaedic Surgeon 5. em 5, pp 125—123. Redrawn 'irom Nattiv A, Louclts AB,
Ma nore MM, Sanbom CF, Sundgot-Borgen I, Warren MP; American College of Sports Medicine: American foliage
of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 1013?: 39i1b}:lEET-1EEE.

Features of the Triad

Lovv EA
The first of the three components of the Triad is EA,
defined as the difference in energy intake and exercise
energy expenditure. To appropriately fuel their bodies
and allow proper recovery from physical activity, athletes
must have adequate EA. 1When EA is reduced, the risk
for detrimental changes in bone health and hormon-
al function in girls and women is increased, leading to
adverse short-term and long-term consequences such
as menstrual dysfunction, infertility, an increased risk
of stress fractures, early osteoporosis, and endothelial
dysfunction.”
Low EA can occur fer several reasons. In its most
severe and pathologic form, an eating disorder, such as
anorexia nervosa or bulimia nervosa, is present. Low EA
also can be seen with disordered eating, such as restric-
tive eating and the avoidance of certain foods, without
meeting the criteria for an overt eating disorder. In other
cases, as a female athlete attempts to lose weight, she
may reduce total caloric {energy} intake without patterns
consistent with disordered eating or an eating disorder,
which also can result in low EA. In addition, low EA can
result from an increased caloric expenditure along with
an inadvertent failure to increase intake sufficient for the
energy demands of the body.
It is important to recognise that an eating disorder
diagnosis is not necessary to diagnose the Triad. The most
important factor is the inadequate availability of macro—
nutrients for the body to maintain its normal function
given the increased demands of exercise. Equally impor-
tant, when an athlete is suspected of having low EA, fur-
ther evaluation for eating disorders is warranted, because
elite athletes are at increased risk?
Menstrual Dysfunction
The second component of the Triad is menstrual dysfunc-
tion. Low EA disrupts normal hormonal function, leading
to menstrual irregularity.MI In its most severe form, the
hypoestrogenic state results in functional hypothalamic
amenorrhea. The less severe spectrum of menstrual dys-
function includes oligomenorrhea, anovulatory cycles,
and luteal phase dysfunction, which can develop before
amenorrhea.
Estrogen and progesterone offer protection of BMD,
whereas testosterone has osteoblastic properties that can
increase bone growth. If the availability of these hor-
mones becomes diminished, bone mass, bone density,
and bone strength also decrease, raising the risk of low
BMD and stress fractures. In addition, estrogen is pro-
tective to endothelial cells and the cardiovascular system
and, although not a component of the Triad, is important
to consider in the overall health of active females with
menstrual dysfunctionfi
Although seemingly easy to recognise, menstrual
dysfunction often can be missed because many athletes
do not realise the importance of regular menstrual cy-
cles. It has been noted that some athletes believe that
occasionally missing a menstrual cycle is normal, has
no negative consequences, or is even a sign of successful

firthopaedic Knowledge Update: Sports IvIedich'ie S Q lfllfi American Academy of Orthopaedic Surgeons

training.”I Subclinical menstrual disturbances such as
luteal phase dysfunction and anovulatory cycles are fre-
quently found in exercising women but are not readily
apparent clinically.11
Bone Healfli
Low EA and hypoestrogenism negatively affect bone
health, the final component of the Triad. The peak time
of bone mineral deposition in girls occurs during adoles-
cence, with bone maturity reaching its maximum genetic
potential in young adulthood. After a prolonged period
of low EA and menstrual dysfunction, the effect on bone
may be irreversible.”
This change in bone health increases the risk of stress
reaction, stress fractures, and early osteoporosis in wom—
en [Figure 1}. This situation is cause fer concern in an
athlete because of the effect on her ability to perform and
compete. Long-term morbidity and mortality also must
he considered. It is well documented that women older
than 50 years have a 50% chance of development of an
osteoporosis-related fracture and that almost 3fl% of
these experiencing a hip fracture die within 1 year of the
fracture?“ During adolescence and young adulthood,
good nutrition and the maintenance of normal hormonal
balance is thus critical for long—term health.
Screening
The active female is often unaware of the signs of the
Triad and its negative consequences. Partly because of
the silent nature of this disorder in its early stages, it is
very important for health professionals such as athletic
trainers, physical therapists, and physicians, as well as
coaches, parents, and the athletes themselves to be aware
of the components of the Triad and the risk factors for
developing disease. Early identification of affected and at-
risk athletes, along with early intervention, is important
to minimize potential negative consequences.
Athletes competing in endurance sports such as
long—distance running, sports that involve iudging such
as skating and gymnastics, and weight-class sports such
as martial arts or wrestling, are traditionally at increased
risk of development of the Triad. Athletes in all sports
have some risk because of the possibility of low EA.”
Multiple organisations recommend screening female
athletes during the preparticipation physical evaluation
{PPE} or the yearly physical examination. The recom-
mendation from the 2fl14 Female Athlete Triad Coalition
{FATE} Consensus Statement is that screening of female
athletes should begin during adolescence; if any part of
the screening is positive for the Triad, a thorough evalu—
ation should be undertaken.”
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 41: Female Aflllete Triad
sanssl leaipaw :,1;
Figure 2 M Fl! shows stress fracture of the femoral neck.
In a standard screening PPE form used by multiple
American medical societies, several questions related to
risk factors for the Triad are included. These questions,
along with additional questions recommended by the
FATE, elicit information about menstrual health, weight
and nutrition, and bone health, as summarized in Table 1.
Other warning signs and risk factors for the Triad, if
seen, should prompt further evaluation. Some of them
include involvement in sports that stress leanness and
estheties, psychosocial pressures for thinness, low self-es-
teem, increased training intensity especially at young ages,
declining performance, mood changes, and weight loss.
Further Evaluation and Diagnosis
After it has been determined that an athlete is at risk for
the Triad, a full evaluation that assesses nutrition, energy
expenditure, menstrual history, and bone health is neces-
sary. A multidisciplinary team, including a physician, a
mental health professional, and a dietitian, should be in-
volved. Many of the signs and symptoms of the Triad can
be seen in other medical conditions and a complete medi-
cal evaluation for these conditions is necessary {Table 2}.
Key components of the history include a nutritional
history detailing eating habits, diets, and disordered eat-
ing habits such as restrictive eating, binging, or purging.
Important aspects of the menstrual history include the age
at menarche, the most recent menses, the frequency and
pattern of the menses, any history of oligomenorrhea or
amenorrhea, and the maternal menstrual history. A fur-
ther history covering the incidence of stress fractures and
traumatic fractures, a previous diagnosis of low BMD,
and low vitamin D levels, is also important. If the patient
has a history of stress fractures, details including the
Drthopaedic Knowledge Update: Sports Mediehte 5
 Section ?: Medical Issues

number of such fractures, the severity of fracture, and
the site of injury are important. The involvement of the
family, teammates, and coaches can provide insight into
the athlete’s health and behaviors such as eating small
portions, doing extra workouts, not eating with others,
using restrooms inunediately after eating, andfor rapid
changes in weight.
Proposed Set of Screening Questions
for the Female Athlete triad
Have you ever had a menstrual period?
How old were you when you had your first menstrual
n peflod?
E EA. Parotid gland swelling, ianugo, enamel erosion, and
E
When was your most recent menstrual period?"
.E
'U How many periods have you had in the past 12
E
'1?
months?
r:
Are you presently taking any female hormones
(estrogen, progesterone, birth control pills?I
Do you worry about your weight?
Are you trying to gain or lose weight, or has anyone
recommended that you do so?
Are you on a special diet. or do you avoid certain
types of foods or food groups?
Have you ever had an eating disorder?
Have you ever had a stress fracture?
Have you ever been told you have low bone density
{osteopenia or osteoporosis]?I
'. Hot specifically listed on the prepartidpation physical evaluation
forms.
As with any thorough medical history, evaluation for
the signs and symptoms of diseases that can cause similar
symptoms such as thyroid disorder, polycystic ovarian
disease, and hyperandrogenism should be documented. It
is critical to obtain a history of the medications the patient
is currently taking or has taken, especially those affect—
ing menstruation and BMD such as oral contraceptive
pills, patches, and rings, medroxyprngesterone acetate
{Depo-I’rovera}, glucocorticoids, and antiepileptic drugs.
A family history of osteoporosis, fractures, menstrual
dysfunction, and eating disorders can provide insight.
Physical examination findings also can help diagnose
the Triad and evaluate for other causes of its components.
Bradycardia, orthostatic hypotension, hypothermia, a low
body mass index {BMI}, and weight loss can indicate low
calluses on the knuckles {the Russell sign} may indicate
an eating disorder. Bone health can be evaluated on eac-
aniination by assessing for scoliosis, hyphosis, and signs
of stress fracture.
Low EA
Diagnosing low EA can be challenging because of the
inherent bias in recording dietary intake, and the diffi-
culty determining the exact caloric content of food and
obtaining an accurate assessment of 24—hour energy eit-
pendit ure. Multiple tools are available to help assess EA,
however. A 3?l less than 17.5 mgi'lrzgl or a BMI less than
35% of expected body weight can indicate low EA. It
is possible to have a normal body weight with low EA,
however, because the body suppresses some physiologic
functions to maintain the balance, leaving the patient at

-—
Diagnostic Testing for the Female Athlete Triad
Energy Availability Menstrual Dysfunction Bone Health
csc. Esa LH. FSH oexa scan for amp
CMP hCG {blood or urine] Vitamin D
Albumin Frolactin 24-hour urine calcium
T3 TSH, free T4 PTH
DEKA scan [for FFM) Estradiol. testosterone [free and total}.
DH EAJ‘S, 1?—DH progesterone
HMR Pelvic ultrasonography
ECG Frog este ro ne challenge
{BC I complete blood count, ESE - eryfl'l rocyte sedimentation rate, EMF - complete metabolic panel, TEI - triiodofliyronine, DEJILA - dual-
energy may absorptiometry, FFM = fat-free mass, EMF: = resting metabolic rate, EEG = electrocardiogram. LH = luteiniaing hormone,
FSH = follicle-stimulating hormone, hCE = human chorionic gonadotropin, TSH = thyroid-stimulating hormone, Til = thyrosine. DH Edi-5 =
dehydroepiand rosterone sulfate, DH - hydronypro-gesterone, BMD - bone mineral density, FTH - parathyroid hormone

Diag nostic studies may be indicated to evaluate for other causes andilor consequences of components of the Triad.

firthopaedic Knowledge Update: Sports lvledich'ie 5 fl lflld American Academy of Orthopaedic Surgeons

risk of negative physiologic consequences .if not corrected.
A resting metabolic rate (RMR) can be tested; if it is low
or if the ratio of measured EMF. to predicted RMR is less
than {1.90, low EA is indicated. The more practical ways
to calculate EA are based on dietary records, estimates of
exercise expenditure, and measurement of fat-free mass
{FFM} as described in the most recent FATE Consensus
Statement.” Unline calculators to determine EA can be
found at www.femaleathletetriad.org. Studies have re-
ported that, at less than 3i] kcalfkg of FFM per day, a
girl or woman is at risk of the development of menstrual
dysfunction and diminished BMD; therefore, 45 kcaliIr
kg of FFl'vl has been recommended for physically active
females to maintain normal EA.“5
Menstrual Dysfunction
A variety of menstrual disturbances can be found in the
Triad. Primary amenorrhea is diagnosed if menses has
not occurred by age 15 years. Secondary amenorrhea is
defined as 3 consecutive months without menses after
menarche, and oligomenorrhea describes cycles longer
than 35 days. Functional hypothalamic amenorrhea and
other types of menstrual dysfunction are diagnoses of
exclusion, and other causes to consider include outflow
obstruction, pregnancy, thyroid dysfunction, hyperandro-
genic syndromes, hypothalamic and pituitary disorders,
primary ovarian insufficiency, and hyperprolactinemia
{Table 2}. Physicians in other specialties can help evalu-
ate these patients, such as when the diagnosis of another
gynecologic disorder or endocrinopathy is expected.
lone Health
fisteoporosis is the most severe abnormality of bone
health that can be found in the Triad, and evaluating
for deficits in BMD and bone integrity is essential for
patients at risk. The gold standard for determining BMD
in children and adults is du al—energy x—ray absorptiometry
{DEXA}. Athletes should have a 5% to 15% higher bone
density than sedentary controls.” In premenopausal wom-
en, the American College of Sports Medicine iACSM}
defines low BMD as a Z-score of -1.[i to -2.fl, with sec-
ondary clinical risk factors for fracture such as the Triad.
lEisteoporosis is defined as a Z-score less than or equal to
-2.i'.i, plus secondary risk factors for fracture.E
The use of DEXA to evaluate bone health in the Tri-
ad is determined by risk stratification. According to the
recent FATC consensus statement, having one high-risk
factor for the Triad warrants DEEA evaluation“5 {Ta—
ble 3}. These factors include a diagnosis of an eating dis-
order, a BMI less than or equal to 1?.5 kgiml, less than
35% of estimated weight or a weight loss greater than
10% in 1 month, menarche at age 16 years or older, any
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 42.: Female Athlete Triad
history of fewer than 6 menstrual cycles over 12 months,
2 prior stress reactions or 1 high-risk stress reaction, or
a prior Z—score less than 41.0 at least 1 year from a base-
line DEE A. If moderate risk factors exist, a patient must
exhibit at least two before DEXA evaluation is warrant-
ed. The location of BMD testing using DEKA varies for
children and adults. In those younger than 2|} years, the
lumbar spine and the whole body are recommended loca-
tions. For women 20 years or older, weight-hes ring sites
including the spine, total hip, and femoral neck should
be used. If weight-bearing sites are not available, then the
radius BMD can be used in adults.“““~“J
sanssl leagpew :,1;
After an athlete is identified as having evidence of or risk
factors for the Triad, early intervention and treatment
are essential. When the condition is recognized early and
treated, it is possible to prevent many of the detrimental
effects of the Triad. The key to treatment is to address EA
through a combination of increased energy sources and
reduced energy expenditure. This protocol often requires
the resources of a multidisciplinary health team, a key
player being a sports dietitian to help formulate a specific
diet for the individual and to help ensure compliance. A
psychiatrist or sports psychologist also may be necessary
if disordered eating or an eating disorder is present. As
a general goal, changes should be made gradually, and
often a Efl‘i‘rii increase in caloric intake is recommended.
In the recent consensus statement from the FATE, a goal
of 45 kcali'kg of FFM is recommended. Furthermore,
athletes need to restore lost weight or in some cases attain
a higher weight than that at which amenorrhea devel-
opedfidfl Maximizing the intake of micronutrients such
as calcium and vitamin D may be beneficial in addition
to the calorie increase.
Although oral contraceptives can increase estrogen
levels, they have not been shown to have a beneficial effect
on EMU. Interestingly, the transdermal estrogen patch,
although not an effective contraceptive, does seem to
confer some benefit in improving BMD in women. At this
time, estrogen or combined oral contraceptives is not the
recommended solo therapy for low BMD or amenorrhea
but can be used in some cases. Either bone agents, such as
bisphosphonates and teriperatide, although not routinely
used, could be considered in select patients, under the care
of a metabolic bone specialist.
Prevention
Education is key to prevention and involves providing
information about the Triad to athletes, coaches, parents,
Drthopoedic Knowledge Update: Sports lvledichie 5
 Section T: Medical Issues

-—
Female Athlete Triad Cumulative Risk Assessment

Magnitude of Risk
Risk Factors Low Risk = i] Points Each Moderate Risk = 1 Point High Risk = 2 Points Each
Each
Low EA with or without El No dietary restriction El Some dietary El Meets DEM-v criteria
DEi'ED restriction;il currentipast for ED"
history of DE
Low Blvll El BMla1B.5 or a sass El Ell'vll115 c135 or c El Eilvlls115 or c 35%
EW‘ or weight stable 513% EW or 5 to -c fill-ii EW or a iii'iii weight
weight lossimonth lossi'month
Delayed menarche El Menarche c 15 years El Menarche 15 to c15 El Menarche .1: 15 years
years
n fliigomenorrhea andr'or El :5 9 menses in 12 El 6—9 menses in 12 El -: E menses in 12
E
E amenorrhea months“ months” months'"
.E
'U Low BMD El Z-score a -1.i} El Z—score -i.i}" -c -2.0 III Z-score s 41.0
'11
E Stress reactionifracture El Hone CH D2321 high riskorof
r:
trabecular bone sites“
Cumulative risk {total points + points + points
each column. then add = _ Total Score
for total score}I
BMD = bone mineral density, BMI = body mass index, DE - disordered eating, EA - energy availability, cw - expected weight, ED - eating
disorder. DEM-V = Diagnostic and Statistical Manual-5.

The cumulative risk score is used to determine an athlete's clearance for sport participation.

'Some dietary restriction as evidenced by self-report or lowii nadequate energy intake on diet logs.

b Cu rrent or past history.

‘ sou EW. Absolute EIMI cut-offs should not be used for adolescents.

i' Weight-boa ring sport.

' nh-rlslr. skeletal sites associated with low BMD and delay In return to playI In athletes with one or more components of the Triad include stress
reactio nitractu re of trabecular sites {femoral neck, sacrum, pelvis}-

Adapted with permission from the sum Female Athlete Triad Coalition consensus statement on treatment and return to play of the female
athlete triad: 1st international Conference held in San Francisco. CA. May 2fl12. and 2nd lntematlonal Conference held In Indianapolis. liIi. May
2MB. CiinJ Sport Med 2014;2flflli95-115.

and all others involved with active girls and women. It is
important to be awa re of the risks, signs, and symptoms
of the Triad to intervene early if symptoms do develop
and to help affected athletes develop an adequate nutri-
tion strategy and a sound exercise plan. Useful infor-
mation can he found online at sites such as the FATE
website {www.fcrnaleathlctetriad.otg} and the Internau
tional Dlympic Committee Healthy Body Image website
[www.olympic.org,lhbil. Many other organisations also
make information available to athletes, parents, coaches,
and health care professionals such as ACSM, the Ameri-
can Medical Society for Sports Medicine, the American
Academy of Pediatrics, and the American Academy of
Family Physicians.
Return to Play
The first step in return to play is to appropriately treat
any secondary complications such as stress fractures. For
affected athletes without acute injuries, the FATE in 2i] 14
developed a risk stratification and provided a framework
for helping make return-to-play decisionslfifTable 3 and
Table 4}. The cumulative risk score is used to determine
an athlete’s clearance for sports participation. Patients
are stratified by evaluating their risk factors for the Triad
and determining the number of risks in each category.
The patient is designated as low, moderate, or high risk.
These deemed low risk can continue to compete and train
with education to prevent increased risk of the Triad and
overt disease. Those in the moderate-risk category often

firthopaedic Knowledge Update: Sports Medich'ie 5 fl lflld American Academy of Orthopaedic Surgeons

Table-:1
Female Athlete Triad Clearance and Return-tn-Play Guidelines by Medical Risk Stratificaticin
Cumulative Risk ".iccilreEl
Full clearance iii-1 paint
Pruvisicinalr'limitecl 2—5 points
clearance
Restricted from a 5 points
training and
tvmsstltlvn
' The Cumulative Risli Scare is determined by summing the scare at each risk factcir flaw. rnciderate. high risk} train the Cumulative Rislt
Assessment shnwn in Table 3.
Adapted with permissian treat the 2G1! Female Athlete Triad Eaalitian ccinsensus statement an treatment and return tci play at the female
athlete triad: ‘lst lntematlcinal Eunierence held In San Francisco. CA. May ENE. and 2nd lnternatlcinal Centerence held in Indianapolis. I". May
EH13. Elfin .l Splint Med 2hld;2d[2]:96-115.
can have previsienal clearance, which allews them ta par-
ticipate in physical activities, with recummendatipns fur
mudificaticins eutlined by a multidisciplinary team. These
modificaticins can include limited er mndified training,
dietary plans, and psychulngic therapies and can be pre—
gressecl as the patient’s health status impruves and risks
decrease. These at high risk fur the Triad er with specific
significant pathalpgy (such as stress fractures, amenc-r—
rhea, an eating discrrder}, are fully restricted frnm training
and campetitinn se the medical canditiens affecting the
athlete can be treated. In these circumstances, cluse ful—
lciw-up with different members ef the health care team
is essential tn treat and mpnitcir the PI’Dgl‘ESSlflfl of the
disease and its symptc-ms. A written treatment cantract is
recemmended te- allnw the athlete tn fully understand her
disease, the treatment, and the expectaticins fcir fellcnv—up
and prpgressicin. If the athlete makes sufficient prpgress
in her treatment, and her disease and risk facts-rs fer the
Triad imprcive, she shciuld be restratified fer her risks and
may eventually be cleared fcir participaticin.
S um maryr
The Triad can affect any female pf menstruaticln age,
causing pathelcigic changes to her bane health and men-
Strual functicin. The spectrum of disease can range frcim
a healthy energy balance, nurmal menses, and gciud brine
health tfl disc-rdered eating, amenerrhea, and esteem:-
resis. Because hi the detrimental health effects cif this
cunditicin, it is impurtant that all active ytiung females
be screened fur the Triad, and if any cnmppnent of the
screening is pesitive, a thereugh investigatian sheuld
begin. After the disorder has been reccigniaed and either
causes ruled nut, treatment shnuld focus an increasing
IE! this American Academy pf flrthnpaedic Surgeens
Chapter slits Female Athlete Triad
Low Risk Moderate Risk High Risk
El MIA MIA
MIA El Pruvisicinal MIA
clearance
El Limited clearance
MA MA El Restricted training:Ir
cempetiticin previslcinal
El Disqualified
sanssl leaipaw :,1;
EA te all-aw resumptien ef nermal menstrual functicin
and bane health. Further research is needed tn determine
the Icing-term cansequences ef the Triad, even after EA
ncirmalises and regular menstrual functicin returns, and
whether medicatiens may be helpful in treatment.
Key Study Paints
I The female athlete triad can affect any active girl
er wnman, causing shart-term and icing-term cun-
sequences tn her health.
Ii Early awareness and recegniticin ef the signs and
sympttims ed the Triad are irnpcirtant sci that inter-
ventinn can nccnr and prevent any negative health
eensequenees.
l Lew energy availability is the main target c-f ther-
apy at this time. Effarts tn regain adequate energy
availability thruugh increased intake andfnr de-
creased energy utilisaticin are essential campnnents
pf treatrnent.
Annotated References
1. Haticmal Federatinn cif State High Schenl Asseeiatinns:
Parriripatinn data far 19?} re 1972. Available at: httpa'i'
www.nfhs.ergl'ParticipatinnStaticsfParticipatienStatics.
aspstl'. Accessed June 20, 1015.
The Haticmal Federatinn cif State High Schucil Assncia-
tinns {HFHS} is the naticinal authnrity far high schecil
interschcila stic athletics. Its website pmvides statistics far
high schc-nl afllleric participatinn in the United States frum
1965' an El] 14.
Drthepaedic Knawledge Update: Spnrts Medicine 5
 Section 1': Medical Issues
National Federation of State High School Associations:
2313-2314 HighI Schooi Athletics Participation Survey.
Available at: http:.I'iwww.nfhs.orgiIi'articipationi'itaticsulr
PDFiEGI3i-l4_Participation_3urvey_PDF.pdf. Updated
2314. Accessed June .10, 2015.
NFHS is the national authority for high school inter-
scholastic athletics. Its website provides statistics for high
school athletic participation in the United States from the
years 1969—2314.
Gibbs JC, Williams NI, De Sousa M]: Prevalence of
individual and combined components of the female ath-
lete triad. Med Sci Sports Eater-c 2013;45i5 1:935 396.
Medline DUI
The authors reviewed the literature and developed a
meta-analysis of the prevalence of the Female Athlete
= Triad and its individual components.
A"
Zeni Hoch A, Dempsey RL, lBarrera GP, et al: Is there an
E
.E
'U
'11
association between athletic amenorrhea and endothelial
E cell dysfunction? Med Sci Sports Exerc 2333;35i3]:3??—
ri-l
333. Medline DUI
Hoch A2, Lal S, Jurva 1W, lGutterman DD: The fe-
male athlete triad and cardiovascular dysfunction. Phys
Med Rehahii Ciir: N Am 133T;13I[3}:335-40fl, vii-viii.
Medline DUI
Nattiv A, Louclts AB, Manore MM, Sanhorn CF, Sund-
got-Eotgen J, 1iiiiiarren MP; American College of Sports
Medicine: American IEollege of Sports Medicine position
stand. The female athlete triad. Med Sci Sports Exerc
2i] 3T;33{1{}}:136 ?—1331. Medline
Sundgot-Eorgen J, Torstveit MK: Prevalence of eating dis-
orders in elite athletes is higher than in the general popula—
tion. Cfin J Sport Med 2334;14i1]:25—32. Medline DUI
Cordon CM: Clinical practice. Functional hypotha—
lamic amenorrhea. N Engi J Med lfllflflofiflhfifij-fifl.
Medline DUI
The author presents a review of functional hypothalamic
amenorrhea including the definition, pathophysiology,
diagnosis, and treatment.
Mallinson Ft], De Sousa M]: Current perspectives on
the etiology and manifestation of the “silent“ compo-
nent of the Female Athlete Triad. fut] Worries-rs Heaitf:
2014;5:451—46?. Medline
This study explores the current literature on the Triad,
with a specific focus on bone health. The authors report on
the pathophysiology of the bone changes related to the Tri-
ad, specific outcomes, and treatments of those outcomes.
11“.}. Feldmann JM, Eelsha JP, Eissa MA, Middleman AB: Fe-
male adolescent athletes’ awareness of the connection be-
tween menstrual status and bone health. J Pediatr Adoiesc
Gynscni 2311;24i5]:311-314. Medline DUI
Urthopaedic Knowledge Update: Sports Medicine 5
The authors discuss the knowledge of high school athletes
about menstrual dysfunction and bone health and their
attitudes toward menstrual dysfunction.
11. De Sousa M], Toombs R], Scheid JL, U’Donnell E, 1iiii'est
3L, 1liliiilliams NI: High prevalence of subtle and severe
menstrual disturbances in exercising women: Confir'
mation using daily hormone measures. Hum Reprod
1313;25i2]:491-533.Medline DUI
The authors present the results of a study evaluating hor-
monal changes that are used to detect subclinical men-
strual disturbances related to exercise.
12. Johnell U, Kanis J: Epidemiology of osteoporotic fractures.
Usteoporos Int 2005;16i5uppl 21:53-51 Medline DUI
13. Keene U5, Parker M], Pryor GA: Mortality and morbid-
ity after hip fractures. BM] 1993;33?{6914}:1243-125i}.
Medline DUI
14. Schnell S, Friedman 3M, Mendelson DA, Eingham KW,
Hates SL: The 1-year mortality of patients treated in a hip
fracture program for elders. Geriatr Urthop Serg Rebahii
2313;1{1}:E-14.Medline DUI
This study evaluated the mortality and associated mortal-
ity risk factors in a series of patients age 61'] years or older
with hip fracture being treated at one institution after
implementing a new treatment protocol for hip fractures.
15. Torstveit MK, Sundgot-Eorgen J: The female athlete triad
eatists in both elite athletes and controls. Med Sci Sports
Exerc lflflS;3?{9}:1449-1453. Medline DUI
16. De Sousa MJ, Hattiv A, Joy E, et al; Female Athlete Triad
Coalition; American College of Sports Medicine; Ameri-
can Medical Society for Sports Medicine; American Bone
Health Alliance: 2314 Female Athlete Triad Coalition
consensus statement on treatment and return to play of
the female athlete triad: 1st International Conference held
in San Francisco, CA, May 2312, and 2nd Internation-
al Conference held in Indianapolis, IN, May 2313. Cliff
J Sport Med 2314;24{2J:96—113. Medline
The consensus statement from the FATC from the first
and second international conferences gives an overview
of the Triad and makes recommendations for screwing,
evaluation, treatment, and return to play.
1?. Fehling PC, Alekel L, Clasey J, Hector A, Stillman R]:
A comparison of bone mineral densities among female
athletes in impact loading and active loading sports. Bone
1995;1Ti3}:2{iS-21[}.Medline DUI
13. Crabtree NJ, Arahi A, Bachrach LE, et al; Internation-
al Society for Clinical Densitometry: Dual-energy X-ray
absorptiometry interpretation and reporting in children
and adolescents: The revised 2013 ISCD Pediatric Uf-
ficial Positions. J Cite Deesitom 2314;1?{2]:225-242.
Medline DUI
The position paper from the International Society for
Clinical Densitometry, as revised in 2013, describes the
D 231:5 American Academy of Urrhopaedic Surgeons
 Chapter #2: Female Athlete Triad

use [If DEKA fer BMD in children and adeleseents and 10. Gnlden NH, Jaeebsen MS, Sehehendaeh J, Selantn MU,
defines nstenperesis in this pepnlatinn. Hertz 5M, Sheri leer IR: Resumptinn nf menses in anerexia
nervesa. Arch Pediatr Adelese Med 199?;151illtlt‘i-11.
19. Internatinnal Sneiet}r fer Clinical Densitemetty: 2013 {If}?- Medline DUI
eiel Pnsitinns: Adult {it Fedisn'ie. Available at: httpa'fwww.
ised.erg.l"dnentnentst"2il14ffl2i'2013-ised-nffieial-pnsitinn-
hrnehureqsd F. Updated EDIE. Accessed June 21, 2'01 5.
This pnsitinn paper frnm the Internatinnal Sdeietjr fur
Clinical Densitemetts, as revised in EMS, deserilses the
use emf DEER fer EMU densityr in adults and defines as-
tenpernsis in this pnpulatinn.

sanssl leagpaw :1

IE! Eillfi American Aesdetny ef flrthnpaedie Surgenns Drthnpeedie Knnwledge Update: Spurts Medicine 5
®
Chapter 43
Infectious Disease in the Athlete
Matthew Leisaler, MD Kari Sears, MD David Smith, DU
Abstract
Infectious disease in the athletic population is a common
cause of morbidity and missed practice and competition
in athletes. Clinicians should be familiar with common
dermatologic, head and neck, pulmonary, gastrointesti-
rial, genitourinary, and blood-borne infectious diseases
to provide comprehensive care to the athlete. They also
should be cognizant of the specific caveats associated
b with managing these illnesses in the athletic patient.
Keywords: infectious disease; athlete; sports
medicine: skin infection; infectious mononucleosis:
MESA; return to play
Introduction
Athletes often are considered the healthiest segment of so-
ciety, given the activity level and conditioning that many
athletes maintain. However, certain aspects of athletics
and team sports at times will actually increase the risk
of infectious disease in athletes. An understanding of
common infectious diseases in the athletic population
is critical for any medical provider managing the health
care of athletes.
Two main factors can play a role in infection in ath-
letes: compromise of the immune system and exposure to
potential infection. llvlioderate—intensit}r exercise appears
to improve immune function, which has been shown to
result in a better outcome following respiratory infection.‘
It is generally accepted that moderate-intensity exercise
can improve the function of circulating cells in the innate
immune system, and this seems to have a positive effect
None of the foiiowing authors or any immediate family
member has received any-“thingI of vaiue from or has stock or
stock options held in a coi'ni'nerciair company or institution
related directiy or indirectiy to the subject of this chapter:
Dr. Leiseiec Dr Sears, and Dr. Smith.
fl lflld American Academy of Drthopaedic Surgeons
on reducing the risk of infection. Intense exercise training,
however, can have the opposite effect and increase the risk
of infection, in part because of the decreased secretion
of immunoglobulin A {Igf'il in the saliva during intense
sanssl leagpaw :,1;
exercise and stress, which in effect, takes down the first
line of defense against infection.2
Managing the exposure to infection becomes partic-
ularly challenging in the team setting. Close physical
contact during practices and competitions, the sharing
of space, towels, and bathroom toiletries in the locker
room, and team travel in congested vehicles increase the
chances of transmitting contagious diseases to teammates.
Prevention is therefore vital, with a focus on minimizing
these risk factors that can increase transmission in the
team setting. Key elements include hand hygiene, the
relative isolation of infected individuals, the avoidance
of shared personal items, and the adequate cleaning and
disinfection of common areas. Vaccination is also an
important element of prevention. Ensuring that vaccines
against infectious illnesses such as influenza, meningecoc-
cal disease, and pertussis are up to date is an important
element of team care. Vaccination can help to minimize
the initial cases of such illnesses in a single member of a
team and potential outbreaks in teammates.
As with any musculoskeletal problem, the differential
diagnosis should he carefully considered, even in seem-
ingly straightforward cases of infection. In a prospective
study of elite and recreationally competitive triathletes,
cyclists, and controls, nasal swabs were collected in those
with symptoms of a probable upper respiratory infection.
Dnly Sikh: of swabs identified an infectious cause of symp-
toms.3 This underscores the importance of considering
other causes, such as allergies, in athletes with upper
respiratory symptoms.
In cases of infection, retu rn-to-play guidelines include
a general recommendation that fever be resolved before
the athlete returns to sports participation. In many cases,
however, return—to—play guidelines are not clear. The med-
ical provider has the responsibility to ensure the safety of
the athlete in question, as well as that of other athletes.
This standard will help to guide return to play in areas
without clear guidelines. The provider also must take
Drthopaeclic Knowledge Update: Sports Meme 5
 Section 7’: Medical Issues

into consideration the effect of illness on performance to

determine if a return to sports participation is reasonable.
This chapter highlights the recent advances and the
current standard of care in the prevention, diagnosis,
and management of infectious diseases. In particular,
the specific factors that are unique to the management of
infectious disease in athletic populations are discussed.
Evidence-based guidelines are presented when possible.

Bacterial Skin Infections

Although many bacterial conditions can affect athletes,

commonly encountered skin in fections can include methi-
cillin—resistant Staphylococcus omens {MESA}, impetigo,
= furunculosis, hot tub folliculitis, and pitted kcratolysis.
A"
E

.E
'U Memicillin-Hesistant Staphylococcus aureus
E
'11
MESA is a highly infectious strain of the bacteria S aa-
I: reas. It was previously thought to be restricted to hospital-
acquired infections following its discovery in the ISSfls.
During the late 1990s, MESA became the leading cause
of community-acquired bacterial infections, with approx-
imately SUSS of the general population colonised. Df all
community-acquired MESA infections, Wis}. to 95% are
infections of the skin and soft tissue.4 MESA is spread
via direct contact with the skin, particularly through an
open, contaminated wound. The sports placing athletes
most at risk for MESA skin infections are wrestling,
football, and rugby, although cases have been described
among athletes from most mai or spurts. MESA can have
a wide spectrum of presentations, ranging from streaky
erythernatous skin without abscess to frank necrotieing
fasciitis. The most common appearance is a localized,
purulent zone of tender erythema {Figure 1}. MESA of-
ten forms an abscess, or multiple small abscesses, over a
regional but poorlyr defined area.
The diagnosis of MESA often is made clinically, al—
though a culture of purulent fluid can be obtained for
confirmation. A MESA abscess is often confused with
a spider bite, because both can follow a similar clinical
course. Either diagnoses to consider are infectious se-
baceous cyst, septic bursitis, impetigo, and alternative
bacterial etiologies. The mainstay of treatment is inci-
sion and drainage of the abscess using sterile technique.
Incision and drainage alone is often sufficient for an unu
complicated clinical picture.Jr Antibiotics can be admin—
istered for concomitant large surrounding skin infection,
systemic symptoms, or failure of incision and drainage
alone. Treatment is based on regional resistance patterns
but clindamycin or trimethoprimi'sulfametboxacole is
most often effective against MESA. Lineaolid has been
shown to be effective in some clinical settings, although it
Figure 1 Photograph shows the most common
appearance of methicillin-resistant
Staphylococcus aureus.
has a larger side-effect profile. For hospitalized patients,
vancomycin and daptomycin generally are adequate to
treat MESA.
An athlete with active MESA infection of the skin can
participate in most sports, assuming that the wound is
adequately covered and that only minimal risk of acciden-
tal wound exposure exists during sport. Wrestling may
be an exception, and return is based on state guidelines.
Utherwisc, return to play often is at the discretion of the
athletic trainer, the coach, and the athlete. Because of the
infectious nature of MESA, substantial focus has been
placed on prevention. A statewide epidemiologic study
in Nebraska followed confirmed MESA cases (of one or
more individuals} in high schools and showed an increase
in involvement from 4.4% of schools in 2'00? to 14.4%
of schools in 2fl03.5 Efforts are being made to educate
coaches and schools about the importance of hand by-
giene and equipment cleanliness in sports.
Impetigo
Impetigo is a common superficial skin infection. Like
MESA, it is spread most often via direct contact with the

firthopaedic Knowledge Update: Sports Medicine 5 fl lfllui American Academy of Orthopaedic Surgeons

skin. An athlete is most susceptible to impetigo if direct
skin contact occurs during skin breakdown. Athletes in
direct competition, such as wrestlers, martial artists, foot—
ball players, and rugby players, are at highest risk, as are
athletes with poor hygiene. Impetigo is most commonly
caused by S nurses and less commonly by group A Strep-
tococcus pyogeues.‘ Two types, bullous and nonbullous,
are seen. Bullous impetigo is almost universally caused
by S nureus. It is seen clinically as multiple thin-walled,
fluid-filled vesicles that typically start as small vesicles
that can coalesce to form one or more larger lesions. The
blister eventually collapses, leaving behind a characteristic
honey-crusted lesion. Erythematous plaques form at the
base of the lesion and drain serous fluid when the crust
is removed or healing. Nonbullous impetigo accounts for
almost T'fl'h': of impetigo cases.*" It begins as one or more
small vesicles that do not coalesce and is more commonly
associated with a classic crusting of lesions {Figure 2}.
Impetigo is diagnosed clinically. Confirmatory culture
of the serous fluid can be performed if the diagnosis is
unclear. It can appear similar to tinea, especially in non-
bullous cases. Tinea almost never appears on the lips, as
impetigo can, however. The differential diagnosis also
should include erysipelas, inflammatory or viral dermato-
ses, and {much less commonly} pemphigus vulgaris. The
treatment of impetigo has two components: the removal of
the crusting and antibiotic therapy. In all cases, the lesions
must be kept clean and should be washed directly with
soap and warm water to remove the crusting and serous
fluid. Antibacterial soap is not necessary, although it is not
discouraged. The first—line therapy for impetigo should be
a topical antibiotic that supplies coverage for both Steph-
ylococcus and Streptococcus bacteria. lupirocin and
fusidic acid are both effective first—line treatment options.
Mupirocin is highly effective against all Staphylococcus
and Streptococcus strains, except group D streptococcus.
Bacterial resistance is low, at near fl.3%.‘ Fusidic acid is
slightly less effective against Streptococcus and is not mar-
keted in the United States. fiver-the-counter compound
antibiotic ointments are not recommended because of
multidrug resistance, desensitization from overuse, and
side effects of contact dermatitis in (5% to 3% of cases.‘5
Although topical preparations are more effective and
carry fewer side effects, oral antibiotic therapy is some-
times used. Ililral options may include dicloxacillin and
cephalexin; erythromycin is used if the patient is allergic
to penicillin.
The National Athletic Trainers Association {NATA}
recommends that any suspicious lesions should be tested
and cultured for antimicrobial sensitivity. Return-to-
play criteria require the appearance of no new lesions
for at least 43 hours, completion of T2 hours of antibiotic
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 43: Infectious Disease in the Athlete
sanssl leoipew :,1;
Figure 1 Photo-g re ph depicts the small vesicles of the
nonbullous form of impetigo. [He produced with
permission from Hawke M: Rhinitis. Available
at: httpdi'rhinitis.hawltelibrary.com. Accessed
Dctoher19, 2015.}
therapy, and no further drainage or exudate from the
wound site. Simply covering active lesions is not sufficient
to allow return to competition.
Folliculitis and Furunculosis
Folliculitis and furunculosis are closely related disease
processes. Folliculitis is a superficial infection of the hair
follicle, whereas furunculosis relates to the deep follicular
base. Folliculitis and furunculosis typically are caused by
S nuns-us, except in special cases.
Hot tub folliculitis is contracted, as the name implies,
after exposure to wet environments. Pseudornoncs seru-
gr'uosn commonly can colonize hot tubs, swimming pools,
and wet heating pads in athletic training rooms. Athletes
can be exposed when submerged in the water and are at
particular risk with open or broken skin. Pseudomonns
is known to thrive on moist surfaces and carries a high
antibiotic resistance profile. A study conducted at a Di-
vision I university indicated that 9633 of Pseudomortns
isolates from athletic hot tubs and swimming pools dis-
played multidrug resista ncefi' Hot tub folliculitis presents
as multiple pruritic pustules with a follicular appearance.
In some cases, pustules can have a subtle green appear-
ance. Symptoms typically develop 5 hours to 2 days after
exposure and are confined to the skin that was exposed?-B
In severe cases, the athlete may experience systemic symp-
toms such as malaise, fever, and chills.
Furunculosis is frequently described as an abscess or
boil. Furuncles are most common in areas of increased
friction and heat such as the groin, axillae, or gluteal folds.
Presentation may be similar to that of MESA-related
Drthopnedic Knowledge Update: Sports Medichse S
 Section 7’: Medical Issues
abscesses, although MRSA is implicated in only approx-
imately lfl'fi- of cases.Ell
A history and physical examination are often adequate
to diagnose furunculosis and hot tub folliculitis. Culture
may be accurate only if the wound is pyogenic, because
swabbing the skin is unlikely to yield the pathogenic bac—
teria. Hot tub folliculitis often is observed in a “dunked“
distribution with a discrete horizontal demarcation. The
differential diagnosis should include acne vulgaris, con-
tact dermatitis, impetigo, and urticaria. The management
of folliculitis and furuncles should begin with placement
of a warm compress over the area to encourage consolida—
tion. Large foruncles may require incision and drainage if
they do not resolve. Topical mupirocin may be of benefit.El
= If surrounding cellulitis is present or systemic symptoms
A"
E develop, oral antibiotics to cover Staphylococcus and
.E
'U Streptococcus can be given, usually for 1'] to 14 days. The
E
'11
management of hot tub folliculitis is largely supportive.
ri-l
Most mild cases are self-limited and resolve over 1 to
2 weeks. Resultant abscesses rarely form. If symptoms
are severe or lesions are widespread, antibiotic therapy
can he prescribed and directed to combat Pseudomosas.
Antibiotics usually are reserved for severe cases because
of the multidrug resistance displayed}
The return-to-play criteria are identical to those for
impetigo. The athlete should have no new lesions for 43
hours, take T2 hours of directed antibiotics {if indicated),
and have no drainage from active lesions. The lesions
should not be covered to allow play.
Fitted Iteratolysis
Fitted keratolysis is a noncontagious superficial infection
of the feet and, rarely, the hands. This condition is char-
acterized by well-defined, 1 to 3 mm, discrete pits along
the soles of the feet. Lesions become pronounced when the
feet are moist or are submerged in water. Gram-positive
bacteria, chiefly Coryoefrecterfum and Actioomyces spe—
cies, commonly are implicated. Although athletes with
hyperhid resis are most at risk, tight-fitting or infrequently
changed socks or gloves are also predisposing factors.
Figure skaters and ice hockey players may be at increased
risk because of the prolonged time spent in skates in wet
environments.
The diagnosis is based on clinical examination. In
addition to skin pitting, athletes may often present with
excessive sweating and odor. Coral red fluorescence un—
der the Wood lamp mayr be seen but is limited to cases in
which Ceryoefvecterfum causes surrounding erythrasma.
Treatment with several topical modalities has been inves-
tigated, although evidence is lacking. Topical clindamycin
or erythromycin has been the mainstay of therapy since
the lflflfls. Topical bactroban also has been effective. A
583 firthopaedic Knowledge Update: Sports Medicine 5
small case study has shown some efficacyr with topical
clindamycin 1% and bensoyl peroxide 5%, when used
with a drying agent.Ell The management includes avoiding
tight-fitting socks and shoes. Cotton or moisture-wicking
soclrs should be used when possible. Good hygiene is
imperative, and footwear, especially skates, should be
kept clean and dry. The application of roll-on antiperspi-
rant containing lfll‘i'ri: aluminum chloride to the feet may
be helpful. A Eflll study performed on the Dutch army
demonstrated that a combination of preventive measures,
topical antibiotics, and the treatment of hyperhidrosis
should be the mainstay of treatment.m Fitted keratolysis
is not communicable and should not warrant disqualifi-
cation from sports participation.
1|u'irel Skin Infections
Although athletes are susceptible to many viral infections,
verruca {the common wart}, molluscum contagiosum,
and herpes gladiatorum and sostcr are among the most
common. These infections can be difficult to treat, which
emphasizes the importance of prevention to minimise
disruption in sports participation.
VEWHCE
1F«ferruca is an extremely common infection caused by
the human papilloma virus {HPV}. Studies show the
prevalence is estimated at 5% to 20% in children and
young adults, although data vary widely among the gen—
eral population. More than 101) types of HPV have been
identified, and the virus can cause warts on various parts
of the body. The virus lies dormant on surfaces and often
is spread by barefoot contact with pool decks, in locker
rooms, and by direct unintentional scraping.
Verruca often is diagnosed clinically. A lesion is de-
scribed as a discrete, hyperlreratotic papule that often
is raised. Multiple black dots representing thrombosed
capillaries are often noted. The differential diagnosis
includes corns and calluses, which are often difficult to
distinguish. Dermoscopy has been used to successfully
differentiate and gauge treatment efficacy. Although warts
often are left untreated intentionally, they can cause sub-
stantial morbidity if located in a painful area, such as on
the plantar surface of the foot. Multiple treatments have
been studied, all with varyied degrees of efficacy. Lesions
often are pared to expose the capillary beds, allowing
the penettance of medication. Topical salicylic acid and
cryothcrapy are the most viable treatment options.“ A
IICochrane clinical review shows that salicylic acid treat-
ment has the most consistent evidence in terms of efficacy
and low side-effect profile and is more effective on plantar
warts. Although cryotherapy is widely used, it is often
fl lflld American Academy of Orthopaedic Surgeons

painful and less effective on plantar warts." Both treat-
ments have been shown to be largely more effective than
placebo, whereas duct tape occlusion has not.” Lesions
can ultimately be difficult to eradicate; thus, prevention
is extremely important. Injection of Candida afbicces
antigen at the base of the wart may be a consideration
for resistant warts.
The athlete may resume sports participation if the le-
sions are covered. Topical salicylic acid can be used with
an occlusive dressing on top. Pain tolerance should be a
consideration if cryotherapy is used before participation.
Molluscum Eontagiosum
Molluscum contagiosum is caused by the molluscum con—
tagiosum virus {MCV}, a virus in the poxvirus family. It
infects only the skin, growing in the epidermis. Although
the incidence and prevalence are highly variable, mollus-
cum contagiosum is more common among young chil-
dren and adolescents living in close quarters. The virus is
transmitted by direct contact with skin or infected water.
A higher transmission risk is demonstrated in those who
use swimming pools and who live in warmer climates.
MCV also can be transmitted sexually or while shaving.”
Molluscum is a clinical diagnosis. Infection appears
as a collection of discrete, umbilicated papules, ranging
from 1 to 5 mm in diameter. The lesions are flesh col—
ored, raised, and round {Figure 3}. In immunocompetent
individuals, fewer than 20 lesions usually are present in
a cluster, although larger clusters have been observed.
Infection is rarely present on the palms, the soles, or
the mucosal areas but can be seen on the genitals when
sexually transmitted. 1|When lesions are broken, a thick,
white material may be expressed. The differential diag-
nosis includes verruca, cystic lesions, and gra uulomatous
conditions and can be aided by examination with a der-
matoscope if necessary. Although lCV infection often
resolves spontaneously, full clearance can take 6 to .9
months. In athletes, the treatment is often destructive,
using cryotherapy or curettage, or topical, using imiqui-
mod, cautharadin, or potassium hydroxide iKflH] 5%
solution. The athlete can return to play immediately if
lesions are curettecl and covered during competition.”
Herpes Simplex Vims
Herpes simplex infection can particularly problematic
in athletes. The herpes simplex virus {HSV} is the parent
virus responsible for herpes gladiatorum and herpes roster
in addition to many other conditions. HSV is transmitted
via direct contact and can rapidly infect a large number of
teammates if not recognized quickly. A 1003 University
of Minnesota study found a 33% likelihood of transmis—
sion from an infected wrestler to the wrestling partner.”
IE! Eillli American Academy of flrthopaedic Surgeons
Chapter 43: Infectious Disease in the Athlete
- a.“ .
7. " '-.‘..
fiat" no" -
_ 'Jl'hka . 2|- .fi - t-fl -
Figure El Photograph shows the typical flesh-
colored, raised, round lesions of molluscum
contaglosurn. {Reproduced with permission
from Centers for Disease Control and
sanssl leagpaw :,1;
Prevention: Moiiuscum contagiosum. Available
at: httpwwww.cdc.govl’poxvirusin1ollustum-
contagiosurn. Accessed flctober 19. EH15.)
Prevalence varies widely and is population dependent,
age dependent, and sport dependent.
Herpes gladiatorum, caused by HSV—l, can carry an
incubation period of 3 to 10 days, which varies depending
on the host’s immune response. Au infected athlete often
experiences a prodromal phase, which can range from
subtle malaise to a flu-like illness.” An HSV outbreak of
the skin occurs after this prodromal phase, presenting as
widespread 2- to 5-mm vesicles, which often are clustered
on an erythematous base. Areas affecred are the trunk,
arms, legs, and head. 1lifesicles can erupt and are virulent.
In late stages of infection, vesicles can become crusted.
In the early stage of infection, the diagnosis is not
always obvious. The differential diagnosis includes follic-
ulitis, acne, dermatitis, and impetigo. Clinical diagnosis
often is made and is easier with a clear prodromal history.
Viral culture is helpful but can take days to obtain; thus
a Teanclt preparation of vesicular fluid can be helpful in
the short term.“ Ural acyclovir and valacyclovir are the
most effective treatments of HSV, although acyclovir is
more cost effective. Acyclovir is dosed five times daily,
however, which could create a compliance issue compared
with valacyclovir, which has a twice-daily dosing. I.Cllral
antivirals are ineffective when lesions are fully formed and
crustiug.” The prevention of herpes gladiatorum infection.
is largely based on hygiene, education, and the recognition
of at-risk athletes. Antiviral prophylaxis has been found
to be helpful to prevent eruptions in those with recurrent
herpes labialis or in those who have had a documented
mass exposure.” National Collegiate Athletic Association
and HATA guidelines state that athletes with HSV-I in-
fection may not return to competition until lesions have
a dried adherent crust, and the athlete has been receiving
oral antiviral treatment for at least 5 days.“
Drtbopaedic Knowledge Update: Sports lvledichie 5
 Section 7’: Medical Issues
Herpes Zoster
Herpes aoster is less common among athletes but can
carry substantial morbidity if not recognised. Herpes
aoster, commonly known as shingles, can present with or
without a significant viral prodrome. After exposure, the
herpes aoster virus lies dormant in a dorsal spinal root
ganglion. Herpes soster carries the highest incidence of
all neurologic diseases, with a lifetime incidence of 30%
among all persons.1f The skin eruption associated with
a roster outbreak can occur weeks to many years after
initial exposure. 1|When skin eruption does occur it often
is preceded by exposure to a significant stressor or illness.
The rash seen in herpes aoster is characteristic of a her-
petic rash, in that vesicles erupt on an erythematous base
= {Figure 4}. The pattern of eruption is different, however,
A"
E in that it follows a specific unilateral dermatome specific
.E
'U to the dormant infection site in the spinal root ganglion.
E
'11
The rash is usually painful, often exquisitely so.
ri-l
The diagnosis is similar to that of herpes gladiato-
rum and other Hl-i‘lvr types. Clinical diagnosis is usually
sufficient and can be aided by a Tsanck preparation and
culture if the diagnosis is uncertain. The differential diag-
nosis includes folliculitis, impetigo, acne, and dermatitis.
Treatment with oral antivirals is considered first line and
should he initiated within ?2 hours of rash eruption to
increase the healing response and reduce pain. Acyclo—
vir, famciclovir, and valacyclovir all are approved and
well-tolerated treatment options. Postherpetic neuralgia
is a complication that may arise after an episode of shine
gles. Prevention with early antiviral treatment is essential
because the pain can be significant. Postherpetic neu-
ralgia has been successfully treated with gabapentin or
controlled-release oxycodone, both of which show some
benefit during the initial 3 days of treatment.
Although shingles cannot be passed from one person
to another, the varicella xoster virus can be spread from
a person with active shingles to someone not previously
infected or vaccinated against varicella soster or chick-
eupox. In this case, chickenpox, but not shingles, may
develop in the new contact. NATA does not have a con—
sensus statement regarding return to play for athletes with
herpes soster. Shingles is less contagious than chickenpox,
and risk of transmission is low even in the active blister
phase if the lesions are covered.
Fungal Skin Infections
Fungal skin infections are common among athletes. Most
fungal skin infections in athletes are caused by tinea {my-
coses of the skin}, and the dermatophytes Trisophyron
rxhrrrrn and Tricopfrytor: tortsxrsrrs are the most common
agents. Fungal infections are often opportunistic, placing
firthnpaedic Knowledge Update: Sports Make 5
Figure 4 Phetog raph depicts the lesions of herpes zoster.
which follows a specific unilateral dermaton'le
specific to the dormant infection site in the
spinal root ganglion. {Reproduced with
permission from Darling D: Shingles rash on the
torso. Available at: httpdhrrwwdaviddarling.
inferencyclopediai’srshingles. Accessed August
5, 2015.}
those with compromised immune systems and poor hy-
giene at higher risk.
Tinea Pedis
Tinea pedis, or athlete‘s foot, is common in athletes and
in the general population, affecting approximately 15%
of the population worldwide and is more common in
adolescents and men. Tinea pedis is transmitted easily
in warm, moist communal areas such as showers and
locker rooms; the fungus incubates in the moist, warm
environment of a shoe. T rnhrnrrr is implicated in most
cases, although Trichophytorr mentagrophytes is most
common in athletes. Infection causes macerated skin,
itching, flaking, and scaling of the feet and commonly
spreads to the interdigital areas. Severe tinea pedis can
cause cracking of the skin and can result in concomitant
cellulitis and onychomycosis. Rarely, a hypersensitivity
response to the dermatophyte can develop in athletes,
resulting in an inflammatory or vesicular eruption.
Clinical examination alone is sufficient for diagnosis.
To confirm the diagnosis, a KGH preparation of skin
scrapings can be performed. Fungal culture can be helpful
in recalcitrant cases. The differential diagnosis includes
Candida infection, dyshidrotic eczema, psoriasis, and
contact dermatitis. Both topical and oral agents have
shown to be effective. Topical agents are prescribed for
1 to 6 weeks, depending on the agent used. Ketoconaaole
2% and clotrimasole 1% are good initial topical choices.
Topical sertaconaeole has demonstrated efficacy agahtst
interdigital tinea pedis when used once daily for 4 weeks.”
Ural agents, although effective, can cause an increase in
fl lfllfi American Academy of Orthopaedic Surgeons

transaminase levels depending nn the agent used. Recur-
rence nf tinea pedis is cnmmnn, and athletes shnuld be
educated abnut preventinn. Keeping the feet clean and
dry, using mnisture-wicking sncks, and wearing sandals
in cnmmunal areas are impnrtant fnr preventinn. Alumi-
num chlnride fnnt pnwder can be used as a drying agent.
NATE. return-tn-cnmpetitinn guidelines recnmmend that
clearance be given when lesinns have adequately respnnrl-
ed tn treatment nr can be cnvered securely.“
11nea Cruris
Tinea cruris is a fungal infectinn nf the grnin reginn. |iEnm—
mnnly knnwn as jnck itch, tinea cruris is an nppnrtunistic
fungal infectinn that infects athletes fnr reasnns similar tn
thnse nf tinea pedis. Trufrrtrm, T metugrnphytes, and C
albicans are the mnst cnmmnn infectinus agents. Athletes
wearing inck straps nr tight-fitting clnthing are mnst at
risk, because the fungus incubates and prnliferates in
the warm, mnist reginns nf the grnin fnlds. Males are
affected mnst nften. Like tinea pedis, tinea cruris causes
pruritic, macerated skin that is nften erythematnus, flaky,
and peeling. A well-defined, hyperpigmented area nf skin
can indicate infectinn.
ten, the diagnnsis is clinical. A KUH preparatinn
alsn can he used when the diagnnsis is in questinn nr if nn
strictly demarcated area nf skin is present. A Wnnd lamp
can be used if erythrasma is suspected, under which the
rash wnuld glnw a pathngnnmnnic red. The differential
diagnnsis shnuld include cnntact dermatitis, intertrign, ac—
anthnsis nigrieans, erythrasma, and [rarely] Hailey-Hailey
disease {familial benign pemphigus}. Tnpical therapy is
usually sufficient. A EDI-i meta-analysis reviewed nver
18,0 Di] cases nf tinea cruris and cnrpnris. Data frnm this
analysis shnwed that many tnpical agents have acceptable
cure rates.“1 Terbinafine and 1% naftifine are effective.
Many cnmbinatinn antifungali'sternid preparatinns are
used but suppnrting data are limited. Preventinn strategies
are aimed at decreasing mnisture and heat in the grnin.
Clean, dry athletic suppnrters and suppnrt shnrts shnuld
be wnrn, and athletes shnuld shnwer immediately after
engaging in activity. In thnse with tinea pedis, care shnuld
be taken when using tnwels, because fungi can spread tn
nther reginns. Clearance may be given if the lesinns are
respnnding tn treatment nr can be securely cnvered."
Tinea Cnrpnris
Tinea cnrpnris is a fungal infectinn nf the trunk, arms,
legs, nr neck, cnmmnnly knnwn as ringwnrm. Tinea cnr—
pnris is alsn an nppnrtunistic dermatnphyte infectinn. The
infectinn is transmitted by skin-tn-sl-tin cnntact, placing
wrestlers at higher risk. It is caused mnst cnmmnnly by
T. rub-rum and T. tnrssttmus; the latter is mnst cnmmnnly
IE! lfllfi American Academy nf flrthnpaedic Surgenns
Chapter 43: Infectinus Disease in the Athlete
sanssl leaipaw :,1;
Figure 5 Phntngraph shnws a tines cnrpnris iesinn.
seen amnng wrestlers. Like nther fnrms nf tinea, tinea
cnrpnris fungi prefer warm, mnist envirnnments in which
they incubate and replicate. Tight-fitting clnthing, wet and
humid cnnditinn s, and excessive sweating are risk faetnrs.
The lesinns appear in a superficial, lnnse, circular pattern
and nften have an erythematnus, scaly cnmpnnent periph-
erally {Figure 5}. Tinea cnrpnris eruptinn is nften pruritic.
Clinical esaminatinn is alsn sufficient tn diagnnse tinea
cnrpnris in mnst cases. A KDH preparatinn and fungal
culture nf skin scrapings alsn can be used tn cnnfirm the
diagnnsis. As with tinea cruris, treatment with a tnpical
nr nral agent is effective. Evidence suppnrts using tnpical
terbina fine and us ftifine, althnugh many aanle agents are
alsn effective. Treatment is usually effective at 2 weeks;
higher cure rates nccur at 4 weeks.” Tinea cnrpnris is
cnntaginus and can be passed easily amnng teammates,
particularly nn wrestling teams. Tinea cnrpnris alsn can
be passed frnm an infected hnusehnld pet. Preventinn
includes using clean, dry clnthing and tnwels, wearing
lnnse-fitting clnthing, and avniding direct cnntact with
an affected persnn nr pet. Athletes with tinea infectinn
shnuld be allnwed tn play if lesinns are securely cnvered nr
are respnnding tn treatment with a tnpical nr nral agent,
althnugh wrestling rules usually require a minimum nf
72 hnurs nf tnpical therapy befnre return tn play.”
Eye. Ear. Maser—1nd Thrnat Infectinns
Conjunctivitis
Cnnjunctivitis is a frequent prnblem amnng athletes and
has many causes, bnth infectinus and nnninfectinus.
Drthnpaedic Knnwledge Update: Spnrts Medichie 5
 Section 7’: Medical Issues
Allergic conjunctivitis is the most common cause, fol-
lowed closely by the infectious causes. Although con-
junctivitis is the most common cause of a red eye, the
clinician also must consider the less common but more
serious causes, including keratitis, uveitis, iritis, and acute
glaucoma.”
1|iv’iral conjunctivitis is the most common cause of infec-
tious conjunctivitis in adults, and up to 90% of cases are
caused by adenoviruses. It is usually bilateral and pres-
ents with conjunctival irritation and sometimes watery
discharge {Figure s}. Treatment is usually symptomatic,
using cold compresses, antihistamines, and artificial tears.
Antibiotics are not helpful for viral conjunctivitis and may
promote antibiotic resistance. Potential complications
n can include epidemic keratoconjunctivitis and phary ngo—
A" conjunctival fever. Because viral conjunctivitis is highly
E
.E
'U contagious, athletes participating in contact sports such as
'11
rugby and football should be withheld from participation
E flctober 19, ENE.)
I:
until symptoms resolve. Good handwashing technique
and cleaning of equipment is important in preventing the
spread of infection to other athletes, especially for athletes
who use shared equipment, such as gymnasts, weight-
lifters, and basketball players. Multiple reports exist of
adenovirus outbreaks in swimming pools, so swimmers
and divers should be kept out of the water until their
symptoms resolve.” Symptoms usually resolve within 7"
days; athletes with persistent symptoms should be referred
for a more comprehensive eye examination. Cine recent
study showed that using combination dexamethasoneiIr
iodine drops might reduce the duration of symptoms by
2 days compared with placebo}1 Using topical steroids
in the setting of a corneal ulcer can result in corneal melt
and loss of vision, and is not currently recommended.”
Bacterial conjunctivitis occurs most frequently in the
winter months. The combination of bilateral discharge,
an absence of itching, and no prior history of conjunc-
tivitis is highly suggestive of a bacterial etiology. Strep—
tococcus and Staphylococcus are the most commonly
isolated bacteria in culture-proven disease, and MRSA is
becoming increasingly common. Treatment with topical
antibiotics is recommended, and no significant difference
in treatment success exists with broad-spectrum antibiotic
options. Appropriate choices include tobramycin, fluoro-
quinolones, and combination drops. Athletes participat-
ing in contact sports should be held from competition
until treatment is complete.
flt'rtis Media
Acute otitis media {ABM} is most frequently a compli-
cation of viral upper respiratory infection {URI} and
resultant eustachian tube dysfunction. The diagnostic
criteria for ADM include otalgia with a mildly bulging
firthopaedic Knowledge Update: Sports Medicine 5
.I.’-I-‘—1'L‘Rvu
rm. , -" w,
_' -_-'-. é hill};
-
Figure E Photograph depicts the typical presentation
of viral conjunctivitis. {Reproduced with
permission from Jacobs D5: Conjunctivitis.
in Trobe 1, ed: UpToDate. Waltham, MA,
Walters Kluwer. Stilts. Available at httpdiwww.
uptodatexomicontentsi'tonjunctivitis. Accessed
tympanic membrane or a moderate to severe bulging tym-
panic membrane {Figure T]. ADM is much more common
in children than in adults, and few data exist to guide
treatment in adults. Athletes often present with otalgia,
au ral fullness, possibly Ever, and a recent URI. Antibiotic
treatment in children is reserved for those younger than 2
years or those with symptoms that persist over 43 to 11
hours. It is reasonable to extend those recommendations
to athletes and reserve antibiotic treatment for those with
persistent or severe symptoms or those with frank tym-
panic membrane perforation. The most common causative
organisms remain Streptococcus pneumoniae, Hosmopb-
Has ixflasaxae, and Moraxella catarrhnlis; amoxicillin is
the first—line choice for antibiotic treatment.“
With a few exceptions, most athletes with otitis media
will be able to continue competition. Adequate pain con-
trol can be achieved with NSAIDs and acetaminophen.
Potential symptoms that can affect performance include
balance problems and temporary hearing loss. Deconges-
tants and nasal steroids have not been shown to relieve
effusion related to ADM, and can have deleterious side
effects}3 Special attention should be paid to divers, who
may experience significant changes in middle ear pressure
if submerged beyond a few feet. Athletes with persistent
symptoms of middle ear effusion should be evaluated for
other potential causes.
Otitis Externa
Gtitis externa is an acute inflammatory condition of the
external ear canal that is almost exclusively caused by a
bacterial infection {Figure 3}. It occurs more frequently in
a moist environment, so athletes who participate in water
fl lflld American Academy of Orthopaedic Surgeons

Phetegraph demenstrates the bulging
tympanic membrane seen in acute etitis media.
(Rep-reduced with permissien frem Hawke I'v'l:
Dtitis media. Available at: httpnliletitismedia.
hawkelibrary.cem. Accessed Dcteber 19, 2015.}
sperts and these cempeting in warm, humid climates are
mere susceptible. Altheugh infectiens are eften pely—
micrebial, the mest frequent causative erganisms are P
aeruginesa and S aareas. Antibietic therapy must include
ceverage for these cemmen pathegens. Therapy fer etitis
eicterna sheuld be tepical rather than systemic, because
much higher lecal drug cencentratiens can be achieved
with dreps placed in the ear. Altheugh it is clear that
tepical therapy is superier te systemic therapy, ne cen-
vincing evidence shews that antimicrebial dreps are mere
effective than ether tepical therapies such as antiseptic
er stereid dreps. The cheice ef tepical therapy largely is
determined by the previder’s cemfert and familiarity with
available treatments. Adequate pain centre] is impertant,
because acute etitis enterna can be an extremely painful
cenditien. NSAIDs are eften effective fer pain centrel,
but strenger pain medicatiens may he needed fer the first
43 re T2 heurs.
Athletes with etitis externa sheuld receive at least 7'
days ef treatment. These participating in water sperts
sheuld cemplete treatment befere returning te cempetiw
tien. If tightly fitting earplugs can be used, participatien
may be allewed when symptems reselve. Acidifying ear—
dreps used befere audier after swimming may help te
pmvent etitis externa in athletes with recurrent episedes.
The additien ef a systemic antibietic with pseudeme—
rial ceverage sheuld be censidered in athletes with an
IE! lfllfi American Academy ef flrthepaedic Surgeens
Chapter 43: Infectieus Disease in the Athlete
sanssl lesgpaw :,1;
Figure 5 Phetegraph shevvs etitis eaterna- {Hepreduced
with permissien frem Hawke M: Utitis externa.
Available at: httpu'i'eachawlcelibrary.cem.
Accessed Dcteb-er 19, HHS.)
eaten sien ef infectien eutside the external ear canal er
in these whe de net respend te tepical treatment alene.“
Pharyngitis
Acute pharyngitis, like mest Hills, is caused mest fre-
quently by viral pathegens. It is impertant te censid-
er bacterial causes, hewever, mest cemmenly greup A
B-hemelytic strepte-ceccus {GABHS}. GABHS and viral
pharyngitis eften can be distinguished frern each ether
by their accempanying symptems. 1Viral pharyngitis eften
eccurs with a sere threat, ceugh, ceryaa, cenjunctivitis,
ulcerative stematitis, er rash. In additien te a sere threat,
GABHS pharyngitis may be asseciated with abdeminal
pain, fever, headache, and tender anterier cervical chain
lymphadenepathy. The well-established Center criteria
can help clinicians determine whe sheuld be evaluated
fer GABHS with a rapid antigen test. GABHS mest eften
eccurs in children aged 5 te 15 years, se it is mere likely
te affect yeunger athletes than these in cellege er elder.
Athletes presenting with i] er 1 ef the Center criteria—
which include exudative tensillitis, fever, tender anterier
cervical adenepathy, and absence ef ceugh—are unlikely
te have GABHS and sheuld net be tested. Athletes with
twe er mere criteria sheuld be tested fer GABHS and
treated if apprepriate.
The mainstay ef treatment ef GABHS pharyngitis cen-
tinues te be penicillin. Cephalescin and clindamycin are
apprepriate secenci-line cheices fer these whe are allergic
Drthepeedic Knewledge Update: Sperts Medichse 5
 Section 7’: Medical Issues
to penicillin. Treatment may reduce the duration of symp-
toms by 1 to 2 days. Athletes may participate in sports if
symptoms are well controlled and hydration and nutrition
status are adequate to perform rigorous physical activity.
Mononucleosis
Infectious mononucleosis {1M} is a clinical syndrome re-
sulting from acute infection with the Epstein-Barr virus.
Up to Elfl‘h': of adults have serologic evidence of previous
exposure to Epstein-Barr virus, although many of those
infections never manifest or demonstrate the severe symp-
toms that can he associated with IM. The incidence of
[M is highest in those age 15 to 25 years, making this
problem particularly evident in college populations and
= collegiate athletic teams. Although no evidence exists that
E
E athletes are more susceptible to list, the risks related to
.E
'U splenic rupture and the almost universal recommendation
E
'11
for a period of limited exercise make it a particularly
ri-l
frustrating diagnosis for college athletes.
The classic clinical findings of IM include a prodro-
mal syndrome of headache, malaise, fatigue, and fever,
followed by pharyngitis and lymphadenopathy. IEither
common symptoms include palatal petechiae (25%} and
rash {lfl‘h}. to 413%]. Pharyngitis is often exudative and
frequently is accompanied by significant tonsillar hyper-
trophy. Physical examination also should include a careful
abdominal examination to evaluate for splenomegaly.
Palpation and percussion for splenomegaly should be a
routine part of the physical examination in an athlete with
possible Ilvl despite a poor sensitivity of sass to son.
Several laboratory tests can be used to aid in the dis
agnosis of IM. The presence of more than 10% atypical
lymphocytes—in the setting of a relative lymphocytn-
sis—suggests IM. A complete blood count also may reveal
other nonspecific signs of a viral infection such as mild
thrombocytopenia and leukocytosis. The heterophile an-
tibody test has a reported sensitivity of F9% to 95% and
a specificity of 31% to 99%, but results may be falsely
negative if the test is performed early in the course of the
illness. Repeat testing may be useful if clinical suspicion
is high but initial tests are inconclusive. Epstein-Barr virus
antibody tests are also available to confirm acute, sub-
acute, or prior infection. Viral capsid antigens Igl'vi and
IgG are present early in the infection, and positive results
are highly suggestive of an acute infection. The presence
of nuclear antigen suggests prior infection.
As for most viral illnesses, the treatment of 1M is
primarily supportive. NSAIDs and acetaminophen are
usually effective in controlling fever and pain. Athletes
with sovere symptoms or dehydration may benefit tempo-
rarily from corticosteroids, although no evidence exists to
show that they provide any lasting benefit in the overall
firthopaedic Knowledge Update: Sports Medichie 5
disease course. Patients who have profound tonsillar hy-
pertrophy with resultant or impending airway compro-
mise should receive corticosteroids and be monitored in
a setting where advanced airway management is readily
available. No indication for using antiviral medications
exists in patients with a competent immune system. A
high incidence of coinfection with group A streptococ-
cus is present, and it is appropriate to treat patients who
test positive with antibiotics. Amoxicillin use in patients
with 1M can cause a diffuse maculopapular rash, so it is
prudent to consider an antibiotic from a different class,
if possible.”
Splenic rupture is the most concerning potential com-
plication of Evil in the athletic population. The overall
incidence in patients with no is about flJ‘i’r‘h to 0.2%, and
most documented cases have occurred within the first 3
weeks of symptoms. For this reason, it is recommended
that athletes not participate in sports for 3 weeks from
the onset of symptoms. Approximately 5fl‘i’i- of splenic
ruptures are atraumatic, so athletes should be advised to
refrain from any exertional activity. Although ultraso-
nography of the spleen can determine its size, it is unclear
whether that information should change clinical decision
making. Due study evaluated the average spleen size of
tall, healthy athletes and revealed that the normal spleen
size in a tall, healthy athlete is much larger than that in
the average-size population, making the benefit of ultra-
sonography even less clear in taller athletes.”5 Although
documentation of an enlarged spleen may provide some
objective support when informing an athlete he or she
may not compete, no data yet support a return to sports
participation earlier than 3 weeks based on spleen size.
Athletes may return to activity 3 weeks after the onset
of symptoms if they are asymptomatic and afebrile. Al-
though some authors report starting light activity be-
fore the 3-week mark, no literature is currently available
that supports return to contact sports within 3 weeks of
symptom onset, irrespective of spleen size or laboratory
vs'illtle'iflr
Pulmonary Infections
Bronchitis
Bronchitis is an inflammatory condition of the tra-
cheobronchial tree resulting in a cough, which is often
productive. It is caused most often by a virus but can oc-
casionally be caused by atypical bacterial organisms. The
most common causative organisms are similar to those
that cause URIs. Rhinovirus, adenovirus, parainfluenaa,
and influenza A and E are the most common viral etiol-
ogies. Elf those, only influenza may benefit from antivi—
ral therapy. Potential bacterial causes include Bordetslfo
fl ems American Academy of Orthopaedic Surgeons

pertussis, Mycopfasnra paenmovrfae, and Cbiamydopfriia
prisons-oxide.
The clinical signs and symptoms of bronchitis overlap
with other respiratory diseases. Athletes usually report a
productive cough. They also may have wheezing related
to airway inflammation, fever, and dyspnea on exertion.
The color or quantity of the sputum cannot reliably dif-
ferentiate bronchitis from pneumonia. The symptoms re-
solve with no specific therapy in most patients. Although
no clear evidence shows that any therapy consistently
improves symptoms, some patients may benefit from a
short course of bronchodilators or antitussives.
Antibiotic therapy should be reserved for patients who
are not improving or those who have underlying medical
problems such as asthma, chronic obstructive pulmonary
disease, or immunosuppression. iviost athletes improve
without antibiotic therapy, and few have true risk factors
for a bacterial etiology. The early identification of athletes
at risk for influenza is important. Treatment with antiviral
medications including oscltarnivir and aanamivir can
be initiated within 43 hours of symptom onset and may
reduce the length of symptomatology. The team physician
also should consider whether prophylaxis with antiviral
medications is appropriate for teammates or close con-
tacts of a student athlete with influenza.EH
If antibiotics are used for the treatment of bronchitis,
amoxicillin, doxycycline, and asithromycin are reason-
able choices. It is important to discuss potential antibiotic
side effects with an athlete before medication is provided,
particularly before administering a drug that is unlikely
to substantially alter the disease course.
Pueumonia
Pneumonia is an infection of the lung parenchyma that
results in several clinical findings. Athletes with pneu-
monia may report any combination of cough, chest pain,
fever, general malaise, dyspnea at rest or on exertion,
or reduced exercise tolerance. Physical examination can
reveal tachycardia, tachypnea, crackles, rales, or tactile
fremitus. No combination of clinical findings can reliably
distinguish pneumonia from other respiratory illnesses;
therefore, evidence of pneumonia on chest radiograph or
other imaging is required for the diagnosis of pneumonia.
The appropriate treatment of pneumonia requires
knowledge of the likely causative organisms. In the pop“
ulation of generally healthy athletes with community"
acquired pneumonia, the most likely organisms are S
paeumoaiae, H influences, and M paeamonfae. First—line
choices for antibiotic coverage include aaithromycin, clar-
ithromycin, or doxycycline. Athletes with risk factors for
hospital-acquired pneumonia or significant comorbidities
and those who recently have traveled internationally may
IE! Ellie American Academy of flrthopaeclic Surgeons
Chapter 43: Infectious Disease in the Athlete
require more broad antibiotic coverage}? The return to
activity for athletes should be undertaken slowly and
gradually. Athletes may increase activity as tolerated when
antibiotic therapy is completed but should be advised that
the recovery after pneumonia may be much longer than
that after a routine URI.
Gastrointestinal and Genitourinary Infections
Gastrointestinal Infection
Acute gastrointestinal [GI] infection, or gastroenteritis,
is the second most common condition in athletes after
respiratory infection. Although acute GI illness generally
is self-limited, the primary concern in athletes is dehydraa
tion. For traveling athletes, diarrhea is a connnon concern
sanssl leaipaw :,1;
and a challenge when away from their home resources.
Acute GI illness is related most often to a viral, bacterial,
or protozoal etiology, with viral illness being the most
common cause.
Viruses cause most cases of gastroenteritis, which oc-
cur most often in the winter months. The most common
viruses identified include norovirns and rotavirus, and
each virus causes millions of GI illnesses in the United
States each year. The incubation period tends to be rela-
tively short [24 to fifl hours}, as does the duration {12 to Ed
hours]. The diagnosis is usually clinical, and the condition
is characterized by diarrhea of short duration. Nausea,
vomiting, and fever with abdominal discomfort also may
be present. The treatment is generally symptomatic, al—
though in athletes, intravenous fluids may be beneficial
for acute dehydration secondary to diarrhea, vomiting,
and intolerance of oral fluids. In addition, loperamide can
be considered to prevent further diarrhea if the episode
is clearly of viral etiology without blood in the stool,
and it may help to minimize dehydration. If vomiting is
occurring often, an antiemetic may be warranted.
For athletic teams, a major concern is the high rate
of transmission with minimal contact. This has been
demonstrated in a documented outbreak among 13 Na-
tional Basketball Association tea ms, as well as in 9 mem-
bers of a teenage girls’ soccer team, who contracted the
same norovirns strain from touching a reusable grocery
bag or consuming its contents.”*31 Transmission may
be fecal-oral or secondary to exposure to vomit and,
potentially, fomites, so members of the team who are ill
should consider using a single restroom separate from
that of healthy teammates. Encouraging the use of hand
soap rather than hand sanitizer, especially during the
winter months, is vital to minimizing outbreaks among
teams. Team physicians also may consider holding ill
athletes from competition for 24 to T2 hours to minimize
transmission.
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 7’: Medical Issues
Most GI illnesses do not need studies for diagnosis.
Unly about 1.5% to 6.3% of all GI illnesses are bacte-
rial in nature.32 Patients with blood or pus in the stool
with persistent fever, severe pain, pregnancy, or recent
antibiotic use should be evaluated for bacterial causes of
gastroenteritis, however. Patients with at least four loose
stools per day for more than 3 days are considerably more
likely to have an important pathogen}3 Tests should in-
clude stool studies for fecal leukocytes and culture, and
practitioners also should consider testing for ova and
parasites if risk factors are present. Einstridiam difficile
testing is indicated if antibiotics have been used recently.
Dbtaining an adequate history is important; the history
should include queries about recent meals, travel, camps
= ing and outdoor activity, natural water exposure, the
h"
E frequency of stools, pets, and contact with others having
.E
'U similar symptoms.
E
'11
Bacteria can cause GI illness in one of three ways: by
ri-l
the production of toxins, by direct invasion of the bowel
with secondary inflammation, or by a combination of
both. Inflammatory gastroenteritis includes infection with
Campyinirccter, Shigeiic, Salmonella, enternhemnrrhagic
Escherichia coli, and C difficiie {Table 1}. Rapid—onset
diarrhea related tn food intake also can help narrow the
diagnosis. Diarrhea from S careas nr Bacillus cereas typ-
ically occurs within IE hours of ingestion, because of a
preformed toxin. Infection with Clostridiam perfringerts
occurs at 3 to 16 hours after ingestion. Patients with signs
of bacterial infection after recent antibiotic use should
undergo stool testing for C difficiie and treatment if the
test is positive. Probiotics may play a role in reducing the
risk of antibiotic-associated diarrhea?l
Protozoa] infections are less common, but can include
Cryptospo n'dmm pervum, Giardie femhlfe, and Entom—
eohc histol'yticc [Table 1).
Genitourinary or Sexually Transmitted Infection
Sexually transmitted infections {STIs} have been de-
scribed as a hidden epidemic, partially because of the
reluctance of society to openly address sexual health.
This is even more critical in some athletic populations
that may demonstrate an increased likelihood of risky
sexual behavior. Dlder male high school athletes as well
as male and female collegiate athletes are more likely to
demonstrate risk-taking behavior than are their peers, in-
cluding having multiple sexual partners and not practicing
safe sex.35r35 Therefore, understanding how to identify,
treat, and prevent common STIs is essential to the sports
medicine provider.
HPV is the most common STI in the United States.
Most men and women in the United States will be infect—
ed with HP'Wr at some point in their lives. I-I'PV usually
firthnpaedic Knowledge Update: Sports Ivledich'ie 5
resolves with time and causes no morbidity, although
some subtypes can progress to genital warts, and other
subtypes have been linked to several cancers, including
cervical, anal, and some oropharyngeal cancers.
Genital warts typically are caused by HP‘lvr 6 and HPV
11 and may present as cauliflower—like, flat, papular, or
keratotic lesions on the penis, vulva, perineum, or muco-
sal surfaces. In general, cryntherapy nr trichlnracetic acid
is used to destroy the lesions, although biopsy should be
considered in lesions that are atypical or if the diagnosis
is not cnnfi rmcd. Approximately i’fl‘lii of all cervical can-
cers are caused by I-IP'lvir types 16 and IS. I-IP‘llr vaccines
are directed at high-risk subtypes, and have been shown
to be effective-“'1” Vaccination is recommended for both
males and females at age 11 or 12 years, and for those not
vaccinated previously, the vaccine is approved through age
21 years for males and age 26 years for females.
Ehfemydie trachomatis is the second most common
STI in the United States, although more than half of cases
are undiagnosed. Chlamydia infections are asymptomatic
in SUSS of women and EDS-i. of men, and it primarily af-
fects those between the ages of 15 and 25 yea rs.“ flf those
who are not treated, the infection resolves spontaneously
in about 3fl%, but the rest remain persistently infected or
pelvic inflammatory disease eventually develops. Infection
with chlamydia increases an individual’s risk of HI‘vir con—
traction. It is therefore recommended that women young-
er than 25 years be screened annually for chlamydia.
Screening has been shown to reduce the incidence of pelvic
inflammatory disease by 50%.“ Symptomatic women
often present with cervical inflammation or yellow, cloudy
discharge from the cervical os, and symptomatic men may
present with discharge from the penis. Urine testing is
effective and has largely replaced the more invasive swab
test. Treatment is simple and effective, with asithromycin
single-dose oral therapy as the primary option. Those
with a positive test should abstain from intercourse for
at least T days after treatment, and partners of infected
individuals having sexual contact within the past 60 days
should be tested or treated presumptively.
Neisseric gonorrhoeee infection is less common than
is chlamydia, but it can be difficult to distinguish from
chlamydia initially on presentation. Both men and wom-
en may have discharge, although women may be more
likely to be asymptomatic. If a high clinical suspicion
for N gonorrhoece or chlamydia is present, providers
may consider treating for both. The treatment of N gna-
orrhoeee is generally effective with a single dose of cefe
triaxone, although resistance to ceftriaxone is possible.
Frequently, coinfectinn with chlamydia is present, and the
US Centers for Disease Control and Prevention {CDC}
therefore recommends treatment with both ceftriaxone
fl ants American Academy of Orthopaedic Surgeons
 Chapter 43: Infectious Disease in the Athlete

Table 1

Dyeryiew of the Etiologies of Nooyir'al Gastroeoteritis

Treatment |iiiptions (in Addition to
Causative Agent Important ICharacterlstics Supportlye Therapy}
Campylobacter Results from ingestion of meatr poultry, dairy |Eirnly small subset of patients
products benefit from antibiotics
Usually self-limited. resolves in 5—? days Azithromycin and erythromycin
are most likely to be beneficial
Shfgefla Mere common in children younger than 5 years Antibiotics may shorten course
More common in developing countries Ciprofloxacin {cautiom may cause
Bloody diarrhea tEndlnltIS}
Eeftriarone
Azithromycin

sanssl leagpayu :1
Salmonella Results from ingestion of poultry, dairy products, Ciproflozacin (caution: may cause
reptile exposure tendinitis}
Outbreaks with peanut products and raw produce Ceftriasone
Azith ro mycin
Enterohemorrhagic More common than enterotozigenic E coii in Azith romycin
E. coli United States
Releases toxins: can cause systemic complications
Most common serotype is 015?:H?
ms of patients with 015?:H? develop hemolytic
uremic syndrome
Enterotoxigenic E coil Most common cause of traveler's diarrhea Likely needs antibiotics
Eiproflozacin {caution: may cause
tendinitis}
lt'Ze'l"triaJ-r.one
Azithromycin
Clostridlum difficlle Associated with antibiotic use Discontinue current antibiotic
Laboratory: stool enzyme immunoassay for toxins agent
A and B Treat with oral metronidazole
Admission recommended unless no systemic Vancomycin (resistant or recurrent
symptoms and no organ dysfunction cases}
Cryptosporfdr‘um Can transmit yia bird or cattle feces leeching Self-limited, usually resolves with
parrum {protozoan through soil into water supply: can transmit symptomatic care
parasite} human to human Nitazorcanide for persistent cases
Causes "rice water diarrhea"r (similar to cholera}
Laboratory: stool microscopy detection of oocysts
or stool test for Cryptosporfd'ium antigen
Giardia lamblfa Fecal-oral transmission Metronidazole
{fla gellated Campers drinking from streams, especially in the Pregnancy, first trimester:
protozoan parasite} mountains Pa ro momycin
Pools can be a source
Laboratory: stool microscopy detection of cysts or
trophozoites
Entamoeba Diarrhea over 1 week Treat with metronidazole initially.
histolytlca 1iiir'eight loss and abdominal tenderness Follow with luminal agent
Can develop liver abscess, rarely, brain abscess paromomycin to eradicate colon
Laboratory: stool test for En tamoeba histofytfca infection.
antigen
Econ: Escherichia coil

IE! lfllfi American Academy of flrchopaedic Surgeons Drtbopaedic Knowledge Update: Sports Medicine 5
 Section 7’: Medical Issues
and asithromycin in cases of a positive N gonorrhoe-
as test. Genital tract infection with N. gonorrhea can
disseminate to other areas of the body and cause skin
and synovial infections, underscoring the importance of
prompt, adequate treatment.
Blood-Borne Infectious Illness
With the rapid escalation in the prevalence and knowledge
of illnesses such as HIV infection and hepatitis over the
past 3!} years, blood-borne illnesses and their potential for
transmission have been a major concern for athletes and
medical care providers. Fortunately, the risk of transmis-
sion during sports activity is relatively low. Of the three
= blood-borne illnesses discussed in this section, hepatitis B
A"
E is 10 times more likely tn be transmitted than hepatitis C,
.E
'U and 1'00 times more likely to be transmitted than HIV.“
E
'11
Hepatitis B has a higher risk of transmission because
I:
of the higher levels of infectious virus in the blood. Docu-
mented cases have been reported of transmission in sumo
wrestlers and Olympic wrestlers, although these cases
were noted in areas with a high prevalence of hepatitis E
in the general population.‘u~” Hepatitis B is most likely
to be transmitted via perinatal mother-to-child exposure,
parenteral exposure, or sexual intercourse; infecdon via
mucosal contact with infected blood or blood products
is less likely. Most of those infected with hepatitis B are
asymptomatic, or the infection clears spontaneously, but
complications such as liver failure, cirrhosis, and hepa—
tocellular carcinoma are possible. The diagnosis is made
primarily on serologic markers, and treatment is based
on chronicity, age, the severity of disease, the likelihood
of response, and potential adverse events. The hepatitis
B vaccine is a routine part of the childhood vaccination
series and should he considered for adults with risk factors
based on lifestyle or potential occupational exposure.
Hepatitis C is much more likely to be contracted by
athletes from parenteral exposure than during sports
activity or SEILIEII intercourse. Therefore, athletes who
are involved in blood doping, steroid use, or other illicit
drug use are at the highest risk of hepatitis C infection.“
0f patients exposed to hepatitis ('3, chronic infection de-
velops in 55% to 35% ,-, of those with chronic infection,
most are asymptomatic. The workup initially includes
testing for antibodies to determine infection, followed
by viral genotyping and viral load testing to determine
treatment options.
HIV continues to be an important illness worldwide,
but with adequate medical treatment including antiretro-
viral therapy, it is not the rapidly terminal illness it once
was. Although many well—known athletes have received
an HIV diagnosis, only one case is thought to have been
firthnpaedic Knowledge Update: Sports Medicine 5
transmitted during sports activity.“ Athletes are much
more likely to contract HIV during non—sport-related
activity, such as blood doping and intravenous drug use,
than by participating in sports.“
In the athletic team setting, meningitis is one of the more
concerning diagnoses, given the potential for transmission
and the severity of illness. Most commonly, the cause
of meningitis is viral or cannot be determined {aseptic
meningitis]. Bacterial ilhless is infrequent, but can pro—
duce substantial mortality, with complications including
neurologic sequelae. Because of the early difficulty in
differentiating between the two etiologies, the clinician
must suspect a bacterial cause initially.“
flutbreaks among sports teams, most commonly
American football teams, have been reported. Echovirus
and coxsacltie virus, both in the Enteroaims genus, have
been isolated in most of these ca ses."”“ These viruses are
spread primarily via fecal-oral transmission, but also can
be spread via respiratory secretions, leading to possible
transmission during the sharing of water bottles among
teammates.
Symptoms of meningitis include nausea, vomiting, pho-
tophobia, malaise, and drowsiness. These symptoms may
be present in viral and bacterial meningitis but are usually
more severe in bacterial meningitis. The classic triad of
signs of bacterial meningitis is fever, neck stiffness, and
altered mental status, but all three signs are present in
only 44% of cases.‘PEI It is important to evaluate for nuchal
rigidity and to determine the presence of meningeal signs,
including the Kernig and the Brudainski signs. A thor-
ough skin examination should be performed to evaluate
for hemorrhagic lesions associated with meningococcal
meningitis. Lumbar puncture is the most important diag-
nostic test in those suspected to have meningitis, although
in some cases, CT of the head should be performed before
lumbar puncture?” In addition, blood should be drawn
for culture as early as possible.
Treatment initially includes antimicrobial therapy un-
til bacterial meningitis can be ruled out. The Infectious
Diseases Society of America guidelines suggest that an-
timicrobial therapy should be instituted as soon as the
diagnosis of bacterial meningitis is suspected or proven
and not delayed to await the results of lumbar puncture
or imaging studies.” After a diagnosis is determined,
treatment depends on the specific etiology of meningitis.
In the team setting, preventive measures are vital if
meningitis has been diagnosed in a single athlete. These
measures should include consistent handwashing, dis—
infecting shared areas, using single-use cups instead of
fl lflle American Academy of Orthopaedic Surgeons

cemmunally served drinks, and iselating the athlete with
meningitis.“ The CDC recemmends vaccinatien fer me-
ninge-ceccal disease at ages 11 te 12 years, with a beester
at age 16 years.
Summary
Infectieus diseases in athletes can be cemmen causes ef
time lest frem training er cempetitien. |Certain facters
relating te immune functieu and petential expesures can
alter an athlete‘s risk fer in fecrieus diseases. The medical
team must therefere be prel'icient in the diagnesis and
management ef these cenditiens re safely guide ret urn-te-
play decisiens fer athletes. Preventive measu res sheuld be
taken when pessible re reduce the risks ef initial infectiens
and eutbreaks ameng members ef athletic teams.
Hey Study Peints
l Infectieus disease illnesses censtitute a substantial
level ef merbidity in athletes, and a familiarity with
these illnesses will aid sperts medicine physicians
in caring fer their athletes.
I Maximising preventative efferts in beth hygiene
and envirenmental expesures is effective re decrease
risks ef several infectiens disease illnesses, including
gastreenteritis and MRSA.
1* Early identificatien and relative iselatien ef athletes
with cemmunicable diseases including influenza and
gastroenteritis will help prevent rapid spread within
the team setting.
Annotated References
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tract viral infectiens. Exerc Spurs Sci Ree lflfl9;37{4]:15?-
164. Medlinc
The aurhers prepesed a medel detailing medulatien ef
immune functieu due re mederare exercise and the eerie-
spending effect en respiratery viral infectiens.
2. Walsh NP, IEleesen M, Shephard R], et al: Pesitien state-
ment. Part ene: Immune functieu and exercise. Esters
Immune! Rev lfll 1;1?:6- 63. Mcdlinc
A pesitien statement frem experts in the field is presented
regarding the current understanding ef the effect ef exer-
cise en immune functieu.
3. Spence L, Erewn W], Pyne DE, et al: Incidence, etiele-
gy, and symptematelegy ef upper respiratery illness in
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Medline D01
IE! lfllfi American Academy ef Drrhepaedic Surgeens
Chapter 43: Infecfiees Disease in the Athlete
Malachewa N, Kebayashi SD, DeLee FR: Cemmuni-
ryvasseciated methicillin-resistant Staphylececcus au-
reus and athletes. Phys Sperssmed 2fl12;4fl{21:13-21.
Medline DUI
This review article eutlined MESA ameng athletes with
regard te epidemielegy and virulence, with special at-
rentien given re eurpatient management and preveerieu
strategies.
Buss BF, Ceenelly S: Surveillance ef physician-diagnesed
skin and seft tissue infectiens censistent with methi-
cillin-resistant Staphylececcus aureus {MESA} ameng
Nebraska high scheel athletes, EDDIE-2012. ] Sch Mars
2fl14;3fl{1}:41-43.Medline DUI
Data cempi led frem this survey-based 2G 14 study shewed
MESA rates ameng Nebraska high scheel students ever
a 4—year span acress different sperrs.
sanssl leagpaw :,1;
Pereira LE: Impetige — review. An Bras Dermatei
2fl14;39{l}:293-299.Medline DD]
This review article detailed the etielegies, types, and clin-
ical presentatien ef impetige and previded a bread eutline
ef available treatment eptic-ns.
Lute JK, Lee J: Prevalence and antimicrebial-resistance
ef Pseudemenas aeruginesa in swimming peels and bet
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Medline DUI
This surveillance study cellected Pseudemenes samples
frem her tubs and peels te measure antibietic susceptibil-
ity and resistance patterns. Level ef evidence: III.
Levy JA: Eemmen bacterial dermatescs: Pretectieg
cempetitive athletes. Phys Spevrsmed 20D4;32[E}:33-39.
Medline DDI
Vlahevic TC, Dunn SP, Kemp K: The use ef a cliedamycin
l‘i'rh-benseyl perexide 5% tepical gel in the treatment ef
pitted keratelysis: A nevel therapy. Adv Skin W’s-and Cere
2Ufl9;22{12}:564-566.Medline Dfll
10. van der Sneek EM, Ekkelenlramp ME, Suylrerhuyk JC:
Pitred keratelysis: physicians’ treatment and their per-
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Venereel'2fl13:1?[9J:112fl-1126. Medline DUI
This cress-scctienal quesrieunaire ceuducted ameng phy-
sicians assessed depleyabiliry and the perceived efficacy
ef treatment ef Dutch seldiers.
11. Kwek CS, Gibbs S, Bennett C, Helland R, Abbett R: Tep-
ical treatments fer cutaneeus warts. Cechrerre Database
Syst Rev 201 2:9:(3DGDITSL Medline
This article is the updated cemprehensive ISlechrane review
detailing all available data regarding the treatment ef
cutaneeus warts, including cemprehensive cemparative
data and practice suggestiens. Level ef evidence: II.
12. Wenner Ill, Askari SK, Cham PM, Kedrewski DA, Liu A,
Warshaw EM: Duct tape fer the treatment ef cemmen
Drthepaedic Knewledge Update: Sperts Medicine 5
 Sectinn 2: Medical Issues
warts in adults: A. dnuhle-blind randnniired cnntrnlled tri-
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13. Chen K, Anstey PM, Bugert J]: Mnlluscum cnntaginsum
virus infectinn. Lancet Infect Dis 2013;13{101:3??-333.
Medline DUI
This review article outlined the cnnditinn’s clinical feaa—
tures, management, and epideminlngy. and prnvided a
detailed review nf mnlluscum cnntaginsum virus virnlngy,
immunnlngy, and genetic patterns.
14. Binder SM, Easier R5, Fnley J, Scarlata C, 1|Inl'asily DE:
Hatinnal athletic trainers’ assnciatinn pnsitinn state-
ment: Skin diseases. ] Athi Train 2GiG;45[4]:411—423.
Medline DUI
This Natinnal Athletic Trainers"I Assnciatinn 2fl1i} cnm-
n prehensive pnsitinn statement nn skin diseases in athletes
E included nverviews nf individual disease prncesses, pnten—
tial treatments, and return-tn-play guidelines.
E
.E
'U
'11
E 15. Andersnn B]: The epideminlngy and clinical analysis nf
ri-l
several nuthreaks nf herpes gladiatnrum. Med Sci Spur-ts
Exerc 2003;35{11}:13i]9-1314. Medline DUI
16. Dwnrkin RH, Earhann ILL, Tyring 5K, et al: A randnmiaed,
placehn-cnntrnlled trial nf nitycndnne and nf gabapentin
fnr acute pain in herpes anster. Pain 2flfl9;142{3]l:2[19-21?.
Medline DD]
This randnmiced cnntrnlled trial studied pnstherpetic neu-
ralgia and the effect nf nirycndnne against gahapentin and
placebn nver 23 days nf treatment. Level nf evidence: II.
1?. Weinberg JIvI, Knestenblatt EK: Treatment nf interdigital
tinea pedis: {Since-daily therapy with sertacnnaanle nitrate.
I Drugs Dermetnl' 2flll:‘lfl[1fl}:1135-114fl. Medline
This small trial shnwed that sertacnnaanle is an effec-
tive nnce daily tnpical treatment nf interdigital tinea pe-
dis, which may prnmnte adherence tn therapy. Level nf
evidence: II.
13. El—Gnhary M, van Zuuren E], Fednrnwics E, et a]: Tnpical
antifungal treatments fnr tinea cruris and tinea cnrpnris.
Cnchmne Database Syst IiletJl 2U14;3:CDD[}9992. Medline
This systematic review nf the existing literature frnm
1946 tn 2013 nutlined and cnmpared available tnpical
treatments nf tinea cruris and tinea cnrpnris. Level nf
evidence: I.
15‘. Atari AA, Barney NP: Cnnjunctivitis: A systematic review
nf diagnnsis and treatment. JAMA 2fl13;310(16}:1?21-
1225'. Mndline Dfll
This review article summarised the tunst recent infnr-
matinn regarding all types nf cnnjunctivitis. Level nf
evidence: II.
2D. Artieda J. Pineirn L. Gnnealea M, et al: A swimming
pnnl-related nuthreak nf pharyngncnnjnnctival fever in
children due tn adennvirus type 4, Giputkna. Spain, 2003.
Earn Scream 2099:14lfli. Medline
firthnpaedic Knnwledge Update: Spnrts Ivledich'ie 5
This article presented a case series nf 59 children in whnm
pharyngn-cnnjunctival fever caused by adennvirus devel-
np-ed as a result nf pnnrly disinfected swimming pnnls in
Spain. Level nf evidence: I‘ll".
21. Pintn RD, Lira RP, Abe RY, et al: liil'ezltamethasnneif
pnvidnnc eye drnps versus artificial tears fnr treatment
nf presumed viral cnnjunctivitis: A randnmised clinical
trial. Curr Eye Res 2914;13:1-3. Medline III-DI
This randnmiaed cnntrnlled trial investigated the effect
nf a denamethasnnea'pnvidnne-indine eye drnp cm the
symptnms and duratinn nf viral cnnjunctivitis. It shnwed
that, cnmpared with artificial tears, dexamethasnnei'pn-
vidnne-indine drnps reduced the duratinn nf cnnjuncti-
vitis by abnut 2 days but caused mnre stinging. Level nf
evidence: II.
22. Harmes KM, Blackwnnd RA, Burrnws HL, Cnnke JM.
Harrisnn RV, Passamani PP: Dtitis media: Diagnnsis
and treatment. An: Fem Physician 2fl13533{?}:435-44i}.
Mcdlinc
This review article repnrted the current recnmmendatinns
fur the diagnnsis and treatment nf acute ntitis media and
ntitis media with effusinn.
23. Ennney AG, |Gnldman RD: Antihistamines fnr children
with ntitis media. Can Fem Physician 2Ul4:6fl(1}:43-46.
Mndlinc
This review article discussed the use nf decnngestants.
antihistamines, nr bath, for ntitis media in children. The
anthnrs cnncluded that nn cnnsistent evidence shnws that
decnngestants nr antihistamines are beneficial in the symp-
tnmatic treatment nr faster resnlutinn nf ntitis media.
24. Rnsenfeld RM. Schwartz 5R, Cannnn CR, et al: Clinical
practice guideline: Acute ntitis enterna. Dtnlaryngnl Head
Neck Surg 2fl14;15i}{1, SupplISI-S24. Medline DUI
This review article presented cnmprehensive guidelines
for the diagnnsis and treatment nf acute ntitis enterna.r
with a cnmplete review nf the current literature. Lewl nf
evidence: V.
25. Putultian M, D‘Cnnnnr FG, Stricker P, et al: Mnnnnu-
clensis and athletic participatinn: An evidence-based
subject review. Elie ] Spnrt Med 2fl03:13{4k309—315.
Medline Dfll
This review article prnvided all the current infnrmatinn
regarding guidelines fur the safe return tn play after infec-
tinus mnunuuclensis. The anthnrs cnucluded that athletes
shnuld be held frnni spnrts participatinn until asymptnm-
atic. There are snme studies that suggest return tn cnntact
activity hefnre .3 weeks is safe.
26. McEnrkle R, Thnmas B, Suffalettn H, Jehle D: Nnrmative
Spleen size in tall healthy athletes: Implicatinns fnr safe
return tn cnntact spnrts after infectinus mnnnnuclcnsis.
Clin ] Spnrt Med 201D:2fl{6}:413-415. Medliue DUI
This cnhnrt study investigated the average spleen size nf
tall healthy athletes cnmpared with thnse having the ac-
cepted average adult spleen sites. The findings cnncluded
fl 2flld American Academy nf Cirrhnpaedic Surge-ens

that tall athletes had much larger spleens than these with
the published average sizes and that spleen size may nnt
reflect pathnlngy in tall athletes. Level nf evidence: I'v".
2?. Becker JA, Smith JA: Return tn play after infectinus
mnnnnuclensis. Spnrts Health 2014;6{3}:132-233.
Medline DUI
In this clinical review cm the evidence fur return tn play
after infectinus mnnnnuclensis, the key cnnclusinns include
the unreliability nf spleen site in guiding return tn play,
individualisatinn in determining the return tn play, and
the recnmmendatinn that athletes he asymptnmatic befnre
returning tn spnrts.
23. Wnrrall G: Acute brnnchitis. Can Fam Physician
2003:54i2]:233-§i3 9. Medline
25'. Smnnr MR, Hnsey RG: Pulmnnary infectinns in the athlete.
Curr Spnrts Med Rep 2Dfl9;3{2}:?1—?5. Medline DUI
This review article summarizes recent infc-rmatinn and
recnmmendatinns nn cnmmunity—acquired pneumnnia
and brnnchitis in athletes.
3G. Desai R, Yen C, Wikswn lid, et al: Transmissinn nf nnr-
nvirus amnng NBA players and staff, winter 201041311.
Ciin Infect Dis 2911;53i11]:1115-111T. Medline DUI
This case series dncumented an nutbteak nf nnrnvirus
amnng teammates and between teams in the Natic-nal
Basketball Assnciarinn. Level nf evidence: I‘v".
31. Repp RR, Keene WE: A paint—snurce nnrnvirus nut—
break caused by espnsure tn fnmites. j Infect Dis
2fl12;205{11}:1639-IE41.Medline DUI
This case review dncuments an nutbreak nf nnrnvirus
affecting several members nf a snccer team, in which a
cnntaminated grncery bag and its cnntents were implicated
as the scarce nf infectinn, suggesting that fnmites can he-
cnme airbnrne and lead tn infectinn. Level nf evidence: V.
32. Guerrant EL, 1it"an Gilder T, Steiner T5, et al; Infectinus
Diseases Snciety nf America: Practice guidelines fur
the management ni infectinus diarrhea. Ciin Infect Dis
2UGI;32{3):331-35 1. Medline DUI
33. Dryden M5, Gabb R], 1i'ii'right 5R: Empirical treatment
nf severe acute cnmmunity-acquired gastrnenteritis with
ciprnflmtacin. Ciin Infect Dis 1995;22{6}:1fl19-1fl25.
Medline DUI
34. Hale—Pradhan PE, Jassal HE, Wilhelm 5M: Rule nf Lactns
bacillus in the preventinn nf antihintic-assnciated diarrhea:
A meta-analysis. Pbannacntherapy Zfllflfiflilhllfl-IZE.
Medline DUI
This article is a meta—analysis examining the use nf the
prnbintic Lactnhaciiins tn reduce the risk nf diarrhea sec—
nndary tn antihintic use. Invel nf evidence: I.
33. Nattiv A, Puffer JG, Green l[Chin Lifestyles and health risks
nf cnilegiate athletes: A multi-center study. Ciin I Spnrt
Med 199?;?[4]:262-2?2. Medline DDI
ID lfllfi American Academy nt' Drthnpaedic Surgenns
Chapter 43: Infectinns Disease in the Athlete
36. Wetherill RR, Frnnlme K: Alcnhnl use, sexual activity, and
perceived risk in high schnnl athletes and nnn—athletes.
J Adniesc Health 21'] fl?:41{3}:294-3 fll. Medline DUI
3?. FUTURE II Study Grnup: Quadrivalent vaccine against hu-
man papillnmavirus tn prevent high-grade cervical lesinns.
N Engijr Med 2flfl?;356{19}:1915-191?. Medline DflI
33. Paavnnen J, Hand P, Salmerdn ], et al; HI”:ir PATRI-
CIA Study lifirnup: Efficacy nf human papillnmavirus
{HPV}-1iii13 ASfld-adjuvanted vaccine against cervical
infectinn and precancer caused by nncngenic HF'I:ir types
{PATRICIA}: Final analysis nf a dnuhle-blind, randnmised
study in ynung wnmen. Lancet 2005:3T4i96iifilfifl1-3 14.
Medline DD]
An analysis nf a randnmised, dnuble-hlind trial assess-
ing the efficacy nf HPV-Itiilfl ASD-d-adjuvanted vaccine
against HI”:F infectinns is presented. Primary nutcnme
sanssl lesipaw :y;
shnwed high efficacy against CIN2+ assnciated with HPWr
ltiilii. Level nf evidence: I.
39. Hennrikus E. lIIIIhertn D, Linder JM, Rempeljivi, Hennri-
kus N: Spnrts preparticipatinn enaminatinn tn screen cnl-
lege athletes fur Chlamydia trachnmatis. Med Sci Spnrts
Exerc lfllfl;42{4}:533—633. Medline DUI
This article is a prnspective prevalence study repntting
the rate nf chlamydia based nn randnm urine testing in
cnlle-ge athletes. Level nf evidence: II.
4D. Echnles D, Stergachis A, Heidrich FE, Andrilla H, Helmes
KR, Stamm WE: Preventinn ni pelvic inflammatnry dis-
ease by screening fnr cervical chla myd ia1 infectinn. N Engi
] Med 1996;334i21}:l3fil-1356. Medline DUI
41. Gutierrez RL, Decker CF: Elnnd-bnrne infectinns and the
athlete. Dis Men 2010;56{?}:43E-442. Medline DUI
This review article fncused nn hepatitis E, hepatitis C, the
risks nf transmissinn in athletic activity, and recnmmen—
datinns fnr preventinn in athletic settings.
41. Eae 5R, "'t'atsuhashi H, Takahara I: et al: Sequen-
tial nccutrence nf acute hepatitis E amnng members
Di 3 high schnnl fiumn wrestling club. ji-Iejii'atcdr Res
2014;44IID}:E16?-E2?2.Medline DUI
This case repnrt discussed a hepatitis B infectinn mnst like—
ly transmitted between twn members nf a Sumn wrestling
team and a cnach. Level nf evidence: V.
43. Bereket-‘i’iicel 5: Risk nf hepatitis B infectinns in Olympic
wrestling. Br I Spnrts Med lflfl?;41i5}:3fl5-31fl, discussinn
310. Medline III-DI
Aitken C, Delalande C, Stantnn K: Pumping irnn, risking
iniectinni‘ Eapnsure tn hepatitis C, hepatitis E and HIV
amnng anabnlic-andrngenic sternid injectnrs in Victnria,
Australia. Drng Aicnhni Depend 20fl1;55{3]:3fl3-3i}3.
Medline DUI
45. are D, Sampietrn C, Ferrarn G, Zernli C, Speranaa F:
Transmissinn nf HIV-1 infectinn via spnrts iniury. Lancet
199fl;335{369?]:1105.Medline DUI
Drrhnpaedic Rnnwledge Update: Spnrrs Medicine 5
 Secfiun 7’: Medical Issues

46. Ewald A]. Mcfleag DB: Meningitis in the athlete. Curr
Spur-ts Med Rep lflfiflfllifll-fl. Mcdlinc DUI
4?. Mnnre M, Bare-n RC, Filstein MR. et al: Aseptic men-
ingitis and high schnnl fncrthall players. HTS and 1930.
JAMA 19335249115 }:1{}39-1l}41. Mcdline DUI
4E. Earnn RC, Hatch MH, Kleeman K, Macrmaclc JN:
Aseptic meningitis amnng members cf a high sci-incl feet-
hall team. An nuthreak assnciatecl with echnvirns It”: in-
fecticm. jAMA 1932;243l14iflfl4-1fll Medline DUI
45'. 1san cle Beelc D, de l{Frans J, Spanjaard L, Weisfelt M, Re-
itsma JB, Vernienlen M: Clinical features and prngnnstic
factnrs in adults with bacterial meningitis. N Engfj Med
10fl45351[13]:1349-1359. Mthtllinc DUI
SD. Tunltel AR, Hartman E], Kaplan SL, et al: Practice guide-
lines fer the management cf bacterial meningitis. Eli's:
Infect Dis lflfl4;39{9]:1257—1234. Medline DUI

=
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flrflinpaedic Knnwledge Update: Slam-ts Medicine 5 fl lfllfi American Academy cif Urthnpaedic Surge-tins
Chapter 44

Facial Injuries
Ielfrey ll. Housner. MD, MBA Laurie D. Donaldson, MD

Ruptured globe
Gornaal abrasion
Because of the nature of current sports activities, the Corneal foreign body
clinician who cares for the athlete must he prepared to Hyphema ,
recognise and assess a variety of injuries that can occur Flelrohulbar Ema?“
hemorrhage “3””? "5

sanssl jeojpew :,1;

to the face. a comprehensive framework is necessary to
guide the evaluation, treatment, and triage of injuries Burns
to the skin, eyes, ears, teeth, and bones sustained as
a result of facial trauma. Life-threatening injuries are Cirbital
given priority and must be ruled out initially. Injuries .
fianoular
blowout
that require emergency department evaluation andlor hemaioma fracture
specialty consultation warrant immediate attention. The Facial
objectives for management include parallel goals: the iraohrres

restoration of normal function and the attainment of

Epietaais
acceptable cosmetics. The prevention of facial injuries, Nasal
particularly dental trauma, remains a critical component trachae
of the preservation of facial structures. Retum-to-play
considerations also should be discussed. Tooth fractures
Tooth diaslaoement
Tooth avulsion

Keywords: facial trauma: facial injuries: sports Figure 1 Illustration shows composite figure of facial
injuries.

Introduction
Facial trauma is common in sports activities, yet the true
incidence of all facial injuries sustained during sports
participation is unknown. Sports injuries to the face occur
in a variety of settings and can be treated with minimal
intervention that is not reported or recorded by tradition-
al surveillance methods.1 A EDH comprehensive review
determined that sports accidents were the causative fac-
tor in approximately 1fl% of all maxillofacia] fractures
worldwide.I Participation in many types of sports can
result in facial injuries, with a higher occurrence noted
during rugby, soccer, cycling, basketball, skiing, and ice
Neither of the following authors nor any immediate family
member has received anythingI of value from or has stock or
stock options held in a commercial company or institution
related directly or indirectly to the subject of this chapter:
Dr. Housner and Dr. Donaldson.
hockey}Ei Most injuries occur in boys and men between
the ages of 1G and 29 years" The mechanism of injury
is usually self-evident and results from contact with the
ground {for example, the field, floor, or mat}; with the
head, elbow, fist, or foot of an opponent; or with equip-
ment such as a ball, puck, stick, or post. Facial injuries
can result in significant physical disfigurement and can
have devastating psychologic effects. Therefore, expedi-
ent and effective treatment is needed to promote optimal
healing and minimise psychologic trauma. An organized
and sequential evaluation, undertaken while considering a
broad differential diagnosis {Figure 1}, is necessary for the
prompt recognition of facial injuries and the appropriate
triage and treatment.
Initial Assessment
Disfigu ring facial injuries can he distracting to the patient
and the clinician. Nevertheless, clinicians must focus on

fl lflld American Academy of Drthopaedic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Section 7’: Medical Issues
the basics of trauma care {the primary survey} and address
all life-threatening injuries before performing a complete
facial examination. As part of the primary survey, and
while maintaining cervical spine immobilization, an
evaluation for airway compromise, impaired breathing,
hemorrhagic shock, and an altered level of consciousness
should be performed immediately. The unconscious ath-
lete should be assumed tn have a cervical spine injury. If
the athlete is conscious, query to ensure no neck pain or
cervical tenderness is present. Any injury above the clav-
icle is assumed to involve the cervical spine until preven
otherwise. 1i'li’hen ongoing reports of neurologic symptoms
or cervical spine tenderness are present, cervical spine
precautions should be undertaken. The initial assessment
n also should focus on the control of bleeding, fracture
A"
E stabilization, and the recognition of a concussion.
.E
'U After problems identified during the primary survey
E
'11
are adequately addressed, a secondary survey, including
I:
careful assessment of facial injuries, must be performed.
The secondary survey should include a systematic ap-
proach and examination of all major facial structures
and functions. Inspection begins by viewing the face
from the front, the side, and below. It is important to
assess for asymmetry before swelling begins and dis-
torts facial features. Hematema, lacerations, erythetna,
a sunken globe, proptosis, pupillary asymmetry, redness
or bleeding within the eye, a widening of the midface,
depression of the sygomatic arch, septa] deviation, and
septal hematoma should be noted to guide the differential
diagnosis. The car should be inspected for laceration,
erythema, abrasion, or hematoma and assessment should
be performed behind the ear for any bruising {the Battle
sign}, which indicates basilar skull fracture. An intraeral
examination should be performed to look fer lacerations
or missing teeth. The facial bones, temporomandibular
joints, muscles, and areas of suspected injury should be
palpated fer tenderness, crepitus, swelling, instability,
dislocation, fracture, and foreign bodies. The lips, the
cheeks, and the floor of the mouth should be bimanually
palpated. A bimanual examination of the maxilla and
mandible is performed to assess for fracture or instability.
flcular movements are assessed for range of motion.
If range of motion is limited, this sign could suggest an
extraocnlar muscle entrapment that can occur with an
orbital fracture. Diplopia or visual disturbance with exu
traocular movements could suggest muscle entrapment
or injury to cranial nerve III, IV, or VI. Sensation should
be checked at the forehead, cheek, and jaw to test cranial
nerve V. Motor function can be tested by having the ath-
lete raise his or her eyebrows, shut the eyelids tight, smile
widely, and pucker the lips. If the athlete is able to perform
these functions, cranial nerve VII is likely intact. Finally,
firthnpaedic Knowledge Update: Sports Medicine 5
whispering or rubbing the fingertips near the ear can test
hearing. An ete-ephthalmescepe also should be used to
assess for blood or fluid in the external canal that could
indicate basilar skull fracture. The tympanic membrane
also can be viewed for rupture, which can occur during
trauma. In addition, the oto-ophthalmoscope can be used
to look into the nose for septa] hematoma.
Soft—Tissue Injuries
Centusiens
Facial contusions are common injuries in the athlete,
ranging from mild to severe. Treatment is primarily sup-
portive, directed at treating pain and swelling. Cryother-
apy typically is used—with caution to avoid cold burning
the skin—to help reduce swelling and discomfort. Most
contusions resolve within a few weeks without any further
intervention.
Abrasions
Abrasions, defined as wounds to the superficial layers of
the skin, are also common soft-tissue injuries. Because of
the mechanism of injury, abrasions involve more surface
area than they do depth. As a consequence, they are not
amenable to suture closure. Healing occurs via the recp-
ithelialisation of the skin layers. Abrasions are managed
by removing any foreign debris and by thorough cleans-
ing and irrigation with soap and water. A nenadherent
dressing can be applied to help prevent contamination
and to promote healing.
Lacerations
Careful exploration of every laceration should be per-
formed to determine its severity, to remove debris, and to
assess for damage to underlying muscles, tendons, nerves,
blood vessels, or bone. The goals of laceration repair are
to achieve hemostasis, avoid infection, restore function,
and achieve optimal cosmetic results. Definitive laceration
management depends on the time elapsed since injury, the
extent and location of the wound, the available laceration
repair materials, and the skill of the physician. The deci-
sion to allow the wound to heal by secondary intention
or to close it is based on clinical judgment.“ The decision
to perform primary closure or refer to subspecialty care
ultimately is based on the physician's level of expertise,
experience, and comfort with managing the laceration?
Laceratien wounds should be irrigated with normal sa-
line or tap water.” Povidone iodine solution, hydrogen
peroxide, and detergents should not be used because their
toxicity to fibroblasts impedes healing in wounds that
penetrate the dermis.“ The wound can be irrigated with
any method that delivers sufficient volume and pressure.
fl lfllii American Academy of Orthopaedic Surgeons

The necessary volume of fluid will vary, based on the
size of the wound and the degree of contamination. a
common delivery method consists of discharging the fluid
from a syringe through a needle or angiocatheter. A useful
on-field tip is to repeatedly puncture a quarter-sized area
of a bottle of normal saline with a needle. The wound can
then be showered by squeezing the bottle.
Primary repair is usually the preforred treatment of
facial lacerations. In general, facial lacerations without
risk factors for infection can be closed within 14 hours if
appropriately cleansed.“ Laceration repair follows com-
mon wound—closure principles of aseptic technique and
universal body fluid precautions. Ifllptimal cosmetic re-
sults can be achieved by using the finest suture possible,
depending on skin thickness and wound tension. Suture
material larger than bio. Iii-l} is rarely used on the face.
Most facial lacerations can be closed with acceptable
cosmetic result using a single interrupted or running clo-
sure technique and nylon suture. Lacerations involving
the lacrimal apparatus, parotid gland, facial nerve, or
vermillion border of the lip should be repaired only by an
experienced practitioner. If the laceration is too complex,
the athlete should be referred to a surgical subspecialist.
Sutures placed on the face should be removed in 5 to T
days. Skin staples should not be used on. the face but can
be considered for use on the scalp.
Eyelid lacerations are an important subtype of fa-
cial lacerations. Superficial, simple lacerations that are
horizontal and follow the skin lines usually heal well
without suturing. More complicated eyelid lacerations
should be referred to subspecialty care for evaluation
and management.
Local anesthesia with lidocaine 1% or bupivacaine
fl.25% is appropriate for small wounds. Anesthetics that
contain epinephrine should not be used on the nose or
cars. The sting of anesthetic injections can he reduced by
injecting slowly, warming the anesthetic, or buffering it
with sodium bicarbonate {1 mL of sodium bicarbonate
per 10 mL of anesthetic}." Although local anesthetic in-
jected directly around the wound border usually provides
adequate anesthesia, a selected facial nerve block can
provide more effective anesthesia without distorting the
wound edges. In a nerve block, anesthesia is injected
directly adjacent to the nerve supplying the surgical field.
Three useful nerve blocks invaluable for facial laceration
repair are the supraorbital, infraorbital, and mental. All
three nerves lie on an imaginary straight vertical line that
passes through the pupil and the corner of the mouth
{Figure 2.}. The supraorbital nerve, which provides sen-
sation to the lateral forehead, emerges from the supra-
orbital foramen along the orbital rim. The supraorbital
notch can be palpated along the superior orbital rim.
IE! lfllti American Academy of flrthopaedic Surgeons
Chapter 44: Facial Injuries
Supraortaltal
nerve
lntraorbltal
sanssl leagpaw :1
Mental nerve
Figure 2 Illustration shows the alignment of the
supraorbital notch. the intraorbital fora men,
and the mental foramen in a vertical line
passing through the pupil and the comer of the
mouth.
The infraorbital nerve, which provides sensation to the
upper lip, cheek, and lateral nose, emerges from the in-
fraorbital foramen just below the inferior border of the
orbit. The mental nerve, which provides sensation to the
lower lip and chin, exits from the mental foramen of the
mandible. All of these nerve blocks can be approached
transdermally using a lE-gauge or 2?-gauge needle gently
advanced through the skin. The infraorbital and mental
nerves also can be approached intraorally with less dis-
comfort to the patient.” The upper lip {for infraorbital
nerve block} or lower lip {for mental nerve block} is re-
tracted and the small-gauge needle is pierced into the fold
where the gingiva and buccal mucosa meet. The needle
is advanced slowly less than 1 cm along the periosteum
until met by external pressure from a guide finger directly
palpating the nerve. Conceptually, this approach may
sound unpleasant, but in practice, less pain occurs than
with a transdermal approach, and the procedure is more
technically straightforward. Generally, only 1 to 2 mL
of anesthetic agent is needed to anesthetise the nerve for
the three previously described nerve blocks.
Tissue adhesives, such as 2-octylcyanoacrylate, present
another option for laceration repair. They are comparable
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 7’: Medical Issues
with sutures in cosmetic results, dehiscence rates, and
infection risk?!” Tissue adhesives can be applied more
quickly, however, without anesthesia, and they need little
or no follow-up}; Tissue adhesives can be used for the clo-
sure of simple lacerations less than 4 cm in length that do
not involve areas of high skin tension. To close the wound,
the edges are approximated and the adhesive is applied in
a thin layer. Three to four layers are applied, waiting 30
seconds between applications. Extreme caution should be
exercised when using adhesive close to the eye.
Epistaxis
Because the blood supply to the nose is extensive, the
athlete who sustains trauma to the nose usually presents
= with epistaxis, which may or may not be associated
E
E with a nasal bone fracture. Epistaxis generally occurs
.E
'U because of microdisruption to the Kiesselbach plexus in
E
'11
the anteroinferior septum. Bleeding can be controlled
I:
by applying pressure with the fingers to the nasal alae
tightly against the septum for If] to 15 minutes or by
using nasal packing with cotton or gauxe. In cases that
do not respond to direct pressure, many otolaryngol-
ogists recommend initial treatment with two sprays
of oxymetaxoline to hasten hemostasis, although few
published data exist to support the practice.” In severe
cases, when the source of the bleeding can be identified,
chemical cautery with silver nitrate can be considered
after determining that topical anesthesia is adequate.
Bleeding from posterior nasal sources usually originates
from a branch of the sphenopalatine artery and may
require posterior packing. If bleeding is not controlled,
the athlete must be seen by a subspecialist for definitive
treatment.
Facial Fractures
The diagnosis of a facial fracture can be determined via
the clinical history, along with physical cxa mination, and
confirmed with imaging. The initial treatment includes
elevation of the head, ice application, and analgesic pain
medication. Facial fractures should be referred to sub-
specialty care as soon as possible. Hondisplaced nasal
fractures can be treated symptomatically.
Nasal Fractures
The nose is the most prominent projection on the face;
therefore, it is the site of one of the most common facial
bone fractures.16 The best time to examine the nose is
within the first few hours after the iuiury, before sig-
nificant swelling occurs and when the injury can be vi-
sualised more clearly. Nasal fractures generally present
with an obvious nasal deformity, tenderness to palpation,
firthopaedic Knowledge Update: Sports Medicine 5
epistaxis, andfor periorbital ecchymosis. Closed reduction
with adequate pain control andfor sedation can be at-
tempted for displaced but otherwise uncomplicated nasal
fractures evaluated within 6 hours.” Some otolaryngol-
ogists prefer to wait 3 to 7" days to allow the swelling to
resolve, however. At the time of injury, the athlete may
be unable to determine whether his or her appearance
will be acceptable because of the degree of swelling over
the nasal bridge.” The athlete with a suspected nasal
fracture should be evaluated carefully for concomitant
injuries to the midface or skull. Clear rhinorrhea from
the nose should raise suspicion for cerebrospinal fluid
leakage, which indicates fracture to the cribriform plate.
The septum should be examined for deviation andfor
septal hematoma. If present, a septa] hematoma must be
drained to prevent abscess formation andr'or the develop-
ment of a collapsed nasal bridge, also called a saddle-nose
deformity.
Maxillary Fractures
The Le Fort classification commonly is used to describe
the fracture pattern of maxillary fractures {Figure 3}.
Although these fractures rarely present exactly in the
classically described form, they typically demonstrate
significant components of one or more of the fracture
patterns. A Le Fort I fracture is a transverse fracture
through the maxilla only. The fracture line runs hori-
zontally above the teeth and lust below the nose. This
pattern results in the separation of the palate and
tooth-bearing portion of the maxilla from the rest of
the face. On visual inspection, facial distortion may
be present in the form of an elongated face, swelling,
and ecchymosis. fln examination, a step-off deformity
of the palate andfor mobility of the maxilla when the
upper teeth are grasped and moved in an anterior-poste-
rior direction may be evident. A Le Port 11 fracture is a
pyramid—shaped fracture involving more of the midface
traversing the nose, infraorbital rim, and orbital floor,
and proceeding laterally through the lateral buttress
and posteriorly through the pterygomaxillary buttress.
These fractured bones may be impacted backward and
upward, or the fragment may be floating free. The ma i-
la and nasal complex will move as a unit when the upper
teeth are grasped and shifted from front to back. In at
Le Fort III fracture, the facial skeleton is separated from
the cranium, which can result in complete craniofacial
dissociation if bilateral. The fracture line runs through
the bridge of the nose and extends along the medial wall
of the orbit, across the floor of the orbit, through the
lateral orbital wall, and then out across the xygomatic
arch. Manipulation of the palate results in movement of
the xygomatic bones.
fl lflld American Academy of Orthopaedic Surgeons

ll“
‘ ““4 on
1 b ii -I
d El
Hg u re 3
Illustration shows the outlines of the Le Fort I,
II, and Ill fractures of fine maxilla.
|lIllrhital Blowout Fractures
flrbital blowout fractures occur when blunt trauma to
the globe results in collapse of the inferior orbital wall.
The force of the trauma creates increased pressure to all
walls of the orbit, but the orbital floor is most susceptible
to fracture because of its thin, eggshell—like construct.
In addition, the orbital floor receives minimal support
from the air-filled, mucosa-lined maxillary sinus sitting
beneath it. Drbital blowout fractures frequently present
with perinrbital swelling and ecchymosis. The injured
athlete should be asked about diplopia and examined
for limited upward gaze; both findings usually are due
to entrapment of the inferior rectus muscle. Infranrbital
hypoesthesia can result if damage has occurred to the
infraorbital nerve that runs through the inferior wall of
the orbit. Enophthalmos can develop secondary to her-
niation {acute} or necrosis [subacutel of perinrbital fat.
If extrancular movements are limited with a suspected
orbital hlowont fracture, immediate CT scan is indicated
to evaluate for strangulation of the extraocular muscles,
which results in muscle necrosis.”
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 44: Facial Injuries
Zygomatic Fractures
In addition to forming the checkbones of the face, the
sygoma, or sygomatic arch, forms a portion of the lateral
and inferior orbital rim and provides an attachment point
for the superior portion of the masseter muscle. Thus,
aygomatic fractures can affect vision, jaw function, and
facial cosmetics.” Eygomatic fractures generally occur
from blunt trauma to the face and cheek. Signs and symp-
toms may include subconjunctival hemorrhage, swelling
or ecchymosis over the zygoma, perinrbital ecchymnsis,
a depressed malar eminence and orbital rim, paresthesia
in the distribution of the infraorbital nerve, emphysema
in the orbit or overlying soft tissue of the cheek, trismus,
malposition of the globe, or diplopia.
sanssl jeajpaw :,1;
Mandibular Fractures and Dislocations
Mandibular fractures are relatively common sports inju-
ries, comprising up to 4G% to SD93 of all sports-related
maxillofacial fracturesfi'fi'i” Two common symptoms de-
scribed by patients are pain and the feeling that the teeth
no longer correctly meet. The teeth are very propriocep-
tive secondary to nerve fibers around the periodontal
ligament, so even a small shift generates an abnormal
feeling of malocclusion. Dther signs and symptoms can
include swelling, bleeding, tenderness, numbness {because
the inferior alveolar nerve runs along the jaw and can
be compressed by a fracture), trismus, and a step-off
deformity at the fracture site. An intraoral sublingnal
hematoma is pathognomonic for a mandibular fracture}I
Stabilisation for transport can be facilitated by using a
Barton bandage {Figure 4}.
Mandibular dislocations frequently result from a lat-
eral blow to the jaw while the month is open. The in-
jury is observed most often in sports such as basketball
and hockey, in which a high incidence of elbow trauma
occurs to the face. Generally, the mandible is displaced
anterior to the eminence of the mandibular fossa. The
athlete presents with an obvious deformity in the tem-
poromandibular region and is unable to close the month.
Go the field, anterior mandibular dislocations can be
reduced using a variety of methods without procedur-
al sedation or local anesthesia. The classic reduction
technique is performed with the athlete seated on the
floor, the ground, or a chair, facing the clinician with the
head stabilized. The athlete is asked to open his or her
mouth widely against resistance; this motion reduces the
muscle tone of the elevator muscles through reciprocal
inhibition and allows concurrent manual reduction. In
a simultaneous maneuver, the clinician exerts maximal
downward reduction force using gloved thumbs on the
patient's lower molars or mandibular ridge while exert-
ing steady and constant downward pressure by moving
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectiun 7’: Medical Issues
T: Medical Issues
Figure 4 Illustratiun depicts a Bartun bandage, usedtu
sta bilize the mandible during patient tra nspurt.
{Hepruduced 'irum La nzi EL: Facial and dental
injuries, in Limpisvasti Ci, lirabalt BJ. Albuhm
Ml. Wadswurth LT. Herring 5A. Pruvencher MTi
The Spur-ts Medicine Field Manual. Easement.
IL, American Acad emy uf llZirthupaedic
Surgeuns. 2015. pp 131-195.}
the mandible duwn, then pusteriurly, and then up, with
the rest uf the fingers and the hand aruund the jaw and
chin, levering upward. The duwnward pressure clears the
cundyle uf the articular eminence, whereas the pusteriur
pressure repusitiuns the eundyle within the mandibular
fussa.” If the maneuver is unsuccessful, the athlete may
need prucedural sedatiun and shuuld be transpurted tu
an emergency department.
Ear InjuriesiAuricular Hematuma
Blunt trauma tu the ear is cummun in spurts such as
wrestling, buxing, rugby, and mixed martial arts. Shear-
ing furces uecur at the external ear as it sustains direct
cuntact with surfaces such as the fluur ur a mat. These
furces cause bluud tu accumulate in the subperichundrial
space, creating an auricular hematuma. The perichundri-
urn supplies nutrients cu the underlying cartilage, and if
the hematuma separates the underlying cartilage frum the
perichundrium, necrusis uccurs. This disrupted vascular
supply cu the external ear cartilage alsu increases the risk
uf infectiun.
603 firthupaedic Knuwledge Update: Spurts Medicine 5
Athletes with an auricular hematuma rep-urt substan-
tial pain er pressure at the external ear, perhaps uut ef
prupurtiun tu the visible trauma. Later, swelling, less uf
the external ear landmarks, ur fluctua nee palpated at the
external ear cunsistent with hematuma may be present.
If an athlete sustains an auricular hematuma and is able
tu tulerate pain, he ur she may be alluwed tu euntinue
spurts participatiun, with advisement abuut the risk ef
further injury tu the en r. Acutely, an untreated hematuma
can enlarge and rupture. Chrunieally, an untreated an-
ricular hematuma can result in a disfiguring caulifluwer
ear, resulting frum pressure necrusis and the furmatiun
uf new cartilage and fibruus tissue.
If an auricular hematuma is suspected, early recug-
nitiun and treatment are impurtant. An utularyngul-
ugist can be cunsulted fur definitive treatment. Befure
the bleed within the hematuma cuagulates, it shuuld be
deeumpressed as seen as pussible thruugh aspiratiun ur
incisiun and drainage. This step shuuld be fullewed by
the placement uf a prutective mulding, wurn fur 3 tu 7’
days. If adequate cuverageiprutectiun is nut pussible, the
athlete shuuld be restricted frum play until evidence uf
healing is present. Dtherwise, repeated injury can lead
tu recurrent bleeding and hematuma. Antibiutics uften
are prescribed te prevent infectieu, especially if incisiun
and drainage are perfurmed. In high-risk spurts such
as wrestling, a prutective ear cuvering shuuld be wurn
tu prevent reinjury. All wrestlers shuuld be encuuraged
tu wear prutective gear at all times during practice and
cumpetitiun.
Eye Injuries
{if the lflflfiflfl eye injuries resulting frum spurts each
year, an estimated 42,0(10 are treated in the emergency
department, and 13,5flfl athletes end up legally blind.“~“
(if spurts—related eye injuries, sees can be prevented by
wearing pruteetive equipment.“ Spurts cummunly re-
spunsible for injury te the eye include baseball, basketball,
suftball, racquetball, fuutball, and succer.15
The evaluatiun uf eye injuries can be appruached sys-
tematically. First, visual acuity shuuld be assessed with a
handheld Snellen chart, fulluwed by visual field testing. At
the same time, extraueular mevements can be eunfirmed.
Pupil size shuuld be assessed fur reactivity tu light and
accummudatiun. The relative afferent pupillary defect can
be assessed with the swinging flashlight test. If the pupil
paraduxically dilutes when expused tu light, injury tu the
uptie nerve ur retina is suggested. Cunjunctival erythema,
hyphema, and laceratien shuuld be visualized. Finally, the
facial bunes shuuld be inspected and palpated tu assess
for assuciated buny injury.
fl lflld American Academy at Cirrhupaedic Surge-ens

|L'Iorneal Abrasion
Corneal abrasions are one of the most common eye inju-
ries encountered in sport. They occur from blunt trauma,
such as injury from a fingernail or a stick. The symptoms
of corneal abrasion are sharp pain, a foreign body sensa-
tion, tearing, redness, and possibly reduced vision. The
diagnosis can be confirmed with fluorescein dye instilled
into the eye by touching the strip to the inner lower lid
and using a Wood lamp or a blue light from an ophthal—
moscope. A corneal scratch will he highlighted by the
fluorescein dye.
If the abrasion is small {for example, from a finger
poke}, supportive care only may be needed. Corneal abra-
sion is treated with topical antibiotics and cycloplegics.16
Eye patches no longer are recommended for more than 1
day because they can lead to loss of vision and have not
been proven to help with painffir” Contact lens wearers
should discontinue using contacts until the antibiotics
are discontinued and should be considered for referral
to an ophthalmologist for close follow—up because of a
higher risk of infection. l'viost corneal abrasions resolve
within 24 to 43 hours; if the abrasion is still symptom-
atic after this time, the athlete should be referred to an
ophthalmologist.
Corneal Foreign Body
Foreign bodies acquired from environmental debris and
particles can present with symptoms similar to a corneal
abrasion. If a foreign body is suspected, the upper lid
should be everted and the lower lid pulled out to assess
for foreign body. The eye can be irrigated with saline,
or a moistened cotton swab can be used to remove the
foreign body if visible. If the particle cannot be extract-
ed, an evaluation in the emergency department or by an
ophthalmologist should be obtained. Topical antibiot-
ics typically are not used for corneal foreign bodies but
can be considered in unhygienic or wilderness settings.“
Athletes with a corneal abrasion or corneal foreign body
can return to play if the pain is tolerated and no loss of
vision has occurred.“
Ruptured Globe
A ruptured globe occurs during high-velocity trauma
from a missile object such as a hockey puck or stick, bat,
racquet ball, or baseball. A ruptured globe can result
from a blunt blow or penetrating injury. The cornea,
sclera, or both can be disrupted partially or fully {open
globe rupture]. Athletes will present with a history of a
direct blow or trauma, severe pain, visual disturbance,
and decreased extraocular movements. Subconjunctival
hemorrhage that is present 360“ around the cornea is
highly suspicious for a ruptured globe.” A hyphema is
IE! EDIE American Academy of flrthopaedic Surgeons
Chapter 44: Facial Injuries
present in many cases. A sunken and distorted eye, pu-
pil irregularity, and leakage of vitreous material may be
present. Alternatively, in a closed globe rupture without
a full-thickness tear through the cornea and sclera, the
globe may look normal.
A ruptured globe requires emergent evaluation in the
emergency department and should be treated as an ocular
emergency. |Clo transport, a rigid eye shield, or the lower
half of a Styrofoam cup if a shield is not available, should
be placed, and manipulation or pressure on the eye should
be avoided. These injuries have a high rate of vision loss.
Ruptured globes are not always obvious on physical ex-
amination; therefore, a high index of suspicion should be
maintained, and referral to an ophthalmologist should be
considered for any athlete with significant high-velocity
sanssl lesgpew :,1;
trauma to the eye.”
Hyphema
Blunt trauma such as a projectile object or a fist punch
also can result in a hyphema. The shearing forces on
the blood vessels of the iris cause rupture, with leakage
of blood into the anterior chamber. Layering of blood
at the inferior iris can be seen, and the pupil may be
irregular or sluggish. Vision may be blurred if the hyphe-
tna is large, and pain and photophobia may be present.
Most hyphemas layer over less than one—third of the
anterior chamber. If severe, however, blood can fill the
entire anterior chamber, creating an 3-ball hyphema.
All hyphemas require urgent ophthalmology evaluation
because of possible complications and their association
with other intraocular injury. IZil'ccasionally, hospitalized
tion is required. Typical treatment includes an eye patch
and shield, rest, and elevation of the head of the bed.
Most hyphemas resolve within a few days, but rebleed-
ing occurs in approximately 25% of cases within the
first 3 to 5 days. Rebleeding is associated with corneal
staining, possible increased intraocular pressures, and a
poorer prognosis. For this reason, aspirin and HSAIDs
should be avoided. In athletes with sickle cell disease,
caution should be exercised because sickliug can occur
where blood accumulates in the anterior chamber. In ath-
letes with sickle cell trait, an association with secondary
bleeding, increased intraocular pressures, and permanent
visual impairment is present:l1 All players with hyphema
need clearance by an ophthalmologist before returning
to play because of the risk of rebleediug, which can per-
manently affect vision.
Retrobulbar Hemorrhage
Blunt trauma to the eye, which often occurs in sports, can
lead to bleeding in the closed orbital space. The result
ing increased pressure leads to decreased perfusion and
Drthopeedic Knowledge Update: Sports Medicine 5
 Sectinn 7’: Medical Issues
ischemia as well as a cnmpartment syndrnme nf the eye.
The nptic nerve and retina will be damaged fmm isehe-
mia. Elevated intrancular pressure lasting lnnger than
90 minutes can lead tn blindnessf‘1 Physical enaminatinn
may reveal perinrbital bruising, reduced visinn, pmptnsis,
pain, and a relative afferent pupillary defect. A high index
nf suspicinn shnnld be maintained because this injury
needs tn be treated emergently tn avnid irreversible isehe-
mia and subsequent blindness. The treatment cnnsists nf
surgical decnmpressinn.
Retinal Injury
Retinal injury alsn can nccur as a result nf blunt trauma.
The athlete may repnrt severe pain nr reduced visinn.
= Flashing lights and flnaters are symptnms specific tn ret-
E
E inal injury and shnnld prnmpt urgent nphtbalmnlngic
.E
'U evaluatinn.“l
E
'11
ri-l
Burns and Radiatinn Espnsure
In athletic events held at high altitude, nn water, nr nn
snnw, ultravinlet burns tn the cnnjunctiva and cnrnea can
nccur. Athletes present with severe eye pain, tearing, phn-
tnphnbia, and eyelid spasms. With flunrescein dye, a fine
punctate staining pattern will be seen. Treatment cnnsists
nf systemic analgesics and tnpieal antibintics. These in-
juries can be prevented by using ultravinlet ray—blncking,
shatter-resistant eyewear.
Dental Injuries
The incidence nf spnrts-related dental trauma varies frnm
14% tn 5?%, depending nn the type and cnmpetitive level
nf the spurt}3 These injuries can result frnm cnntact nr
nnncnntact fnrces transmitted tn the teeth. Studies have
shnwn that spnrts such as basketball, biking, ice hnckey,
rugby, baseball, and wrestling are cnmmnn culprits nf
dental trauma in males.”‘“ In females, the highest risk
fnr dental trauma nccnrs during basketball and field
hncltey.”
The tnnth cnnsists nf a crnwn that is visible abnve the
gum line and the rnnt, which is imbedded in the alven-
lar sncket nf the jaw bnne and secured in place by the
perindnntal ligament. The tnnth is made up nf multiple
layers: the enamel, which is the hard white nuter cnvering;
dentin, a snfter layer nf yellnwish cnnnective tissue; and
pulp, which cnntains the neurnvascular bundle.
Tnnth Fractures
Crnwn fractures cnmmnnly nccur tn the permanent an-
terinr teeth. a class I fracture, nr simple chipped tnnth,
invnlves the nuter enamel nnly. The athlete may nntice a
rnugh edge nf the tnnth, which shnnld nnt be painful nr
firthnpaedic Knnwledge Update: Spnrts Medicine 5
sensitive. These injuries dn nnt require urgent evaluatinn
and can be seen by a dentist nnnemergently tn smnnth
nut the enamel. Class II fractures eitpnse the yellnw den-
tin and are suitable fnr nutpatient care by a dentist. If a
fracture nf the crnwn has nccurred, with dentin nr pulp
visible, the athlete will repnrt pain when eapnsed tn cnld,
air, nr palpatinn. Class III fractures enpnse the dental
pulp, seen as a red line nr dnt, and are exquisitely painful.
If the brnken fragment is lncated, it shnnld he placed in
a snlutinn such as milk, saline, nr cnmmercial balanced
salt snlutinn. These mnre severe injuries require urgent
evaluatinn by a dentist nr endndnntist.
Rnnt fractures nccur much less frequently than crnwn
fractures. The diagnnsis nf a rnnt fracture typically is
made snlely by radingraphic appearance. A rnnt fracture
shnnld be suspected if mnbility nf the rnnt segment is pres-
ent withnut mnvement nf the apical segment nn palpatinn,
hnwever. Rnnt fractures shnnld be treated emergently tn
preserve pulp vitality.
Tnnth Displacement
a tnnth can becnme displaced frnm a direct nr indirect
blnw that results in stretching nr rupture nf the peri-
ndnntal ligament. The tnnth may be luaated nut nf the
sncket {extruded}, cnmpressed intn the sncket {intruded nr
impacted, appearing shnrter than adjacent teeth], nr there
may be buccal nr lingual lateral displacement. An extrud-
ed nr laterally displaced tnnth shnnld be repnsitinned as
quickly as pnssible. If the teeth is intruded, hnwever, it
shnnld nnt be manipulated in the field.
Tnnth Avulsinn
A tnnth avulsinn is a dental emergency, and every attempt
shnuld he made tn replace the tnnth as quickly as pnssi-
hle. The eventual vitality nf the tnnth depends directly
cm the time lapsed befnre reimplantatinn.” If treatment
is delayed mnre than 2 hnurs, nnly a 5% chance nf tnnth
survival exists.“ Every effort shnnld be made tn attempt
reimplantatinn nf the tnnth within 10 minutes fnr the
greatest chance nf survival.” The tnnth shnnld he lncat—
ed, with attempts made tn preserve its vitality. Ulnly the
crnwn shnnld be handled tn avnid damage tn the fragile
perindnntal ligament. If debris is present nu the tnnth, it
shnnld be rinsed gently with saline, water, nr milk. If the
athlete is cnnscinus, the tnnth shnuld be repnsitinned intn
the alvenlar sncket. The athlete can then gently bite nn
sterile gauze in preparatinn fnr tra nspnrt tn the emergency
department andl'nr dentist. If the tnnth ca nnnt be repnsi—
tinned, it can be placed in a cnmmercial tnnth saving kit
such as milk nr cnmmercial balanced salt snlutinn. Tnnth
avulsinns invnlving primary teeth in ynuth shnnld nnt be
replaced in the alvenlar sncket.
fl lflln American Academy nf Cirrhnpaedic Surge-nns

Prevention
Facial Protection
Protective facial devices can lower the risk of facial in-
juries significantly. Prior to 1959, before facemasks were
mandatory in American football, 50% of injuries were
defined as facial or dental trauma. In 1933, the incidence
declined to 1.4%.“ The rules governing protective equip-
ment vary by sport as well as by participant level of play.
In the National Collegiate Athletic Association, athletes
currently are required to wear facemasks for facial pro-
tection in men’s lacrosse, football, men’s and women’s ice
hockey, and fencing. Goalkeepers in women’s lacrosse
and catchers in softball and baseball also are required
to wear facemasl<.s."":I Although debate continues in the
world of hockey regarding the appropriate level of facial
protection, a substantial reduction in facial injuries has
been demonstrated when a full facemask is worn versus
a half shield.“+‘”'
Mouth Guards
l'viouth guards protect the teeth and dissipate energy from
a direct blow, which significantly reduces the risk of den—
tal injury. The Academy for Sports Dentistry recommends
using a properly fitted mouth guard Professionally fab-
ricated for fit and function for all contact and collision
sports.“ Uver-the-counter mouth guards can provide a
small degree of protection and remain an appropriate
choice for many youth sports because of their easy availv
ability and low cost.
Eye Protection
Athletes need to be counseled on the importance of eye
protection, because most eye injuries in sports can be
prevented with proper eye protection.” lli'ii'hen categoris-
ing sports based on the risk to the eye in the unprotected
player, only two sports were considered eye safe: track
and field {with the exception of javelin and discus, unless
good field supervision is present} and gymnastics.“ All
athletes involved in organized sports should be advised to
wear appropriate eye protection. The American Society
for Testing and Materials has sta ndardised specifications
for eye protection in racket sports, women's lacrosse, field
hockey, basketball, baseball, soccer, skiing, and snow-
boarding. These standards can be reviewed at: httpalf
www.astm.orntandardsfFSD3.htm.
The American Academy of Pediatrics and the Amer-
ican Academy of Uphthaimology recommend that all
functionally one-eyed athletes (having less than EBA-ll}
vision in the affected eye with corrected vision] wear
appropriate eye protection for all sports. It is also recom—
mended that they not participate in hosting or full-contact
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 44: Facial Injuries
martial arts. For sports that require a facemask or hel-
met, it is recommended that sport goggles also be worn
if the facemask becomes displaced and while sitting on
the bench.
Summary
Facial injuries are common in many sports activities. Ev-
ery injury should be approached methodically, including
an initial evaluation for life-threatening injuries, followed
by an assessment tailored to the nature, severity, and lo-
cation of the injury. A broad differential diagnosis should
be entertained to recognize injury patterns and determine
the urgency of treatment. A low threshold for subspeciala
ty consultation should be upheld for significant injuries
sanssl jeajpaw :g
to the face, eyes, and mouth. Facial and oral protection
is vital in preventing disfiguring andIor vision-altering
injuries.
Key Study Points
- A thorough evaluation of all facial injuries should be
performed, including a broad differential diagnosis
to consider injury to the skin, eyes, ears, bones, and
soft tissue.
*- Depending on the severity of facial injuries, emer-
gency services and subspecialty consultation should
be implemented when indicated.
Annotated References
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head and face in women’s collegiate field hockey. Cl'ir:
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studies during the last 30 years. Br I Ural Maxillofcc Sarg
2fl14;52{lfl}:9fl1-9flfi.MedIine DUI
This systematic review of 69 articles published worldwide
over the past 30 years evaluated the incidence of maxillo-
facial injuries from all causes, including sports activities.
Level of evidence: V.
3. Antonn JS, Lee KH: Sports-related manillofacial frac-
tures over an 11-year period. I Ural Maxfflofrrc Sari-g
Zflflfigfifijfiififl4-503.Medline DUI
4. Enadalttylos AK, Eggensperger NM, Eggli S, Smolka KM,
mmermann I-I, Iiauka T: Sports related maaiilofacial in-
juries: The first maxillofacial trauma data base in Switzer-
land. Bi"; Sports Med Eflfl4;3lijfi}:?.5fl -'.'-'"53. Medline [ll-DI
Drthopoedic Knowledge Update: Sports Medichie .‘i
 Sectien 1': Medical Issues
Maladiére E, Bade F, Meningaud JP, Cuilbert F, Ber-
trand JC: Aetielegy and incidence nf facial fractures
sustained during sperts: A prespective study ef 140 pa-
tients. In: ] Oral Maniiiefac Sn-rg lflfl1;3{i{4}:191-295.
Medline DCII
Meureusis C, Keunieura F: Sperts—rclated masillefacial
fractures: A retrespective study ef 125 patients. Ins] Ural
Maxiiiefac Snrg 1Dfl5;34{d}:635-633. Medline DUI
Remee S], Hawleyr C], Remee MW, Remee JP, Hensil-t
KA: Sideline management nf facial injuries. Curr Sperts
Med Rep 2Dfl?;6{3}:155-161. Mcdlinc
Hellander JE, Singer A]: Laceratien management. Ann
Emerg Med 1999:34iSifiSer361 Medline DCII
= Fersch RT: Essentials ef sltiu laceratien repair. Ans Fain
E A specific chapter in this atlas nf craniefacial diserders
E Physician 1003:?3l3}:945-951. Medline
.E
'U
'11 11}. Fernandez R, Griffiths R: Water fer weund cleansing.
E
Cecisrane Database Syst lien 2:11 2:2:CDEI :13 861. Medline
I:
This systematic review assessed the infectinn and healing
rates ef water and varieus ether snlutiens used fer weund
cleansing.
11. Scarfene R], Jasani M, ifiracel].r E]: Pain nf lecal anesthet-
ics: Rate ef administratien and buffering. Ann Ernerg Med
1998:31i1]:36-4fl.Medline DUI
12. Ferrera PC, Chandler E: Anesthesia in the emergency
setting: Part II. Head and neclt, eye and rib injuries. Arr:
Farn Physician 1994;5lll4}:TST-Sl}fl. Medline
13. Quinn J, Wells G, Sutcliffe T, et al: A randemized trial cnm-
paring ectylcyaneacrylate tissue adhesive and sutures in
the management ef laceratiens. IA MA 199?;2??{19}:152?—
1531']. Medline DD]
14. Singer A], Hella nder IE, Valentine SM, Turque TW, Mc-
Cusltey CF, |Quinn JV; Steny Ereelt Dctylcyannacrylate
Study |Ernup: Prespective, randemised, centrelled trial ef
tissue adhesive {Z-ectylcyaneacrylatei vs standard weund
clesure techniques for laceratien repair. Acad Ens-erg Med
1993;5{11t94-99.Medline DUI
15. Krempl GA, Hnerily AD: Use ef estymetazeline in the
management ef epistastis. Ann Dtei Rhine! Laryngef
1995;1fl4i9 PI: 11:?04-7'flfi. Mcdlinc DUI
16. Higuera S, Lee EI, Cele P, Hellier LH Jr, Stal 5: Nasal trau-
ma and the deviated nese. Piast Recenstr Snrg EDGEIZDIF,
Suppl liS-i-S-TSS. Medline DUI
1?. Mendin V, Rinalde A, Ferlite A: Management ef nasal
hene fractures. An: I Diniar'yngef 20fl5;26[3]:131-135.
Medline DUI
13. Recital P: Facial injuryr in spurt. Curr Sperts Med Rep
2fl1059[1}:1T-34.Mcd]ine DUI
Clrthepaedic Knewledge Update: Sperts Medicine S
This review article described the evaluatien, treatment,
and preventien ef the facial injuries that can e-ccur as a
result ef sperts participatien.
19. Kelley P, aper R, Gruss J: Evaluatien and treatmwt
ef zygematic fractures. Pfast Recenstr Surg lflfl?,11i}{'?,
Suppl 2155-155. Medline DUI
ll]. James RB, Fredricltsen C, Kent JN: Prespcctive study ef
mandibular fractures. I Cirai Snrg 1931:39i4}:2?S-231.
Medline
21. Springer 1, Haerle F: Sublingual hematema: Pathegne-
menic nf fracture cf the mandible, in Haerle F, Champy
M, Terry E, eds: Arias ef Craniefaciai Osteesynthesis:
Micrepfases, Minipiates, and Screens ,ed 2. Stuttgart, Ger-
many, Thieme Medical Publishers, lflflfl, pp Iii-11.
fecused n the clinical finding ef a suhlingual hematnma
and hew it is believed te be pathegnemenic fer a man—
dibular fracture.
22. Chan TC, Harrigan RA, Ufberg J, 1ii'illte CM: Man-
dibular reductien. ,7 Ernerg Med Zflfl3;34[4}:435-44fl.
Medline [ll-DI
23. Napier 5M, Baker RS, Sanferd DG, Easterhrnnlt M: Eye
injuries in athletics and recreatinn. .Snrt' Uphthafrrsnf
1996;41l3}:225—244.Mcdlinc DUI
14. United States Censumer Preduct Safety Cemniissien:
Sperts and Recreatienai Eye Injuries .Washingten,
DC, U.S. Cnnsumer Preduct Safety lCnmmissinn, lflfll}.
Medline [II-DI
25. Geldstein MH, Wee D: Sperts injuries: An nunce nf
preventien and a peund ef cure. Eye Centact Lens
2H11;3?l3i:1iifl-153.
This review ef the available literature cevered sperts-
related ecular trauma and its preventinn.
26. Fraser S: Cerneal abrasien. Cfin Dpistisafrnei 2G1fl:4:3 8?-
SSi}. Medline DUI
This article discussed up-te-date treatment eptiens fer
cerncal abrasiens.
1?. Turner A, Rabin M: Patching fer cerneal abrasien. Ce-
chrane Database Syst Rev .10 fle;2{2]:CD{ifl4Tfi4. Medline
13. Ellcrten JA, Zuljan I, Agassi G, Beyd J]: Eye prehlems in
meuntain and remete areas: Preventien and ensite treat-
ment—efficial recemmendatinns ef the Internatienal
Cemmissien fnr Meuntain Emergencyr Medicine ICAR
MEDCOM. Wilderness Enniren Med 1fl09;2fl{l}:165-
1?5. Medline DID]
This article is a censensus epinien frern the Intematienal
Cnmmissien fer Meuntain Emergency Medicine. Practical
advice is given regarding the management ef eye preblcms
in remete, high altitude, er wilderness settings. Preventien
ef eye prnhlems in these settings is discussed.
Q lfllfi American Academy ef Cirrhepaedic Surge-ens

29. Truhe JD: Ophthalmic tramna, in The Pbysicfuns’ Guide
In Eye Care .ed 3. San Franciscu, CA, American Academy
uf Dphthalmulugy, EDDE, pp 35-92.
3!}. Pulrhrel PK, Luftns 5A: Dcnlar emergencies. An: Fern
Physician EOD?;?EI[E}:329 -336. Medline
31. Nasrnllah A, Kerr NC: Sickle cell trait as a risl: factur
fur secundary hemurrhage in children with traumatic
hyphema. An: I Upfrflnrfnruf 199?;123ffij:7E3-?90.
Medline DDT
32. Hayreh 55, Hulder HE, 1|blii'eingeist TA: ISentral retinal ar-
tery uccln siun and retinal tulerance time. prhalrnulugy
193fl;3?[1]:?5-?8.Medline DUI
33. Ashley P, Di Iuriu A, Cule E, Tanday A, Needleman I: IUral
health uf elite athletes and assnciatiun with perfurmance:
A systematic review. Br ,1 Spurts Med 2fl15;49{1}:14—19.
Medline DDI
This systematic revievl.r article cf the available literature
examined the uverall nral health nf athletes, including a
subsectiun un urali'dental trauma. Level uf evidence: V.
34. Supuruwslti N], Tesini DA, Weiss AI: Survey uf urufacial
spurts-related injuries. } Mass Dent Sue 1994;43j4}:16-10.
Medline
35. Lee-K night ET, Harrisun EL, Price C]: Dental injuries at
the 1939 Canada games: An epidemiulugical study. I Can
Dent Assue 1992;53flflirfllfl-315. Medline
35. Andreasen JD, Andreasen PM, Skeie A, Hjnrting-Han-
sen E, Schwartz D: Effect uf treatment delay np-un pulp
and periuduntal healing uf traumatic dental injuries —
a review article. Dent Trunrnurul lfifllrlflfljrllfi-IZE.
Medline DUI
3?. Huwe AS: Craniumanillufacial injuries. in Seidenherg PH,
Bender Al, eds: The Spurts Medicine Resumes Manual.
ID Eillfi American Academy uf Drthupaeclic Surgeuns
Chapter 44: Facial Injuries
Philadelphia, PA, Saunders Elsevier, HIDE, pp 2.53.1?1.
DUI
33. Barrett E], Kenny D]: Avulsed permanent teeth: A review
uf the literature and treatment guidelines. Endud Dent
Trunmstul 199?;13j4}:153-1ti3. Medline DDI
35'. Welhuty RR, Murray J]: Preventiun uf trauma tu teeth.
Dent Update resentment-121. Medline
40. 21314-15 NCAA Spurts Medicine Handhuult, Prutective
Equipment, August 2014, pp. 1134-103.
This ufficial handhuulr cf the Natiunal Cullegiate Athletic
Assuciatiun and spurts medicine cuntains a sectiun un pru-
tective equipment discussing the specific safety equipment
required in individual spurts.
sanssl jenjpaw :,1;
41. Eensun 3W, Muhtadi HG, Ruse M5, Meeuwisse WH:
Head and neck injuries amnng ice hucl-rey players
wearing full face shields vs half face shields. IAMA
1999:232E241fl323-2332.Medline DUI
41. Stuart M], Smith AM, Malu-Drtignera 5A, Fischer TL,
Larsun DE: A cumparisun uf facial prutectiun and the
incidence cf head, neck, and facial injuries in Juniur A
hucltey players. A functiun uf individual playing time. An:
I Spurts Med lflfllj3flfllr39-44. Medline
43. Academy fur Spurrs Dentistry Pusitiun Statement: A prup-
en'y fitted munrbgnurd. Available at: httpdAvvvvvncade-
myfurspurtsdentistrycrgfpusitinn-statement. Accessed:
July 2i}, 21:115.
This ufficial pusitiun statement frum the Academy fur
Spurts Dentistry cuvers the qualificatiuns uf a Team Den-
tist, munth guard recummendatinns, spurts dentistry in
the dental schuul curriculum, and a smulreless tnhaccn
pusitiun statement.
44. "Finger PF: A practical guide fur spurts eye prutectiun.
Plays Spurrsnsed 2000:23ju}:49-69. Medline
Drthupaedic Knuwledge Update: Spurrs Medicine 3
Chapter 45
Abdominal Injuries
Stephen R. Paul, MD Sagir Girish Beta, DD, MPH, MS
abstract
Abdominal injuries make up a small percentage of
sports—related injuries, with a recent I'D—year review
demonstrating an incidence of 0.56% of pediatric
sports-related injuries due to abdominal or testicular
trauma. Despite the relatively low incidence, the outcome
of abdominal injuries can be poor, even including death,
making the diagnosis, management, and treatment
of such injuries of the utmost importance. The most
commonly injured organs from blunt abdominal trau-
ma are the spleen, kidney, intestines, and liver. These
injuries can result from direct or indirect trauma, often
presenting without overt signs of trauma. Frequently,
symptoms can present with a delayed onset or not at all
and therefore, knowledge of the mechanism of injury is
important. Athletes with suspected abdominal injuries
should be directed to a facility appropriately equipped to
manage such injuries, with access to CT, angiography,
on-demand surgical capabilities, and ability for continu-
ous monitoring. Management decisions are determined
by the hemodynamic status of the athlete. CT in most
cases is the diagnostic modality of choice, with Focused
Assessment with Sonography for Trauma examination
used in the initial workup. In the hemodynamically
stable athlete, the treatment of choice is nonsurgical.
Many organ systems have grading systems based on CT
scans. There is no consensus for return-to-play decisions
and often the degree of injury is a factor. In all cases,
attention to the readiness of the athlete to return to
play should be based on normalization of their physical
findings—laboratory examination, hemodynamic status
with evidence of continued injury—and psychologic
Lprepareduess.
None of the following authors or any immediate family
member has received anythingI of vaiue from or has stock or
stock options held in a commercial company or institution
related directly or indirectly to the subject of this chapter:
Dr. Paul, Dr. Here, and Dr. Eaiciic.
fl lflld American Academy of Drrhopaedic Surgeons
Brenden l. Balcik. MD
Keywords: abdominal injuries: blunt abdominal
trauma
Introduction
sanssl jeajpew :,1;
Blunt abdominal trauma {BAT} in sports is not very com-
mon. Furthermore, high—quality research performed in
randomized controlled trials [RCTs} and clear undisputed
guidelines for return to play after injury are few. Most
statistical analysis of sports injuries fails to identify,r ab-
dominal injuries as a reportable category.1 Many review
articles in the literature cite the incidence of sports-related
abdominal trauma as being as high as 1fl%.l The inci—
dence actually may be quite a bit lower, however. In a
10-year review of the National Pediatric Trauma Registry,
of 31,923 cases of trauma, 6.64% were related to sports
injuries, with only {3.56% due to abdominal or testicular
trauma.3
According to recently published studies on abdominal
injuries {those that involve the spleen, kidney, intestines,
and liver, as well as abdominal contusions and abdominal
muscle tears], no organ system reaches even 1% of all in-
juries reported. Discrepancies exist about which organ is
injured most commonly in BAT and about the differences
in adult and pediatric populations. Generally, however,
the abdominal organs most commonly injured are the
spleen, liver, and kidney. The pancreas, bladder, gastro-
intestinal tract and diaphragm were injured less often.
Although abdominal injuries are not the most common
injuries in sports, the outcome of an abdominal injury
can be catastrophic.‘ Therefore, every sports medicine
practitioner should be familiar with the presentation,
evaluation, identification, and treatment of traumatic
abdominal injuries.
The mechanism of abdominal injuries is related to
force mechanics: high~velocity forces, along with well-
placed direct contact with lower velocity forces, cause
injury. Abdominal injuries can result from collisions in
sports such as football, soccer, or skiing; from well-placed
local contact with a lacrosse ball, hockeyr stick, or bicycle
handlebars; or from rapid deceleration such as during
falls while snowboarding, surfing, or playing extreme
Drthopaedic Knowledge Update: Sports Medicine 5
 Section if: Medical Issues

7 DIepltt-nyl'r
I l‘inee—to-ohest maneuver if shortness of breath, usually self-limiting
I Abdominal contents can migrate into thorax with nipture
I Consider radiographs or CT if concerned about rupture
I FiTF': no universal guidelines, typically can retum when asymptomatic

3 Liver | ww- :
I Supportive manage ment if efabfe I Supportive management if stable
I Urgent laparotomy if unstable I Urgent laparotomy if unstable
I Preferred imaging: lDEBT I Preferred imaging: GEGT
I If extensive injury {contrast blush on GT} I FtTP: variable {E weeks to 5 months}
consider an giog raphy wilh embolization dependent on gradeiextent of injury
I FlTP: variable {3 weeks to 4 months]; quicker
recovery for laceration than contusion U_ Pancreas I
= I High morbidityimertality with delayed
l'iitlneyr
E diagnosis
I Supportive management it statute, until I Elevated amylaseiiipase suggestive, but
E

.E
'U he irratuna clears not diagnostic
'11
E I Imaging if gross hematuria or microscopic I Preferred imaging: begin with CT to help
t: hen'returia with hypotension diagnose: consider EFiGP {or MFIGF'J for
I Preferred imaging: CEET with delayed inages further evaluation
I GT all pediatric patients with hematuria I Drainage with low-grade Injuries {closed
{ta-5i] REG on urinalysis) suction preferred over sump drainage},
I FITF': variable {2 weelts to 12 months}, resection with high grade
dependent on grade and resolution of hematuria I FITP: no unive rsal guidelines

Bladder Uretere i
I Supportire management if extrape ritoneal nrptura or contusion I Delayed diagnosis common. usually with other
I Surgical exploration with intrap-eritoneai mpfure injuries noted initially
I Imaging if gross hematu ria without signs of pelvic fraemte or I Hematu rta may be present in only Suit-Eh. of
microscopic hematuria with signs of pelvic fracture trauma patients
I Preferred imaging: cystography {with ET} I Preferred imaging: CT
I FiTP: no universal guidelines; if contusion, may refum after I FtTP: no universal guideline-s
hematu ria clears

Figure ‘1 Illustration shows abdominal injuries from blunt trauma. ItTP - return to play. EECF - contrast-enhanced CT. EHEP
= endoscopic retrograde cholagniopano'eatogra phy, MHEP = magnetic resonance cholangiopancreatograpliy.

sports.” Differences exist between pediatric and adult
BAT. In children, the diaphragm is more horizontal, so
the abdominal organs are more anterior and inferior com—
pared with those of adults and are therefore more exposed
to injury. Additionally, in children, the rib cage is more
pliable and there is less protective musculature and fat
present to protect the internal organs.
Early suspicion for and recognition of blunt trauma
to the abdominal contents, along with appropriate ma n-
agement, can be life saving. Awareness of the mechanism
of injury and performing repeated assessments are essen—
tial. After the athlete is stabilized, quick transport to an
emergency facility equipped for in-depth assessment and
appropriate management is important if infra-a bdominal
injury is suspected.
In this chapter, discussion will be limited to the he-
medynamically stable athlete without signs of peritonitis.
Additionally, unless noted otherwise, the nonsurgical
treatment or observation will be the preferred treatment
of choice in a facility equipped for ongoing clinical mon-
itoring with the availability of angiography, imaging,
and on-demand urgent surgical capabilities. Key issues
related to blunt abdominal trauma in a sports setting are
presented in Figure 1.
General Sideline Approach
Awareness of the mechanism of injury and a high index
of suspicion are paramount when identifying abdominal
injuries. Direct contact will often result in abdominal wall

firthopaodic Knowledge Update: Sports Medicine 5 fl lfllii American Academy of Orthopaedic Surgeons

trauma with outwards signs such as coutusions, abra-
sions, and hematomas, and also may involve underlying
organs. Indirect trauma from rapid deceleration often
show no visible outward signs of trauma and may involve
|the internal organs such as the spleen, liver, kidney, and
hollow viscera.
Any athlete with a suspected abdominal injury should
he removed from play for a comprehensive evaluation.
Repeat examinations are essential and should include
inspection for signs of trauma, peritonitis (guarding, re-
bound tenderness, rigidity, and pain with jostling of the
abdomen}, and shock, along with any progression of pain
in terms of quality, radiation, localization, provocation
timing, and severity. 1Fv’ital signs should be taken, along
with a general survey performed according to Advanced
Trauma Life Support guidelines to include the spine,
thorax, and pelvis. Often, abdominal injuries present
innocuously, with delayed symptoms or worsening pain
occurring later. Symptoms presenting hours to days later
may be due to hollow viscous perforation and abscess
formation.
Specific signs can be seen in abdominal trauma. The
Kehr sign, presenting as pain referred to the left shoulder,
can signal splenic injury. Signs of hemoperitoneum include
the Saegesser sign [phrenic nerve pressure, producing neck
pain}, the Ballance sign {fixed left flank dullness}, the
lCullen sign {a periumbilical bluish discoloration}, and the
Grey Turner sign {a bluish discoloration of the left flank}.
Further Evaluation
In the emergency department, most patients with sports
abdominal injury are evaluated based on whether they
are hemodynamically stable or unstable. If the patient is
stable, CT with contrast is the gold standard, the goal
being to reduce unnecessary laparotomiesfld'" If the pa-
tient is hemodynamically unstable, Focused Assessment
with Sonography for Trauma {FAST} examinations often
are done initially to determine whether exploratory lap-
arotomy is needed. Diagnostic peritoneal lavage {DPL},
because of its invasive nature, lack of specific information
about organ injury, inability to determine retroperitoneal
injuries, and substantial false-positive rate {leading to un-
necessary laparotomies] has been replaced by FAST. FAST
examinations are cost effective, quick, and especially
useful in hemodynamically unstable patients because they
involve no radiation exposure and rely on identification of
intraperitoneal fluid and injuries.E The sensitivity of the
FAST examination is user-dependent and not very high
when the examination is performed by less experienced
clinicians. Sensitivities reported in the literature are 46%
for the liver, 50% for the spleen and renal injury 44%.”
IE! Elllli American Academy of flrthopaedic Surgeons
Chapter #5: Abdominal Injuries
Additionally, 5% to 37% of intra-abdominal organs in-
jured are without free peritoneal fluid?
No RCTs exist that screen for high—energy blunt ab-
dominal trauma to determine whether CT should be done
selectively or routinely.11 A Cochrane review found no
REIT—based evidence to support the use of ultrasonogra-
phy in algorithms for blunt abdominal trauma. There was
no evidence that the use of ultrasonography in algorithms
improved mortality, reduced diagnostic time with better
precision, or reduced unnecessary interventional proce-
dures? In clinical practice, the FAST examination remains
an integral tool in the initial workup for blunt abdominal
trauma to help assess the need for lapa rotomy, especially
in a hemodynamically unstable patient. FAST also is used
in the patient with clinical suspicion of high-energy blunt
sanssl jeajpaw :,1;
trauma in whom CT should be avoided}MEI
The sports medicine physician should be able to infer
which organs have been injured from observation and
the mechanism of injury involved. This knowledge can
assist in the diagnostic evaluation and workup. Most of
the literature on EAT concerns multiorgan injury, but not
necessarily that resulting from sport-related injury. In
clinical presentations with a high index of suspicion for
injury, a focused examination will alert the clinician to
possible intra-abdominal injury, leading to an appmpriate
diagnosis and treatment.
Types of Abdominal Injuries
Diaphragmatic Spasm
Diaphragmatic spasm was first reported in 194? and is
usually the result of a blow to the epigastrium, causing a
spasm of the diaphragm muscle, and resulting in difficulty
breathing accompanied by chest or abdominal pain.”- The
athlete experiences “getting the wind knocked out.“ This
injury is self-limiting, and the initial treatment is enabling
relaxation of the diaphragm by flexing the hips, stretching
the torso, and loosening any tight-fitting outerwear. The
athlete may return to play after resolution of symptoms.
Abdominal Wall Injuries
The incidence of abdominal wall injuries has been report-
ed to be between HESS and T93, including injuries to the
torso.” These injuries may involve a contusion or strain
to the abdominal wall and musculature, which includes
the rectus abdominis, internal and external oblique, and
transverse abdominis muscles. These muscles protect the
abdominal contents and aid in trunk flexion and compres-
sion of the abdominal space, pulling the chest down to aid
respiration. The lower abdominal muscles are important
for pelvic stabilization and for supporting the core as an
aid in upper extremity function.
Drthopaedic Knowledge Update: Sports Mediehse S
 Section 7’: Medical Issues
Contusion of the abdominal wall can occur by a direct
blow or while straining the muscles with indirect force,
such as in a forceful contraction of the muscles. The athlete
often will report anterior abdominal pain, which is wors-
ened with trunlr extension, contraction of the abdominal
muscles in flexion or rotation, or during a supine leg raise.
The pain may present as an “acute abdomen,” rigid and
with guarding. The abdominal wall should be palpated to
localize the pain. The pain is reproduced with tensing of
the abdominal muscles {the Carnett signj,“ trunk flexion
and rotation, and raising of the leg when supine—all of
which involve use of the abdominal muscles, which can
discriminate between injury of the abdominal muscula-
ture and the parietal peritoneum and underlying visceral
= structures. The pain may be relieved with passive trunk
E
E flexion.IEI The workup is limited to examination only if
.E
'U no other worrisome signs are present. Treatment consists
E
'11
of relative rest {allowing the trunk to remain partially
I:
flexed and limiting trunl-r extension and rotation}, ice,
and analgesics. Progression to abdominal wall stretching
and return to play when the athlete regains full range of
motion without pain usually occur within 1 to 2 weeks.
Rectal Sheath Hematoma
Rectal sheath hematoma {RSH} is an injury of the abdom-
inal wall that often is self—limiting and benign, but may
require additional workup and invasive treatment. The
mechanism of injury is similar to that of the previously
described abdominal wall injuries but usually involves
more force. The inferior epigastric artery loosely cours-
es between the rectus abdominis muscle and posterior
rectus sheath. It must move with muscle contraction and
therefore is susceptible to tearing with enough force. RSH
has a presentation similar to that of other abdominal
wall injuries, with abdominal pain worsened by con-
traction of the abdominal muscles. If the pain is severe,
it may be accompanied by nausea and vomiting. ten,
a mass may be palpable at or below the level of injury.
A delayed presentation may be periumbilical ecchymosis
{the Cullen sign}.
In a large or enlarging hematoma, evaluation and li-
gation of the epigastric artery may be necessary. Initial-
ly, ultrasonography can be useful, but it is not reliable
for determining the accurate location of the source of
bleeding; therefore, CT is recommended.‘*” Treatment
of RSH is supportive, including relaxed trunk flexion,
ice, and analgesics. As permitted, gentle stretching of the
abdominal wall may be performed.
Injuries to the Spleen
The spleen is reported to be the most frequently injured
organ from BAT in sported-‘5‘”r The incidence is low,
firthnpaedic Knowledge Update: Sports Medicine 5
however, and improved diagnostic evaluation and nonsur-
gical treatment methods have led to fewer intra-abdomi-
nal complications and improved mortality.”91“; Because
undiagnosed splenic trauma still carries high morbidity
and mortality,1'5~”' the sports medicine practitioner should
be able to recognize the condition and its characteristics.
The spleen resides in the left upper quadrant below
the diaphragm and, in adults, is protected by the costal
margins of ribs 9 through 11. When enlarged, or as a
normal variant in children, the spleen can extend beyond
the costal margins. The spleen is encapsulated and can
contain a large amount of blood, which can delay signs
of trauma. Injuries to the spleen during sports activity
occur from a direct blow to the left upper quadrant or
from deceleration injuries during high-speed activities or
falls. Certain preexisting conditions, including infections
leg, infectious mononucleosis}, hematologic disorders,
and fever can cause splenic enlargement and facilitate
splenic injury.”
Clinical symptoms of splenic injury can include sharp
abdominal pain in the left upper quadrant and general-
ieed abdominal pain or distension with or without signs
of peritonitis. Pain may be referred to the left shoulder
{the Kehr sign] because of peritoneal irritation of the
diaphragm. Rib pain on the left side and signs of trauma
or fracture may be present. If blood extravasates into
the peritoneal cavity, signs of peritonitis and shock may
ensue. A potential difficulty in diagnosis may stem from
bleeding being contained by the splenic capsule. After
sharp pain from the initial injury, symptoms may case
until they present in a delayed fashion, a situation that
can be catastrophic. A high level of suspicion for splenic
injury should be maintained by the sideline physician,
resulting in prompt transport to an appropriate trauma
center for workup.
In the hemodynamically unstable patient, the FAST
examination {or DPL if FAST is unavailable} plays a role
before laparotomy. Contrast CT is the diagnostic study of
choice for splenic trauma in the hemodynamically stable
patientlu'“ The grading of splenic injuries follows the
American Association for the Surgery of Trauma {AASTJ
organ grading system, the Spleen Injury Scale. Capsular
containment, the depth of parenchymal involvement, and
the location and degree of laceration are important com-
poneots.21 |Grade I [small] hematomas have less than NW:-
of surface area or capsular laceration and less than 1 cm
of parenchymal depth. Grade II {moderate} hematomas
involve lfl'ili: to 5[1% of surface area or an intraparenchy-
mal depth of less than 5 cm and have capsular laceration
measuring 1 to 3 cm not involving a trabecular vessel.
Grade III [large] hematomas have more than 50% of
surface area or are expanding, have greater than or equal
fl lflld American Academy of Orthopaedic Surgeons

to S cm of intraparenchymal depth or are expanding,
and involve a laceration more than 3 cm of parenchymal
depth or involve trabecular vessels. Grade IV {large with
partial devasculariaation} lacerations involve segmental
or hilar vessels with more than 25% devascularieation of
the spleen. Grade V {total devascularisationj represents
a completely shattered spleen or laceration of the hilar
vasculature with major devascularieation. Although not
used to a substantial degree or reported in the litera—
ture, the Baltimore CT grading system is an alternative
classification methodology that incorporates vascular
injuries tn aid the assessment for use of angiography and
embolisation.12
The presence of a vascular contrast blush, the pooling
of contrast within or around the injured organ noted on
CT, can represent active bleeding. Debate exists about
the optimal management of this condition. The Eastern
Association for the Surgery of Trauma {EAST} Practice
Management Guidelinesm state {level III evidence} that
contrast blush noted on CT is not by itself an absolute in-
dication for laparotom].r or angingraphic intervention. The
authors concur that other factors need to be accounted
for, such as patient age, the grade of injury, and hemo-
dynamic status.
Nonsurgical management includes initial monitoring
and activity restriction with serial hematocrit measure—
ments. The timing and frequency of these interventions
have not been standardized by research to date. The
grade of injury plays a role. In grade I injuries, monitor—
ing should be performed in a supervised environment,
with discharge as early as day I or 2 if the hematocrit
levels and the patient remain stable. Patients with grade
II injuries should be rested in an inpatient, monitored
bed. Those with grade III or higher injuries should be
kept in an intensive care unit for variable lengths, with a
minimum total stay of at least 3 days.‘5~j3
Repeat CT in the management of splenic injuries is
also controversial.M Most authors recommend against
repeating CT for lower grade (grade I or II} injuries. In
those with higher grades of injury or with evidence of
continued bleeding or symptoms, repeat CT can be in-
dicated. Also, in elite, high-level athletes, repeat (IT can
be done for higher grade injuries to help with return to
activities, but it is not recommended. Also, nltrasonogra-
phy may be used to serially document healing and to help
satisfy rcturn~to~play recommendations if the findings on
ultrasound correlate with CT findings.15 The mean time
to healing was studied using ultrasonography in splenic
injuries graded by CT in children.“ The nltrasonographic
organ grading system differs from that of AAST in that
the nltrasonographic system contains four grades, with
grade III equivalent to the EAST grades II and IV, and
IE! 2illii American Academy of flrthopaedic Surgeons
Chapter 445: Abdominal Injuries
_
CT Grade and Healing Time Noted With
Ultrasonography for Splenic Injury in Children
Grade of Injury Equivalent Healing by US
[Buntain System] AAST Grade {mean time.
isileeirs}I
| I 3.1 +i- 3.Dfi
II | 3.21 +.I'— 3.55
111 III, IV 12.11 +l'— 54.32
IV 'v‘ 213.21 +i— 122
MST - American Association for the Surgery of Trauma, US I
ultrasunng ra phy.
sanssl jeajpayu :,1;
llHealing time noted by Lynch et al at time of discharge ultrasound
comparing grade of injury by tvvo systems of splenic injury.
Data from Lynch .Iivi. Mesa MP. Newman ii. Gardner Ml. Alba nese
Ci: Eomputed tomography grade of splenic injury Is predictive
of the time required for rad iographic healing. J Fediab' Starry
193?:32fijflfl93-1D55, discussion IDES—11396.
the ultrasound grade IV equivalent to the AAST grade
V25 {Table 1].
The time for return to play is not consistent in the
literature. Factors to consider are healing time for the
spleen and the potential for rebleeding. The incidence of
delayed splenic rupture has been reported to be 1% to 3%
in adults a nd only zero to 15 “if: in pediatric patients.” The
risk of splenectomy in the 130 days following discharge
home was 1.453.133 I«Consultation with the surgeon is
recommended. The following ranges are suggested for
the return to full activity, but not necessarily to contact
sports. In grade I and II injuries, the time to return ranged
from less than 6 weeks to 6 months. For grade III injuries,
the time to return ranged from 6 weeks to 6 months.
Grade IV and V injuries resulted in a return of from 2
or 3 to 5 months, with 5% of those surveyed restricted
longer than 6- months.” A case series describes hockey
players with grade III injuries who were allowed to return
to play at 2 months without complications.”
It is interesting to note that, after splenectomy, athletes
often return to activity sooner than those treated non-
surgicallyJVf An important consideration for patients
who have undergone splenectomy is having the appro-
priate pneumococcal, Haemopbflus fnflaeness type B,
and Neisserfa meningitides vaccines. Patients who have
undergone splenectomy are also at increased risk for pro-
toanan infections such as babesisosis and malaria and for
Cupsocyropbugs canimorsas after dog bites.”
The recommendations for the management of splenic
injury are listed in Table 2.
Drtbopaedic Knowledge Update: Sports Medicine 5
 Section 1': Medical Issues

——
Recommendations for Managing Splenic Injury
Recommendations Level of Evidence
Patients hemodynamically unstable or with diffuse peritonitis should have urgent 1
Iaparotomy.
In the hemodynamically stable patient without peritonitis, routine laparotomy is “(IT 2
indicated.
Nonsurgical management trial is not contraindicated in hemodynamically stable patients 2
regardless of severity of injury grade, neurologic status, presence of associated injuries,
or age a- 55.
In hemodynamically stable patient without peritonitis, CECT should be performed. 2
Honsurgical management for splenic injuries should take place only in a setting equipped 2
to monitor the patient and perform serial examinations and with an operating room
= on standby for urgent laparotomy.
E
E
EEET = contrast-enhanced CT.
.E
'U
'11 Data from Stassen HA, Bhullar I, Eheng ID, et al: Eastern Association for the Surgery ofTrauma: Selective nonoperative management of blunt
E splenic injury: An Eastern Association for the Surgery ofTrauma practice management guideline. J Trauma Acute Care Surg- 2I112_:?3{5, Suppl 4]
ri-l
5294-53fl-L'l.

Injuries to the Liver whereas grade V has massive disruption.

The liver is reportedly the most commonly injured in-
tra-abdominal organ from all trauma.5~EH Common inju-
ries include hematoma or laceration of the subcapsular
or intrapa renchymal tissue. Evaluation may demonstrate
right upper quadrant abdominal pain, referred pain, and
possible injury to the ribs.
In a review article of EAST Practice Management
Guidelines, level II evidence recommendations for liver
trauma were su mmarized.“ Evaluation with contrast-end
hanced CT remains the gold standard for the diagnosis of
liver injuries in the stable patient without signs of peritoni-
tis. Angiography with emboliaation should be considered
when evidence of active bleeding [a contrast blush noted
in the parenchyma) is present on CT. The success rate
for nonsurgical management has been reported to be be—
tween 3294’: and moan The use of liver function tests to
determine diagnostic and treatment paradigms has been
studied?”2 Most of these studies have been small andl'or
retrospective. Therefore, no consensus exists on the use
of elevated liver enzymes to aid in the diagnosis of liver
injury, given varied results and thresholds.”
The organ injury grading system according to the
AAST criteria has been used to aid in the diagnosis and
management of liver injury.21 The system grades injury
based on the location and the extent of lesions noted on
CT. Grades III or higher include subscapular hematoma
greater than 5fl%, intraparenchymal hematoma greater
than 10%, or a laceration deeper than 3 cm. In gener-
al, the higher the grade, the more anatomic disruption
is noted. For example, grade I has minimal disruption,
The duration of hospital observation has been pro-
posed to be at least 24 hours for grades I and II and at
least 36 hours for grades III and higher?” The overall
success rate for nonsurgical management was 94%; fail-
ures were related to the development of peritonitis from
concomitant bowel injuries or hemorrhage attributed to
a source other than the liver.
Complications, reportedly low at {1% to 11%, often
present later in the clinical course as abdominal pain,
jaundice, nausea, vomiting, or biliary peritonitis.33 These
complications include bile leaks, bile peritonitis, hepatic
abscess, bilious ascites, and hemobilia.19 Intervention
with endoscopic retrograde cholangiopancreatography
{BEEP}, angiography, percutaneous drains, or lapa-
roscopy may be needed for the management of these
complications.
Current evidence does not support the need for routine,
follow—up CT before or after discharged‘h“ Follow—up CT
would be recommended if clinically indicated for hemo-
dynamic deterioration or signs of peritonitis.
Return to play also has been linked to the degree of in-
jury. For isolated liver injury involving a simple laceration
or subscapular hematoma, healing has been reported to
take 2 to 4 months. A higher grade injury may take up
to 6 months to heal.” The healing times of liver injury
were evaluated by ultrasouograpbic follow-up” {Table 3].
It was noted that healing time was faster for lacerations
than for hematomas. The authors of a 2011 study noted
that the average length of inpatient stay after isolated liver
injury was 2.2 days.“ The protocol used in that study

firthopaedic Knowledge Update: Sports Medicine 5 fl 21.115 American Academy of Orthopaedic Surgeons
 Chapter #5: Hbduminal Injuries

alluwed light activity after the secund clay. Patients were
restricted frum cuntact spurts fur 3 munths.
|lillnly limited, high-quality literature is available re—
garding activity restrictiuns and return tu play after liver
injuryfirli-d‘v“ The American Pediatric Surgical Assucia-
tiun recummends ‘nurmal’ age-apprupriate activity re—
strictiun currelated with CT staging ranging frum 3 tu 6
weeks fur stages I tu W, respectively.“ Impurtantly, this
recummendatiun uf age—apprupriate activity restrictiun
was nut an endursement fur the time required tu safely
return tu cuntact spurts. i'viust studies and review articles
that du address return tu play in cuntact spurts recum—
mend tailuring the return-tu-play decisiuns based un the
athlete's degree uf injury recuvery, the nurmalizatiun uf
liver enzymes, and readiness in terms uf physiulugic cun-
The kidney is a retruperituneal urgan, prutected by
the luwer ribs, the abduminal muscles, and the latissimus
clursi and paravertebral muscles uf the back. Mechanisms
uf injury tn the kidneys include direct bluws, punctures
frum a fractured rib, ur deceleratiun frum a high veluc-
ity, because the kidney is partially mubile. Spurts and
uther activities in which these types uf injury are seen
include bicycling, all-terrain vehicle riding, playgruund
falls, mutur vehicle racing, skatebuarding, in-line skating,
hurseback riding, gymnastics, and cuntact spurts such as
fuutball, succer, and rugby.
Pediatric patients repurtedly are mure susceptible than
adults tu kidney injury in BAT because uf the physical
differences between the kidneys uf children and thuse uf

sanssl jeajpaw :j;

ditiuning and mental fitness, with an infurmed cunsent
appruach. _
Liver Healing TimriNuted was
Table 4 uutlines the recummendatiuns fur the man-
agement uf liver injury.29 Ultrasunugraphy Per CT Stage uf Injury
Hematuma Laceratlun
Injuries tn the Kidney
In BAT, the kidney is the third must cummun urgan in-
‘T 5‘59“" {days} {days}
jured in adults and the must cummun urgan injured in I E —
children, accurding tu the pediatric literaturer" Dverall, ll 45 29
the kidney is the must cummunly injured urgan in the III we 34
genituurinary tract and cumpriscs 1.5% uf all traumas“5 IV — TB
Uf all renal injuries, 90% tu 95% are frum BAT. Must Data frum Tiberiu tin, Purtulani H, Eunigliu A, et al: Evaluatiun
injuries tu the kidneys {95% tu 93%} are mild, huwever, cf the healing time crl‘ nun-uperatlvely managed llver Injuries.
and can be treated nunsurgically.” Hepetugastruenterulugy EUDB.‘ sstselnmu-rme-

Recummendatiuns fur Managing Liver Injury

Recummendatiuns Level of Evidence
BAT patients vvhu are hemudynamically unstable ur vvhu have diffuse 1
peritunitis shuuld undergu urgent laparutumy.
BAT patients vvhu are hemudynamically stable withuut peritunitis 2
shuuld undergu IISEtIT.
The severity uf liver injury by grade, neurulugic status. age greater 2
than 55 years, andrur the presence uf uther assuciated injuries are
NOT absulute cuntrainclicatiuns fur nunsurgical management that is
hemudynamically stable.
Angiugraphy with embulizatiun shuuld be cunsidered in 2
hemudynamically stable patients with evidence uf active
extravasatiun {cuntrast blush un ET}.
Nunsurgical management shuuld be cunsidered in liver injuries unly 2
in a facility that uffers munituring, serial clinical euaminatiuns, and
urgent uperating ruum availability un standby.
BAT = blunt abcluminal trauma. |ItEl-‘ZT = cuntrast—enhanced cum putecl tumu-graphy.

Data frum Stassen HA. Elhullar l. Cheng .ID. et al: Eastern Assuclatlun fur the Surgery at Trauma: Hunuperatlve management uf blunt hepatic
injury: An Eastern Assu-ciefiun fur the Surgery uf Trauma practice management guideline. J Trauma Acute Care Sung ED123315, Suppl 4}
5285-5293.

El Elllli American Academy uf flrthupaedic Surgeuns Drthupaedic Knuwledge Update: Spurts Medicine 5
 Seeden 7’: Medical Issues
adults. The kidney is prepertienately larger in dimensien
te budy size in childheud. In children, the kidney is alsu
mere expesed because it is situated lewer in the abdemen
and is less pretected by the ribcage; alse, children have
a lewer amuunt ef perirenal fat and weaker abduminal
musculature.“ It has been neted in ene study that elder
children had a higher number ef blunt trauma injuries
during spurts than did yuunger athletes.-q This finding
stands in centrast re the expected greater number ef in—
juries in yeunger patients, accerding te anether study.“
The discrepancy may be explained by the distinctiun
between trauma caused by incidents eccurring eutside
ef spurts leg, rneter vehicle accidents, falls, penetrating
trauma} and these eccurring frem EAT in spurts. It has
= been theerised that the elder athletes played with mere
E
E speed and mass and had greater furce in cullisieus than
.E
'U did their yeunger ceunterparts.J
E
'11
Renal injury in adults is manifested by gress er mi-
ri-l
crescepic hematuria, hyputensiun, and signs uf trauma
such as abdeminal er flank pain, rib fractures and cen-
tusiens te the abdemen, flank, er ribs}? CT is erdered
if an adult presents with gruss hematuria, micrescepic
hematuria with hypetensien, and penetrating injury, with
a suspected mechanism fer renal injury. If micrescepic
hematuria witheut hyputensiun is present, ubservatiun
with frequent examinatiens and laberatery studies are
required. Pediatric patients may net be hypetensive with
renal injuries; therefure, the threshuld fer urderiug imag-
ing studies is lewer than in adults. CT is erdered fer all
pediatric patients if hematuria, defined as haying mere
than 50 red bleed cells per high—pewer field present en
urinalysis, a mechanism fer renal injury, and abdeminalir
flank symptems are present.“ Using these criteria, nu
injuries were missed en CT.“~"‘"
Centrast three-phase CT renal pretecel is helpful in
establishing the diagnusis, directing treatment, identi-
fying ether injuries, and defining the anatemy ef lacer—
atiens and devascnlarised renal parenchyma, as well as
urinary extravasatiun er retreperiteneal bleeding.“ The
AAST ergan grading systemi't1 cerrelates CT findings {the
extent and grade ef kidney injury} with the treatment
recemmeudatiuus.“
lGrade I injuries include centusiens er subcapsular he-
matema that are nenexpanding, with ne parenchymal
laceratien. |Grade II injuries are classified as a nenexpandu
ing perirenal hematema cenfined re the retreperiteneum
er a laceratien less than LID cm ef the depth uf the renal
certex, witheut urinary extravasatien. A grade III injury
is a laceratien less than 1.0 cm ef the parenchymal depth
ef the renal certex net inyulying the cellecting system
and witheut urinary extravasatien. A grade IV injury is
a parenchymal laceratien extending threugh the renal
firthupaedic Knuwledge Update: Spurts Medicine 5
certex, the medulla, and the cellecting system er the main
renal artery, ur a vein injury with centained hemurrhage.
A grade ‘4' injury is a cempletely shattered kidney er an
avnlsien ef the renal hilum, with asseciated devascular-
isatiun uf the kidney}1
Neusurgical management initially censists ef bed rest
with clese ebservatien and frequent serial examinatiens,
urinalysis, and hematucrits. As gruss hematuria clears,
light activity is permitted. Must kidney injuries are grades
I and II and respend te nensurgical management. Many
grade 111 injuries alsu are treated with nensurgical man-
agementdfld'i Debate exists regarding the eptimal treat.
ment uf grade IV injury but treatment eften starts with
nensurgical management, with censideratien fer diag-
nestic angiegraphy fer renal embelisatien. Indicatiens
fur laparutumy include hemudynamic instability, ether
asseciated abdeminal injuries, an expanding er pulsatile
perirenal hematema er mass, renal pelvis injury, and
grade ‘1." injuries.”"‘3
Return te play depends en the grade ef injury and the
reselutien ef micrescepic hematuria, with miner injuries
taking 2 tu a weeks and majur injury taking ti tu 12
menths.‘Ll Renal injuries in the Natienal Feetball League
ever 14 years were reviewed and it was neted that cen-
tusiens were the must cummuu injuries and that injuries
eccurred 1i] times mere eften in games than in practice.‘H
Ne reperted less ef kidney functiun and ne reinjury ef
the kidneys eccurred after resumptiun uf play. Return
te play was reperted as eccurring 2 re a weeks frem the
date uf must centusiens, with laceratiens taking 3 weeks.
Mere severe injuries were reimaged.
Table 5 eutlines the recummendatiens fer the man-
agement ef kidney injury.”
Athletes With a Selitary Kidney
Recummendatiens exist fur alluwing athletes with a sul-
itary kidney te participate in spurts. The PPE Prepartici—
patien Physical Evaluatien Menegraph, 4th editien, gives
a qualified “yes“ fur alluwing participatiun in cuntact
spurts.” “If the athlete cheeses te play in a spert that
may place a selitary kidney at increased risk fer damage,
a full explanatiuu shuuld be given tu the athlete, his er
her parentjs} er guardianjsj, and the ceaches. The expla—
natiun shenld include the centreversial use ef available
pretectien [flak er sheckuabserbing jacket}, which has
net been preved te reduce the risk ef injury, petential
seriuus lung-term censequences ef petential injury, and
treatment ef injuries if they eccur.""'5 Studies have shewn
that must kidney injuries resulting in less eccurred as a
result uf meter vehicle accidents, pedestrian and meter
vehicle accidents, and falls. Ne kidneys were lest frem
injury during participatiun in cuntact spurts. The enly
fl lfllui American Academy uf Cirrhupaedic Surge-ens

-_
Recommendations for Managing Kidney Injury
Recom mendations“
1. Hemodynamic stability should be assessed on
admission.
2. Findings on physical examination such as
hematuria; pain, abrasions, and bruising of the
flank: fractured ribs; abdominal tenderness; and
abdominal mass or distension could indicate renal
injury.
3. Urine from a patient suspected of renal trauma
should be evaluated for hematuria by visual
examination and dipstick.
4. Patients with hematuria [gross or microscopic} and
hypotension should undergo CT.
5. CECT with delayed images is the gold standard
for diagnosis and grading of renal injuries in
hemodynamically stable patients.
5. Hemodynamically stable patients with blunt renal
trauma should be treated nonsurgically until gross
hematuria clears.
EEL'I' = contrast-en hanced CT.
" Grade of all recommendations is A.
Data from '5Ll mmerton Ill. Djakovic H. ltltrey MD. et al: Guidelines on
urological trauma. 201-! European Assodation of Urology. Available
at: httptfiurowuhcrgfguidulinefurologicaI-traumal'. Accessed July 25,
2D15.
kidneys lost to injury during sports participation occurred
in highaspeed sports such as skiing, sledding, and in-line
slcatingfl‘ld‘5
Injury to the Bladder
Bladder trauma is also uncommon in sports and has an
overall incidence of 1.6% of all BAT, with 44% having
at least one other associated intra-abdominal injury.“-"’"
This factor may explain the high mortality rate of 10%
to 12% associated with traumatic bladder injuries.43 An
estimated 2% to 11% of patients with pelvic fractures
sustain bladder injuries,” and fracture of the pelvis in-
creased the risk of bladder rupture from 1.6% to 5.?%.‘”'
Serious bladder injury in sports is infrequent, however.
In adults older than 2i] years, the emptied bladder is pro-
tected anteriorly by the pelvic ring and posteriorly by the
peritoneum and lower abdominal contents. As the bladder
fills, it rises out of the protective pelvic ring. Importantly,
in children, the bladder is located in the abdomen because
the bony pelvis is not developed, leaving children more
susceptible to injury.
The bladder can sustain three types of injuries: contu—
sion, extraperitoneal rupture, or intraperitoneal rupture.
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter #5: Abdominal Injuries
The mechanism of injury can assist in making the diag-
nosis. Typical mechanisms include rapid deceleration,
high-velocity impact, and collision, as well as penetra-
tion.” Examples of sports reported to cause bladder injury
are motor vehicle racing, horseback riding, bull riding,
high—speed alpine sports, gymnastics, martial arts, rugby,
and football.
The most common type of bladder rupture is extra-
peritoneal, with an incidence of TH% to 90%, resulting
from pelvic ring rupture that causes bony fragments to
penetrate and rupture the bladder near the anterolateral
aspect of the base of the bladder.“"if Urine then leaks into
the perivesic ular space and can even track into the thigh,
scrotum, or perineum. The next most common type of
bladder rupture is intraperitoneal, with an incidence of
sanssj jeajpaw :1
15% to 25%, in which the bladder ruptures near the
dome (the weakest part of the bladder] when distended
and exposed out of its pelvic protection.“l This type of
injury often is caused by blunt force. Here, the urine can
leak into paracolic gutters and in between loops of bow-
el. A combined intraperitoneal and extraperitoneal type
of rupture of the bladder, having an incidence of 5% to
12%, also is seen.“
Cardinal symptoms of bladder rupture include gross
hematuria, abdominal pain, and difficult or absent void-
ing. Gross hematuria is present 95% of the time, partic-
ularly if an associated pelvic fracture is present. flnly
microscopic hematuria is noted, however, 5% to 15 %
of the time.43 The clinician also may note bruises to the
abdomen, signs of trauma, and distension, as well as
swelling of the thigh, scrotum, or perineum.
The workup for bladder rupture starts with suspicion,
based on the mechanism of injury and presenting symp-
toms. According to the European Association of Urology
position statement, when signs of trauma are present,
cystography should be obtained if the following factors
are seen: {1} gross hematuria without pelvic fracture, {2}
microscopic hematuria with pelvic fracture, or [3} isolated
microscopic hematuria. The presence of gross hematuria
and signs of pelvic fracture are absolute indications for
cystography.” Cystography with CT is preferred in the
setting of other suspected trauma, for example, to visu-
aliae the kidneys and ureters.
Treatment is based on the location and type of injury as
well as concomitant injuries. Most uncomplicated extra-
peritoneal ruptures may be treated nonsurgically with a
catheter and antibiotics. llCliften, when open reduction and
internal fixation is done for the pelvic ring, surgical repair
of the bladder is performed to prevent further contamina-
tion of the surgical site. Also, if the neck of the bladder is
ruptured, surgical repair often is indicated. Intraperitoneal
ruptures are treated with surgical exploration and repair.
Drthopoedic Knowledge Update: Sports Medicine 5
 Section 7’: Medical Issues
Although often unreported, bladder contusions are
probably more common if no sustained hematuria is pres-
ent. Most bladder contusions are self—limiting, and require
a diagnosis of exclusion. The injury represents a partial
tear of the bladder mucosa. The mechanism of injury is a
flaccid bladder reverberating on itself. A presentation of
atraumatic hematuria warrants evaluation for other causes
of hematuria such as infection, medication, nephrolithi-
asis, malignancy, sickle cell disease, and rhabdomyolysis.
The presence of microtraumatic bladder contusions should
be noted. In this setting, the trauma is repetitive and re-
portedly mild. An example would be distance running, in
which the empty bladder reverberates against itself. The
result can be asymptomatic hematu ria, and after exclusion
n of other causes, the treatment is rest and hydration until
A" the resolution of the hematuriafiiifl A partially filled blad-
E
.E
'U der can help mitigate this potential seguela of repetitive
'11
E microtrauma causing asymptomatic hematuria.
r: Ho published guidelines exist for return to play after
bladder rupture. Therefore, as for other BAT to intra-ab-
dominal organs, the clinician should wait until the ath-
lete is asymptomatic and physically and mentally ready
to resume graded return—to—play activities. Ideally, this
progression would be managed with the consultation of
an appropriate urologic specialist. The EAST recommen-
dations for the treatment of bladder injuries state that
nonsurgical treatment of blunt extraperitoneal rupture
of the bladder has outcomes similar to those of primary
suturing, with level III evidence.51
Injury to the Ureters
Ureter injury is rare, accounting for only 1.13% to 2.5% of
urinary tract injuries. {if the injuries to the ureters, only
approximately one—third result from blunt trauma; most
are related to motor-vehicle accidents due to deceleration
forces.” When the ureters are injured, other accompany-
ing abdominal—pelvic injuries usually are present.
The mechanism of injury in BAT is deceleration, in
which the renal pelvis can be sheared from the ureter.
The diagnosis often is delayed. Hematuria may be present
only in 5fi% to 75% of patients presenting with trauma?"-
A high index of suspicion is needed to diagnose ureter
injuries. When they are suspected, CT is useful in demon-
strating the extravasation of contrast, ascites, hydrone-
phrosis, urinoma, or dilation of the ureter.43 Treatment
varies, based on the degree of injury and the associated
injuries. Stenting is useful when indicated.
No literature on return-to-play standards exist. There—
fore, the clinician should wait until the athlete is asymp-
tomatic and physically and mentally ready to resume
graded return—to—play activities, after consultation with
an appropriate specialist.
flrdiopaedic Knowledge Update: Sports lviedich'ie 5
—_
Eastern Association for the Surgery of Trauma
Guidelines for Managing Pancreatic Traurua
Recommendations for TreatmentI
Delay in Dr. or main pancreatic duct injury causes
increased morbidity.
ET is suggestive but not diagnostic of pancreatic
injury.
Amylaseflipase levels are suggestive but not
diagnostic of pancreatic injury.
Grade 1 and 2 injuries can be managed by drainage
alone.
Grade 3 injuries should be managed with resection
and drainage.
Closed suction is preferred to sump suction.
[hr = diagnosis.
‘ Level of evidence for all treatment recommendations is lil.
Data from Boirhari F, Phelan Hr Holevar M. et al: EASE Eastern
Association for the Surgery of Trauma: Pancreatic trauma. diagnosis
and management of. lflDEII. Available at: httpsailrwvvvv.east.org.f
resourcesflreatment’guidelinesi'pancreatic-n'auma-diagnosis-and-
management-of
Injury to the Pancreas
The pancreas is the fourth most commonly injured or-
gan in EAT, but its treatment presents a dilemma for
the sports medicine practitioner. High morbidity and
mortality are associated with a delay in diagnosis and
management. Also, the diagnostic workup is less proven
and clear than that for other organs. Furthermore, the
pancreas is retroperitoneal, so most signs and symptoms
of abdominal organ injury may not apply to the pancreas.
Scant good literature exists to help the clinician diagnose
and manage pancreatic injuries related to BAT. The EAST
review found no RCTs, and most studies reviewed were
small, retrospective, and without controls?3 The best
recommendations supported were of level III evidence at
best“3 {Table {-3}.
The incidence of pancreatic injury in EAT has been
reported in similar ranges for the pediatric and adult
populations, 2% to IDEA and 3% to 12%, respectively.5‘=55
lviost traumatic pancreatic injury results from penetrat-
ing trauma {such as gunshot or knife wounds] or blunt
mechanisms. As described previously, the pancreas is
retroperitoneal, and in sports, the usual mechanism of
injury is compression against the spine, commonly at the
junction between the headand the body of the pancreas.
These injuries have been reported in soccer, football,
rugby, and karate and from bicycle handlebars directly
compressing the pancreas. In children and lean adults,
fl lflld American Academy of Orthopaedic Surgeons

the pancreas may be mere espesed.” The cemplica-
tiens ef pancreatic injury are asseciated with the nrgan’s
presimity te ether structures {such as the aerta, superier
mesenteric artery, vena cava, duedenum, and bewel}.
Cemplicatiens have been reperted in 19% te 55% ef all
pancreatic injuries and include pancreatic pseudecyst,
fistula, and pancreatitis.“
The sperts medicine practitiener needs te have a high
level ef suspicien and be aware ef the mechanism ef in—
jury, because abdeminal pain and periteneal signs—if
initially present—eften will diminish ever a shert time,
usually within 6 tn 3 beers.” CT, which is helpful but net
diagnestie, is net the best mndality fer accurate staging.
Furthermere, cemmen pancreatic duct injuries can be
missed en CT.53' Additinnal studies can help diagnese
pancreatic injuries. ERCP can identify duct injuries and
he therapeutic, allewing stent placement. It is invasive,
hewever, and has a petential fer further cemplicatiens,
including iatregenic pancreatitis, gastreintestinal tract
perferatien, and hemerrhagc. Magnetic resenancc chel-
angiepancreategraphy has gained faver as a neninvasive
alternative tn ERCP, with equally geed results in identi-
fying pancreatic duct anatemy and witheut the petential
cemplicatiens ef BREE-‘5
Pancreatic enzymes have been investigated as a diag-
nestic aid. Studies pcrfermcd bcferc the EAST summary
was published were lacking in the use nf ceutrels, were
net randemised, and had lew numbers ef subjects.53
ll'3enclusiens frem these limited studies shewed that el—
evatien ef serum amylase and lipase were suggestive nf
pancreatic injury but did net pessess adequate sensitivity
er specificity te diagnese pancreatic injury.53 Additienal-
1y, when cencemitant craniefacial trauma was present,
the likeliheed ef falsely elevated salivary amylase levels
existed.”fl mere recent prespective cehert study with
seme centrels demenstrated cembined serum amylase
and lipase predicted pancreatic injury with a sensitivity
ef lflflfii: and a specificity nf 35%.” It was neted that
significant elevatien in amylase was ebserved in pancreas
and bewel injuries, whereas elevatien ef lipase shewed
specificity ef pancreatic injury with nr witheut injury
tn the bewel. These findings were time dependent, enly
being valid if measured lenger than ti heurs pestinjury.
Higher grade injuries were asseciated with higher levels
ef amylase and lipase. The cuteffs were greater than
lllfl IU fer serum amylase and greater than ZSU IU fer
serum lipase.
The classificatien ef pancreatic injuries fellews the
EAST grading system and is based en pancreatic duct
invelvement.ll Grade I and II injuries have miner te majer
centusien and miner te majer laceratien, respectively,
witheut duct invelvement er tissue less. Grade [II injury
IE! lfllli American Academy nf flrthepaedic Surgeens
Chapter #5: Abdemiual Injuries
includes distal transectien er parenchymal injury with
duct invelvement. Grade IV invelves presimal transectien
er parenchymal injury invelving the ampulla, and grade V
represents massive disruptien nf the head ef the pancreas.
Management largely is based en the suspected invelve-
ment ef the ducts, but again, few ge-ed-quality studies
exist, and censensus is lacking, especially fer grade IV tn
V injury. The infermal censensus is te treat grade I and
II injuries with nensurgical management, using clesed
drainage if necessary. In grade III injuries with duct in-
velvement, management ranges frem suturing the duct er
placing stents tn resectien. IEl'utcemes vary, and the rate ef
cemplicatiens, including fistula fermatien and abscesses,
varies, with higher rates neted fer drainage alene than
fer resectien. The management ef grade IV and higher
sanssl jeejpew :,1;
injuries remains centreversial, with peer clarity in the
literature. Resectien with drainage is used eften, as are
mere cemplicated surgical precedures such as pancreati-
ceduedenectemy (the Whipple precedurel and Rees-eu-Y
pancreaticejejunestemy.“ The surgical management ef
higher grade pancreatic injuries is beyend the scepe ef
this chapter. The cee sensus is that earlier interventien fer
higher grade injuries reduces merbidity, hewever.
Return-te-play guidelines are net discussed in the liter-
ature. Thus, return-te-play decisiens sheuld be based en
tissue healing, the nermalisatien ef symptems and labora-
tery assessment, the resnlutien ef cemplicatiens if present,
and in general, the athlete’s physical and mental readiness
te resume a stepwise increase in levels ef activity.
Gastrnintestinal Tract Injury
Traumatic injury tn the gastreintestinal tract is net cem-
men, and the literature en the subject is limited te case
reperts and cencemitant treatment ef ether ergan injuries
in BAT. Gastrnintestinal tract injury is neted in 5% tn
re ef laparetemies perfermed fer BAT. In penetrating
trauma, gastreintestinal tract injury is fairly cemmen and
is seen in 80% nf presenting cases.”
The causes ef injury include centusien, which can lead
te rupture er tears ef the bewel er viscera and mesen-
teric vessels. Several mechanisms fer injury have been
prepesed, including crushing ef the gastreintestinal tract
between the blunt ebject and the spine, as well as rapid
deceleratinn that causes shear fetces between the fitted
and mnbile gastreintestinal tract segments, which eften
is where mesenteric tears nccur, causing bleeding. Alse
described is a burst injury pattern, resulting frem the pres-
sure gradient between clesed leeps ef bewel en impact.
Sperts in which gastreintestinal tract injuries repertedly
eccur include seccer, feetball, herseback riding, high-
speed alpine sperts er meter vehicle racing, and cycling,
frem handlebar penetratinn.”
Drthepaedic Knewledge Update: Sperts Medichie S
 Section 7’: Medical Issues
Presenting symptoms can be unreliable and may in-
clude signs of peritonitis, abdominal pain, and emesis.
ten, symptoms are absent or delayed until leakage
occurs, causing peritoneal irritation or hemodynamic
compromise. Maintaining clinical suspicion for gastro-
intestinal tract injury is important, based on the mech—
anisms described.” Laparotomies performed solely on
clinical symptoms were reported to have false-negative
rates of 4111986.” Close observation, serial examinations,
and the monitoring of hemodynamic status are essential.56
In the hemodynamically stable patient, FAST examina-
tions may show hemoperitoneum or pneumoperitoneum,
leading to laparotomy. CT with contrast is recommended
if clinical suspicion exists, along with an applicable mecha
= anism of injury and serial examination findings. Definitive
E
E treatment involves surgical management.“5
.E
'U No recommendations for return to play exist in the
E
'11
literature. So again, in consultation with the surgeon,
I: return to play is achieved in a graded fashion when the
athlete is physically and mentally prepared.
Dlaphragmatlc Rupture
Diaphragmatic rupture occurs mainly from BAT or pen—
etrating trauma, although most studies demonstrate a
higher occurrence from penetrating trauma.5“"5“ The in-
cidence of diaphragmatic rupture ranges from 4% to
3%, with mortality, usually from associated injuries, as
high as 1% to 23%.59~5‘-fl A dearth of sports medicine
literature related to diaphragmatic rupture exists; most
articles are case reports. The mechanism of injury is rapid
deceleration, often with a caudally directed force. Sports
in which diaphragmatic rupture has been reported include
skiing, snowboarding, luge, skeleton, swimming, and
diving. |flue case report of a spontaneous, atraumatic
rupture during Pilates was presumed to result from deep-
breathing eiv.ercises.f'J
The pressure gradient between the thoracic and ab—
dominal cavities allows the contents of the abdomen to
invade the thorax after a tear. The organs most likely to
herniate are the stomach and the bowel, and most organs
do so on the left hemidiaphragm, in a 3:1 ratioi‘m'd'i2 The
liver acts as a barrier to the bowel contents on the right be-
cause of tears and herniation. Associated injuries include
fractured ribs, lung contusion and tears, and laceration
of the liver and bowel.
Diagnosis is difficult in the absence of associated in-
juries, because a diaphragmatic tear often fails to cause
blood loss or signs of peritonitis; therefore, isolated tears
may present initially as being hemodynamically stable.
Possible associated symptoms can include tachypnea,
dyspnea, chest pain, and signs of intestinal obstruction.
Bowel sounds may be heard in the left thorax more than
Drthopaedic Knowledge Update: Sports Medicine 5
in the right thorax, with decreased breath sounds in the
affected hemirhorax.“1
Radiographs may be helpful in the diagnosis, although
the sensitivity is approximately 50% on initial exam-
ination and may increase up to E1% on delayed chest
radiographs.” Useful signs on radiographs include loss of
normal hemidiaphragm contours, observation of viscus in
the hemidiaphragm, and mediastinal shift. FAST exam-
ination may identify abnormal diaphragm motility but is
not relied on for diagnosis.“ CT is helpful to identify dia-
ph ragmatic tear and often is used to better delineate other
potential injuries to organs.“ In clinically stable patients,
MRI can aid in the subtleties of diagnosis. Management
most often includes surgical exploration and repair with
nonabsorbable sutures.
No literature exists addressing the return to play after
diaphragmatic rupture. The sports medicine practitioner
should apply the same approach as that used for other
organs for return to play when no guidelines are available.
5 u m m a ry
Abdominal trauma, although rare, is still associated with
a substantial risk of morbidity and mortality. The sports
medicine practitioner should be aware of the mechanism
of injury and, when a high level of suspicion for abdom—
inal trauma exists, should refer the patient to an appro-
priate facility for observation, workup, and management,
as indicated. Although ultrasonography should still be
part of the diagnostic workup, in a hemodynamically
stable patient contrast—enhanced CT is the preferred study.
Nonsurgical management is successful in most mild to
moderate grade injuries. In these cases, little need for
follow-up CT exists, especially for the determination
of readiness for return to activity. Poor evidence exists
from randomized controlled studies regarding the time
of observation, return to activity, and return to play, and
additional studies are needed. Finally, return-to-play de-
cisions should be made when the athlete is asymptomatic,
with informed consent regarding the risk of reinjury.
Assessment of the physical and mental readiness of the
athlete is of paramount importance.
fl lfllfi American Academy of Orthopaedic Surgeons

- 4. Walter KD: Radingraphic evaluatien nf the patient with
Key 5;d Pnlnts
' Athletes suspected nf having abdetninal injuries
pfteu based fl"_kHDWInE Df the mechanlsrn ”f 1n-
lurr shvuld be Immediatflls rammed frflm Play and
evaluated fer blunt abdemiual trauma. Signs and
symptnrns, if present, nften have a delayed unset.
In children, the kidney and bladder efteu are injured
- -
Iunre cnnunnuly than 1n adults.
The imaging study ef cheice fer the hemedyuami-
cally stable athlete is a CT scan with centrast. FAST
eltamiuatinus are helpful in the hemndynamically
5'53b afljlf‘tfl ’“ ma“? “if? “3 Wild lapam‘iflmms'
Nnnsurg1cal management 1s typ1cally the treatment
of chnice fer must blunt abdnminal injuries in a
hemndyuamically stable patient. Evaluatinn and
treatment fer blunt abdnminal trauma shnuld be
in a facility with capabilities f0: CT scanning, an-
' h d t'
gilngrapi Y: surgery an cnn 1nunus mnn1 nrlng nn
ernan ‘
Blunt abdnminal trauma involving the pancreas
peses a dilemma: high merbidity and mertality with
nu gen-ed means nf evaluatinu {CT scan, labnratnry
[seagull-g:r and Physical Eflmjnatifin findings are nut
diagnestic}
' _ _
Return-tn-play (1313510113, altheugh thEI'E 15 11'” cnn-
sensus, are based en the lecatien and extent ef in-
jury, and repeat CT scans are net recnutuiended for
1 t d - 1 _
m“ h "11' ab ”mm [mm
Annutated References
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scheel spurts-related injury surveillance study 201 2-2fl13.
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www.ucdenver.edur'acadeniicsfcnllegesfPublicHealth!
researchr’ResearchPrejectsfpipen'prejectsIDIDecu-
mentsflflll-flpdf. Accessed e11 july 25, 2015.
This surveillance repert by high scheel athletic trainers
is the must recent published data cnllectinn nf the high
scheel spans—related injury surveillance system, with an
euliue reperting system. Level ef evidence: III.
2. Bergqvist D, Hedclin H, Karlssen G, Lindblad E, Mitrsch
T: Abdeminal trauma during thirty years: Analysis ef a
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3. Wan J, Cnrvinn TF, |lEreenlield 5P, DiScala C: Kidney and
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the uatienal pediatric trauma registry. j Ural 1003;1?fl{4
r: muses-153:1, discussieu 1531-1532. Medline net
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spurt-related abdemiual trauma. Carr Sperts Med Rep
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5- bfflfibidflg.hHflE§Eflli-i Kgfihizfik? Ks Et 9:: Sppwbparding
- *
IHin r}, 1999,3flj1}:4?—49.
lflllll'lflfi- ID I' E- H.
lliilllIl'l'lffl'l:
MH"inE Dfll
nmparlscrn “qt 5 llflE HIJIIEIIEE.
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{mm 51“ and EHDWbflflrdmg fl‘ifilfiifi'fltfi- Em”? ME"! AHE-
traias 2Dfl5:1?[2j:15?—162. Medlme DD]
s. Eallautyue u, Ling a, Faainnis a, Hnebntham aw: The
current rule of fecused assessment with Seuegraphy fer -.1
Efflumfl lFHSTl in this EVEI'EVDl‘i'iflE flPPfflflEh “1 flbdflm' El
1nal trauma. UWDM} Ebll;31[1j:l{}—22. 3
This review article summarizes the diagnestic appreach tn 3
the blunt abdemiual trauma patient. Level ef evidence: V. g
't ' E
9. Steugel D, Bauwens K, Rademachet G, Eldcernkamp A,
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This Cechrane review ef trauma algerithms includes ul-
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insufficient evidence nf quality studies randcuniaed cun-
_ trnlled trials tn justify using ultrasnuud—based clinical
decisieu making. Level ef evidence: II.
10. Sag-.2:l M, Yeshii H: ReEraluatLtzlu ef ulIILrasenegraphg fer
se i -ergan injury in unt a emina trauma. I U tra-
snared Med20D4:23{12):1533-1596. Medliue
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This Cnchrane review assesses the difference between
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high-energy trauma. The autbers feund ue RU?s te sup-
pert either methed. Level ef evidence: I.
12. war 5: Sustained centractien ef the diaphragm, the mech-
anism nf a cnrntnnn type nf dyspnea and precnrdial pain.
I Clin Invest 194?;15lfijfllll'l. Medline
13 . Jnhnsnn II: Abde-rninal wall injuries: Rectus abdnminis
strains, ublique strains, reetus sheath hematema. Curr
Sperts Med 113;; gupggjjgjfiyqflg, Mgdljng [10]
DUI 14. Suleiman 55 Jehnstnn DE: The abdnminal wall: ,1“, mgr.
leaked seu rce ef pain. Arr: Fam Physician lflfl1:64{3}:431-
433_ Healing
» - , - - -
15' fltgfiffigflgifljflfifffiflifigfijfifiifli
trauma. Injury 1014;45{11:146 4.50. Medliue DUI
Drtbepaedic Knuwledge Update: Sperrs lvledicbie 5 ®
 Sectien 7’: Medical Issues
This retrespective study leeks at intra—rater and inter—rater
reliability, cemparing the AAST grading system and the
Ealtimere grading system using CT fer splenic trauma.
The Ealtimere CT grading system was develeped in 101]?
and predicts the need fer angiegraphy, embeliaatien, er
surgery. Beth grading systems appear tn be equally reli-
able, but because the Baltimnre system incerperates vas-
cular injury, it may he superier in the clinical management
ef blunt splenic injuries. Lavel ef evidence: III.
15. 1llit'egner S, lI'Jelletti JE, Van Wie D: Pediatric blnnt abdem-
inal trauma. Pediatr Cffn Nnrth Am 2f] flS;SS[2}:143-256.
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1?. |Gannnn EH, Hnward T: Splenic injuries in athletes:
A review. Curr Sperts Med Rep lfllfl;9{2}:111—114.
Medline DUI
n ieatien stay befnre and after implementatien nf treatment
E This review article summarizes the current appreach te
E
splenic injuries in athletes and addresses the return-tn-play
.E
'U
cnnundrum. Level nf evidence: V.
'11
E was shnrter after implementing the guidelines. Level ef
ri-l 13. Stassen NA, Ehullar I, lIEheng JD, et a]; Eastern Asseciatinn
fer the Surgery ef Trauma: Selective neneperative man—
agement ef blunt splenic injury: An Eastern Asseciatien
fer the Surgery ef Trauma practice management guideline.
Jl Trauma Acute Care S'urgr 2fl11;?3{5, Suppl 4j5294a53flfl.
Medline DID]
The practice management guidelines cemrnittee ef the
Ea stem fisseciatien fur the Surgery ef Trauma made rec-
nmmendatiens fer the nnnsurgical treannent ef splenic
injuries based en the level ef evidence. They summarized
the areas ef peer censensus and the need fer future re-
search. Level nf evidence: III.
19. Ehangn A, Nepegediev I}, Lal N, Eewley DIM: Me-
ta-analysis nf predictive factnrs and nutcnmes fer failure
ef nen-eperative management ef blunt splenic trauma.
Injury 2fl12;43{93:13311346. Medline DUI
This systematic review with meta-analysis analyzes the
predictive factnrs and eutcemes nf the failure nf nnnsurgi-
cal management in splenic trauma. Level nf evidence: III.
If}. |[inmee D, Haas E, AI‘AII K, l'vfenneuse Cl, Nathens AB,
Ahmed bl: Centreversies in the management ef splenic
trauma. Injury 2fl12;43{1]:55-61. Medline Ell-DI
The anthers surveyed ?fl experts in trauma care frem III]
ceuntries te eitplnre the centreversies in the nnnsurgical
management nf splenic trauma including, imaging, an-
gieembeliaatien, and nensnrgical management in special
pepulatiens. Level ef evidence: IV.
21. IvIeere EE, Cegbill TH, Jnrkevich G], Malangeni MA,
Juicnvich G], Champien HR: Scaling system fer ergan
specific injuries. l[lisrr Dpiu Crit Care 1996;2:45D-462.
DflI
. {'Jlthef DC, van der Vlies CH, Jeesse P, van Delden UM,
Jurltevich GJ, Geslings JD; PYTHIP. Cellaberatien
|IGrnup: IEnnsensus strategies fer the neneperative man-
agement nf patients with blunt splenic injury: A Delphi
firthepaedic Knewledge Update: Sperts Medicine 5
study. J Trauma Acute Care Surg 2013;?4116]:156?-1 5?4.
Medline DUI
This is a study using the Delphi methed ef pelling experts
in their field, in this case, blunt splenic trauma. This study
netes the censensus ef appreach and dees net su mmariee
randemiaed centrelled studies. The anthers did nete that,
ameng practitieners, a lack ef censensus remains regard-
ing the time te return te play, with reeemmendatiens
ranging frem 4 weeks te 3 menths, depending en the
grade ef injury and activity status. Level ef evidence: IV.
2.3. Lee HS, Ryan M, Markert R], Elteh AP, McCarthy MC:
Impact nf splenic injury guidelines en hespital stay and
charges in patients with iselated splenic injury. Surgery
lflflflgl4dl4j:?fl?-?91, diseussien Fill—F93. Medline DUI
This retrespective study cempares the cest and hespital-
guidelines fnr nensurgical management in splenic injury.
The anthers fennd ne cest difference but did find a sub—
stantial difference in the length ef hespital stay, which
evidence: III.
24. Sharma DP, C'swanslti MF, Singer D: Rule ef repeat cem-
puterieed temegraphy in neneperative management ef sel-
id ergan trauma. Am Surg 1005:?1l3lfl44-249. Medline
2.5. Juyia RF, Kerr He: Return te play after liver and spleen
trauma. Sperts Health 3fl14;6{3]:2 39-245. Medline DUI
This article reviews the literature nn return te play after
liver and spleen injuries {grade C recnmmendatinns]. Level
ef evidence: III.
16. Lynch JM, Mesa MP, Newman E, Gardner M], Alba-
nesc ET: Eemputcd temegraphy grade ef splenic injury
is predictive ef the time required fer radiegraphic healing.
,7 Pediatr Surg 199T;32{Tj:1093-1fl95, diseussien 1fl95-
11196. Medline DUI
1?. Zaraaur EL, 1|Ill'ashi S, Magnetti L], Crnce MA, Fabian
TC: The real rislt ef splenectemy after discharge heme fel-
lewing neneperative management ef blunt splenic injury.
I Trauma 20fl9;56{5}:1531-1535, diseussien 1536-1533.
Medline DUI
This prespective cehert study leeks at the number ef
blunt splenic trauma patients whe were readmitted after
being treated nensurgically and discharged heme. The
anthers fnund that 3.5% ef these readmitted within 13f}
days [1.4% ef the tetal discharged heme} had nudergene
splenectemy. [if interest, 64% were readmitted within 1
week nf discharge. Level nf evidence: III.
23. HnImes JF, Snknleve PE, Era nt WE, et al: Identificatinn nf
children with intra—abdnminal injuries after blunt trauma.
Ann Emerg Med lflfl2539{5]:50l}—5fl9. Medline DUI
19. Stassen NA, Bhnllar 1, Cheng JD, et al: Eastern Asseei—
atien fer the Surgery ef Trauma: Neneperative manage-
ment nf blunt hepatic injury: An Eastern Asseciatien fer
the Surgery nf Trauma practice management guideline.
fl lfllfi American Academy ef Cirrhnpaedic Surge-ens

_,I Trauma Acute Care Sarg lflllfflifi, Suppl {6133-5293.
Mcdline DUI
The practice management guidelines enmmittee fur the
Eastern Assnciatinn fur the Surgery at Trauma made
recnmmendatinns fer the nnnsurgical treatment nf liver
injuries based en the level nf evidence. The areas nf pnnr
ennsensus were summarized and the need far future re-
search was discussed. Level nf evidence: II.
3G. Karam U, La Seals G, Le Cnultre C, |Uhardnt C: Liver
functinn tests in children with blunt abdnminal traumas.
Ear } Pediatr Sarg EUGEIHE1:313-316. Medlinc DUI
31. Puranilt SR, Hayes ]5, Lung J, l'vlata M: Liver enzymes
as predictnrs nf liver damage due tn blunt abdnminal
trauma in children. Snail: Med I 2fl02:95{2}:ED3-106.
Medline DUI
32. Tian Z, Liu H, 5n K, et al: Rule nf elevated liver trans-
aminase levels in the diagnnsis nf liver injury after blunt
abdnminal trauma. Exp Ther Med 2fl11;4{21:255-260.
Medline
This retrnspeetive study evaluates using liver enaymes tn
predict the presence and severity nf liver injury. Level nf
evidence: III.
33. Parks NA, Davis JW, Ferman D, Lemaster D: Ubserva-
tinn fer unnnperative management nf blunt liver injuries:
Hnw lung is lung ennughi' J Traarrra 2011:?fli3jmlfi-629.
Medline DUI
This retrnspective review nf trauma patients with blunt
liver injuries leaks at the length nf nbservatinn. Level nf
evidence: III.
34. Stylianns S: The APSA Trauma Unmmittee: Evidence—based
guidelines fnr resnuree utilisatinn in children with isnlated
spleen nr liver injury. J Pediatr Sarg lflfi0;35{2]:164-IE?,
discussinn 161169. Medline DUI
3.5. Tiberin GA, Pnrtnlani N, Cnniglin A, et al: Evaluatinn
cf the healing time nf nnn-nperatively managed liver in-
juries. Hepatngastrneraerningy lflflfl:55[34}:1flIfl-IDIE.
Medliue
36. van der Vlies CH, Ulthnf DC, van Delden UM, et al: Man-
agement nf blunt renal injury in a level I trauma centre in
view cf the Eurnpean guidelines. Iafary 1fl12;43{11}:1316-
1820. Medline DUI
This is a retrnspeetive review nf the management nf renal
trauma patients ever 4 years. Level nf evidence: III.
3?. 1ni'inla TA: IElnsed kidney injury. Clair: Spurts Med
2fl13;32{2}:119-221Medline DUI
This is a review article nf ltidney trauma. Level nf
evidence: V.
33. Brawn CK, Dunn EA, Wilsnn K: Diagnnstic evaluatinn of
patients with blunt abdominal trauma: A decisinn analysis.
Acad Emerg Med 2&00:?[4]:3 35-39E. Medline DUI
IE! lfllfi American Academy nf Urthnpaeelie Surgenns
Chapter 45: Abdnminal Injuries
39. Bernard J]: Renal trauma: Evaluatinn, management, and
return tn play. Earr Spares Med Rep EflflflfijljflfivIUC-i.
Medline DUI
This review article assessed at renal injuries and cnndi-
tinns, frnrn micrnscnpic hematuria tn blunt trauma. Level
nf evidence: V.
4D. tnes FE, Hunt j], Sevier TL: Renal injury in spurt.
Carr Sparts Med Rep lflfl3glilj:103-Ifl9.Medline DUI
41. Santucci BA, McAninch JW, Safir l'vi, Marin LA, Service
5, Segal MR: Validatinn nf the American Assneiatinn fer
the Surgery at Trauma nrgan injury severity scale fur the
kidney. } Trauma lflfll:5fl{lj:195—Eflfl. Medline D'UI
42. Nicnla R, l'v'lenias CU, Mellnick V, Bhalla S, Raptis C, Sie-
gel C: Spnrts—related genitnurinary trauma in the male ath-
sanssl jeajpaw :,1;
lete. Emerg Radini 2fl15;22{2]:15?v163. Medline DUI
This review article discusses male genitnurinary trauma.
Level nf evidence: V.
43. Summertnn D], Dja knvie N, Kitrey ND, et a1: Guidelines
nn urnlngical trauma. 2fl14 {update an 2i}13 published
guidelines}. Eurnpean Assnciatinn nf Urnlngy. Available at:
http:durnweb.nrgiguidelinei'urnlngical—traumai. Accessed
July 25, 2015.
These updated guidelines, published nnline, summarize
the literature and recc-mmend an evidence-based apptnach
tn managing urnlngic trauma. Level nI evidence: III.
Brnphy RH, lGamradt 5C, Barnes RP, et al: Kidney inju—
ries in prnfessinnal American fnntball: Implicatinns fur
management at an athlete with I functinuing kidney. Arr:
J Spurts Med asssasmes—su. Medline nnt
45. Bernhardt D, Rnberts WU, eds: PPE Prepartt'ct'patinrt
Physical Eaaiaatinrr ,ed 4. Elle Grave 1|v'illage, IL, Ameri-
can Aeademy nf Pediatrics, May 2010. httpsdi'wwwaap.
nrgi'en-uslabnut-the-aapfflnmmittees-Cnuncils-Sectinnsi'
CUlll'lflll-UI'I-SFDIIIE--[l'l'E!EllElflE-EIflEl-fitflESSIDUCUDIEflTSdPPE-
4-fnrms.pdf
46. jnhnsnn B, Christensen '3, Dirussn 5, Chnudhury M, Fran-
ce 1: A need fur reevaluatinn nf spnrts participatinn rec-
nmmendatinns fnr children with a snlitary kidney. ] Ural
2flfl5;1?4{2j:635-639, discussinn 539. Medline DUI
4?. Games: RU, Ceballns L, Cnburn M, et al: Cnnsensus
statement nu bladder injuries. BjU Lat 2Bfl4;94{1}:2?—
32. Mcdline DUI
4B. McGeadyJB, Breyer EN: Current epideminlngy nf genita-
urinary trauma. Urni Elie Marti: Arr: 2DI3:4G[3}:323-334.
Medline DUI
This review article summarizes the majnr injuries tn the
genitnurinary system. Level nf evidence: V.
49. IIEuttmann I, Kerr HA: Blunt bladder injury. Elias Spurts
Med lfl]3;32{'2]:139-146. Medline DUI
Urthnpaedie Knuwledge Update: Spnrts Medicine 5
 Seeders 1': Medical Issues
This article reviews the literature and summarizes the
pathuphysiulugy, diagnusis, and management uf cammun
bladder injuries. Level crf evidence: 1.".
Si}. Bryan ST, Culeman NJ, Blueitt D, Kilmer NI: Bladder
prublerns in athletes. Curr Sports Med Rep lflfl S:?{2}:1fl3-
112. Medline DUI
.51. Hulevar M, Ebert J, Luchette F, et a1: Genituurinary
trauma, management cf. Management guidelines fur
the management uf genitcrurinary trauma, the EAST
Practice Management Guidelines Wurk Gruup. Pub-
lished EDITH; east.nrg. Available at: https:!.l'www.
east.crrg.r‘educatinnipractice-management-guidelines.Ir
genitnurinary-trauma-management—uf
51. Erandes S, |IEnburn M, Armenaltas N, McAninch J:
= Diagnusis and management cf ureteric injury: An evi-
E dence-based analysis. BjU int lflfl4594{3}l:2??—239.
E
Medline DUI
.E
'U
'11
E 53. Enkhari F, Phelan H, Hulevar M, et a1: EAST, Eastern
ri-l
Assnciatien fur the Surgery of Trauma: Pancreatic trauma,
diagnusis and management uf. Published 2111119 Available
at: httpsn'i'www.east.c-rg.iresnurcesil'treatment-guidelinesIr
pancreatic-trauma-cliagnusis-and-management'uf Ac-
cessed an July 2.5, 11115.
These management guidelines accumpany a review and
summary cf the literature, pruviding evidenced-based
recnmmendatinns fer the recngnitinn and management
uf pancreatic injury from trauma. Level cf evidence: III.
54. Haugaard MY, 1|ifli'ettergren A, Hillingsa JG, Gluud C,
Penninga L: Nun-uperative versus uperative treatment fur
blunt pancreatic trauma in children. Cashmere Database
Syst ReeI 2D14;2{Nu CDDDST4E]:CDflfl9T4E. Medline
This Cnchrane review cnmpares nunsurgical manage—
ment with the surgical treatment af pancreatic injuries
frnm trauma. Summaries in the literature are net based
an RCTs. Level uf evidence: II.
55. Echlin PS, Klein WE: Pancreatic injury in the athlete. Curr
Sparta Med Rep 2fl05;4{2}:96-1fll. Medline DUI
.56. Mahajan A, Kadavigere R, Sripathi S, Rndrigues GS, Eat}
V11, Keteshwar P: Utility nf serum pancreatic enzyme levels
in diagnusing blunt trauma tn the pancreas: A pruspective
@ firthnpaedic Knuwledge Update: Sparta Medicine 5
study with systematic review. injury 2fl14:45{9}:1334-
1393. Medline DUI
This pruspective cc-hcrrt study lnulcs at the AAST CT grad-
ing nf injury, nltrasnnugraphy, and pancreatic enzymes.
The authcrrs alsu systematically reviewed the literature
fnr cemparisnns tn their findings. Level nf evidence: III.
5?. Hughes TM, Eltnn C: The pathnphysinlngy and manage-
ment of b-awel and mesenteric injuries clue tu blunt trau-
ma. Irrjnry 10fl2;33{4}:295-3fl2. Medline http:fi'dir.dni.
erg!111.101EfSflDlfl-lSSSiflflflflflfi-fl Medline
53. Gelman R, Mirvis SE, Gens D: Diaphragmatic rupture
due tn blunt trauma: Sensitivity nf plain chest radiugraphs.
AJE Am J Rncntgennl' 1991:156i1}:51-5T. Medline [ll-DI
59. Hanna WC, Perri LE, Fara P, Razelc T, Mulder DS: The
current status uf traumatic diaphragmatic injury: Lessuns
learned item 105 patients ever 13 years. Ann Thurac 5mg
lDflE;35[3}:1fl44-lfl43.Mctlline DUI
ED. fllcada M, Adachi H, Kamesahi M, et a1: Traumatic
diaphragmatic injury: Experience frcm a tertiary emer-
gency medical center. Gen Theme Cardintrase Surg
1fl12;6i}{1fl}:649-554.Medline DUI
This retruspective lucrlc at traumatic diaphragm injuries
ever 12 years identifies the facturs affecting mentality and
mcrhidity. Lewl nf evidence: III.
61. Shehata SM, Shabaan BS: Diaphragmatic injuries in
children after blunt abduminal trauma. J Pediatr Stir-g
lflflfi;41{1fl}:1?2?—1731.Medline DUI
62. Simpsun J, Lube DH, Shah AB, Ruwlands B]: Traumatic
diaphragmatic rupture: Assuciated injuries and uutccrme.
Ann R Cull Snrg Eng! lflflflgflliliflilflfl. Medline
63. Yang “I'M, Tang HE, Park J5, Kim H, Lee 5111’, Kim JH:
Spnntanenus diaphragmatic rupture cumplicated with
perfuratinn cf the stomach during Pilates. Am J Emerg
Med 2G1fl:23[2}:159.e1—159.e3. Medline [101
This article presents a case repurt cf a unique presenta-
tinn cf diaphragmatic rupture with-nut trauma. Level cf
evidence: 1.".
64. Hchimi A, Szapirn D, Ghaye B, et al: Helical {3T nf
blunt diaphragmatic rupture. AJR Am J Ruentgerrui
lflfl55134{1}:24-30.Medline DUI
fl 211115 American Academy at Urrhnpaedic Surge-ans
Chapter 46
Heat Illness and Hydration
Alexander E. Ebinger, MD
Abstract
Heat illness is a frequently encountered disease state
in athletes. The sports clinician should understand the
diagnosis, recognition, and treatment of the spectrum
of pathologies related to this condition.
Keywords: heat illness: heatstro'lre: hydration:
hyponatrernia
Introduction
Exertional heat-related illness {EHRI} is a frequently
encountered but preventable issue. It remains, howev-
er, one of the leading causes of death in athletes every
year}: EHRI refers to a spectrum of disease states. Most
commonly encountered in American football, the risk
of heat illness is present for athletes across a variety of
sports, especially for those exercising in warm, humid
climates and in events with a prolonged length of par—
ticipation. This risk also extends to nonathletes, notably
those with jobs requiring strenuous exertion, including
military personnel, firefighters, and outdoor laborers.
It is important for the clinician to comprehend how the
body's thermoregulatory system responds to the effects of
exercise. This understanding will enable the physician to
provide recommendations about ways to recognize, treat,
and prevent heat-related illness. This chapter discusses
the clinical presentation and pathophysiology of the con—
tinuum of heat illness, the implications for performance,
and the recommendations for treatment and prevention.
Neither Dc Ehinper nor any immediate family member
has received anything of value from or has stoclr or stoclr
options held in a commercial company orinstitution related
directly or indirectly to the subject of this chapter.
fl lflld American Academy of Drtbopaedic Surgeons
Background and Epidemiology
The incidence of heat illness is likely underreported. Es—
timating from data collected between lflflj and 10ml,
high school athletes had exertional heat illness at a rate
of 1.2 to 1.6 occurrences per lflflfiflfl athlete-exposures.3
sanssl leagpaw :,1;
This report likely underreported the true incidence of heat
illness, because only participants losing at least 1 day of
activity were included. Heatstrolce is among the leading
causes of death among high school athletes.2 American
football maintains the highest rate of heat illness and in-
jury with a rate 10 to 11 times more frequent than that
of other sports.“ August is the peak time of year for ex-
ertional heat iniury because of the initiation of practices
in hot, humid conditions in unacclimatixed individuals.j
Among high school football players, the highest rates
occurred in offensive linemen, defensive linemen, and
linebackers.‘l Since 1995, 51 football players have died
from exertional heatstrokefi In .1011 alone, five cases
of heatstroke death occurred in high school athletes. In
2012 and EMS combined, only one death attributed to
heatstroke was reported."- Despite the association with
hot weather conditions, heat illness also can occur in
cool climates and even has been reported in swimmersfii'f
Pathophysiology
Exercising muscles generate increased metabolic energy.
This increased energy production creates excess heat,
which must be transferred to the environment to maintain
normothermia, defined as a body temperature of S?"C.
The preoptic nucleus of the hypothalamus regulates body
temperature, with a range of SFC plus or minus 1‘13.
1llli'hen body temperature exceeds the preferred threshold,
the body works to dissipate heat by one of four mecha-
nisms: evaporation, conduction, convection, or radiation.
Evaporation is the primary mechanism by which exercis-
ing athletes dissipate heat. Water vaporixes from either
the respiratory tract or the skin via sweat. Evaporation
is limited by environmental humidity, and a water vapor
pressure gradient must exist for heat to be transferred
via this method. lilli'hen relative humidity exceeds Tfi‘lii,
evaporation becomes an ineffective method for heat loss.
Drthopaedic Knowledge Update: Sports Medicine 5
 Seeders 7’: Medical Issues

Cnnductinn is the direct transfer nf heat frnm the bndy by

direct centact nf a cnlder entity. Cnnductinn is therefnre Ennveciinn

dependent nn relative temperature. If the temperature nf {Hind}

a given nbject exceeds hndy temperature, nn heat lnss via
cnnductic-n may nccur. Cenvectic-n is the transfer nf heat
tn a gas nr liquid mnving nver a hndy; it alsn depends
nn relative temperature. If the temperature nf the air nr
liquid is greater than hndy temperature, we heat lnss via
cnnvectinn may nccur. Radiatinn is heat less by eleetrn-
magnetic waves; nn direct cnntact is required.
Heat lnss requires a functinning cardinyascular system.
As bndy temperature rises, cardiac nntput rises, the va-
sndilatinn nf peripheral blnnd vessels nccurs, and blnnd
flnw tn the skin increases. These prncesses allnw cnre heat
n tn be transferred tn the periphery, where the heat can be
E
E transferred tn the external envirnnment. Many elements
.E
'U play a rnle in this prncess. Cine nf the main factnrs is
E
'11
hydratinn status. Circulating plasma vnlume is directly
ri-l
affected by hydratinn status, and individuals whn are de- lllustratien shews the fnur mechanisms nf heat
dissipatinn: radiatinn, evapnrafinn. cnnvectinn,
hydrated have a reduced circulating plasma vnlume. Sweat and cnnductinn.
generatinn and respiratnryr lnsses further cnmplicate vnl-
ume depletinn during exercise. aume depletinn reduces
strnke vnlume and cardiac nutput, inhibiting peripheral
blend flnw and, thus, heat dissipatinn. It is estimated that Medicatinns and Other Substances Assnciated
fnr every 1% at hndy mass lnst frnm dehydratinn, cnre 1"iii'ith Exercise-Related Heat Illness
hndy temperature rises fl.12"C tn H.915 “(3.3 This elevatinn
can lead tn cardinrespiratnryr cnmprnmise and neurnlngic Stimulants (amphetamines, ephedra, Ievnthyrnrtine,
methylpheniclate}
injury and is further described in the nest paragraphs.
Trained and acclimatiaed athletes experience several Antich nline rgics
physinlngic changes that help prevent heat illness. In- Antihistamines
creased plasma vnlume, an increased rate nf sweat prnduc- Cardinvascular drugs {fl-blnciters, calcium channel
tinn, increased cutanenus vasndilatinn, decreased urinary hlnckers. diuretics)
and sweat sedium cnncentratinns, reduced heart rate fur a Illegal drugs icecaine. herein. lysergic acid
set wnrklnad, and a decreased sweat-prnductinn threshnld diethylamide [LSD], phencyclidine [PCP],
are all adaptatinns that reduce the nccurrence nf heat methamphetamine}
illness.9 Additinnally, maximum sweat rates can vary by Laxatives
age, level nf physical fitness, and cnnditinning. Elite adult Alcnhnl
athletes can sweat up tn 3 t [Figure 1}. Caffeine

such as diarrhea, recent febrile illness, and sunburn alsn

Significant variability fnr heat tnlerance exists amnng
individuals because nf a cnmbinatinn nf genetic, adaptive,
and neurnendncrine factnrs. Envirnnmental stress, pnnr
baseline physical fitness, a lack nf beat acclimatiaatinn,
inapprnpriate clnthing, previnus episndes nf heat illness,
and a lack nf understanding cf heat-related illness are all
risk factnrs fnr EHRI. Annther pnssible risk factnr for
heat illness is a lack nf sleep.m Chrnnic medical prnb-
lems including nbesity, cardinvascular disease, peripheral
vascular disease, pn-nrly cnntrnlled diabetes, and hyper—
tensinn are risk factnrs fnr EHRI. Acute medical issues
may predispnse tn EHRI. Additinnally, certain medica-
tinns may predispnse tn heat illness [Table l}. Prntective
equipment such as helmets and shnulder pads as well
as restrictive clnthing can reduce the heat dissipatinn
capacity, leading tn an increase in EHRI. Furthermnre,
fnntball players may exhibit up tn dnuhle the sweat rates
nf crnss—cnuntry runners, leading tn dehydratinn.“ At
nne time, children were thnught tn be at greater risk fnr
heat illness, given their larger ratin cf hndy surface tn
mass, but recent literature has shnwn this assumptinn tn
be incnrrect.11

firthnpaedic Knnwledge Update: Spnrts Medicine 5 fl lfllfi American Academy nf Cirrhnpaedic Surge-ens

ICensideratien must be given te the envirenmental heat
stress placed an exercising athletes. The wet bulb glebe
temperature {WEST} is a measure ef envirenmental heat
stress, which takes inte acceunt ambient air temperature,
radiant heat, and percent humidity. The equaticn fer
determining WRIST is:
1illl'hiGT = {ill} dry bulb temperature + {0.2) glebe tem-
perature + {05’} wet bulb temperature
Dry bulb temperature measures the ambient air tem—
perature, glebe temperature measures the radiant heat,
and wet bulb temperature measures the relative humidity.
The greatest weight is placed en wet bulb temperature, a
reflectien ef evaperatien being the mest critical methed
ef heat dissipatien.
1l'ili'IMET is used te guide exercise participatien. The
greatest risk fer heat-related illness eccurs when the
WBGT exceeds 23°C.” Individual variatien exists de—
spite these gnidelines, and nenacclimatized individuals
may experience heat-related illness at a WEST lewer
than 23"C {Table 2}. Cenversely, cardievascula rly fit and
heat-acclimatized individuals may be able te centinue te
exercise with minimal difficulty even when the WEST
exceeds 23°C, with cautien.
Heat Illnessi’Heat Injuryv'Heatstreke
Heat illness is a spectrum ef disease, ranging frem mild
symptems such as muscle cramping te mere severe symp-
tems such as neurelegic dysfunctien, end—ergan failure,
and death. Seme centreversy exists abeut the exact classi-
ficatien ef heat illness and the effects directly attributable
te heat?“
Ameng the milder ferms ef exercise-related heat
illness are heat edema, heat rash, and exercise-related
muscle cramps. Heat edema is simply edema presenting
in dependent bedy parts during exercise. Heat rash is a
papulevesicular pruritic rash that presents with exercise.
Heat cramps are cemmen in athletes exercising in her, hu-
mid weather. Despite their asscciatien with heat, muscle
cramps eccur independent ef ambient temperature and
are peerly understand. They are theught te be related
te sweat less and dchydratien, sediurn depletien, elec-
trelyte imbalance, and muscle fatigue.”'” Predispesiug
facters include heavy sweating [werse in these with high
sweatusedium cencentratiensl, preexercise dehydratien,
insufficient sedium intake befere and during exercise, and
a lack ef acclimatizatien. Heat cramps may be preceded
by muscle fasciculatiens and may be a precurser te heat
exhaustien. Per the diagnesis ef heat cramps, the cere
temperature must remain nermal, and ne ether, mere
severe, signs may be present.
Heat syncepe is a mere serieus cenditien. Again,
IE! Ellie? American Academy ef flrthepaedic Surgeens
Chapter 45: Heat lllJIecs atld Hydratiun
centreversy exists as te whether heat syncepe, mere ap-
prepristely termed exercise-asseciated cellapse {EMS}, is
truly a heat—related illness. Heat dees net directly cause
the syncepal event, because cere bedy temperature is net
elevated, altheugh heat indirectly centributes threugh
peripheral vasedilatery effects. Athletes undergeing EAC
experience syncepe directly after finishing an event. The
pathelegic cause fer EAC is bleed peeling in the pe-
riphery via bleed vessel vasedilatien requisite fer heat
dissipatien. Skeletal muscle centractiens augment veneus
return during exercise. "When a sudden decline cf skeletal
muscle centractien eccurs, such as at the end ef a race,
an abrupt reductien in veneus return and a cencemitant
decrease in cardiac eutput eccur, leading te a syncepal
sanssl leaipaw :y;
event. Heat syncepe is net asseciated with an increase in
cere temperature and dees net preduce persistent neure-
legic deficits after measures are taken In impreve veneus
return lie, laying the athlete flat and elevating the legs}.
Physicians must be careful te distinguish EAC frem ether
causes ef neurelegic dysfunctien such as heatstreke er
hypenatremia. This distinctien requires a careful eval-
uatien ef the circumstances surreunding the cellapse,
an adequate physical examinatien, and petentially, an
evaluatien ef cere bedy temperature and a measurement
cf serum sedium. Additienally, censideratieu must be
given te ether etielegies ef syncepe such as arrhythmia er
underlying heart disease, particularly in elder individuals.
Any syncepal event that is net asseciated with a sudden
reductien in exercise intensity needs te be carefully ex-
amined fer alternative causes ef cellapse.
Heat cxhaustien is the presence ef extreme weakness
witheut neurelegic dysfunctien. Sheuld any cenfusien be
present, it is very transient. Athletes eften demenstrate
tachycardia and prefuse sweating. Additienal symptems
may include headache, cramps, nausea, vemiting, and di-
arrhea. An elevatien in cere temperature may eccur, but it
is less than 4U°C {1fl4“F), which is the key differentiatien
peint between heat cxhaustien and heatstreke. The skin
may he ceel and clammy, and eccasienally, hypemnsien
may be present.
Exertienal heatstreke (EH5) manifests as a mnltisys-
tem dysfu nctien, including the presence cf central nerveus
system dysfunctien such as cenfusien, headache, an al-
tered level ef censcieusness, seizure, er unrespensiveness.
This dysfunctien is the result ef central nerveus system
damage at the cellular level. In additien te neurelegic
dysfunctien, a cere temperature greater than 4D°C must
be present te establish the diagnesis. Athletes are eften
tachycardic and hypetensive and have many ether ever-
lspping features such as nausea, vemiting, weakness,
dizziness, and dchydratien. Histerically, the absence ef
sweating was pathegnemenic for heatstreke; hewever,
Drthepaedic Knewledge Update: Sperts Medichie 5
 Section 7’: Medical Issues

"Wet Bulb Globe Temperature Levels for the Modification or Cancellation

of Athletic Workouts or Competition in Healthy Adults
WBGT [“F] WBET {“C} Continuous Activ and Training and Nonconfinuous Training and
lEorrIp-etltlon Actlvlty for Nonacclimatlzed. Honcontinuous
Unfit, High-Risk lndivid uals' Activity for
Acclimatixed. Fit.
Low-Risk Individuals”
55M} 51M] Generally safe; Normal activity Normal activity
exertional heatstroke
can occur associated
with individual factors
5fl.1—55.D 1o.1-1a.s Generally safe; Normal activity Normal activity
= exertional heatstroke
E can occur
651-1111! 18.4-22.2 Risk of exertional Increase restivvork ratio; monitor Normal activity
E

.E
'U
'11 heatstroke and other fluid intake
E heat illness begins
ri-l
to rise; high-risk
individuals should
be monitored or not
compete
F2.1-?3.I'J 22.3-25.5 Risk for all competitors Increase restiwork ratio and Normal activity;
is increased decrease total duration of monitor fluid intake
activity
13.1-32.0 253-213 Ftisk for unfit. Increase restfwork ratio; decrease Normal activity;
nonacclimatized intensity and total duration of monitor fluid intake
individuals is high activity
32.1 -BE.IJ 21.5-30.2 Cancel level for Increase restiwork ratio to 1:1. Plan intense or
exertional heatstroke decrease intensity and total prolonged exercise
risk duration of activity; limit with discretion‘;
intense exercise; watch at-risk watch at-risk
individuals carefully individuals carefully
36.1 -5fl.fl Sill-32.2 HA Cancel or stop practice and Limit intense exercise‘
competition and total daily
exposure to heat
and humidity; watch
for early signs and
symptoms
29M #323 NA Cancel exercise Cancel exercise,
uncompensable
heat stress“I exists
for all athletesE
WEET - wet hulh globe temperature; NA - not applicable.

' While wearing shorts. a T-shlrt. socks. and sneakers.

“ Acclimatized to training in the heat for at least 3 weeks-

'5 Differences in local climate and individual heat acclimatization status may allow activity at higher levels than outlined in the table, but athletes
and coaches should consult with sports medicine staff and should be cautious when exceeding these llm its.

" Internal heat production exceeds heat loss. and core body temperature rises continuously. without a plateau. Adapted from Joy 5M: Heat and
Hydration, in flihler WE, ed: flrtflopaecfic Knowledge Update Sports Medicine, ed 4. Basement, IL, American Academy of Drthopaedic Surgeons,
IDES. P 353.

Data from Easa DJ. Armstrong LE: Exertional heatstroke: A medical emergency. in Armstrong LE. ed; Exertlonal Heat illness. Champaign. IL.
Human Itinen'cs, 1M5, pp 26-55.

firthopaedic Knowledge Update: Sports lvledicine 5 fl lflld American Academy of Orthopaedic Surgeons
 Chapter 45: Heat Illness and Hydration

Spectrum of Heat Illness

Symptulna: Symptoms:
Painful crampingfpm I'itic Presyneupal vs syncope]
rash. event. :4
Physical examination: Physical examination: g
Tense muscle.If 1|uFaIies depending on cause. %
pepuiovesiouler rash. Ho persistent neurological “—'
Truman“ deficits should be present E
Depends on clinical with improved venous rein m- a
Etruscan, Consider It confusion persists,
waning", tempumry consider other more
removal from spurt until serious “W535 [if EMPE-
symptoms improve. Treatment:
Removal from play,
rehydration dependng on
cause: an saline, Advanced Cardiovacular Lite Support.

Heat exhaustion Heetstrolce

symptoms:
Extrema weakness without
neurologic dysfunction, headache,
nausea, cramps, vumiiing. If any
confusion, must be h'ansient.
Physical examination:
hlu persistent altered mental
status. May be tachycardic
Temp "i mil:-
Treatment:
Fiamove from play. Hydrate-
Continued reevaluation.
Symptoms:
Buniusion, altered mental
status, seizure, unresponsive.
Physical examination:
Tachycardic, “mgn§w_
Temp ::- INT. 1 sweating.
Treatment:
Aggressive cooling, emergency mecical service;
transport to emergency department. Intravenous fluids.

Illustration shows the spectrum of heat illness.

sweating may be present and does not exclude heatstroke.
Unrecognized or untreated EHS may progress to multisys-
tem organ failure, cardiac arrhythmia, acute respiratory
distress syndrome, disseminated intravascular coagula-
lion, and ultimately, death {Figure 2}.
M an ag ame nt flf H eat—Related ||| “9555.5
Recognition of EH5 is of paramount importance. Eval-
nation begins following BLSIACLS {Basic Life Support!
Advanced Cardiac Life Support] protocol, with airway,
breathing, and circulation assessment: followed by an as-
sessment of neurologic function. Measurement of the core

ID lfllii American Academy of flrthopsedic Surgeons Drrhopaedic Knowledge Update: Sports Medicine 5 ®
 Sectinn 7’: Medical Issues
temperature and serum sndium are alsn key in diagnnsis
and illness severity stratificatinn. If the temperature is
elevated, especially if it is greater than 413°C, immediate
and aggressive cnnling must be instituted. Emergency
medical services {EMS} shnuld be activated. If symptnms
are attributable tn a certain diagnosis nf heatstrnkc, im—
mediate cnnling shnuld be perfnrmed before transpnrt. If
the diagnnsis is uncertain, the temperature is nnt elevated,
nr severe hypnnatremia is nnt present, the patient shnuld
be transpnrted immediately tn the nearest emergency
department. Remnva] frnm the heat is impnrtant, alnng
with ittunediate clearance nf all items preventing heat
dissipatinn {shnulder pads, running tights, shnes). Cnnl-
ing measures such as ice—cnld tnwels nu the axilla, grnin,
= and neck, fanning, cnnling blankets, and cnld-water im-
E
E mersinn {36°F tn 50°F} all are apprnpriate therapies fnr
.E
'U reducing cnre bndy temperature. Cnld-water immersinn
E
'11
is the mainstay nf treatment fnr beatstrnke because it
I:
prnvides the quickest methnd fnr lnwering cnre bndy tem-
perature. The exact temperature at which cnnling shnuld
take place is a matter nf current debate.” Cnnling shnuld
be discnntinued when cnre bndy temperature reaches
1fl1°F tn 102T, and cnntinunus careful mnnitnring nf the
patient’s mental status and vital signs shnuld nccur during
cnnling and after the cnnling precess steps. An estimate
nf cnre temperature reductinu is 1": fnr every 5 minutes
(1“F fnr every 3 minutes} nf cnld-water immersinn. Rectal
and gastrnintestina] prnhe temperature prnvide the nnly
satisfactnry measurement nf cnre bndy temperature, nther
measurements lnral, aural, tempnral, axillary} shnuld nnt
be used tn guide treatment. If cnnling is initiated befnre
transpnrt, transfer tn the clnsest emergency department
can nccur when the rectal temperature reaches 102T.
Antipyretic agents play an current rnle in exercise-related
heat illness. If available, intravennus fluids may be giv-
en. Dral vnlume repletinn may take place if the patient’s
mental status is sufficient. Return—tn—activity guidelines
suggest that athletes refrain frnm exercise fnr at least 7'
days after the event and fnllnw up with a physician 1
week after the event fnr further evaluatinn and testing.‘9
Management nf the milder fnrms nf heat illness de-
pends nn the clinical situatinn. Heat exhaustinn requires
remnval nf the athlete frnm cnmpetitinn. [f the tempera-
ture is elevated, cnre temperature reductinn methnds
may be instituted, althnugh as previnusly stated, bndy
temperature by definitinn dnes nnt exceed 40°C. aume
repletinn may be achieved via enteral fluid administratinn
nr, if the patient is unable tn tnlcrate liquids by mnuth,
administratinn nf intravennus fluids. Individuals experi-
encing heat exhaustinn shnuld be held nut nf cnmpetitinn
fnr at least 24 hnurs, lnnger if symptnms have nnt cnm—
pletely resnlved. Muscle cramps may be treated with rest,
firthnpaedic Knnwledge Update: Spurts Medicine 5
fluid resuscitatinn, massage, and ice baths. Preventinn
nf muscle cramping generally fncuses nn maintaining
hydratinn status thrnughnut participatinn.
Exercise-Assnciated Hypnnatremia
Exercise-assnciated hypnnatremia [EAHJI is a pntentially
sEvere electrnlyte disturbance related tn prnlnnged exer-
cise. EAH is defined as a serum nr plasma sndium level
belnw the nnrmal reference range, which typically is less
than 135 mgd, nccurring during nr up tn 24 hnurs after
prnlnnged physical activity.” Clinical manifestatinus nf
EAH range frnm nnnspecific symptnms such as weakness,
dizziness, nausea, and headache tn mnre severe symptnms
including seizures, cnnfusinn, cnma, and death. The in-
cidence nf hypnnatremia is estimated tn be between [1%
and 13% in marathnns and triathlnus?1 Twn nf the main
risk factnrs fnr BAH are excessive fluid intake during a
race and failure tn suppress antidiuretic hnrmnne (A DH}
release during exercise.12 Mnst cases nf EAH nccur due
tn ingestinn nf large amnunts nf hypntnnic fluid, includ-
ing free water, ever a prnlnnged period nf exertinn. In-
creased ingestinn nf hypntnnic fluids leads tn dilutinual
hypnnatremia. Nnrmally, a cnmpensatnry mechanism
fnr hypnnatremia is suppressinn nf ADH release. Failure
tn suppress ADH diminishes the bndy’s capacity tn get
rid nf free water.” Persistent hypnnatremia may lead tn
seizures, cerebral edema, and cnma in additinn tn respi-
ratnry arrest and death.
Event staff shnnld be equipped tn measure pnint-nf-
care serum sndium levels. Mild symptnms with dncu-
merited hypnnatremia may be managed by remnval frnm
participatinn and fluid restrictinn. Severe symptnms re-
quire intravennus hypertnnic saline (lflfl mL nf 3% sa-
line} and transport tn the nearest emergency department.
Strategies tn prevent the nveringestinn nf hypntnnic fluids
include participant educatinu abnut fluid type and drink—
ing rates and increasing the distances between marathnn
hydratinn statinns.
F'reventinn nf Heat Illness
Numernus strategies can help tn prevent exercise-related
heat illness. The first steps are recngnitinn nf the climate
cnnditinns that predispnse tn heat illness and allnwiug
athletes tn acclimatize tn hnt and humid cnnditinns. This
is achieved by gradual increases in practice intensity and
duratinn and the gradual intrnductinu nf items that limit
heat dissipatinn such as helmets and shnulder pads. Pre-
ventinn nf dehydratinn is key tn the preventinn nf heat
illness.
As previnusly discussed, 1"ifli'13‘llll3T can be used by
fl lfllfi American Academy nf Urthnpaedic Surge-ans

physicians, coaches, and event coordinators to gauge the
risk of heat illness. Participants—and even spectators—
should be made aware of the implications of elevated
1'tiiil'EiCTs. 1|When 1iiii'liiCT exceeds 23°C, event organizers
should seriously consider canceling events or modifying
them so they start earlier in the morning or later at night.
A worldwide precedent was set when the 2014 FEdération
Internationale dc Football Association {FIFA} lWorld Cup
mandated water breaks for players and officials because
of elevated WBCT. Heat acclimatiaation is a crucial com-
ponent of the prevention of EHRI. The NCAA {National
Collegiate Athletic Association} has implemented guide—
lines for heat acclimatiaation.
Individual risk factors should be acknowledged. Ath—
letes who have previously experienced EHRI should be
identified and closely monitored. Medical conditions that
predispose to EHRI should be noted. Medications that
may contribute to EHRI should be identified and, de-
pending on the underlying medical condition, could be
changed to a different medication, or the athlete could
be monitored for signs of heat illness. Educating medical
personnel about the prevention of dehydration is import-
ant. The medical training staff should understand hovI.r to
recognize hear-related illness and have measures set up
to treat EHRI, including shady areas, ample cool fluids.
bags of ice, and if available, intravenous fluids. Rapid
body cooling with cold-water immersion should be readily
available. Most importantly, early activation of the EMS
system should be emphasized. A written action plan can
be an important component of treating EHRI.
Individual efforts to combat heat illness include main-
tenance of the preexercise hydration status. Cine easilyr
available estimate of dehydration is day-to-day weight
measurement. For every 1 kg of body mass loss, I L of
fluid replacement should be initiated within 2 hours of ex-
ercise. Preparticipation maintenance of hydration is essen-
tial to performance. A balance must be struck between the
ingestion of free water, sodium, and carbohydrate-con-
taining beverages. Research suggests cool or cold borer-
ages are preferred over those at room temperature, and
carbohydrate-containing beverages are more palatable,
which may induce fluid consumption. Dietary sodium is
required to maintain extracellular fluid osmolality. This
typically can be achieved through consuming a normal
diet. Free water ingestion without adequate sodium will
lead to a decrease in the plasma sodium concentration.
Preexercise hyperhydratiou is not currently known to be
of measurable benefit, although it possibly could serve to
restore euvolemia in dehydrated athletes.
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter +5: Heat IIhiess and Hydration
Summary
EHRI is a potentially deadly but preventable condition.
The recognition and modification of external and internal
risk factors is important in reducing the danger of EH RI.
This process includes maintaining hydration status before
and during exercise and being cognizant of the environ-
mental conditions. For athletes, coaches, organizers, and
physicians, recognizing and understanding the spectrum
of EHRI is important.
Key Study Points
I Early therapy is key to the management of EHRI.
I EHS is a medical emergency, and cold-water im—
sanssl leagpaw :,1;
mersion is the gold standard of care.
' EMS activation should not be delayed, particularly
if the diagnosis is uncertain.
' Core temperature {rectal temperature} is requisite
for the diagnosis of heat injury.
Annotated References
1. Maron E], Doerer J], Haas TS, Tierney DIM, Mueller FU:
Sudden deaths in young competitive athletes: Analysis of
1366 deaths in the United States, lflflfl-Zflfle. Circniarion
2DD9;119{3}I:1D35-1i}92.Medliue ill-DI
This is a report of sudden deaths in high school athletes from
a national registry. Data were collected from 1930 to 2006.
2. Iliucera K, Klossner D, Colgate E, Cantu R: Annaai Barney
ofFoothaii injury Research flit-3:913. American Foot-
haii Coaches Association; Nationai Coifegiate Atisietic
Association; i'ilatiornslr Federation of State I-l'ig'f:I Schooi
Associations. National Athletic Trainers’ Association,
Carrolton, TX, 2014.
This study examined the incidence and characteristics
of heat-related illness among high school athletes from
2005 to lflfifl.
.3. Yard EE, Gilchrist J, Haileyesus T, et al: Heat illness
among high school athletes—United States, EDUS-lflflfl.
] Safety Res 2fllflt41{6}:471-4?4. Medline DUI
This is a report of high school football deaths from 1931
to EMS, including their direct and indirect relationship
to football as well as the type of injury.
4-. Kerr ET, Casa D], Marshall SW, Comsto-ck RD: Epide-
miology of exertioual heat illness among LLS. high school
athletes. Ans _i Prev Med 2013;44ilhfl-l4. Medline DUI
This retrospective analysis of National High School
Sports-Related Injury Surveillance Study data reported
the incidence, geography, and timing of exertioual heat—rc—
lated illnesses.
Drthopoedic Knowledge Update: Sports Medicine 5
 Section 7’: Medical Issues
Baden BF, Ereit I, Beachler JA, Williams A, Mueller FD:
Fatalities in high school and college football players. Am
J Sports Med EDISHHSIflIDS-IIIS. Medline DUI
This epidemiological analysis reported the causes of high
school and college football deaths from 19911} to 1010.
Mountioy M,]unge A, Alonso JM, et al: Sports injuries and
illnesses in the 2G [1'5" FINA World Championships {Aquat—
ics}. Br] Sports Med 20 10;44{T}:522-521 Medline DIDI
A prospective recording and analysis reported the frequen-
cy and characteristics of injuries and illnesses sustained
during the EDD? Fridération Internationale de Football
Association {FINA} World Championships.
Macaluso F, Eatone R, Isaacs AW, Farina F, Moriei C,
Di Felice V: Heat stroke risk for open-water swimmers
= during longudistance events. Wilderness Environ Med
A"
E
2fl13;l4{4}:362—365.Mcdline DUI
.E This article presented a review of the risks of heat illness
'U
E
'11
in open'water swimmers.
ri-l
Casa DJ, Stearns RL, Lopes RM, et al: Influence of hy-
dration on physiological function and performance during
trail running in the heat. I Art-I Train lfl'l fl:45{2}:14'?-:1 5S.
Medline DUI
This semirandomiaed crossover analysis reported the
effects of hydration status on physiologic function and
performance in athletes during trail running.
Nichols AW: Heat-related illness in spurts and exer-
cise. Curr Rey Mnscuioshelet Med 2fl14;T{4}:SSS-355.
Medline DUI
This review of the current concepts surrounding heat
illness in sports and exercise included pathophysiology,
clinical syndromes, effects of hydration status, and risk-re-
duction strategies.
11“.}. Rav-Acha M, Hadad E, Epstein Y, Heled Y, Moran DS:
Fatal exertional heat stroke: A case series. An: 1 Med Sci
lflfl4;323{2}:34-31Medline DflI
II. Sawka MN, Burke LM, Eichner ER, Maughan RJ, Mon-
tain S], Stachenfeld HS; American College of Sports Medi-
cine: American College of Sports Medicine position stand.
Exercise and fluid replacement. Med Sci Sports Exerc
2i] fl?;39{2]:3??—39 fl. Medline
13. Bergcron MP, Dcvorc C, Rice SC: Council on Sports Med.
icine and Fitness and Council on School Health; American
Academy of Pediatrics: Policy statement—Climatic heat
stress and exercising children and adolescents. Pediatrics
2fl11:IES{3]:e?4I-e?4?. Medline
This is a policy statement from an expert panel on heat
stress in children.
13. Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS,
Pyne SW, Roberts WU; American College of Sports Medi-
cine: American College of Sports Medicine position stand.
Exertional heat illness during training and competition.
Med Sci Sports Exerc lflfl?;39(3}:555-5T2. Medline [ll-DI
CIrthopaedic Knowledge Update: Sports Medicine S
Hoakes TD: A modern classification of the exercise-re-
lated heat illnesses. j Sci Med Sport lflflSflIlIlfiS-Sfl.
Medline DD]
IS. Cass D], Clarkson PM, Roberts WC}: American College
of Sports Medicine roundtahle on hydration and physical
activity: Consensus statements. Carr Sports Med Rep
20fl5:4{3}:IIS-121 Medline DUI
IS. Eichner ER: The role of sodium in ‘heat cramping’. Sports
Med Zflfl?:3 TH-S }:SSS-3?fl. Medline DCI'I
IT. Eergeron MF: Exertional heat cramps: Recovery and re-
turn to play. I Sport Rehnbil 1013?;1 Elihl flfl-I 96. Medline
IS. Casa D], Armstrong LE, Kenny GP, U’Connor FG, Hug-
gins RA: Exertional heat strolce: New concepts regarding
cause and care. Carr Sports Med Rep 2011341 1(3}:115-113.
Medline DUI
Novel concepts regarding treatment of EHS were presented
in this article.
19. D’Connor FG, Casa D], Bergeron MF, et al: American
College of Sports Medicine Eoundtablc on exertional
heat stroke—return to dutyireturn to play: Conference
proceedings. Carr Sports Med Rep 2D10:9{S}:314-321.
Medline DD]
This is a report on an expert conference convened to dis-
cuss relevant cxertional heat illness issues such as potential
long-term consequences, the concept of thermomlerance,
and the role of thermal tolerance testing in return-to-play
decisions.
2f]. How-Butler T, Ayus JC, Kipps C, et al: Statement of the
Second International Exercise-Associated Hyponatremia
Consensus Development Conference, New Zealand, 3160?.
Clin ,l Sport Med ZflflSflSillflIl-IEI. Medline DUI
21. Hoffman MD, Hew'Butler T, Stuempfle K]: Exercise-as-
sociated hypooatremia and hydration status in IEI-lcm
ultramarathoners. Med Sci Sports Exerc 2fl13;45{4]:?34-
7’91. Medline DUI
This study represents a S-year analysis that attempted to
define the relationship between postrace blood sodium
{[Na]! concentration and change in body weight; to ex-
amine the interactions among EAI—I incidence, ambient
temperature, and hydration state; and to explore the effect
of hydration status on performance.
22. Hew-Entler T: Arginine vasopressin, fluid balance and
exercise: Is exercise-associated hyponatraemia a dis-
order of arginine vasopressin secretion? Sports Med
201D:4fl{fi}:459-4?9.Medline DUI
This article is a review of the role of arginine vasopressin
and the effects of exercise.
23. Hew-Butler T, Jordaan E, Stuempfle K], et a1: Usmotic
and nonosmotic regulation of arginine vasopressin during
prolonged endurance exercise. 1 Clin Endocrinoi Match
Zflflfligdifilflflifl-EGTS.Medline DUI
D lfllfi American Academy of Orthopaedic Surgeons
Chapter 4?
Osteochondritis Dissecans
Kevin G. Shea, lvll'} Ted I. Ganley, MD
flsteocbondritis dissecans most commonly affects the
knee, ankle, and elbow, and is typically seen in young,
active populations. It is important to review the epide-
miology, presenting clinical complaints, and nonsurgical
and surgical treatment options for osteochondritis
dissecans for optimal patient outcomes.
Keywords: osteochondritis dissecans; cartilage
reconstruction; cartilage repair
Introduction
lC'Isteochondritis dissecans {GED}, first described in the
19'“ century, affects a substantial number of young ath-
letes and can result in pain, mechanical symptoms, and
development of intra—articular loose bodies of osteocar—
tilagenous tissue. A contemporary definition of 0CD is a
“focal, idiopathic alteration of subchondral bone with risk
for instability and disruption of adjacent articular carti-
lage that may result in premature osteoarthritis.“I Eon-
temporary research refers to the GED lesion as progeny
bone and the surrounding normal tissue as parent bone.
The etiology of 0CD remains unknown, although
many causes have been proposed, including acute trauma,
overuse, and genetic and vascular causes. Ischemia is
thought to be present in some cases, although this has not
Dr. Shea or an immediate family memberserves as an on-
paid consultant to Clinical Data Solutions: and serves as a
board member; owner officer; or committee member of the
American Academy of firthopaedic Surgeons, the American
Drtl'ropaedic Society for Sports Medicine, the North Pacific
Drthopedic Society. and the Pediatric Drthopaedic Society
of North America. Neither Dr. Ganley nor any immediate
family member has received anythingI of value from or
has stoclr or stoclr options held in a commercial company
or institution related directly or indirectly to the subject
of this chapter.
fl sens American Academy of Drthopaedic Surgeons
been confirmed in all cases, based on histologic studies}
BC!) is called osteochondrosis in animals and is quite
common in horses and pigs. Veterinary animal model
research, including detailed anatomic evaluation of the
condyle vascularity of the knee, suggests a vascular eti-
ology in most cases.J
Location of GED
Although numerous studies confirm that the most com-
mon location for DCD is the kncc joint, the ankle and
elbow joints are also commonly affected. DCD is rela-
tively rare in other joints, but has also been reported in
the hip and shoulder. Epidemiologic studies evaluating
DC!) in large populations have demonstrated that the
knee is the most common location. Within the knee, DIED
is located in the medial femoral condyle {64% of cases},
atamtu fiunoy, au_|_ :g
the lateral femoral condyle {32% of cases}, and the patel-
la, trochlear groove, and tibial plateau (less than 4% of
casesl.“ Approximately 513% of lesions appeared on the
right side, 43% appeared on the left side, and only 7%
were bilateral; however, other studies have suggested that
bilateral cases may be as prevalent as 30%. 0CD was
not identified in patients age 2 to 5 years, but was seen
in patients age IE to 11 years, and was most common in
patients age 11 to 19 years. Patients age 12 to 19 years
were almost four times more likely to have a diagnosis of
0CD of the knee compared with those age a to 11 years.
Males had a 33-fold higher risk of the development of
GED of the knee than females. This condition was also
more common in African American populations than in
Caucasian, Hispanic, or Asian populations.
Another large population-based study reviewed 0CD
of the ankle. As with knee GCD, ankle {1CD was not
reported in those younger than 5 yea rs, and was increas-
ingly common in those between age 12 and 19 years.5
Females had a higher risk of 0CD of the talus than males.
0n the basis of race and ethnicity, non—Hispanic whites
had the highest relative risk for disease, and African
Americans had the lowest rislr.
Drthopeadic Knowledge Update: Sports Medicine 5
 Section B: The Young Athlete
Figure 1 Lateral view radiograph depicts osteochondritis
E dissecans of the medial femoral condyle.
E {Courtesy of St. Luke‘s Clinic. lntermountain
:5 Orthopaedics. Boise. ID.]
fl:
Eh
E Standard AP and lateral knee radiographs {Figure 1} alone
E
3...
I1: CiCD of the Knee
.I:
'—
Eci In EU] 1, the American Academy of l[Tirthrypaedic Surgeons
published a clinical practice guideline on {JED of the
Knee, which reviewed important clinical questions for
evaluation and treatment. Few higher level prospective
studies are available on this topic, and few long—term
follow-up studies are available.“ Multicenter prospective
cohorts and randomized trials will be critical to develop a
better understanding of the outcomes and best treatment
options for this condition.
Clinical Presentation
Many patients with 0CD of the knee present with fairly
benign symptoms. Lesions that are stable and remain in
situ may lack swelling or mechanical symptoms. Some
patients may only report activity-related pain. The symp-
toms may overlap with growing pains and patellofemoral
pain, for example. "With more advanced lesions, symp-
toms can be much more substantial, including swell-
ing, mechanical complaints, and reports of occasional
limping. The examination can reveal swelling and some
flrdinpeadic Knowledge Update: Sports Medicine 5
ha .'.:-..
Figure 2 Notch view radiograph depicts bilateral
osteochondritis dissecans of the medial
femoral condyles. {Courtesy of St. Luke's Clinic,
intermountain Orthopaedics. Boise. ID.}
mechanical complaints similar to those of a meniscus
iniury, especially in more advanced cases, but many pa-
tients will have minimal to no findings on examination.
In most patients, the pain is localized to the anterior knee
region around the femoral condyle. Many will have an
entirely normal gait pattern with walking andi'or running.
Multifocal lesions of the knee are less conunon, but can
occur in some cases?
Imaging Evaluation
may not identify 0CD lesions. The use of notch and Met-
chant view radiographs can help identify more lesions.
Up to 30% of DCD cases may be bilateral, so imaging
evaluation of both knees may be advantageous {Figure 2].
For those with more advanced lesions or in cases in which
surgical treatment is considered, MRI sequences can assist
with surgical planning. Historically, alignment has not
been evaluated in patients with 0CD, but research sug-
gests lower extremity alignment may be a consideration for
some patients.3 Specifically, varus and valgus mechanical
axis alignment of the knee may be associated with {1CD
of the medial and lateral condyle, respectively.
Classification
Numerous classification systems for DIED of the knee
exist, although validation of these systems remains a
concern. Classification systems using MRI have been
proposed to help assess lesion stability and the poten-
tial for healing. MRI criteria for 0CD instability have
been proposed {high Til-weighted signal intensity rim,
surrounding cysts, high TZ—weighted signal intensity
cartilage fracture line, and fluid-filled osteochondral
fl lflld American Academy of Orthopaedic Surgeons

defects], although the capability of MRI to accurately
predict lesion stability in slteletally immature patients has
been questioned? {Figure 3]. Arthroscopic classification
systems exist, although future studies on reliable, valir
dated systems are necessaryJ“ A multicenter 0CD study
group has developed and validated arthroscopic" and
radiologic” classification systems for 0CD. Ultimately,
the validated classifications system may be important for
prospective trials and registry—based outcomes for the
treatment of DIED. Arthroscopic classification systems
are the gold standard for evaluating lesion size, cartilage
condition, and fragment stability, and therefore may be
more definitive for treatment decisions.
Treatment
Honsurgical treatment in skeletally immature patients,
especially for those with substantial growth remain—
ing, may have a better prognosis for healing. In cases in
which the patient does not have substantial mechanical
symptoms, and the MRI sequences do not show signs
of substantial instability, a nonsurgical program can be
used. Predicting stability on MRI can be challenging,
especially in younger patients.13 Healing rates greater
than 50% to 60% have been reported for appropriately
selected patients.” An ideal nonsurgical treatment option
has not yet been demonstrated, but activity restrictions
that include a period of casting or the use of an unloading
brace can improve healing rates. Activity changes for 4
to 5 months or longer may be necessary to obtain adev
quate healing in these patients.”~” Research on healing
predictors could help determine the best treatment options
and help with patient-centered decision making.” These
predictors can include age, presence of cyst-like lesions,
mechanical symptoms, and lesion size.
For patients in whom nonsurgical treatment has failed,
different treatment options exist.” Most literature pub-
lished on knee {1CD relates to condyle location, but sev—
eral recent series were published on patellar and trochlear
0CD, which are relatively rate?” For stable lesions,
treatment options include both transarticular and retroar—
ticular drillingml”; studies have demonstrated excellent
healing with both techniques.11H Retroarticular drilling
can be more technically challenging in some locations,
and increased radiation use during the procedure can also
be a limitation, but the clinical outcomes are excellent.
Ultrasonographic guidance for percutaneous drilling has
been described, although this approach does not allow for
direct evaluation of cartilagei'lesion stability; therefore,
its use may be limited to cases in which cartilage lesion
instability is a potential concern.“
Retroarticular drilling and bone grafting with mini—
mally invasive techniques have been describedl‘h“ for
IE! Efllfi American Academy of flrthopaedic Surgeons
lChapter 4?: fleteochuudrifis Dissent-us
\ *l i
---:I..- L! ' 1‘
I
Figure 3 Coronal TLweighted MRI of the knee depicts
osteoch ontlritis dissecans of the medial
femoral condyle with risk of lesion instability.
{Courtesy of St. Lu ke's Clinic. lnterrnountain
flrthopaedim, Boise, ID.)
more advanced, stable lesions, and allow placement of F“?
bone grafting behind the lesion using minimally invasive
to
techniques with arthroscopic and C—arm fluoroscopic
ElI::
guidance. Longer term follow-up and larger study sites :I
u:
will be necessary to confirm treatment outcomes. I!"
For patients with unstable lesions, or those close to or
Fl
E
at
boyond skeletal maturity, more advanced treatment op- m
F.
tions may be necessary {Figure 4}. Fragment excision may
not have ideal outcomes,” and attempts to salvage the na-
tive cartilage and bone can provide a better prognosisrl'i'1H
These options include drilling, which may be combined
with different approaches to bone grafting, and internal
fixation with an attempt to salvage the native cartilage
tissue.”~“13“ Numerous studies have shown successful
outcomes in patients who undergo lesion stabilisation,
especially in younger patients.“J1 Prospective cohorts
and randomised clinical trials will be necessary to fully
evaluate these techniques because most are retrospective
case series.
Hardware selection is debated in the literature, with
proponents of both metallic and bioabsorhable fixation
devices.”*“'34 {Table 1] Numerous reconstruction and
salvage techniques with their inherent limitations and
biases have been studied in smaller case series. Osteo-
chondral autograft transplantation {HAT} has been eval-
uated in retrospective cases series.35t3'5 Biologic fixation
Drthopeadic Knowledge Update: Sports Medicbte 5
 Section E: The Young Athlete

was advocated based on the use of small osteochondral
autografts. A prospective study on 0CD compared micro-
fracture with osteochondral autograft implantation.”
Both groups improved functionally after surgery, but
patients in the osteochondral implantation group had
better results at an average follow—up of 4.2 years. Cis—
teochondral autograft combined with screw fixation has
also been described.33 Cine study suggested that donor
site morbidity for osteochondral autografts may not be
significant in young patients,” but some adult studies
have shown symptoms at CIAT harvest sites.
E with relatively minor symptoms, including occasional
E mechanical symptoms, minimal loss of motion, and occa-
:5
s1:
U'II
E
The treatment of defects using autologous cartilage im-
plantation [ACI] has also been evaluated. Several studies
reported good outcomes using AC1 techniques."'”*‘“ The
use of cell-free, biomimetic osteochondral scaffold has
been studied, with promising results reported at short-
term follow—up. Bulk osteochondral allogra fts have been
described, showing good results at short-term and longer
tcrrn follow-utiliu"M
DIED of the Elbow
Clinical Presentation and Imaging Evaluation
DIED of the elbow and Panner disease may represent dif-
ferent stages of a related condition. Historically, Panner
disease has been described in younger patients {younger
than 10 years}, and in many cases, it will resolve with
time. 0CD of the elbow is thought to develop in older
patients, and in many cases, these lesions do not heal. In
many athletes, the cause of these conditions is thought
to be related to overload of the lateral elbow compart—
ment, and perhaps to the limitations of elbow vascula rity.
The contribution of vascular etiology to 0CD has been
proposed for both the knee and elbow, and secondary
overload can also enhance the risk of development andlf
or progression of the condition.
Many young patients with GED of the elbow present
sional effusion. Baseball, gymnastics, and other overhead
sports pose a relatively high risk for this condition.” In

E
3... some cases, the only notable physical examination finding
I1:
.I:
'— may be a loss of 5" to 10° of extension compared with
Figure 4 Coronal Tl-weig htecl M iii of the knee depicts
lid osteochondritis dissecans of the medial the contralateral elbow. Most 0CD lesions are identified
femoral condyle with risk of lesion instability. using plain radiography. Some cases can be better seen
[Courtesy of St. Luke's Clinic. Interrnountain using MRI, which is also good at identifying substantial
Orthopaedics, Boise, Ill}
bone edema, loose bodies, or more subtle lesions not

Bioabsorbable Versus Metal Implants for 0CD Fixation

Implant Advantages Disadvantages
Bioabsorbable Removal may not be necessary Concerns about strength and implant failure
Do not produce substantial artifact Incomplete absorption
Wlth MRI Backing out from bone
May result in substantial cyst formation around
implants
Metal Do not leave cystic lesions during screw Ivlay produce substantial artifact on MRI studies
ahfivrptlfln Removal may be necessary if close to cartilage
Titanium screws may induce less MRI surface and not recessed within stable bone
artifact Backing out from bone
DIED = nstenchondrltls cllssecans.

firthopeadic Knowledge Update: Sports lvledicb'ie 5 fl lflld American Academy of Orthopaedic Surgeons
 IChapter 4?: flsteechendrids Disseeans

Figure 5 AP radiegraph depicts esteecheridritis dissecans

ef the elbew. {Ceu rtesy ef 5t- Lu lte's Clinic,
Intermeuntain Grthepaedics, Eeise, ID.)
“Ti, N
fully appreciated en radiegraphy {Figures 5, E, and F}.
Newer techniques may be valuable fer cartilage evalua-
tien, including these using ultrasenegraphy, and may be ‘3", si-
templementary te ether ferms ef advanced imaging in me 8t RIC!
the future.“

Treatment Optlens i.

Yeungcr patients with substantial grewth remaining may Figured Sagittal MRI efthe elbew depicts
reap-end well te activity medifieatiens, and in seme eases, esteech endritis dissecans. (Ceurtesyr e‘l 5t.
Lulte's Clinic, lntenneuntain Drthepae-dics, F“?
heth rest and sherter perieds ef immebiliratien can be Beise. Ill}I in
beneficial. Fer threwing athletes, switching te anether
E?I:
pesitien with less threwing demands can be helpful, such :I
u:
as having a pitcher er catcher switch te first base. Fer New techniques, including the use ef ebliqne grafts, have 1"
these whe de net respend te activity medificatiens ancliIr been develeped te address challenges te jeint access.”
Fl

E
as
er restrictiens, surgical treatment is an eptien. Larger A 2011 study previded an excellent review ef surgical m
F.

lcsiens, including these that expand te invelve the lateral
wall ef the capitellum, as well as these with intra-articular
leese hedies, can pregress te surgical treatment mere
frequently than small lcsiens {Figure 3}. The staging sys—
tem develeped in 2fl11 can help with the evaluatien and
management ef this cenditien.“ Mest published series en
elbew DC!) are based en level IV evidence er case series,
se treatment reeemmendatiens are net based en higher
levels ef evidence.“~“9 Arthrescepic déhridemeut with
and witheut drilling has shewn reasenable eutcemes in
sherter term fellew-up, altheugh lenger term fellew-np
fer threwing sperts, gymnastics, and ether higheclemand,
upper extremity sperts are limitedfi'i'r“
Uncentained lesiens can have a werse pregnesis than
centaincd lcsiens.fl DAT harvest frem the knee and mesa—
icplasty precedures have been examined for the treatment
ef larger, uncentained lesiens.53-5'* Larger lcsiens may have
a werse pregnesis,fl and access te the jeint fer certain
lesien sizes and lecatiens can be technically challenging.
treatment eptiens.‘“r
DCD ef the Talus
The etielegy ef DCD ef the talus remains unknewn,
altheugh many talar lcsiens are asseciated with a histery
ef trauma. A histery ef trauma may be less likely with
pesteremedial lesiens.fl
Clinical Presentetien and Imaging Evaluatien
Many patients with talar {3CD present with symptems ef
ankle pain alene, witheut substantial swelling er mechan-
ical symptems in early stages ef the cenditien. In patients
with a histery ef ankle sprain and anterelateral lesiens,
patients may have tenderness ever the lateral aspect ef
the talus. The Berndt and Hardy classificatien system fer
radiegraphic staging ef talar 0CD is currently in use. In
additien te plain radiegraphy {Figures 9 and 10], MRI can
be a useful reel te evaluate the extent ef the lesien, as well

IE! lfllfi American Academy ef Clrthepaedic Surgeens Drrhepeadic Knewledge Update: Sperrs Medicine 5
 Seeded B: The Yeung Addete
.matégr ve
l“
Figure 3' Cerenal MRI ef the elhew demenstrates
esteechendritis dissecans. |[Ceurtesy ef 5t.
Lulce's Clinic, lnterrneuntain Drthepaedirs,
Beise, ID.)
3: The "feung Athlete
WT BEARING
w...
AP racliegraph ef the ankles depicts
esteechenclritis dissecans ef the pesteremedial
talus en the left ankle. {Ceurtesy at St. Luke’s
Clinic, lntermeuntaln Drthepaedlm, Beise, ID.)
as the cenditien ef the cartilage. MRI fer pesteperative
evaluatieri may be limited, and several series have shetvu
imprevement in clinical functien despite persistent MRI
ahnermalities after surgery.”
firthepeadic Knewledge Update: Sperts Medicine 5
Figure B Arthrescepic view depicts esteechendritis
dissecans ef the elhew with intra—articular
free hedies. {Ceurtesy ef 5t. Lulte's Clinic,
Intermeuntain Clrthepaedics. Eleise. ID.)
77 WT BEARING
Figure 1|] Lateral radiegraph ef the ankle depicts
esteechenclritis dissecans ef the pesteremeclial
talus. (Ceurtesy at St. Lu lre‘s Clinic.
Intermeuntein Urthepaedics, Beise, Ill}
Treatment Dpfiens
A systematic review fer the treatment ef talar {JED re-
vealed almest exclusively level IV case series evidence, and
ne streng recetnrnendatiens ceuld he made fer specific
treatment eptiens given the limitatiens ef the evidence.”
Many ef the case series had limited fellew~up {53 years},
which further limits the understanding ef the surgical
eutcemes and the effect en patient functien.
In patients with stable lesiens and in these witheut
mechanical symptems and effusiens, nensurgical treat-
ment [activity medificatiens, immehiliaatien} is an ep-
tien, and healing has been reperted in seme series using
this appreach. Published series ef nensurgical treatment
fl lflld American Academy ef Cirthepaedic Surge-ens

are limited. A case series in children shnwed relatively lnw
rates nf healing with nensurgical treatment, and surgical
interventinn was recnmmended if healing did nnt nccur
within 6 mnnths.“
Drilling ef the talus has been described using several
techniques including direct arthrnscnpic visualisatinn.
Access tn the pnsternmedial reginn nf the talus is limit-
ed, even with the ankle in full plantar flexinn. Access tn
this reginn can he gained by using several apprnaches,
including retrngrade drilling techniques {including the
use ef three-dimensinnal imaging guidance} and trans-
mallenlar drilling.
Treatment using nstenchnndral autngraft transfer frnm
the knee has been described in several studies, including
nne with a mean shnrt—term fnllnw-up nf 2.5 years.“ In
this series, elder patients were mere likely tn have sub-
stantial symptnms at the knee jnint after graft harvest,
and cautinn was recnnunended fer use nf this prncedure in
elder patients. lvlalleelar estentemy has been described as
a technique tn gain access fer UAT graft placement, and
relatively lnw rates ef wnund healing cnmplicatinns and
delayed unien ef the esteetemy site have been described.“
[n 2014, an excellent review nf treatment nptinns fnr OED
nf the talus was publishedfi'l
Summary
Treatment nf knee, elhnw, and talar UCD will cnntinue
tn evnlve, and determining the nptimal treatment will
centinue te challenge researchers. Multicenter study
designs, including prnspcctive cnhnrts and randemised
clinical trials, may prnvide adequate pnwer tn determine
nptimal nutcemes.
Hey Study Pnints
' Treatment nf {3CD cnntinues tn evnlve, and mul-
ticenter studies will be essential tn develnp higher
levels nf evidence fnr nptimal treatment prntncnls.
1* Fer patients with lesinns that dn nnt heal with nnn-
surgical measures that include activity mndificatinn,
surgery can improve jeint functieu in the chem term.
Annotated References
1. Edmnnds EW, Shea KG: Dstenchnndritis dissecans: Edi-
terial cnmment. Gin: Drtbep Relat Res 2013:4?I[4}:11fl5v
11%. Medline BID]
The purpnse nf this sympnsium was tn highlight what
is and what is net understnnd regarding the histnlngy,
natural histnry, nutcnmes, and treatment nf 0CD. BED
is a fecal, idiepathic alteratien ef subchnndral buns with
IE! EDIE American Academy nl' flrthepaeclic Surgeens
l[L‘halziter 4?: flstencbnudrids Dissenans
risk fnr instability and disruptinn nf adiacent articular
cartilage that may result in premature estcearth ritis.
. Shea KG, Jacnbs JC Jr, Carey JL, Andersen AF, Gnterd
JT: Dsteechendritis dissecans knee histelegy studies have
variable findings and thenries nf etinlngy. Cline firth-n1}.-
Reint Res 2313;4?1{4}:112?-1135. Medline DUI
Future studies with cnnsistent methndnlngy are necessary
tn draw majer cenclusinns abeut the histelngy and pre-
gressien ef OED lesiens. Incensistent histelegic findings
have resulted in a lack nf cnnsensus regarding the pres-
ence et estennecrnsis, whether the necrnsis is primary er
secendary, the asseciarien ef cartilage degeneratien, and
the etinlngy nf DIED. Level nf evidence: III.
. l[I’Ilstad II, Hendricksen EH, Carlsen CS, Ekman 5, Delvik
N]: Transectinn nf vessels in epiphyseal cartilage canals
leads tn nstenchnndresis and nstenchnndrnsis dissecans
in the fetnere~patel|ar inint ef feals; a petential medel nf
juvenile nstenchnndritis dissecans. Dstendrthritis Carti-
lage 1fl13:11[5}:?3fl 333. Medline DUI
Transectinn nf blend vessels within epiphyseal cartilage
canals resulted in necresis ef vessels and chendrecytes
{ischemic chendrenecresis} in feals. The ischemic hypeth-
esis fur the pathngenesis nf GED has been reprndnced
experimentally in fnals.
. Kessler JI, Nikisad H, Shea KG, Jacnhs JC Jr, Eehchnk
JD, Weiss ll: The demngraphics and epidemielegy ef
nstenchnndritis dissecans ef the knee in children and
adnlescents. Am I Spurts Med Efl14;42{2}:32l}-326.
Medline DD]
F“?
In this pepulatien-based cehert study ef pediatric 0CD
ef the knee, male patients had a much greater incidence m
nf GED and almnst fnur times the risk nf {3CD cnmpared 3‘I:
with female patients. Alsn, patients age 12 tn 19 years had :i
In
3.- times the risk ef {JED nf the knee as cnmpared with 1"
6- re Il-year-nld children. Level ef evidence: IV.
Fl
E
n:
m
F.
. Kessler JI, Weiss JM, Nikisad H, et al: flsteechnndri-
tis dissecans nf the ankle in children and adnlescents:
Demngraphics and epideminlngy. Am ] Spnrts Med
2014;42{9}:2165—21?1. Mcdline DUI
In this pepulatien-based cehert study et pediatric ankle
0CD, female patients had a greatm incidence ef DCD and
a 1.5 times greater risk fnr ankle GED cnmpared with
male patients. Teenagers had nearly seven times the risk
fer ankle 0CD cnmpared with children 6 tn 11 years ef
age. Level nf evidence: IV.
. Chambers HG, Shea KG, |Carey JL: AADS Clinical Prac-
tice Guideline: Diagnnsis and treatment nf nstenchnndritis
dissecans. I Am Acad firthnp Snag lflllglfllfilflfllfifli
Medline
IElinical questinns regarding evaluatien and treatment ef
GED nf the knee are presented.
Backes JR, Durbin TC, Bentley JC, Klingele KE: Mul-
tifncal juvenile nstenchnndritis dissecans nf the knee:
A case series. } Pedintr flrrhep 2914;34i4}:453-453.
Medline DUI
Drthnpeadic Knnwledge Update: Spnrts Mediums 5
 Seetien E: The ”feeling Athlete
Lesiens leeated en the medial femeral cendyle healed at
a statistically significant greater rate than ether lecatiens
within the knee. Sex, age, and asseciated disceid menisci
had ne effect en healing pregnesis. Level ef evidence: IV.
. Jacebi M, lElli-lab] P, Beuaicha 5, Jakeb RP, Gautier E:
Asseciatien between mechanical axis ef the leg and es-
teechendritis dissecans ef the knee: Radiegraphie study
en 103 knees. Am I Sperts Med 2010;33(?}:1415-1413.
Medline DD]
An asseciatien was feund between medial cendyle GED
and vs rus axis, and between lateral cendyle GED and val-
gus axis. This evekes higher leading ef the affected knee
cempartrnent than ef the unaffected knee cempartment;
therefere, axial alignment may be a eefaeter in GED ef
the femeral eendyles. Level ef evidence: IV.
Kijewski R, Blankenhaker DIG, Shinki K, Fine JP, lGraf BK,
De Smet AA: Juvenile versus adult esteechendritis disse-
cans ef the knee: Apprepriate MR imaging criteria fer in—
stability. Redielegy 2i] flflfldflfllfi F1 1573. Medline DID]
1When used tegether, the criteria were lflfl% sensitive and
11% specific fer instability in juvenile 0CD lesiens and
1flfl% sensitive and lflflbh specific fer instability in adult
GED lesiens. Previeusly described MR] criteria fer 0CD
instability have high specificity fer adult but net juvenile
lesiens ef the knee. Level ef evidence: IV.
111}. Jacehs JC Jr, Archibald-Seiffer N, Grimm NL, Carey jL,
Shea KG: A review ef arthrescepic classificatien systems
fer esteechendritis dissecans ef the knee. Clive Sperts Med
E 2fl14;33{2}:189-191Medline DUI
E
:5 Currently, ne arthreseepic classificatien system has been
:1:
Ch
universally accepted. A future classificatien system sheuld
E he develeped that recenciles the discrepancies ameng the
E
3... current systems and prevides a clear, censistent, and reli-
I1: able methed fer classifying GED lesiens ef the knee during
.I:
'— arthrescepy. Level ef evidence: IV.
dd
11. |IEarey JL, Grimm NL: Treatment algeritltm fer estee-
chendritis dissecans ef the knee. Grrhep Gl'irt Netti: Am
2fl15;4fi{1}:14l.—14fi.Medline DUI
Fer unstable yet salvageable GED lesiens, the senier au—
ther's preferred treatment is fixatien with bene grafting.
Fer unstable and unsalvageable GCD lesiens, the senier
auther's preferred treatment is autelegeus chendrecyte
implantatien with heme grafting. Level ef evidence: V.
12. Wall E], Peleusky JD, Shea HG, et al: Research en lL’Istee-
Chflfldritis Disseeans ef the Knee {EDGE} Study GIUIJP:
Nevel radiegraphic feature classificatien ef knee estee-
chendritis dissecans: A multicenter reliability study. .Am
] Sperts Med 2fl15:43{2]:3fl3-309. Medline DD]
Many diagnestic features ef femeral cendyle DIED lesiens
can be reliably classified en plain radiegrapbs, supperting
their future testing in multifacterial classificatien systems
and multieenter research te develep pregnestic algetithms.
|Either radiegraphic features sheuld be excluded, hewever,
because ef peer reliability. Level ef evidence: III.
643 firthnpeaclic Knewledge Update: Sperts Medicine 5
13. Samera WP, Chevillet J, Adler E, Teung GS, Klingele FEE:
Juvenile esteechendritis dissecans ef the knee: Predic-
ters ef lesien stability. I Pedfetr Grthep 2fl12;32{1}:1-4.
Medline DUI
MRI centinues te be reliably sensitive te juvenile 0CD
lesiens and a geed predicter ef lew-grade, stable lesiens.
Hewever, MRI predictability ef high-grade, unstable ju-
venile {3CD lesiens is less reliable. Level ef evidence: IV.
14. Wall E], Veurazeris ], Myer GD, et al: The healing pe-
tcntial ef stable juvenile esteechendritis dissecans knee
lesiens. I Hesse Jet's-t Serg Am Zflflflflfltlllfldfij-EISM.
Medline DD]
In twe-tbirds ef skeletally immature patients, fi menths ef
nensurgical treatment that includes activity medificatien
and immehilisatien results in pregressive healing ef stable
GED lesiens. Lesiens with an increased size and asseciat-
ed swelling andl'er mechanical symptems at presentatien
are less likely te heal. Level ef evidence: III.
15. Krause M, Hapfelmeier A, Miller M, Amling M, Behn—
derf K, Meenen NM: Healing predicters ef stable juve-
nile esteechendritis dissecans knee lesiens after ti and
12 mentbs ef neneperative treatment. Am I Sperts Med
1013:41{10}:2334-2391.Medline but
A E-menth peried ef surgical treatment with er with—
eut casting might be apprepriate if the healing petential
is greater than 43%. A 12-menth peried ef nensurgi-
cal treatment may be successful if the cyst-like lesien is
less than 1.3 mm in length as assessed en MRI. Level ef
evidence: II.
16. Yang IS, Eegunevic L, 1|Wright RT: Neneperative treat-
ment ef esteechendritis dissecans ef the knee. Giirr Sperts
Med 1fl14;33{1j:195-3fl4. Medline DUI
Pregnesis and treatment depend en the stability ef the
lesien and the age ef the patient. Skeletally immature
patients with stable lesiens are amenable fer nensurgical
treatment. Nensurgical treatment is less predictable in
skeletally mature patients and patients with unstable le—
siens. [cvel ef evidence: IV.
1?. Kramer DE, 1I'en ‘I'M, Simeni MK, et al: Surgical man.
agement ef esteechendritis dissecans lesiens ef the patella
and trechlea in the pediatric and adelescent pepulatien.
An: ] Sperts Med 1015;4dl3ltfifi4-Efil. Medline DO]
Surgical treatment ef patellefemeral DIED in children and
adeleseents preduces a high rate ef satisfactien and return
In sperts. Female sex, prelenged duratien ef symptems,
and internal fixatien may be asseciated with werse eut—
cemes. Level ef evidence: IV.
13. Wall E], Heywerth BE, Shea KG, et al: Trechlear greeve
esteechendritis dissecans ef the knee patellefemeral jeint.
j Pedinrr Grthep 2fl14;34{6}:615-63fl. Medline
MRI aids in the diagnesis and staging ef treehlear greeve
{1CD lesiens, as almest half ef these lesiens may net be
identifiable en radiegraphs, and ene-quarter are asseci-
ated with GED lesiens in ether lecatiens ef the same
knee. Multiple surgical treatments can he used te achieve
fl lflld American Academy ef Urthepaedic Surge-ens

healing at reselutien ef symptems in stable and unstable
lesiens; hewever, a larger cemparative study is needed te
make specific recemmendatiens. Level ef evidence: TV.
15". Abeuassaly M, Petersen D. Salci L, et al: Surgical man
agement ef esteechendritis dissecans ef the knee in the
paediatric pepulatien: A systematic review addressing
surgical techniques. it“nee Serg- Sperts Treametef Airfares-c
2014:22jéiflllfi-1224.l‘vlcdlinc DUI
The mest cemmen techniques te treat GED were trans-
articular drilling fer stable lesiens and bieabserbable pin
fixatien fer unstable lesiens. The key findings were that
mest lesiens healed pesteperatively, irrespective ef tech-
nique, and that geed-quality trials are required tn mere
apprepriately camp-are the effectiveness ef techniques.
Level ef evidence: IV.
1f}. Edmends EVE, Albright J, Eastrem T, Chambers HG:
IZl‘utcemes ef estra~articular. intrawepiphyseal drilling fer
esteechendritis dissecans cf the knee. I Pedfntr 011p
101i};3fl{3}:3?fl-3?3. Medline Dfll
Extra—articular, intraepiphyseal drilling ef 0CD lesiens
preduced excellent results ever the histerical centrels using
intra-a rticular drilling fer these patients in whem initial
censervative management failed. This technique ave-ids
intraeperative damage tn the everlying intact articular
cartilage and premetes esseeus healing by feuestratien
ef the scleretic rim surreunding the GED lesien. Level
ef evidence: IV.
21. Adachi I‘ll, Deie l'vl, Nakamae Pt, Ishikawa l'vl, Meteyama
M, |iiichi lvl: Functicnal and radiegraphic eutceme ef sta—
ble juvenile esteechendritis dissecans ef the knee treated
with retrearticular drilling witheut bene grafting. Ar-
tibmsenpy lilflflgljjljfl-ilE—ISZ. Medline Dfll
This study shews that retrearticular drilling witheut bene
grafting leads te imprevecl clinical eutcemes and high
healing rates. Eetrearticular drilling is recemmended fer
patients with stable juvenile {3CD ef the knee in whem ini-
tial nensurgical treatment has failed. Level ef evidence: IV.
22. Eeugha nem J, Riaa R, Patel lib-Ii, SarwarltJF: Functienal
and radiegraphic eutcemes ef juvenile esteechendritis
dissecans ef the knee treated with extra-articular retre-
grade drilling. Arr: ] Spnrts Med lflll;39f10}:2212-121T.
Mctlline DUI
Retregratlc extra-articular drilling previded clinical and
radiegraphic imprevement in mest juveniles with {JED
lesiens in whem nensurgical treatment has failed. This
methed serves te decempress the lesien and allew revas-
cularieatien witheut disrupting the articular cartilage
surface in stable DIED lesiens. Lavel ef evidence: IV.
23. Berna~5erna jD, Martinez F. Reus M. Berna-Mestre
JD: |[listenchendritis dissecans ef the knee: Senegraph-
ically guided percutaneeus drilling. I Uftresermd Med
lflflfi;l?{2}:ESS-259. Mcdlinc
A. 14-year-eld bey had {JED ef the external fcmeral
cendyle. Cenventienal radiegraphy. MRI, and seneg-
raphy revealed the esteechendral lesien. DI] the basis ef
the geed results ebtained in the case, it is theught that
IE! lfllfi American Academy ef flrthepaedic Surgeries
lChapter 4?: flsteecbendrilis Dissecans
senegraphically guided percutaneeus drilling may be a
gee-d alternative te arthrescepic drilling in cases ef early
GED lesiens witheut displacement ef the fragment. Level
ef evidence: IV.
14. Lebelt JR, Wall E]: Retrearticular drilling and benc graft-
ing ef juvenile esteechendritis dissecans ef the knee. Ar-
tbrescepy lflfl?;13{?J:?94.el-?94.e4. Medline DUI
The authers presented an effective technique fer retreat-
ticular drilling and bme grafting ef juvenile GED. Majer
advantages ef this technique include the ease ef harvestilr
transfer ef antegraft, readily available instrumentatien te
perferm the precedure. and the ability te aveid vielatien
ef stable articular cartilage. Level ef evidence: IV.
15. Lykissas MG. Wall E]. Nathan 5: Rene-articular drilling
and bene grafting ef juvenile knee esteechendritis disse-
cans: a technical descriptien. Knee San-g Sparta Traumatic!
Artferesc 2014;22[E]:2?4~2?3. Medline DUI
The geal ef surgery in stable juvenile DIED is te premete
revasculariaatien and reessilicatien ef the esteechendral
fragment by creating channels, linking the subchendral
bene tn the GED lesien. The prepesed technique rep-
resents a premising adjunct fer the management ef stable
juvenile {3CD lesiens that fail tn heal after 3 tn 6 menths
ef nensurgical treatment and fer nendisplaced, unsta-
ble 0CD lesiens that underge internal fixatien. Level ef
evidence: IV.
26. Murray jR. Chimavis J. Disen P. et al: l[Z'Isteechentlritis
dissecans ef the knee; lung-term clinical eutceme fellew-
ing arthrescepic debridement. Knee lflfl?;14{l}:94—93.
Medline D0] F“?
m
The anthers reviewed 32 knees in 26 patients whe had
previously undergene arthrescepic debridement fer E?I:
symptematic DCD ef the knee. Patients undergeing eat- :I
In
cisien ef DIED fragments did wersc than these in whem 1"
the fragment was preserved: hewever. the risk ef further
Fl
E
n:
surgery was raised if a fragment was left in situ during re
P.
initial surgery. Level ef evidence: IV.
2?. Magnussen RH, |Earey IL, Spindler KP: Dues epcrative
fixatien ef an esteechendritis dissecans leese bedy result
in healing and leng-term maintenance ef knee functieni'
Art: ] Sparta Med 2099;}?{4jfl54 J59. Medliue Dfll
Surgical fixatien ef grade IV DIED leese bedies results
in stable fixatien. At an average cf 9 years after surgery,
patients had ne symptems ef esteearthritis pain and had
nermal functie-n in activities ef daily living. Hewever, pa-
tients reperted substantially reduced knee—related quality
ef life. Surgical fisatien ef {JED leese bedies is a better
altemative te lesien escisien. Level ef evidence: IV.
2.8. Trinh TQ, Harris JD. Flanigan DC: Surgical management
ef juvenile esteechendritis dissecans nf the knee. Knee
Burg Sports Treamntel Arthresc 101 lfiflflljfl‘l-l $2419.
Mcdline D01
Surgical treatment ef juvenile {JED has substantially im-
preved clinical and radiegraphic eutcemes at shert-, mid-,
and lung-term fellew-up. Ne difference in clinical er radie-
graphic eutceme was demenstrated in camparing different
Drthepeadic Knewledge Update: Sperrs lvledichie 5
 Sectien E: The Teung Athlete
surgical techniques, with the exceptien ef peerer results
with iselated fragment excisien. Level ef evidence: IV.
29. Adachi N, Deie M, Nakamae A, Ukuhara A, Kamei G,
|lClIchi M: Functiena] and radiegraphic eutcemes ef unsta-
ble juvenile esteechendritis dissecans ef the knee treated
with lesien fixatien using bieahserhable pins. J Pediatr
Orthep 2U15:35{I]:31-EE. Mediine DUI
The fixatien ef the unstable juvenile DIED lesinns with
binabserbable pins demenstrated imprnved clinical eut-
cemes and radiegraphic high healing rates at a mean ef
3.3 years ef fellew-up. This precedure is advecated fer
patients with unstable juvenile DCD lesinns ef sufficient
quality te enable fixatien, which will preserve the nermal
centeur ef the distal femur. Level ef evidence: IV.
3|]. Carey JL, Grimm NL: Treatment algerithm fer es—
teechendritis dissecans ef the knee. Chit: Sperts Med
2fl14;33{2}:375-332.Medline DD]
Fer unstable yet salvageable DCD lesinns, the senier au-
ther‘s preferred treatment is fixatien with bene grafting.
Fer unstable and unsalvageable {JED lesiens, the senier
auther's preferred treatment is autelegeus chendrecyte
implantatien with bene grafting. Level ef evidence: IV.
31. Kecher MS, Cearnecki J], Andersen J5, Micheli L]: In-
ternal fixatinn ef juvenile esteechendritis dissecans le-
siens ef the knee. film I Sperts Med EDGEM{5 1:?12J13.
Medline DID]
lEiven the relatively high healing rate, geed functienal
eutceme, and lew cemplicatien rate, the anthers advncate
E internal fixatien c-f unstable juvenile DEED lesinns ef the
E
:5 knee, even fer detached lesinns and in patients with a his-
:1:
Ch
tery ef surgery fer the GED lesien. Level ef evidence: IV.
E fer children yennger than 13 years. Level ef evidence: I.
E
3... 32. |Camathias C, Fesn'ing JD, Ga sten MS: Eieabserhahle lag
I1:
.I:
screw fixatien ef knee nsteechnndritis dissecans in the
|_-
skeletally immature. } Pediatr Drthep B 1fl11,1fl{1}:?4-
id Sfl. Medline DUI
There was substantial imprevement in knee functien
sceres, with all patients reperting imprnvement er much
imprevement in functien. Simple arthrescepic fixatien
ef GED with SmartScrews is prepesed as an effective
treatment in the pediatric pepulatinn leading te a rapid
recnvery nf premerbid functien. Level ef evidence: IV.
33. |Grimm NL, Ewing CK, Ganley T]: The knee: Internal
fixatinn techniques fer esteechendritis dissecans. flit:
Sperts Med 2014:33{2}:313-319. Mcdline DID]
Per the athlete with a newly diagnesed DC]:- ef the knee,
the first step in fermulating a treatment plan is determin-
ing the stability nf the lesien. Determining the must ap-
prepriate methed fer fisatien depends en several variables
and sheuld include the athlete's level ef play, spert, and
nveralI geals. Level ef evidence: IV.
34. Camathias C, Gegfls U, Hirschmann MT, et a1: Implant
failure after biedegradable screw fixatien in nstenchendri-
tis dissecans ef the knee in skeletally immature patients.
Arthrescepy Efl15:31{3}:41fl-415. Medline DD]
@ Drthnpeadic Knewledge Update: Sperts Medicine 5
This series reperted a 23% rate ef failurel'fracture ef bie-
abserbable screws asseciated with GED lesien fiscal-inn.
Level nf evidence: IV.
35. Miniaci A, Tytherleigh-Strnng G: Fixatien ef unstable
esteechendritis dissecans lesinns ef the knee using arthre-
scepic autegeneus esteechendral grafting {mesaicplasty}.
Arthrescepy Zflfl?:23[3]:345-351. Medline DD]
Autegeneus esteechendral grafting ef unstable 0CD
lesinns in the knee is a reliable and minimally invasive
technique that prevides a stable bielegic fixatien using
autegeneus bene graft and has few cemplicatiens. Level
ef evidence: IV.
36. Miura K, Ishibashi ”'1’, Tsuda E, Sate H, Tnh 5: Results ef
arthrescepic fixatinn ef esteechendritis dissecans lesien cf
the knee with cylindrical autegeneus esteechendral plugs.
Am I Spars: Med Eflfl?;35l3}:215-222. MECIIIIIE DUI
Bielegic fixatinn ef 0CD lesinns with cylindrical estee-
chendral autegraft previded healing nf the esteechendral
fragments. Level of evidence: IV.
3?. Gudas R, Simenaityte R, Cekanauskas E, Tamnsiflnas R:
A prespective, randernired clinical study ef esteechen—
dral autelegeus transplantatien versus micrefracture fer
the treatment ef esteechendritis dissecans in the knee
jeint in children. } Pedintr firthep Iflfl9;19{T}:?41-?43.
Medline DDI
At an average ef 4.2 years fellew-up, a prespective, ran-
demieed, clinical study in children yeunger than 13 years
shewed significant superierity ef the mnsaic-type DAT
ever micrefracture fer the treatment ef DEID defects in
the knee. Hewever, the study has shewn that hath rnicre-
fracture and DAT previde enceuraging clinical results
33. Lint: F, Pujel H, Pandeirada C, Enisrenenlt P, Eeaufils P:
Hybrid fixatien: Evaluatien ef a nevel technique in adult
esteechendritis dissecans ef the knee. Knee 5mg Spares
Trenrrretef Arthresc 2011;19f‘llfififl-5T1. Medline DDI
This premising technique cembines bielegic fixatien us-
ing an autegraft esteechendral plug with metallic screw
fixatien. Level ef evidence: IV.
39. Nishimura A, Merita A, Fukuda A, Kate K, Sude A:
Functienal recevery ef the dener knee after autelegeus
esteechendral transplantatien fer capitellar esteechen-
dritis dissecans. first I Spert‘s Med 1D11;39{4}:333-342.
Medline DDI
A time lag in recevery was reperted between pestepera-
tive symptems and muscle pewer at 3 menths. Hewever,
harvesting esteechendral grafts did net have adverse ef-
fects en dener knee functien in yeung athletes at 2 years
fellewing esteechendral autegraft transplantatien fer
capitellar DCD. Level ef evidence: IV.
40. Filarde G, Ken E, Berrutn M, et a1: Arthrescepic sec-
end generatien autelegeus chendrecytes implantatinn
asseciated with bene grafting fer the treatment ef knee
fl lfllti American Academy ef Drrhepaedic Surge-ens

usteuchundritis dissecans: Results at 6 years. Knee
2312;13i5}:653-633.Mcdline DUI
Secund—generatiun AC] assuciated with hune grafting is
a valid treatment uptiun fur knee UCD and may uffer
a guud, stable clinical untcume at a mean fulluw-up uf
6 years. Additiunal studies are needed tu cunfirm the re—
sults uver time, and tu determine if the impruvement is
unly symptumatic, at if this prucedure may alsc: prevent
c-r delay further knee degeneratiun. Level uf evidence: IV.
41. Krishnan 3P, Skinner JA, Earringtun KW, Flanagan AM,
Briggs T‘ilif, Bentley G: Eullagen-cuvered autuluguus chun-
drucyte implantatiun fur usteuchundritis dissecans uf the
knee: Twu- tu seven-year results. I Harte jufrtt Surg Br
1335;333i1}:1i}3-135. Medline DUI
The study included 3? patients who were evaluated at
a mean fulluw—up uf 4.03 years. The age at the time uf
cullagen-cuvered AC1 determined the clinical uutcume fur
juvenile-unset disease {P = 3.35}, whereas the size cf the
defect was the maiur determinant uf uutcume in adult—un-
set disease iP = (Lilli. Level uf evidence: III.
42. Lyun R, Hissen C, Liu If}, Curtin E: Can fresh usteu-
chundral allugrafts resture functiun in juveniles with us-
teuchundritis dissecans cf the knee? CHI: Urtfeup Relat
Res zulsgsvnajntss-uvs. Medline DUI
The authurs suggested that fresh usteuchundral allugrafts
restured shurt-term functiun in patients whuse juvenile
UCD did nut respund tu standard treatments. Level uf
evidence: IV.
43. Murphy R, Pennuck AT, Bugbee WD: Usteuchundral
allugraft transplantatiun cf the knee in pediatric and adu-
lescent pupulatiun. Arr: I Spurts Med 2014:42i3}:635-E4D.
Medline DUI
With 33% guudfexcellent results and 33% salvage rate uf
clinical failures with an additic-nal allugraft, usteuchun-
dral allugraft transpla ntatiun is a useful treatment uptiun
in pediatric and adulescent patients. Level uf evidence: IV.
44. Murphy RT, Pennuck AT, Bughee TD: Dsteuchundral
allc-graft transplantatiun cf the knee in the pediatric and
adulescent pupulatiun. Arr: I Spurts Med 2314;42{3}:335-
340‘. Medline DUI
Usteuchundral allugra ft transplantatiun was shuwn tu
he a useful treatment uptiun in pediatric and adulescent
patients, with 33% guudfexcellent results and 33% salvage
rate uf clinical failures with an additiunal allugra ft. Level
uf evidence: TV.
45. Nissen CW: flsteuchundritis dissecans cf the elbuw. Elie
Spurrs Med lfll4;33l{2j:251-265. Medliue DUI
UCD affects the elbow uf many yuung, skeletally imma-
ture athletes. There is a predilectiun fur these invulved
in uverhead—duminant spurts and spurts that require the
arm tu he a weight-hearing limh. Lewl uf evidence: IV.
Nishitani I-‘i, Nakagawa T, Gutuh T, Kuhayashi M,
Nakamura T: Intrauperative acuustic evaluatiuu uf
living human cartilage cf the elbuw and knee during
ID 2316 American Academy uf Urehupaedic Surgeuns
l[L‘hapter 4?: Uste-uchuudrilis Dissecans
musaicplasty fc-r usteuchundritis dissecans cf the elhuw:
An in vivu study. Am I Spurrs Med lDflE;36{12}:3345-
2353. Medline DUI
The UCD lesiun had luwer signal intensity than did the
intact part cf the capitellnm. Althuugh the macruscupic
view lucked intact, the radial head cartilage was degen-
erated as measured acuustically. Level uf evidence: TV.
4?. Ahmad CS, Vitale MA, Elfittrache N3: Elhuw arthrus-
cupy: |Capitellar usteuchundritis dissecans and radiucap-
itellar plica. Instr Cuarse Leer 2311;153:1314 93. Medline
Radiucapitellar plica can cause chundrumalacic changes
en the radial head and capitellum, with symptums in-
cluding painful clicking and effusiuns. Arthruscupic plica
resectiun is indicated when nunsurgical treatment fails.
Level cf evidence: IV
43. Chen NC: Usteechundritis dissecans cf the elhuw. j' Hand
Surg Arr: 2313;35[?}:1133-1133. Mcdline DUI
Euth recunstructiun and arthruscupic dehridement yield
nutahle impruvement after surgery. There is sume evidence
that recunstructiun yields better results than débride-
ment fur larger defects at mid—term fulluw-up. Level uf
evidence: IV.
43. de Graaff F, Krijnen MR, Puulman aw, 1|ilii'illems W]:
Arthruscupic surgery in athletes with usteuchundritis dis-
secans [If the elh-uw. Arthruscupy 2311;2?{?}:936-993.
Medline DUI
This review suggests that surgical treatment must be cun-
sidered fur athletes with UCD after a periud uf unsuc- F“?
cessful nunsurgical therapy. Nevertheless, larger studies
with enhanced methc-dulugic quality and [anger fcrlluw-up :1:
shuuld he perfurmed tu suppurt this cunclusiun. Level uf 3:I:
evidence: III. ::
ID
1"
SD. Arai Y, Hara Ii, Fujiwara H, Minami G, Nakagawa Fl
E
5, Kuhu T: .4. new arthruscupic-assisted drilling meth- n:
:1:
Fl
ud thruugh the radius in a distal-tu-prmtimal directiun
fur usteuchundritis dissecans cf the elhuw. Artbruscupy
2Ufl3:24{2]l:23?.el-23?.e4.Medline DUI
1|iiii'ith this technique, the entire UCD lesiun can he verti-
cally drilled under arthruscupic guidance. This methud
is minimally invasive, and an early return tn spurts cuuld
he pussihle. Level uf evidence: IV.
51. Rahuseu FT, Erinkman li, Eygendaal D: Results uf
arthruscupic dehridement fur usteuchundritis dissecans
uf the elhuw. Br ,I Spurts Med 2336;40j12}:966-939.
Medline DUI
The clinical uutcume after arthruscupic dehridement fur
DIED uf the elhuw shuws guud results, with pain relief
during activities crf daily living and spurt. The functiun
DI the elhuw, as reflected by the mudilied findrews elbuw
scuriug system scure, impruved frum puur tu excellent.
Level uf evidence: IV.
.52.. Shi LL, Bae D5, Kucher MS, Michell LJ, Wa-
ters PM: Cuntained versus uncuntained lesiuns in
Urthupeadic Knuwledge Update: Spurts Medichte S
 Sectian E: The 1fuming Athlete
juvenile elbaw asteachandritis dissecans. j Pediatr flrrbap
2fl12;32{3}:221-125.Medline Dfll
At shart-term fallaw—up, uncantained elbaw 0CD lesians
have greater flexian cantracture when campared with
cantained lesians. Elbaw 0CD lesians alsa have higher
rates af jaint effusic-n and are braader and shallawer. Icvel
af evidence: IV.
53. Tania mata Y, Ishibashi Y, Tsuda E, Sata H, Tab 5: Listen-
chandral autagraft transplantatian far asteachandritis dis-
secans cf the elbaw in juvenile baseball players: Minimum
2-year fallaw-up. Am 1 Sparta Med lflflfi:34{5}:?14-?2fl.
Medline DUI
l[I'lstea-chandral autagraft transplantatian is a useful treat-
ment far reattachment cf the lesian as well as asteachan—
dral resurfacing af elbaw DELI. Level af evidence: IV.
54. Iwasaki bl, Kata H, Ishikawa J, lvlasuka T, Funakashi
T, Minami A: Autalagaus asteachandral masaicplasty
far asteachandritis dissecans cf the elbaw in teenage
athletes. } Barre Jl'afrrt Surg Am 2009;91j10}:1359-136£.
Medlinc D0]
The mean clinical scc-re described by Timmennan and
Andrews {with a maximum af Elli} paints] impraved sig-
nificantly fram 131 +.I'- 13 paints preaperatively ta 191
+f— 15 paints pastaperativcly {P e flflflflll. The current
midterm results indicate that masaicplasty can pravide
satisfactary clinical autcames far teenage athletes with
advanced capitellar 0CD lesians. Level af evidence: IV.
55. Habuta S, Ugawa K, Sata K, Nakagawa T, Hatari M, Itai
E E: Clinical autcame af fragment fixatian far asteachandri-
E
:5 tis dissecans cf the elbaw. Ups 1 Med Sci lflfllifllfijlhlfll-
all:
Eh
2GB. Medline DUI
E Sparta Traumntaf Artbrasc 2013;21jfl}:1915-1930.
E
3...
Fragment fixatian far 0CD af the humeral capitellum was
I1:
effective in patients whase lesian thickness was less than
.I:
'— 9 mm. Fixatian by flexible wire cr thread and revascu-
Ed Iariaatian by drilling far the fragment were cansidered ta
be insufficient far large lesians with a thickness af 9 mm
ar mare. Level af evidence: IV.
5'6 . Miyamata Ill-l, Yamamata 5, Eli R, Uchia ‘1’: lIDblivque as-
teachandral plugs transplantatian technique far astea-
chandritis disseca ns af the elb-aw jaint. Knee Surg Sparta
Traumataf Arthraac lflfi9;1?[lj:ED4-lflfl. Medline DD]
This pracedure addresses same cf the challenges assaci—
ated with the placement af asteachandral autagrafts in the
elbaw jnint, clue tn the smaller size bf and limited access
tn the capitellum. Level af evidence: IV.
5?. |Elanale ST, Eelding RH: Usteacbandral lesians cf the talus.
I Bane faint Sarg Arr: Iflflflfiljlkfillfll. Medline
Lang—term results indicated that few lesians unite when
treated nansurgically. Degenerative changes in the ankle
jnint, whether symptamatic nr nat, were camman {sass
af the ankles} regardless af the type af treattnent. Level
af evidence: IV.
firthapeadic Knawledge Update: Sparta Medicine 5
53. Wnelfle jV, Reichel H, Javaheripaur—Dtta K, Nellte l'vI:
Clinical autcame and magnetic resanance imaging after
asteachandral autalagaua transplantatian in asteachandri-
tis dissecans cf the talus. Feat Ankle let 2013:34j2}:1?3-
1?9. Medline DUI
DAT was reparted as a safe pracedure with gnarl clinical
results far talar DEL}. Because an abnnrmal MRI finding
was nat necessarily diagnastically canclusive, llI might
be af limited value in pastaperative fallaw—up. Level af
evidence: IV.
59. Zwingmann J, Siidkamp NP, Schmal H, Niemeyer P:
Surgical treatment af asteachandritis dissecans af the
talus: A systematic review. Arch Urthap Trauma Surg
lDIEflSElfljfllfl-Ilfil}. Medline DUI
Althaugh GED cf the talus represents a frequently ab-
served arthapaedic pathalagy, evidence cancerning sur-
gical treatment af talar DCD is still lacking. Pram this
study af mare than 1,1fIfl patients, na strang rccammeu—
datians can be given based an scientific evidence. Level
af evidence: IV.
ED. Petumal V, Wall E, Babekir N: Juvenile asteachandritis
dissecans cf the talus. I Pediatr Grids-up 2f] U?:2?[TI:EEI-
315. .Medline DUI
In skeletally immature patients, few juvenile OED cf the
talus lesians respand ta 6 manths cf nnnsurgical treat-
ment. Surgery shauld be adapted if pain persists and if
the patient is nat willing tn mcdify activities. Level of
evidence: IV.
61. Waellle JV, Reichel H, Nelita lvl: Indicatians and lim—
itatians af asteachandral autalagaus transplantatian
in asteachandritis dissecans af the talus. Knee Saarg
Medline Dfll
{DAT is a safe pracedure with gacd clinical results in talar
GED. Because advanced age is assaciated with increased
danar site marbidity, indicatians far DAT in alder pa-
tients shauld be carefully cansidercd. Because an ether
variables affected the clinical autcame af DAT adversely,
na cantraindicatians exist far DAT {far example, in as-
teachandral lesians requiring mate than ane graft, lateral
lesic-ns, patients with bady mass index greater than 25 kg:r
n11, preexisting asteaarthritis, ar unsuccessful previaus
surgery}. Level af evidence: IV.
62. Talusan PG, Milewslti MD, Tay JD, Wall E]: |[listen-
chandritis dissecans af the talus: Diagnasis and treat—
ment in athletes. {The Sparta Med 2014:33j2]:26?—234.
Medline DD]
DIED af the talus is a subset af asteachandral lesians
af the talus that alsa includes asteachandral fractures,
aeteanecrasis, and degenerative arthritis. II'.l'-'stcach-::sndral
lesians cf the talus can be assaciated with ankle injury.
This article discusses the anatamy, pathaanatamy, histary,
physical cxamiuatian, imaging, management algarithm,
and autcames af surgical treatment af asteachandral le-
sians in these patients. Level af evidence: IV.
fl lfllfi American Academy cf Cirrhapaedic Surge-ans
Chapter 48
Anterior Cruciate Ligament Tears
in Skeletally Immature Athletes
Benton E. Heyworth. MD Melissa A. Christine. MI}
Anterior cruciate ligament {ACL} tears are becoming
increasingly common injuries in young athletes, with
surgical treatment in the skeletally immature knee
posing unique challenges. Surgical intervention using
physeal—sparing or physeal—respecting techniques are the
preferred treatment strategies and have been shown to
be successful at restoring knee stability and function-
ality while avoiding iatrogenic growth disturbance or
deformity. Because of the uniquely high activity level of
children and adolescents, establishing reliable strategies
to prevent ACL tear and retear, still in their nascent
stages for this age group, requires special attention
and advancement.
Keywords: anterior cruciate ligament; ACL;
pediatric sports: sports injuries: pediatric ACL
Introduction
Anterior cruciate ligament {ACL} tcars in children and
adolescents, previouslyr perceived as a rare clinical entity,
are now increasingly common injuries being treated by
orthopaedic surgeons throughout the United States and
internationally. Sports-related injuries in children have
increased as a result of higher participation rates, high—
er levels of competition, and earlier focus on individual
sports.“2 “Whereas tibial spine avulsion fractures were
Dr. Heyworth or an immediate family member serves as
a board member. owner: officer: or committee member
of the American Drthopaeo‘ic Society for Sports Medicine
and the Pediatric Drthopaedic Society of North America.
Neither Dr. Christioo nor any immediate family member
has received anything of value from or has stoclr: or stock
options heici in a commerciai company orinstitution related
directly or indirectly to the subject of this chapter.
fl lflld American Academy of Drtbopaedic Surgeons
historically considered the pediatric equivalent of an adult
ACL tear, intrasubsta nce ACL ruptures are occurring
more commonly in skeletally immature patients of var-
ied age.J Because children have important anatomic and
physiologic differences from adults, treatment algorithms
for young athletes with ACL tears have evolved to respect
these differences.
The Growing Athlete
The physes, or growth plates, generate the longitudinal
growth of the human skeleton. In children, the cartilag-
inous physes are open, or biologically active, and are
therefore vulnerable to metabolic or mechanical injury
that can cause angular deformity of the extremity or
fiunoy, aq_|_ :g
growth arrest. The two growth plates around the knee
are the fastest growing physes in the lower extremity
and are vulnerable to growth disturbance resulting from
surgical intervention for ACL reconstruction. The distal
femoral physis accounts for approximately 10 mm of
atajuw
growth per year, and the proximal tibial physis accounts
for approximately 6 mm of growth per year. Skeletal
maturity is attained after the growth plates of the long
bones have closed, or ossified, and this generally occurs
after puberty [in girls, at approximately age 14.5 years;
in boys, at approximately age 16.5 years}.M Females
grow for approximately .1 years after menarche, and
their peak height velocity occurs at approximately 11.5
years; the peak height velocity for males occurs later,
at approximately 13.5 years. Based on the presence or
absence of secondary sex characteristics at the onset
of puberty, physiologic maturity can be estimated us-
ing the Tanner staging system.E However, because of
challenges in assessing Tanner stage in adolescents and
preadolescents in the office setting, as well as recent
literature demonstrating large interobserver variability
among sports medicine surgeons using this systemfi" the
standard of care for the assessment of skeletal maturity
has evolved to include radiographs of the left hand to
determine bone age, with estimates of skeletal age using
Drthopaedic Knowledge Update: Sports Medicine 5
 Section B: The Young Athlete
SBA Method: A Stepwise Approach
Male ages
{in years}:
Female ages
{in years)
E with partial transpbyseal and all-epiphyseal reconstruc-
E Figure 1 Illustrations demonstrate stepwise shorthand
:5 bone age assessment {SBA}- {Reproduced
s1:
with permission from Heyworth BE, Dsei DA,
Eh
E Fabricant PD, et al: The shorthand bone age
d
3... assessment: A simpler afternative to current
I1: methods. J Pediatr Orthop 2013;33l5]:5l59-5?4.
I
|_-
id
the Greulich and Pyle Atlas” or more efficient shorthand
methods derived from the atlas” {Figure 1}.
Despite the rapid growth changes occurring around
the time of puberty, the position of the ACL footprint
on the lateral femoral condyle within the intercondylar
notch is unchanged and remains close to the distal fem-
oral physis. A. cadaver study showed the distance from
the femoral AEL footprint to the distal femoral physis
remained constant (slightly less than 3 mm} from fetal
stages through adolescence.” Although this relationship
does not change with age and growth, anatomic varia-
tions about the lcnee esist during development. An MRI
study of adolescent patients with open physes showed that
intercondylar notch volume was substantially smaller in
a population of patients with ACL tears than in those
without; notch volume was also found to be substantially
smaller in girls than in boys.” The anatomic variations
firthopaedic Knowledge Update: Sports Medichie 5
in notch volume can therefore increase predisposition to
ACL injury.
1When considering surgical intervention in growing
children and adolescents, it is paramount to avoid iatro-
genic injury to the growth plate that can cause growth dis-
turbance. Cine rabbit model demonstrated that although
disruption of 3% of the cross-sectional surface area of
the distal femoral growth plate did not cause growth
disturbance, disruption of ass or more caused substantial
growth disturbance.” A subsequent rabbit study showed
that although 3% physeal disruption in the distal femur
did not cause growth disturbance, both valgus angulation
and growth arrest were observed with 4% cross-sectional
disruption in the proximal tibial physis.” Because phys—
eal volume increases with age, the percentage of physeal
disruption from a given reamer size was less in the older
children studied.” Moreover, tunnel diameter and graft
size had the largest effect on determining the volume of
growth plate disruption in children age ID to 15 years
because of nonlinear variable relationships. Similarly, a
computer simulation model showed that because the vol-
ume of physeal damage influenced growth arrest, the ef-
fects of dou ble—bundle drilling on the distal femoral physis
should be avoided in skeletally immature patients." A
recent clinical MRI study in skeletally immature patients
suggested that some degree of physeal disruption occurs
tion techniques, which are described in greater detail later
in this chapter.“‘ However, at short—term follow—up, this
disruption had not translated into clinically significant
sequelae of altered alignment or limb-length discrepancy.
Elvergrowth has also been a reported concern in pre-
pubescent children undergoing ACL reconstruction.”11
Minimizing iatrogenic damage to the distal femoral and
proximal tibia physes, if not avoiding them altogether,
remains a central objective in the management of ACL
injuries in children with substantial growth remaining.
Patient Historyl'Mechanism of Injury
The mechanism of injury for ACL tears in skeletally
immature patients is similar to that of adults, in whom
either contact or noncontact lcnee twisting injuries oc-
cur. Patients often report hearing a “pop," followed by
substantial effusion and pain. ACL tears were identified
in 12% of patients age ll} to 14 years and in 4d% of
patients age 15 to 13 years who presented with an acute
hemartbrosis.“ Young patients can also have a delayed
presentation, with reports of continued pain, instability,
and effusions after a remote injury. Patients with a delayed
presentation may have been evaluated previously for their
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 43: Anterior Cruciate Ligament Tears in Skeletally bnmature Athletes
injury but the diagnosis of an ACL tear may not have been
considered because of their age.
Risk Factors
Recent evidence suggests that pediatric and adolescent
patients who engage in high activity levels and year—
round sport specialization may be at increased risk for
the development ofACL injuries.1-”-3 Females younger
than 13 years have been noted to sustain more overuse
and soft- tissue spurts injuries compared with malesfi‘l-if
and females are significantly more likely to sustain ACL
tears than males.“*” Because of age—based differences
in the ratio of collagen types in the ligaments, skeletally
immature children generally have more ligamentous laxity
than adults, and laxity has also been proposed as a risk
factor for ACL tears.”
Physical Examination
In the first 3 to 4 weeks following an ACL injury in a
child, the physical examination usually reveals an ef—
fusion, decreased range of motion, and varied ability
to comfortably bear weight. In skeletally immature pa-
tients with open physes, Salter—Harris physeal fractures
should always be included in the differential diagnosis,
and bony palpation of the growth plates and varusfvalgus
stability testing should be performed. The presence of
hypermobility or generalized ligamentous laxity should
be assessed, and the stability of the contralateral knee
tested because greater variability exists in ligamentous
examination results in children than in adults. Standing
leg alignment should also be assessed and documented;
however, in the acute postinjuty setting, this may have to
be performed with the patient supine. Anterior drawer,
Lachman, and pivot shift test results will be asymmetric
from the contralateral knee in a patient with a complete
ACL tear. Some evidence exists that in the rare partial
ACL tear, which can primarily involve one bundle of the
ligament, a positive pivot shift test result correlates highly
with disruption of the posterolateral bundle.” The patient
also may demonstrate other findings on physical exam—
ination consistent with concomitant knee injuries such as
meniscal tears, chondral injuries, or other ligamentous
injuries. Depending on the age and comfort level of the
child, level of cooperation with the examination can vary,
and the most reliable examination will be under general
anesthesia, making it a critical confirmatory step before
all knee procedures.
Imaging
Knee radiographs should be obtained to rule out bony
abnormalities such as fractures, tibial spine avulsions,
oseeochondral injuries, or physeal injuries. However, MRI
IE! Eillfi American Academy of flrthopaedic Surgeons
is the imaging test of choice to confirm a suspected ACL
tear. Because the diagnostic efficacy of MRI in evaluating
children’s knees has previously been questioned,” 3T
MRI has more recently been shown to have a high level of
accuracy in diagnosing ACL tears in children and teenag-
ers, and therefore can be valuable if there are questionable
or equivocal findings with lower resolution studiessl‘l A
PA radiograph of the left band should be obtained, and
the bone age determined with the Greulich and Pyle At-
las”I or a shorthand method.11 This information is used
for ACL preoperative planning purposes to determine
whether a physeal—spariug, physeal—respecting, partial
transphyseal, or traditional transphyseal reconstruction
technique should be used.
Associated Injuries
Additional knee injuries are common in children and
adolescents with ACL tears, including meniscal tears,
chondral injuries, and ligamentous injuries.“ In a review
of 124 skeletally immature patients with acute ACL tears,
the prevalence of meniscal tears was 69.3%, and lateral
meniscal tea rs were more common than medial meniscus
tears, as with adults:H Another study demonstrated that
children with ACL tears and open physes had similar
rates of meniscal tears and chondral injuries compared
with children with closed physes.“ Medial meniscus tears
have been associated with greater patient weight and age F“?
older than 15 years, and patients with both an ACL tear
m
and a meniscal tear are at higher risk for chondral injury
E?I:
in the affected meniscal compartment.” Delay in AOL :I
In
surgery in children has also been associated with higher 1"
rates and severity of medial meniscus tears and chondral
Fl
E
as
injuries?” and the number of instability episodes has as
F.
been found to be an independent predictor of su bsequeut
intra-articular injuryfiiii’i
Nonsurqical Management
Historically, children with A’CL tears were treated by
delaying ACL reconstruction until skeletal maturity to
avoid the potential risk of physeal damage during recon-
struction that could result in longitudinal growth dis-
turbance or deformity. However, multiple recent studies
have continued to substantiate more historic evidence,
which suggested that nonsurgical management of pe-
diatric ACL injuries, even with bracing and attempted
activity modification, has poor results because of undue
risk of meniscal and chondral injuries, even in the first I
to 2 years after injury.3”3135-3‘5-39'“ A recent meta-analysis
suggested that early surgical treatment of pediatric ACL
injuries has more favorable outcomes than nonsurgical or
delayed surgical management.“ Nonsurgical management
Drthopaedic Knowledge Update: Sports Medichse .‘i
 Section E: The Young Athlete
of ACL injuries in the skeletally immature should be re-
served for patients with low-grade partial ACL tears in
knees without instability, particularly without rotational
instability,” and for patients who have substantial medi-
cal or psychologic barriers to surgery or compliance with
postoperative rehabilitation.
Surgical Management
Surgical management of ACL tears in active, skeletally
immature patients has become the preferred treatment
strategy to sta bilixe the knee, thereby protecting the knee
from cartilage and meniscal injuries, and more safely al-
lowing functional participation in activities with cutting
andi'or pivoting exposuresflfr‘"r In adolescents approaching
skeletal maturity who have minimal growth remaining
{skeletal age: older than 13 years for girls, older than 14
years for boys], traditional transphyseal ACL reconstruc-
tion can be considered because the potential for clinical-
ly significant growth arrest is minimal at this stage of
maturity.” For younger patients, traditional techniques,
particularly those involving the placement of graft bone
plugs {for example, patellar tendon} or implants across
the physis, can adversely affect the growing athlete’s phy-
sis.”'” Multiple techniques have been described to avoid
growth complications in prepubescent patients, which
E involve minimal to no growth plate violation and fixation
E away from the physes [Figure 2].
:5
:1: Recent high—level evidence suggests that allograft has a
higher failure rate in young patients than autograft, and
Ch
E
S
3... should therefore ideally be avoided in children undergoing
I1:
.I:
|_- ACL reconstruction.‘9~5“ Patellar tendon grafts, which
dd involve use of bone plugs on the graft, are generally also
a suboptimal graft choice in young children because of
the greater potential of forming a tethering bony bridge
across the growth plate if bone plugs are placed or fixed
in the area of the physis. Thus, hamstring or iliotibial
band {ITB} autograft are the most common graft choices.
Physeal-sparing techniques have demonstrated successful
clinical results, with few reported instances of growth
disturbance.
Extraphyseal
The outcomes of a combined intra-articularfextra-articu-
lar reconstruction using ITE autograft were described in
44 skeletally immature patients with a follow—up period
longer than 5 years5‘-” {Figure 2, A}. In this technique,
the [TB remains attached to the Gordy tubercle distally
and a free limb of graft tissue is harvested proximally,
tubularized, wrapped around the posterior lateral femoral
condyle, and passed through the intercondylar notch in
the over-the-top position and under the intermeniscal
firthopaedic Knowledge Update: Sports Ivledicine 5
ligament in a small trough in the proximal tibial epiphysis.
For femoral fixation, the graft is sutured to the postero-
Iateral periosteum of the lateral femoral condyle and cap-
sular tissue, and tibial fixation is achieved by suturing the
free graft end to the metaphyseal tibial periosteum distal
to the proximal tibial growth plate. 1With tendon—to—bone
healing of the graft in the epiphyseal tibial trough over
time, tibial fixation eventually approximates the native
ACL footprint. Excellent results have been reported with
this technique, with no reported instances of growth dis-
turbance, a low graft failure rate, and a revision rate of
4.5%.
Although the extra-articular ITE technique can place
the ACL graft in a relatively less anatomic position than
other described techniques, biomechanical studies have
suggested that ITB reconstruction restores anterior-pos-
terior and rotational stability to a greater degree than
all-epiphyseal and over-the-top transtibial techniques,
possibly to the point of overconstraint, although the
implant-based fixation approach in these adult cadaver
models does not mirror the periosteal suture fixation in-
herent in the described tech nique.” Importantly, the [TB
technique precludes the need for implants, protects phys—
eal function according to medium-term follow-up studies,
and optimizes future options for revision in case of re-
tear, which appears to be rare. Figure 3 is an algorith-
mic approach to pediatric ACL injuries that is currently
used}1 Longer term and higher volume studies are needed
to further elucidate the outcomes for this technique.
All-Epiphyseal
Several techniques for all-epiphyseal reconstruction have
been described in small series. Although the drilling of
femoral and tibial epiphyseal tunnels can facilitate more
anatomic positioning of the ACL graft relative to its native
footprint, imaging guidance and technical precision are
required to position tunnels within the epiphyseal bone
while avoiding injury to the physis or articular cartilage.
A technique has been described in which femoral and
tibial epiphyseal tunnels are established using fluoroscopic
guidance, and a quadruple hamstring autograft is secured
with suspensory fixation on the femur and a screw-and-
post construct on the tibial metaphysis“ (Figure 2, B].
A In a series of 12 patients, excellent postoperative sta-
bility and functional outcomes were reported. Femoral
and tibial interference screws were used for epiphyseal
fixation and demonstrated that the use of intraopera-
tivc CT scan with three—dimensional reconstruction can
help avoid physeal injury” {Figure 2, C]. An all-inside,
all-epiphyseal, triple-looped semitendinosus technique
has been described that used retrograde drilling with
fluoroscopic guidance and adjustable-loop, suspensory
fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 43: Anterior Cruciate Ligament Tears in Elmehtally bnmacure Athletes

F“?
m
3:
I:
:r
u:
1"
Fl

E
re
re
P.

D
Figure 2 lllustratinns depict anterinr cruciate ligament recunstructinn techniques tn amid grewth camplicatiens in
prepubescent patients. A. The Micheli technique at intra-articula rIestra-articular extra physeal recenstructicrn
using ilietibial band autegraft. {Repreduced with perrnissien frem flbcher M5, Earg 5, Micheli LJ: Physeal sparing
recenstructien cIf the anterinr cruciate ligament in slceletally immature prepubescent children and adelescents:
Surgical technique. J Bane .i'cu'nt Surg Am 2006;33l5uppl 1 Ft 21133-2911 B. The all-e pip hyseal technique with tibial
metaphyseal screw—past fisaticrn. {Hepruduceci with permissien fren1 Andersen AF:Transepiph1.rseal replacement
at the anterier cruciate ligament using quadruple ham string grafts in slceletally immature patients. .1 Rune Jaint
Surg Am 2DM:EE[suppl 1 pt 2. ]:2fl1-2fl9.} 1:. The all-epiphyseal technique with femeral and tibial epiphyseal
interference screw tisatium D. The all=epiphyseal technique with femeral and tibial blind epiphyseal seclcets and
suspensclryr fiaatinn.

IE! lfllfi American Academy at flrchapaedic Surgeens Drtbepaedic Knewledge Update: Sparta Medicine 5 ®
 Sectien E: The Telling Athlete

Adelescem wilh er adciescent

grewth remaining clcelng phyees
Tanner stage 2 er 3 Tanner stage 5
Melee: 13-16 years elcl Males: :- 16 years cld
Falhales: 12-14 years Females: :- 14 years cid

hansphyseel Adult AGL

reccnstructicn 1arIIh rec-mstructlcn
hamstrings and with lnterierence
metaphyseei screw fixaticn
fittaiicn
Ftnrseel-sparln
had intra-
recenstru
with llletlblal hand

Figure 3 Illustratien depicts alge rithm te determine treatment appreach ef anterier cruciate ligament {AEL} injuries in
skeletelly immature patients. [Adapted with permissien frem itccher M5, Gsrg 5, Micheii Li: Physeal sparing
recenstructien cf the anterier cruciate Iiga ment in skeletally immature prepubescent children and adelescents:
Surgical technique. J Bene Jeinr Surg Am 2Dflfi;flfl[suppl 1 pt 21:233-293.}

E
E fisatien ccnstructs an bath the femeral and tibial sidesihii
:5
s1: {Figure 2, D]. Twe—year feilewrup eutcemes have been
reperted with a similar appreach using a single hamstring
Eh
E stability53 and knee kinematics.”
E
3... graft with interference screw fiaatien ever suture tape and
I1:
.I:
'— relatively sherter, blind tunnels-‘3'”
Ed Revisien rates fer all-epiphyseal techniques have net
been cemprehensively reperted, altheugb ene study net-
ed twe graft failures ameng 23 recenstructiens i?%} at
2-year fellew-up.“ a case repcrt described distal femeral
vaigus defermity and slight limb-length discrepancy in a
skeletally immature patient, which was appreciated after
revisien all-epiphyseal recenstructien that fellewed a
graft failure asseciated with the same technique.“ MRI
was performed in 15 patients at 6 and 12 menths feilew-
ing all-inside all-epiphyseal recen structien and it was re-
p-erted that altheugb ne physeai disruptien was tiered en
the femeral side with this technique, 10 patients demen-
strated a small ameunt ef tibial physeai cemprernise
(mean, 2.1%), which was net asseciated with clinically
appreciable grewth disturbance.” Substantial limb-length
discrepancy resulting frem evergrewth has been repertcd
in twe cases, with mere mild limb-length discrepancies
seen in feur additienal patients.m
Bieruechanical studies suggest that the ail—epiphy—
seal technique enhances anterier stability ef the knee
cempared tn the MIL-deficient statefiifldl Hewever, re-
sults have suggested incempiete resteratieu ef retatienal
Transphyseal
Transphyseai recenstructien in prepubescent patients typ-
ically inveives smaller, mere vertical tunnels te minimize
grewth plate disturbance, which can eccur with large
er ehlique tunnels. Ccmplete and partial transphyseal
recenstructiens have been described, in which ene er both
grewth plates are drilled, and fixatien is generally placed
in the metaphyseal regien te aveid the physis.
Seventeen transphyseal ACL recenstructiens were
perfermed in prepubescent patients, with ne evidence
ef grewth disturbance at an average fellew-up ef 2i}
menths}12 Several reperts have described geed clinical re-
sults at final fellew- up and ne cases ef grewth disturbance
fellewing transphyseal recenstructieugfl'” ether reperts
have described cases ef limb-length discrepancy, angular
defermity, er evergrewth within series ef transphyseal re-
ceustructieus.“-”*'59 flue case repert described twe cases
ef limb-length discrepancy secendary te evergrewth in
children whe underwent partial transphyseal ACL recen-
structien using autegeneus ITE, with ever—the—tep suture
lit-ratien en the femeral side and tibial placement threugh

firthepaedic Knewledge Update: Sperts Medicine 5 fl ants American Academy at Cirrhepaedic Surge-ens
 Chapter 43: Anterior Cmtiate Ligament Tears in Skeletally humature Athletes
a transphyseal tunnel with metaphyseal metal staple fixa-
tion.” An MRI study of 43 pubescent patients with open
physes at the time of tra nsphyseal reconstruction demon—
strated that bone tunnels comprised less than 3% of the
growth plate, but areas of fecal physeal disruption and
bony bridging were seen in 12% of patients. No clinical
evidence of growth disturbance was observed in these
patients, which was likely related to the limited growth
remaining of the study population 5'“ Another MRI study
showed that partial transphyseal reconstruction caused
tibial physeal disturbances in an average of 5.4% of the
physis, without clinical evidence of growth compromise.”
Given the continued practice by some surgeons of trans-
physeal reaming in the skeletally immature, comparative
evidence assessing outcomes of these techniques relative
to newer physeal-sparing techniques will be particularly
beneficial.
Surgical Outcomes and Rehabilitation
Young children with high activity levels are at risk for
primary ACL tears as well as subsequent injuries and ACL
graft re—tears. Although multiple studies have suggested
that age younger than 2|] years is a risk factor for revision
in general,5“+7"-~i'I one study demonstrated that skeletally
inuoature patients have rates of early revision and early
reoperation similar to those of older adolescents with
closed physes.“ Younger patients have also been shown
to have a higher risk of undergoing contralateral ACL
recenstructionfl In a recent large-scale cohort study, ade-
lescence and playing soccer were risk factors independent—
ly associated with higher revision rates, and the two risk
factors combined demonstrated a threefold increase in
the likelihood of revision surgery?3 Adolescents with an
ACL reconstruction have a sixfold higher incidence of
subsequent ACL injury on either the surgical or centra-
lateral knee compared with healthy control patients, and
29.5% of the TB adolescent patients studied sustained a
second ACL injury within 24 months of return to sport?“
Meniscal repairs in adolescents undergoing ASL re—
construction have been shown to be substantially more
successful than isolated meniscal repairs?‘5 A study of
meniscal repairs in patients younger than 13 years showed
a T4% overall healing rate of meniscal repairs associated
with ACL reconstruction. Simple tears had a healing rate
of 34%, and complex tears, bucket-handle tears, medial
meniscus tears, and skeletal immaturity were found to
be risk factors fer failed repair.
Return to sport among skeletally immature athletes
is reported to be behveen s and 9 months in most series.
However, substantial strength and functional deficits
were found in skeletally immature patients more than
ID Ellie American Academy of flrtbepaedic Surgeons
1 year following ACL reconstruction, suggesting these
patients may require longer rehabilitation efforts?j Re-
cent literature also suggested that perioperative femo-
ral nerve blocks in pediatric patients may be associated
with postoperative functional strength deficits, and a
decreased likelihood of meeting return—to—sport criteria
6 months postsurgery.” Proper rehabilitation is critical
to preventing further injury or graft re-tear with return
to activity. Pediatric athletes may be the age group most
likely to prefer returning to a high activity level following
ACL reconstruction. This not only places them at risk for
reinjury, but it also can predispose a high risk for mood
disturbance, depression, threatened athletic identity, and
fear of reinjury following ACL injury.” A pediatric pa-
tient’s emotional response to injury and rehabilitation
can be important prognostically and should be closely
observed.
Injury prevention can play an important role in the
pediatric population. Universal neuremuscular injury
prevention training programs have been advocated as
cost-effective interventions that could potentially decrease
the incidence of ACL tears in this age group by 53%.“
Programs focusing on strengthening, proximal muscle
control, and varied exercise modalities have been success-
ful in reducing ACL injuries in young females.“
Although physeal-sparing or transphyseal techniques
provide young athletes with safe surgical options for ACL P?
reconstruction with good surgical outcomes, preventing
re
the initial ACL injury and minimizing the likelihood of
3‘I:
reinjury in this young, extremely active population re- :I
a:
mains a priority for optimizing the long-term health of 1"
pediatric athletes.
Fl
E
to
re
P.
Summary
ACL tears in skeletally immature patients are increasingly
common injuries in a challenging patient population.
Various surgical techniques have successfully restored
lrnee stability and allowed continued participation in
sports and activities, while minimizing injury to growing
physes. Longer term outcomes for these techniques have
yet to be described, but prevention strategies to minimise
initial injuries as well as recurrent injuries following ACL
reconstruction may be valuable in such a young, active
population. Further studies are needed to better elucidate
the natural history of ACL tears in young athletes.
Drthopaedic Knowledge Update: Sports lvledichse 5
®
 Section E: The Young Athlete
Hey Study Points
I ACL tears in skeletally immature patients are be-
coming increasingly common injuries.
I In the setting of a large effusion or suspected hemar—
throsis in a young patient who has sustained a knee
contact injury or twisting mechanism, because of
the high frequency of ACL tears, physical examina-
tion and MRI should be directed toward assessing
for intra'articular injury.
Nonsurgical management, which was historically
pursued for pediatric MIL injuries, has been associ-
ated with high rates of meniscal or chondral injury
in young athletic or physically active patients.
Multiple physeal-sparing or physeal-respecting sur-
gical techniques have been described and shown to
be successful in restoring knee stability in skeletally
immature patients, including estraphyseal recon-
struction using ITB autograft, all-epiphyseal recon-
struction techniques with hamstring autograft and
various fixation options, and transphyseal recon-
struction that minimizes growth plate disturbance.
Young athletes are at higher risk for rerupture and
revision surgery than their adult counterparts, in-
cluding contralateral limb ACL tears.
- Injury prevention programs may play a valuable
E role in preventing AGL injuries in young patients.
E that this may not be a reliable method to guide surgical
:5
fl:
Eh
E
S
3...
I1:
Annotated References
.I:
|_-
id
l. Dodwell ER, Lamont LE, Green DW, Pan T], Mars RG,
Lyman S: 2i] years of pediatric anterior cruciate ligament
reconstruction in New York State. r-‘rrn ] Sports Med
2fl14;42{3}:6?5—53fl.Medline DUI
This population-based study quantitatively examined the
increasing rates of AGL injuries diagnosed in young pa-
tients in the state of New York between 1991] and lflfl'li'.
. Mall NA, Paletta GA: Pediatric ACL injuries: Evalua-
tion and management. Curr Resr Muscufosrlrefet Med
2fl1356[2,l:131—14{l.Medline nor
This review highlights current concepts related to the
diagnosis, management, and treatment of AGL injuries
in pediatric patients.
. |l'S‘anIey T]. Knee injuries in kids: Why the increase? Avail-
able at: http:ffwww.medscape.comfviewarticler'TSS155.
Accessed August 5, 11915.
Giver a 12—year period [1999 to 21311], the incidence of
meniscal tears, tibial spine fractures, and AGL ruptures all
increased at Children's Hospital of Philadelphia; however,
® flrdiopaedic Knowledge Update: Sports Medich're S
a more than 490% increase in AGL ruptures occurred
compared with tibial spine fractures during this time.
Anderson M, Green WT, Messner MB: Growth and pre-
dictions of growth in the lower extremities. I Horse Jl'oiil'rt
Surg Arr: 1953;45:1-14. Medline
Anderson M, Messner ME, IGreen WT: Distribution of
lengths of the normal femur and tibia in children from
one to eighteen years of age. ] Boris joint Ssrg Arr:
1964;46:1199-12D2. Medline
Pritchett JW: Longitudinal growth and growth-plate
activity in the lower extremity. Cfirt Drtirop Refa't Res
1992;195:2754 -2?9. Medline
Paley D, Ehave Pt, Hersenberg JE, Bowen JR: Multiplier
method for predicting limb-length discrepancy. I Horse
joint Surg Am lflfl'fljfl 2(1fl]:1431-1445. Medline
Tanner Jl'vf, Whitehouse RH: Clinical longitudinal stan-
dards for height, weight, height velocity, weight velocity,
and stages of puberty. Arch Dis Chifrf 19?S,-.51{3}:1Tl}-1?9.
Medline Dfll
Slough JI'vf, Henurikus W, Chang '1’: Reliability of Tan.
ner staging performed by orthopedic sports medicine
surgeons. Med Sci Sports Exerc ED13;45{?}:1229-1234.
Medline DO]
High intraobserver and interobserver variability were
observed when Tanner staging was performed by ortho—
paedic surgeons based on clinical photographs, suggesting
decision making.
If]. Greulich WW, Pyle SI: Radiographie Atfas of Sire-feta!
Deneiopmsnt ofsirs Hand and Wrist, ed 2. Stanford, cs,
Stanford University Press, 1959.
11. Heyworth BE, l[Ilsei DA, Fabrieant PD, et al: The short—
hand bone age assessment: A simpler alternative to cur-
rent methods. ] Pedintr Drtfrop 2fl13;33{5):569-5?4.
Medline DUI
A shorthand bone age method was developed based on
certain radiographic parameters. This method of quanti-
fying skeletal maturity was found to be simple, reliable,
and efficient. Level of evidence: III.
12. Eehr CT, Potter HG, Paletta GA Jr: The relationship of the
femoral origin of the anterior cruciate ligament and the dis-
tal femoral physeal plate in the skeletally immature knee.
An anatomic study. Arr: ,I Sports Med 2001;29f6}:?31-?3T.
Medline
13. Swami VG, Mabee M, Hui C, Jaremko JL: Three-di-
mensional intercondylar notch volumes in a skeletally
immature pediatric population: A magnetic resonance
imaging-based anatomic comparison of knees with torn
and intact anterior cruciate ligaments. Arthroscopy
1013;29jlllfl954-19SZ.Medline DO]
Q lflld American Academy of Orthopaedic Surgeons
 |(Shame: 4B: Anterinr Cruciate Ligament Tears in Skeletally Immature Athletes
This MRI study in adnlescent patients with spnrts injuries
shnwed that three-dimensinnal nntch vnlume was smaller
in girls than in bnys. and was alse smaller in knees with
AGL tears cnmpared with fiGL-intact knees. Level nf
evidence: III.
14. hdiikelii EFL. Vaininnpfiii S. Vihtenen K. Mere l'vI. Reit-
kanen P: The effect nf trauma tn the lnwer femnral epi-
physeal plate. An experimental smdy in rabbits. J Renee
Jnirrt Srrrg Br 1933;?fljlj:13?-191. Medline
1.5. Guess nti V. Falciglia F. Gigaute A. Fabbriciani G: The
effect nf inns-articular AGL recnnstructinn en the grnwth
plates nf rabbits. J EnneJnr'nr Surg- Er 1994;?fijfijflt5fl-963.
Medline
1s. Kercher J. Kerngeancs J. Tanuenhaum A. rid-Hakim II.
Black JC. Zhan J: Anterier cruciate ligament recenstruc-
tinn in the skeletally immature: An anatnmical study
utilizing 3—dimensinnal magnetic resnnance imaging
recnnstructinns. J Fediarr Drrhep 20fl9:29{2}:124-125.
Medline DUI
This study used a custnm snftware mndel tn assess the
vnlume nf physeal disruptinn with simulated transphyseal
drilling. Graft radius was fnund tn he the mnst critical
factnr affecting the vnlume nf physeal injury. Level nf
evidence: IV.
1?. Shea KG. Grimm NL. Helzer J5: aumetric injury nf the
distal femnral physis during dnuhle—bundle ACL recnn‘
structinn in children: A three—dimensinnal study with use
nf magnetic resnnance imaging. J Beers Jeinr Sang Am
2011;93j11}:1i}33-1fl33.Mediine DUI
Three-dimensinnal MRI medels nf children's knees
demnnstrated that dnuble—bundle surgical techniques
substantially increased the velume ef physeal injury with
tunnel drilling, and cnuld increase the risk nf grnwth
disturbance.
13. Nawabi DH. Jnnes H]. Lurie E. Pnt'ter HG. Green DW.
Enrdascn FA: All—inside. physeal—sparing anterinr cruciate
ligament recenstructien dnes net significantly cempremise
die physis in skeletally immature athletes: A pnstnperative
physeal magnetic resnnance imaging analysis. Am } Spnrts
Med lflidflljllklflfifi-Zfidfl. Medliuc DUI
tseal-specific MRI in 23 skeletally immature patients
was used tn evaluate the vnlume nf physeal disturbance
with all-epiphyseal and partial transphyseal ACL recnn-
structinns. Tibial physeal disturbance nccurred with both
techniques but was neted tn be miner and did net result
in any clinical grnwth disturbances. Level nf evidence: IV.
19. Chetel F. Henry J. Sci] E. Chenteau J. Mnyen E. Eérard
J: Grnwth disturbances withnut grnwth arrest after AGL
recnnstructinn in children. Knee Surg Sperrs Tmumnrnl
Arifrrnsc lfl]fl;13{11]:1495-15flfl. Medline DUI
This case repert describes twn cases nf evergrnwth in
pediatric patients fellnwing ACL recnnstructinu using
an nver—the—tnp 1TB autngraft with a transtibial tunnel.
Level nf evidence: V.
ID EDIE American Academy nf firthepaedic Surgenns
10. Knch PP. Fucentese SF. Elatter SC: Cemplicatinns after
epiphyseal recnnstructinn nf the anterinr cruciate ligament
in prepubescent children. Hues Surg Sperrs Treamatnl
Arrbrnsc 21314 [Epub ahead nf print]. Medline DUI
This retrnspective review discusses nutcnmes and cum-
plicatinns fnllnwing all—epiphyseal recnnstructinns in 12
prepub-escent patients. Substantial nvergrnwth was seen
in twn patients and miner limb-length discrepancies were
seen in fnur additinnal patients. Level nf evidence: IV.
21. McIntnsh I'LL. Dahm DL. Stuart M]: Anterinr cruciate
ligament recnnstructinn in the skeletally immature patient.
Arthrnscnpy lflflfi;32{13}:1325-133{L Medline DDI
.12. Abbasi D. May MM. Wall E]. Chan G. Farikh 5N: MRI
findings in adnlescent patients with acute traumatic knee
hemarthrnsis. J Pediatr Grrfxnp 2012;32{3}:Tfii}-?fi4.
Medline D01
This study reviewed the knee MRIs nf 131 ynung patients
whe presented with a histnry nf acute knee trauma and
effusinn seen nn MRI. AGL tears were present in 22%
nf ynunger patients {age range. III tn 14 years} cnmpsred
with 411% ef elder patients [age range. 15 tn 13 years].
Level ef evidence: III.
2.3. Straccinlini A. Casciane R. Levey Friedman H. Meehan
WP III. Micheli LJ: Pediatric spnrts injuries: An age cnm-
parisnn nf children versus adnlescents. Am J Sperrs Med
2013;41j3}:1911-1929. Medline en:
This study examined spnrts injuries in children and adnles-
cents presenting te a large academic medical center frem
Zflfll} tn 2009. A substantial percentage nf injuries required F?
surgical interventinn. and elder children tend tn sustain
higher ameunts nf nveruse injuries. Level nf evidence: III. m
3:I:
:I
2.4. Straccinlini A. Casciann R. Levey Friedman H. Stein G]. u:
Meehan WP III. Micheli LJ: Pediatric spnrts injuries: A 1"
Fl
cnmparisnn nf males versus females. rim J Spnrts Med E
n:
2014;42j4}:965—9?2.Medline nnr m
F.
This study examined sex differences in spnrts injuries in
children and adnlescents. Females were fnund tn sustain
a higher percentage nf nveruse injuries and mnre injuries
tn the lnwer extremity. Level nf evidence: III.
15. Straccinlini PL. |IGasciann R. Friedman HL. Meehan WP
III. Micheli L]: A clnser Innk at nveruse injuries in the
pediatric athlete. Elie J Sperr Med 2fl15;25{1}:30-35.
IvIedIine DUI
This crnss-sectinual study examined sex differences in
nveruse spnrts injuries. Females sustained mnre nveruse
injuries than males. but a large prnpnrtinn nf this sex
discrepancy was attributable tn differences in the types
nf spnrts played.
26. Agel J. firendt EA. Bershadslty E: Anterinr cruciate lig-
ament 1njury in natinnal cnIlegiate athletic assnciatinn
basketball and snccer: A 13-year review. An: J Spnrts Med
2Ufl5;33{4}:524-53{i.Medline DUI
27. Prndrnmns CC. Han Y. Regnwski J. Jnyce II. Shi K: A
meta-analysis nf the incidence nf anterinr cruciate ligament
Drthepeedic Knnwledge Update: Spnrts Medicine 5
 Sectien E: The Turing Athlete
tears as a in nctien of gender, sport, and a knee injury-re-
ductien regimen. Arthreseepy 200?;23j12}:131fl-1325.
e5. Medline DUI
13. Kim S], Kumar P, Kim SH: Anterier cruciate ligament
recenstructien in patients with generalized jeint laxity.
Clair: Urthep 3mg lfllfl:2[3}:13fl-139. Mcdlinc DUI
Generalized ligamenteus laxity is a risk facter fer AEL
tears as well as inferier eutcemes fellewing recenstruc-
tien. This paper discusses the issues related te surgical
decisien making in the setting c-f laxity.
29. Teen KH, Lee SH, Park ST, Kang DG, Chung KY: ISan
physical examinatien predict the intraarticular tear pat-
tern ef the antefier cruciate ligament? Arch Urthep Trau-
ma Surg 2014;134llfljfl451-1451 Medline DUI
This study examined the cerrelatinn between physical
examinatien findings and arth rescepic tear patterns. Pivet
shift test results were femd te be a reliable predicter ef
pesterelateral bundle tear er cemplete REL tear.
3|]. Kecher M5, DiCansie J, Eurakewski D, Micheli L]: Diag-
nestic perfermance ef clinical examinatien and selective
magnetic resenance imaging in the evaluatien ef intra-
articular knee diserders in children and adelescents. Am
] Spur-ts .Med lflfl1;29{3]:292-296. Medline
3]. Schub DL, Altahawi F, F Meisel A, Winalski C, Parker
RD, M Saluan P: Accuracy ef 3-Tesla magnetic resenance
imaging fer the diagnesis ef intra-articular knee injuries in
children and teenagers. ,7 Pediatr Urthep 2012:3131:3):?65-
E TEE. Medline DUI
E
.‘E In patients ynunger than 20 years, 3T MRIs were feund
:1:
Ch te have high sensitivity and specificity fer diagnesing ACL
E
injuries. Level ef evidence: II.
E
3...
I1:
.I:
|_-
31. Meksncs H, Engebretsen L, Risberg MR: Prevalence and
End
incidence ef new meniscus and cartilage injuries after a
neneperative treatment algerithm fer REL tears in skel-
etally immature children: A prespective MRI study. Am
] Sperts Med 2fl13;41{3}:1'??1-1??9. Mcdlinc DUI
This prespcctivc study examined 41] skeletally im mature
patients with ACL tears whe fellewed a nensurgical treat-
ment cenrse. The incidence ef new meniscal injuries after
initial diagnestic MRI was 1 9.5 ‘ib, and 32% cf nensurgi-
cally treated patients required subsequent surgical REL
recenstructien.
33. Samera WP III, Palmer R, Klingele KE: Meniscal pa-
thelegy asseciated with acute anterier cruciate ligament
tears in patients with epen physes.} Pediatr Urtbep
2U11;3l|[3l:2?2'2?fi.Medline DUI
In this retrespective review ef 124 skeletally immature
patients, meniscal injury accempanied ACL rupture in
69.3% ef patients, with lateral meniscus tears being
mere cemmen in children with epen physes. Level ef
evidence: I‘v’.
34. lUsintalan RP, Inacie MC, Desmend JL, Funahashi TT:
Anterier cruciate ligament mcenstructien in patients with
Urthepaedic Knewledge Update: Sperts Medicine 5
epen physes: Early eutcemes. j Knee 3mg 2013:26H}:22.5-
131. Medline DUI
This large retrespective study cempared patients with
clnsed physes with patients with epen physes and ESL
tears and reperted ne significant differences in the prev—
alence ef chendral er meniscal injuries, early revisien sur-
gery, er reeperatien rates fellewing ACL recenstructien.
35. Dument GD, Hegue GD, Padalecki JR, Ukere bl, Wil-
sen PL: Meniscal and chendral injuries asseciated with
pediatric anterier cruciate ligament tears: Relatienship ef
treatment time and patient-specific facters. Am I Sperts
Med lflllflfllfilflllfi-fldl Medline DUI
Pediatric patients whe underwent ACL recenstructinn
mere than 15D days after injury had higher rates ef medial
meniscal tears cempared with these treated befere 15:3
clays pestinjury. Level ef evidence: III.
36. Lawrence JT, Argawal N, Uanley T]: Degeneratien ef the
knee jeint in skeletally immature patients with a diagnesis
(If an anterier cruciate ligament tear: Is there harm in delay
ef treatment? Am } Sperts Med 2fl11;39{1.1}:2532—253?.
Medline DUI
In a series ef Tl] patients ynunger than 14 years, a delay
in surgical treatment greater than 12 weeks was asse-
ciated with higher rates ef irreparable medial meniscal
tears and lateral cempartment chendral injuries. Level
ef evidence: III.
3?. Funahashi KM, Meksnes H, Maletis GB, Csintalan RP,
Inacie MC, Funahashi TT: Anterier cruciate ligament inju-
ries in adelescents with epen physis: Effect ef recurrent in-
jury and surgical delay en meniscal and cartilage injuries.
An: ] Spur-rs Med 1014;42i5j:1fl63-1{}?3. Medline DUI
This review nf yeung patients with ACL tears shewed
ne significant asseciatien between time te surgery and
meniscalfcbendral injury: hewever, an increased number
ef substantial enceunters was asseciated with cembined
meniscal and cartilage injury. Level ef evidence: III.
33. Kluczynski MA, Marne Jl'vI, Bissen L]: Facters asseci-
ated with meniscal tears and chendral lesiens in patients
undergeing anterier cruciate ligament recenstructien: A
prespective study. Am I Sperts Med 2913;41l12]:2?59-
1?65. Medline DUI
This case—centre] study shewed that male sex predicted
meniscal tears, age and ebesity predicted chendral injuries,
and number ef instability episedes was an independent
predicter ef intra-artic ular injury. Level ef evidence: III.
39. Unenther ED, Swami V, Dhillen 55, jaremke JL: Meniscal
injury after adelescent anterier cruciate ligament injury:
Hew lung are patients at risk? Clix Urtbep Refer Res
lDl4;4?2{3]:99l1-991 Medline DUI
In adelescent patients, medial meniscal tears were feund
tn increase steadily in frequency mere than 1 year after
REL injury. Level ef evidence: IV.
40. Kecher M5, Saxen HS, Hevis WD, Hawkins R]: Man-
agement and cemplicatiens ef anterier cruciate ligament
U lfllfi American Academy ef Urthepaedic Surge-ens
 |liillapter 4B: Anterior Cruciate Ligament Tears in Skeletally Immature Athletes
injuries in skeletally immature patients: Survey cf the
Herndicus Seciety and The ACL Study lll'irnup. I Pedierr
Drrhep lflfll;22{4l:452-45?. Medline DUI
41. Frusch EH, Stengel D, Brudhun T, et al: Dutcemes and
risks pf pperative treatment pf rupture cf the anterinr
cruciate ligament in children and adelescents. Arthrcscep'y
lflli};26{11}:1539-1550.Mcdlinc DUI
This meta—analysis uf case series examined clinical nut-
cemes and risks of ACL surgery in pediatric patients, and
shpwed lc-w rates crf graft failure after ACL recnnstructic-n
in yuung patients. Level nf evidence: 1V.
42. Cipplla M, Scala A, Gianni E, Puddu G: Different patterns
cf meniscal tears in acute anterinr cruciate ligament {ACLJ
ruptures and in chrenic ACL-deficient knees. Classifica-
tinn, staging and timing pf treatment. Knee Snrg Sports
Trnnrnntnl Armrest. 1995:3{3}:13fl-134. Medline DDI
43. Henry J, Chutel F, Chenteau J, Fessy MH, Bérard J, Meyen
B: Rupture cf the anterinr cruciate ligament in children:
Early recenstructinn with npen physes er delayed recen-
structipn rc- skeletal maturity? Knee Snrg Spprts Trennra-
mi Arthrnsc lflfl9;1T{?}:T43—?55. Medline DUI
Skeletally immature patients whn delayed ACL recunsttuc-
tien until skeletal maturity were fc-und te have higher rates
pf medial meniscal tears and subsequent meniscectnmies
when cnmpared with patients when underwent recpnstruc-
tinn while skeletally immature.
44. Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Gan-
ley T]: Anterier cruciate ligament tears in children and
adplescents: A meta-analysis pf npnpperative versus cI-per-
ative treatment. Arn J Spain‘s Med Ill 14;41[11]:2T59-2?T6.
Mcdlinc DUI
This meta-analysis uf pediatric patients with REL tears
shewed that nunsurgical er delayed management resulted
in mere knee instability and inability tn return tcr previpus
activity levels, thus fawning early surgical stabilisatinn nf
AEL tears in the pediatric pnpulatinn.
45. Kncher M5, Michell L], Zurakewski D, Luke 14: Partial
tears of the anterinr cruciate ligament in children and ad-
plesuents. Am J Spurts Med Eflfllfiflfi }:69?-?03. Medline
46. Fahricant PD, Jnnes K], Delns D, et al: Recnnstructien cf
the anteripr cruciate ligament in the skeletally immature
athlete: a review uf current cencepts: AADS exhibit selec—
tien. J Rene faint Snrg An: 2013:95{5}:e13.Medline DUI
This paper cnmprehensively reviews current literamre re-
garding ACL tears in skeletally immature athletes. Surgical
recenstructien in yeung patients has yielded successful
surgical nutcnmes.
4?. Frank JS, IZiamhaccrrta PL: Anterier cruciate ligament
injuries in the skeletally immature athlete: Diagnnsis and
management. J Han Atari Drthnp Snrg 2013;21l1}:?E-3T.
Medline DDI
This review article discusses the unique characteristics
cf managing the pediatric ACL tear. Natural histnry,
IE! lfllfi American Academy pf Drthnpaedic Surgerms
gtpwth-related cnnsideraticms, current literature, and
surgical uptiuns are described.
43. 1|ii'avken F, Murray MM: Treating anterier cruciate liga-
ment tears in skeletally immature patients. Arthreseepy
2fl11;2?{5}:?'fl4-?15.Medline DUI
This systematic literature review suggests that surgical
management pf ACL tears in skeletally immature patients
is the treatment cf chuice, and nunsurgical management
can result in further meniscal andi'nr chnndral intra-ar-
ticular damage. Level pf evidence: IV.
49. Engelman GH, Carry PM, Hitt KG, Pulpusky JD, Vidal
AF: |Enmparisnn pf allcrgraft versus autngraft anteripr
cruciate ligament recenstructiun graft survival in an active
adelescent cnhnrt. Am I Spur-rs Med 2fl14;42[1fl}:2311-
2313. Medline DUI
In adplescent patients, graft type and pcsteperative knee
laxity were predicters nf graft survival, and autngraft was
recemmended in yeung patients underguing primary ACL
recnnstructic-n. Level pf evidence: III.
SD. Kaeding CC, Arc-s B, Pedrera A, et al: Allugraft versus
autngraft anterier cruciate ligament reccrnstructinn: Pre-
dictc-rs ef failure frnm a MDDN pmspective lengitudinal
cehert. Sparta Health 2fl11;3{1}:?3-31. Medline DDI
Teung patients {age range, 10 re 19 years} were found tn
have an increased risk pf ACL graft failure full-swing re-
censtructinn, and allpgraft was asscciated with a substan-
tially higher risk c-f failure when cumpared with autcgraft.
51. Kecher M5, Garg S, Micheli L]: Physeal sparing recur:- F“?
structien cf the anterier cruciate ligament in skeletally m
immature prepuhescent children and adelescents. J Brine
Jain: Snrg Arn 10D5;ET{11}:23T1-13?9. Medline DUI 3‘I:
:I
in
51. Ke-cher M5, Garg 5, Micheli LJ: Physeal sparing recnn- 1"
Fl
structic-n cf the anterier cruciate ligament in skeletally E
n:
immature prepuhescent children and adelescents. Surgi- m
F.
cal technique. J Bune Jain! Snrg An: lflflfififllfiuppl 1 Pt
3:233:49}. Medline
53. Kennedy A, Cnughlin DG, Metxger MF, et al: Binme-
chanical evaluatinn pf pediatric anteripr cruciate lig-
ament recnnstructinn techniques. An: ] Sparta Med
2fl11;39i5 ]:964-9T1. Medline DUI
Einmechanical test results cpmparing all-epiphyseal, tran-
stihial nver-the-tc-p, and extra-articular ITB techniques
skewed that ITE recunstructien hest restured anterupus-
terier stahility cf the knee and rntatienal centre-l.
54. Andersen AF: Transepiphyseal replacement of the ante-
rinr cruciate ligament using quadruple hamstring grafts
in skeletally immature patients. J Bnne Jnfnt Snrg Arn
lflfl4;35{Pt 1, Suppl 1}:2fl1—lfl'5". Mcdline
55. Lawrence JT, Enwers AL, Eelding J, Cedy SR, Ganley TJ:
All-epiphyseal antetinr cruciate ligament recensttuctinn
in skeletally immature patients. Clin Drrhnp Refer Res
2fl10;4fifl{?]:19?1-19??.Medline DID]
Drthnpaedic Knuwledge Update: Spnrts Medicine 5
 Sectinn E: The Tnung Athlete
This repnrt described a physeal-sparing, all-epiphyseal
ACL recnnstructinn technique.I which uses all-epiphyseal
tunnels with interference screw fixafinn, as well as the use
nf three-dimensinnal intranperative UT tn minimise the
risk nf grnwth disturbance. Level nf evidence: IV.
51:1. McCarthy MM, Graziann J, Green DW, Cnrdascn FA:
All-epiphyseal, all-inside anterinr cruciate ligament re-
cnnstructinn technique fnr skeletally immature patients.
Arthrnsc Tech 2fl1251{2J:e231—e239. Medline DUI
This paper describes a physeal-sparing, all-inside,
all-epiphyseal ACL recnnstructinn, with retrngrade epi-
physeal tunnel drilling and suspensnry fixatinn nf autnge-
nnus hamstring graft.
5?. McCarthy MM, Tucker 5, Nguyen JT, Green DW, Im-
hauser CW, |Enrdascn FA: IL'Inntact stress and kinematic
analysis nf all-epiphyseal and nver-the-tnp pediatric re-
cnnstructinn techniques fnr the anterinr cruciate ligament.
An: ] Spur-ts Med 1013;41{6}:1330-1339. Medline DUI
In this binmechanical cadaver study, all-epiphyseal and
nver—the—tnp recnnstructinn techniques were fnund tn re-
stnre anterinr and rntatinnal stability tn the MIL-deficient
knee, but they did nut restnre nnrmal knee kinematics tn
the ACL-intact knee.
SS. Cassard X, Cavaignac E, i'vlaubissnn L, aen M: An-
terinr cruciate ligament recnnstructinn in children with
a quadrupled semitendinnsus graft: Preliminary results
with minimum 2 years nf fnllnw-up. ] Pedietr Drthnp
1fl14;34{1}:?fl—??.Mcdline DDI
E This paper described the nutcnmes fnllnwing an all-epiph-
E
:5 yseal technique using retrnrea med suckers and shnrt,
:1:
Ch
quadruple semitendinnsus grafts with terephthalatc tape.
E Gnnd nutcnmes were repnrted using this technique in
S
3... skeletally immature patients with nn instances nf grnwth
I1:
.I:
disturbance.
'—
rid 59. Cnllette M, Cassarcl K: The Tape aking Screw tech-
nique {TLS}: A new ACL recnnstructinn methnd using
a shnrt hamstring graft. Urthnp Trnnmntnl Surg Res
2fl11;9?{5}:555—559. Medline Dfll
This technique paper describes the Tape aking Screw
ACL recnnstructinn, using shnrt retrngrade tunnel snck—
ets, shnrt single hamstring graft, and interference screw
fisatinn nver terephthalatc tape strips.
til]. Lawrence jT, West EL, Garrett WE: Grnwth disturbance
fnllnwing ACL recnnstructinn with use nf an epiphyseal
femnral tunnel: A case repnrt. I Enne jnr'nr Surg Am
2fl11;93{3}:e39.Medline DUI
This case repnrt dn-cuments a case nf valgus defnrnlity
and slight leg-length discrepancy in a skeletally immature
patient whn underwent revisinn all-epiphyseal ACL recnn-
structinn after failure cf the same technique. Hn surgical
interventinn was required fnr treatment.
6']. Sena M, Chen], Dellamagginria R, Cnughlin [1G, Lnta
JC, Feeley ET: Dynamic evaluatinn nf pivnt-shift kine-
matics in physeal-sparing pediatric anterinr cruciate
firthnpaedic Knnwledge Update: Spnrrs Medicine S
ligament recnnstructinn techniques. Am I Spnrts Med
lfl13;41{4l:SES-334.Medline DUI
This cadaver study simulated pivnt shift test results tn
assess stability fnllnwing physeal—sparing ACL recnnstruc-
tinn techniques. All—epiphyseal, extra-articular ITE, and
transtibial nver-rhe-rnp techniques all resulted in imprnved
knee stability cnmpared with the REL-deficient state.
62. Streich NA, Eerie fl, |flntterbarm T, Keil M, Schmitt H:
Transphyseal recnnstructinn nf the anterinr cruciate lig-
ament in prepubescent athletes. Knee Sang Spnrts Trea-
metnl Artistes: 2010;13i11]:1431-1436. Medline DUI
This smdy cnmpared surgical and nnnsurgical treatment
nf ACL tears in immature patients whn were Tanner stage
1 er .1: 53% cf unusurgically treated patients required later
surgery because nf instability, and these treated su rgical-
ly with transphyseal recnnstructinn demnnstrated better
clinical results and functinnal nutcnmes.
63. Kncher MS, Smith JT, aic E], Lee B, Micheli L]: Trans-
physeal anterinr cruciate ligament recnnstructinn in skel-
etally immature pubescent adnlescents. 1 Bone Juries Sarg
Am. EDD ?;39{12}:2632 -2 63 9. Medline DUI
64. Enhen M, Ferretti M, Quarteirn M, et al: Transphyse-
al anterinr cruciate ligament recnnstructinn in patients
with npen physes. Arthrnscnpy ID09;15[S}:331-SSE.
Medline DUI
Twenty—sis: skeletallyr immature patients underwent trans-
physcal flCL recnnstructinn with autngennus hamstring
graft, and were found tn have gnnd clinical nutcnmes with
en instances nf substantial grnwth disturbance.
65. Kim S], Shim DW, Park KW: Functinnal nutcnme nf trans-
physcal recnnstructinn cf the anterinr cruciate ligament
in skeletally immature patients. Knee Sui-g Refer Res
1fl12;14{3}:1?3-1?9.Mcdline Dfll
This retrnspective review assessed nutcnmes nf transphyse-
al ACL recnnstructinn in 25 skeletally immature patients
whn had reached skeletal maturity by final fnllnw-up.
Average fnllnw-up was 6 years, and patients repnrted gnu-d
functinnal nutcnmes and nn substantial leg length nr limb
alignment abnnrmalities.
66. Recller LH, Erafman RT, Trentacnsta bl, Ahmad CS:
nnterinr cruciate ligament recnnstructinn in skeletally
immature patients with transphyseal tunnels. Arthrnsenp'y
lDll;13{11}:1?1l]-1T1T.Medline DUI
Eighteen skeletally immature pubescent patients under—
went transphyseal MEL recnnstructinn. At a mean fnl-
lnw-up nf 43.4 mnnths, patients demnnstrated excellent
clinical functinnal nutcnmes with nn instances nf graft
re-tcar nr grnwth disturbance. Level nf evidence: IV.
ET. Kumar S, Ahearne D, Hunt DM: Transphyseal anterinr
cruciate ligament recnnstructinn in the skeletally imma'
ture: Fnllnw-up tn a minimum nf sixteen years nf age.
I Bnne fnint Surg Am Efl13;95{1}:e1. Merliine DUI
Thirty-twn skeletally immature patients whn underwent
transphyseal ACL recnnstructinn were retrnspectively
Q lfllfi American Academy nf Urrhnpaedic Surge-ens
 |Ellajster 43: Anterier Cruciate Ligament Tears in Skeletally Immature Athletes
studied with a minimum fallaw—up uf 4 years. Patients
had satisfactary clinical and functienal eutcemes, and
ane case ef mild valgus defermity was reperted, but this
was nut functianally impurtaut.
ES. Lipscamh AB, Andersan AF: Tears af the anteriur cru-
ciate ligament in adulescents. }' Barre juirrt Surg Arr:
1935;63i1}:19-13. Mcdline
69. Liddle AD, Imhuldeniya AM, Hunt DM: Tranaphyseal
recunstructiun ef the anteriur cruciate ligament in prepu-
hescent children. I Barr-e fair-st Strrg Br 20 fl3;90[1fl}:1317'-
1312. Medline DD]
Pi]. Tau W], Kucher MS, l'icheli L]: Gruwth plate disturbance
after tra naphyaeal recunstructiun uf the anteriur cruciate
ligament in skeletally immature adelesccnt patients: An
MR imaging study. I Pedietr Urtfrap 2Ull;31lti}l:691-696.
Medline DUI
This MRI study and retruapective review uf 43 adulescent
patients whu underwent transphyscal ACL recunstructiun
shewed that fecal physeal disruptien was present in 11.6%
af patients after recunstructiun, must cummunly at the
tibial phyaia. Nu patient demunatrated evidence uf clinical
grewth disturbance.
71. 1iiiu'asserstein D, Khushhin A, Dwyer T, et al: Risk facters
fer recurrent anteriur cruciate ligament recunstructiun:
A pupulatiun study in Untariu, Canada, with 5-year
fulluw—up. Am I Sparta Med 1fl13541ffi}:2D99—2101
Medline DUI
This cehert study ef patients age 15 ta 6i] years shewed
that yuu ng age (range, 1.5 ta 19' years} and use uf allagraft
were assuciated with increased risk uf revisiun ACL re-
cunstructiun. Yeung age was alse assuciated with a higher
risk far centralateral ACL injury and recunstructiun. Level
af evidence: III.
P2. Magnussen RA, Lawrence JT, 1iii'r'est RL, Tath AP, Tay-
lar DC, Garrett WE: Graft sire and patient age are pre-
dicters ef early revisiun after anteriur cruciate ligament
recunstructiun with hamstring autegraft. Arthreacapy
2fl12:23{4}:526-531.Medline DUI
Amung 333 patients underguing primary ACL recunstruc-
tiun, hamstring autugraft sire less than 3 mm and age
yuunger than than 2i] years were assuciated with high
revisiun rates. Level uf evidence: III.
7’3. Andernerd D, Desai M, Bjiirnssen H, Tlander M, Karla-
sun J, Samuelsaun Iii: Patient predicturs uf early revisiun
surgery after anteriur cruciate ligament recunstructiun:
A cahurt study af 16,930 patients with 2-year fellaw-up.
Arr: ,I Sparta Med lfllSHSflltlll-IEI Medline DUI
This praspective cahurt study rep-erred that adulescents
and saucer players had an increased risk uf revisiun surgery
after ACL recunstructiun, and the cemhinatien ef these
twe predicters had an almest threefeld higher risk fer
revisiun surgery. Level af evidence: II.
7'4. Paterne siv, Rauh M], Schmitt LC, Ferd KR, Hewett TE:
Incidence uf Secund ACL Injuries 1 Years After Primary
ID Eillfi American Academy af Drthepaedic Snrgeana
ACL Recanatructiun and Return tu Spurt. Am ] Sparta
Med 2fl14;42{?]:156?-15?3. Madline DUI
In yeung athletes {mean age, 1?.3 years} with primary
ACL recunstructiuns, 29.5% af patients sustained a sec-
und ACL injury within 24 munths uf return ta spurt, and
patients whu have undergene AEL recunstructiun had a
higher risk ef anether ACL tear cempared with central
patients. Level af evidence: II.
PS. IGreenherg EM, Greenherg ET, IICianley T], Lawrence JT:
Strength and functiunal perfarmance recuvery after an-
teriur cruciate ligament recunstructiun in preadelescent
athletes. Sparta Heels}: 2014:6{4ififl5'3ill Medline DUI
Yeung patients with all-epiphyseal ACL recunstructiuns
were reviewed fur their strength and functiunal perfur-
mance measures fulluwing rehabilitatiun. Substantial
strength and functianal deficits were faund in same pa-
tients at I" munths as well as mere than 1 year pustuper-
atively. Level uf evidence: IV.
T6. Luu TD, Aahraf A, Dahm DL, Smart M], McIntush AL:
Femaral nerve black is assuciated with persistent strength
deficits at s munths after anteriur cruciate ligament recen-
strucu'en in pediatric and adelescent patients. Am I Sparta
Med 2015;43i2}:331-336. Medline DD]
In patients 13 years at yuunger whu underwent ACL re-
cunstructiun, femeral nerve blacks were assuciated with
strength deficits at 6 munths campared with central pa-
tients, and patients withaut a black were fuur times mare
liltely ta meet return-tu-spart criteria at E munths. Level
ef evidence: III.
PP
FT. Christine MA, Pantry A], 1|Itepat BE}: Psychelegical aspects
ef recevery fellewing anteriur cruciate ligament recen- m
structiun. ] Am! Acad Urtlrap Sarg 2fl15;23{3}:5ill-Si}9. 3:I:
Medline DUI :
EU
1"
This review summarises the current literature regarding Fl
E
psychelegic sequelae uf ACL tears. Psychelegic facters n:
m
F.
can have impurtaut effects an athletes’ injury experiences
and rehabilitatiun.
PB. Ewart E, Redlet L, Fabricant PD, Mandelhaum BR, Ah-
mad CS, 1|li'lll'ang TC: Preventiun and screening prugrams
fur anteriur cruciate ligament injuries in yeung athletes:
A cast-effectiveness analysis. I Berta faint Sarg Am
2fl14;96[9}:?fl5-?11.Medline DUI
Using a deciaiun-a nalyais mudel, nenrumnacular training
pregrams fer yeung athletes were prepesed ta he a cast-ef-
fective strategy fer preventing ACL injuries and reducing
casts assuciated with ACL injury.
T9. Sugimete D, Myer GD, Barber Fess ED, Hewett TE:
Specific exercise effects af preventive ueurarnuacular
training interventiun en anteriur cruciate ligament in-
jury risk reductien in yeung females: Meta-analysis and
suhgruup analysis. Br ] Sparta Med 1015;49iS }:2 32-139.
Medline DUI
This systematic review fuund that preventive neurumuscu—
lar training efficacy in yeung female athletes was increased
with strengthening exercises, praximal central exercises,
and multiple exercise techniques.
Urthapaedic Knuwledge Update: Sparta Medicine 5
Chapter 49
Patellofemoral Instability and
Other Common Knee Issues in
the Skeletally Immature Athlete
Aristides I. Cruz Jr. MD Matthew D. Milewski. MD
Abstract
The skeletally immature athlete often presents with
sports- and activity—related conditions that are unique
to this patient population. The immature skeleton pres-
ents unique sites of injury and pathology in children
principally because of the presence of open cartilaginous
growth centers. These growth centers represent areas of
weakness that predispose these athletes to injury. The
orthopaedic surgeon must take special care in treating
certain injuries in those with open physes and apophyses
in this patient population.
Keywords: pediatrlr knee: patellar cllslocatlon:
anterior knee pain: knee: immature athlete:
patellofemoral instability; tibial spine ailrulsion:r
discoid meniscus:r osteochondrosis
Introduction
Knee injuries in the skeletally immature athlete are among
the most commonly encountered problems in the clini-
cian’s office and are the result of both overuse and acute
trauma. There are four common knee pathologies in this
population: patellofemoral instability, tibial spine [emi-
nence} avulsion fracture. discoid lateral meniscus, and
knee osteochondroses {flsgood-Schlatter disease and
Sinding-Larsen-Johansson [SLJ] disease}.
Dr. Cruz or an immediate famiiy member serves as a board
member. ovvner, officer; or committee member of the Pe-
diatric orthopaedic Society of North America. Dr. Miiewski
or an immediate famiiy member serves as a board member.
owner; officer; or committee member of the Pediatric Dr-
thopaeo‘ic Society of North America.
fl lflld American Academy of Drtbopaedic Surgeons
Patellofernoral Instability
Patellofemoral instability with lateral patellar dislocation
or sublurtation is a common disorder of the knee in skele-
tally immature athletes. 1n the child or adolescent athlete,
properly treating the cause of instability is important
for return to play and to prevent recurrence. Skeletally
immature patients should receive special consideration
because the presence of open physes influences evaluation
and treatment.
Epidemiology
The incidence of patellofemoral instability in the United
fiunog au_|_ :g
States is estimated to be 2.29 per lflflfiflfl person-years,l
with the peak incidence occurring between 15 and 19
years of age. The rates of instability are equal between
males and females, and 51.9% of instability events occur
during athletic activity. Nonsurgical treatment of first-
a1a|i
time dislocators is successful 62% of the time."- Liga-
mentous larcity or joint hypermobility can also influence
outcome after patellar dislocation, with better functional
results in those without hypermobility.3
Diagnosis. Anatomy, and Biomechanirs
The primary restraint to lateral patellar dislocation is the
medial patellofemoral ligament il'lFL], which resists
lateral translation of the patella. Injury to this ligament
predisposes patients to recurrent dislocation. The MPFL
zone of injury after acute patellar dislocation varies.‘I ICine
study showed that MPFL injury most commonly involves
the patellar attachment {61%}, followed by femoral at-
tachment injury (12%], injury to both attachments {11%},
and midsubstance injuryr {9%}. Sir. percent of patients had
no identifiable injury. The MPFL zone of injury following
acute patellar dislocation differs when comparing skele-
tall}.r mature and immature patients.5 Patellar-side MPFL
injury is more common in skeletally irrunature patients
US$31 than in skeletally mature patients {54%}.
Drthopaedic Knowledge Update: Sports Medich're 5
 Section E: The Young Athlete
In skeletally immature patients, the location of the
MPFL femoral attachment is important because it is near
the distal femoral physis. Cine study showed that the
femoral insertion of the MPFL is distal to the physis.“
Additionally, because of the flare of the medial aspect
of the distal femoral physis, the femoral insertion of the
MPFL can appear to be closer to the physis than it actu-
ally is on a lateral radiograph {Figure 1}. An MRI study
found that the MPFL femoral insertion was distal to the
physis in 36% of patients, 37% were located at the same
level as the physis, and res were located proximal to the
physis.4 Cin average, the femoral insertion of the MPFL
was 5 mm distal to the physis, and 36% of patients had a
femoral insertion within 5 mm of the physis. In skeletally
immature cadavers,"r the center of the MPFL origin was
found to be distal to the distal femoral physis in all speci-
mens. The proximal extent of the MPFL origin footprint
was found to extend above the physis in older specimens.
The distal attachment of the extensor mechanism also
should be considered when evaluating patients with pa-
tellofemoral instability. A commonly used parameter for
assessing the distal attachment of the extensor mechanism
is the tibial tubercle—trochlear groove {TT—Tfi} distance.
An increased TT—TG distance is associated with patellar
instability in pediatric and adolescent patients.a The type
of imaging modality is also an important consideration
E when measuring TT—TG distance: MRI can potentially
E underestimate the TT-TG distance compared with CT?
:5
:1: Patellar height should also be assessed because patella
Ch
E alta can be associated with patellofemoral instability.
S
3... 1Whether this relationship is causative is unclear, and save
I1:
I
'— eral studies have shown that patellar height decreases fol-
Ed lowing MPFL reconstruction.‘”-" Accurate measurement
of patellar height in skeletally immature patients can be
challenging because of incomplete ossification centers. A
2010 studyir1 showed that the Insall-Salvati ratio is most
reliable in patients with near—complete ossification, and
that the Koshino Index” may be more applicable but less
valid in younger children. The lCaton-[ieschamps index
may be a simpler, more reliable method for determining
patellar height in skeletally immature patients” {Figure l}.
Trochiear dysplasia is associated with recurrent insta-
bility even after MPFL reconstruction. In a 2fl14 study,
only 43% of patients returned to sports participation after
MPFL reconstruction if they also had severe trochlear
dysplasia.” In this series, all patients with severe dysplasia
had recurrent instability compared with 9.3% of those
with mild dysplasia.
Tl'eatment
No clear evidence supports surgical over nonsurgical
treatment of acute patellar dislocation.”5 The primary
firthopaedic Knowledge Update: Sports Medicine 5
Figure 1 Medial patelloiemoral ligament insertion site
in a siteletally immature patient. {Reproduced
with permission from Helita M1,. Dreyhaupt
J. Fieit hei H. Woelfle .l. Lippacher S: Anatomic
reconstruction of the medial patellofemoral
ligament in children and adolescents with open
growth plates: Surgical technique and clinical
outcome. Am J Sports Med EH13;41[1]:5Ei-i53.)
absolute indication for surgical treatment of acute patel—
lar dislocation is the presence of an osteochondral loose
body.”
For chronic patellar instability in the child or adoles-
cent athlete, it is important to keep multiple factors in
mind when deciding on treatment. Cine algorithm uses
physeal status, Q—angle, trochlear morphology, and TT-
TG distance to determine the optimal procedure for treat-
ing patients with chronic insta bility.IE Medial imbrication
is recommended for skeletally immature patients, with or
without soft-tissue distal realignment {Roux-Goldthwait
procedu re], depending on TT—TG distance. MPFL recon‘
struction is recommended for skeletally mature patients,
with or without distal realignment (tibial tubercle oste-
otomy}. Additionally, trochleoplasty is recommended in
those with severe trochlear dysplasia. A slightly different
treatment algorithm has been proposed that accounts
for rotational alignment and patellofemoral chondral le—
sions.” Surgical treatment options for chronic patellofem-
oral instability in the child or adolescent athlete are also
listed in Figure 3.
MPH Reconstruction
Several surgical techniques for MPFL reconstruction have
been described for skeletally immature patients. A 2fl13
study describes an l'vIPFL reconstruction technique with
bioabsorbable screw fixation distal to the distal femoral
physis and a looped graft through the patella” [Figure 4}.
A 2014 study describes an MPFL reconstruction tech—
nique using a pedicled quadriceps tendon autograft.11
Double-bundle, anatomic l'vIPFL reconstruction is also
described with two tunnels drilled into the patella.” A
lflil study described MPFL reconstruction in skeletally
fl lflld American Academy of Orthopaedic Surgeons
 llilhapter 49: Patellbfemural Instability and fltller Gammon Knee hstles in the Skeletally Intmatu're Athlete
Caten-Desehamps Indeut lneall-Ealvatl Flatlb
AP
INCH}! — F
Kuahlnb Indett
Figure 2 illustratibns depict methbds at assessing
patellar height in skeletally immature patients.
A, The Caten-Deschamps indent: calculated
by dividing the articular facet length bf the
patella {AP} by the distance between the
interim aspect at the patellar articular facet
and the anteri br cbrner bf superibr aspect bf
the tibial epiphysis {AT}. I. The insaIl-Salvati
ratib: calculated by dividing the patellar tendbn
length {PTL} by the patellar length {PL}. E.
The ltushinb index: calculated by dividing the
distance tram the center at the patella tn the
center bf flte tibial physis [PT] by the distance
frbm the center at the fembral physis tb the
center b'F the tibial physis {FT}.
immature patients using patellar tunnels, with graft tenb—
desis tb the adductbr magnus tb avbid drilling a tunnel
near the distal fembral physis.“ Tb date, nb study has di-
rectly cbmparecl MPFL recbnstructibn techniques in skel—
etally immature patients. During MPFL recbnstructibn in
IE! Efllfi American Academy bf firthbpaedie Surgebns
skeletally immature patients, careful attentibn shbuld be
given tb fembral fixatibu tb minimize the risk bf physeal
damage, and the ambunt bf patellar drilling shbuld be
minimized.
Q' 1itl'ideb 49.1: A Surgical Technique fbr Me-
dial Patellbfembral Ligament Hecbnstruc-
tibn in the Skeletally Immature. Henry B.
Ellis, MD, Philip L. Wilsbn, MD [14 min}
Distal Realignment
In the setting bf an abnbrmal TT—TG distance, distal re-
alignment in additibn tb MPFL recbnstruc'tibniprbscimal
realignment shbuld be cbnsidered. Skeletally immature
patients present a challenge when ebusideriug distal re-
alignment because tibial tubercle bsmbtbmy {such as the
Fullcersbn prbcedure] is cbntraindicated. A technique
bf distal realignment with transfer bf the tibial tubercle
peribsteum has been described tb avbid injury tn the tibial
tubercle apbphysis.13 The Galeaaai prbcedure invblves
tenbdesis bf the semitendiubsus teudbn tn the patella
while preserving its distal attachment. This prbcednre
is designed tb prbvide a eheclcrein fbr lateral patellar
tracking; hbwever, it is “unnanatumie.” An 32% rate
bf recurrent sublurcatibnidislbcatibn at an average fbl-
lbw-up bf Tl] mbnths has been repbrted in patients whb F“?
underwent a Galeaaei prbeedure.“ Additibnally, 35% bf
rs
patients underwent additibnal prbcedures tb treat per-
E?I:
sistent symptbms. The sb-ealled 3-in-1 prueedure iuvblves :t
v:
lateral retinacular release, vastus medialis advancement, 1"
and transfer bf the medial third bf the patellar ligament
Fl
E
as
tb the medial unilateral ligament. Althbugh this prbee- m
F.
dure has been shbwn tb be safe and reliable, isbkinetic
strength testing bf the surgical limb has shbwn persistent
weakness ebmpared with the ebutralateral limb.“ The
Rbuit-Gbldthwait prbcedure invblves lateral retinacular
release and transfer bf the lateral half bf the patellar lig-
ament medially. This prueedure has shbwn gbbd results
in small seriesFiT"
Tmchleaplasty
The fembral trbchlea prbvides a lateral buttress tb resist
patellar dislbcatibn, and trbchlear dysplasia can predis-
pbse patients tb instability. A 2fl13 study repbrted success
treating recurrent instability in patients whbse surgery
fbr patellbfembral instability had failed, by treating the
underlying trbchlear dysplasia with trbchlebplasty."m A
2'313 study described successful butcbmes fbllbwing cbm-
biued MPFL reebusttuetibn and tmehlebplasty in patients
with patellbfembral instability in the setting bf trbchlear
dysplasia.19 A 2011 study repbrted bn trbchlebplasty tb
Drthbpaedie Knbwledge Update: Spbrts Medichse 5
 Section E: The Turing Athlete

IF'ataliclamcirai instabiiiy

! Ekaiatally mature? |

1title

Increased Tr-Te'i | llncreasacl TT-TeiI

El El
m w insider Genaider
Fraternal realisinlnent Presimel reelisnrrent naimal maligiment Prerirrei realignment
" MPFL l'BIIUl'IE‘ll'UC-llfll'l * “PH. l'BlIlIT'IEiI'lflfiflH I MPFL mmtmtmn turg I MPFL mmnstmcfign ya
AND UH medial imbrieatinn mecial imhricatien
Distal realignment laclaied distal realignment AND up
. liel “Aberdesleetr ' lifll whemlflplafiir Distal realignment lsciatad ciststl realignment
- -tissue pmcedure I Snflafiesue prnbedure
[Hats-Geldthwelt] (Ficus-Geldihwaiil

IDllter |Denaiidisiratliitina |
Chendrai iaaiene Hntaflnnal malt-ligament
Gnnaidar M
I Lesibnsspeeilic ireairnent I Arialumicalbi specific estactcmy (Le. lemciral
echendrcipiasty cratetcimy. tibial catacitcimy]
li-Dstauchcindral fiicaticin
leflstecichendral autuyafdalle-grait Tin-ehleer dyapiaala
eAutciegc-us dtcndrcieyte 9311M
E implantation - Trachlacplasty in siuiaietaliyr mature
E
.‘E
sill
Eh
E Figure 3 iilustratinn depicts treatment algcirithm fur chrnnic patellnfemcral instability in the child er adelescent athlete.
E
3...
MPFL - medial patelicrlemciral ligament; TT-TG - tibial 'tubercle-‘trcicl'ielar arc-eve distance.
I1:
.I:
|_-
c'ci treat trechlear dysplasia in patients with patellcifeninral rerww in 2i] 14 chewed that recurrence rates can be higher
instability and ccincludecl that trn-chleciplasty is useful in MPFL repair (26.9%] cir medial retinacular repair!
and reliable; hnweyer, imprciyecl pnstnperatiye knee pain plicaticin {16.5%} ccin'iparecl with MPFL reccinstrnctinn
is less predictable.” {6.6%}.33

Complications
Ccrnplicatinns fellnwing surgery fer patellnfemnral in-
stability include recurrent instability, stiffness, patellar
fracture, patellcifemciral arthrcisis, and persistent pain.
A 2013 study rcpnrted a 16.2% ccrnplicaticiit fer MPFL
recnnstructicin in patients yciunger than 21 years.“ Ferr-
ty-seyen percent Df ccimplicaticins were secnnclary tn tech-
nical facturs ancl ccinsidered presentable. Female sex and
bilateral MPFL recnnstrncticin were risk factcirs asscici—
ated with pcstcperatiye cc-niplicaticns. Ancther 2013
study repnrted that subjective nutccimes and recurrence
rates were wurse ill patients with trcichlear dysplasia c-r
an increased TT—TG distance in which isclated MPFL re-
ccinstructicin was perfcirmecl, further emphasising the im—
portance cif treating assnciated pathciluigy.31 A systematic
Tibial Spine Aunlsicin Fractures
Tibial spine {eminence} ayulsicin fractures uccur when the
antericir cruciate ligament [AC L} arulses frcirn its insertinn
en the prescimal tibia epiphysis. Generally, tibia] spine
ayulsinn fractures are seen in younger patients between
age 3 and 14 years.“ Assneiatecl intra-arricular injuries
are cnmmcin, and the rate bf meniscal er cellateral liga-
ment damage assciciateci with these injuries is estimated
tn be between 3.3% and 4fl.fl%.35'3?
Diagnosis. Anatomy, and Bicimechanic:
The ACL inserticn en the tibia ins-elves the antericir recess
between the medial and lateral interccindylar eminences.
In skeletally immature patients, ayulsinn fracture nccurs

firthnpaedic Knnwledge Update: Spbrts Medicine 5 fl lflld American Academy cif Cirrhcipaedic Surge-ens
 Chapter 49: Fatellofemoml Instability and fltller Cameroon Knee hence in the Skeletally Imrnanrre Athlete
Figure 4 Fluoroscopic image shows bioresorbable
interference screw fixation for femoral
fixation of medial patellofemoral liagament
reconstruction. {Reproduced with permission
from Melitz M1. Dreyhaupt J. Reichel H. WoeIe
J. Lippacher S: Anatomic retonstru ction of the
medial patellofemoral ligament in children and
adolescents with open growth plates: Surgical
technique and clinical outcome. Am J Sports
Med 2fl13;41 [11:53-61]
because of tension failure of the incompletely ossified
tibial eminence. Appropriate treatment of these injuries
is important because nonanatomic healing can result in
loss of appropriate ACL tension and cause functional
instability. additionally, a displaced bone fragment can
block range of motion {particularly in extension] and
result in pain and limitation in activity or difficulty with
sports participation.
The most common classification system for tibial
spine avnlsion fractures uses lateral radiographs of the
injured knee {Figure 5}. Type I fractures have minimal
displacement, type II fractures have displacement of the
anterior third to half of the tibial spine but have an intact
posterior hinge, and type III fractures are completely
displaced.” The classification was later modified and a
type IV fracture was added to describe comminuted and
rotated fractures}9
CT can help evaluate residual displacement after
closed reduction of tibial spine avulsion fractures as well
as assess fragment size and comminution. MRI in the
setting of tibial spine avulsion fracture is controversial.
The advantages of MRI include the ability to evaluate
concomitant injuries or soft-tissue interposition {such as
IE! lfllfi American Academy of flrthopaedic Surgeons
Typol _ Typell
Type III I l
Figure 5 Illustration depicts the Meyers and McKeever
classification for tibial spine avulsion fractures
with the Iaricznyj modification.
F“?
rs
intermeniscal ligament or meniscal entrapment} beneath
EfI:
the tibial spine fracture. In a 2011 study. fifl'if: of tibial :r
a:
spine fractures had subchondral bone bruises and 4fl% 1"
had meniscal tears seen on MRI.” A 2015 study found
Fl
E
o
associated soft-tissue or other injury {including meniscal m
F.
entrapment, meniscal tear and chondral injury} in 59%
of patients with tibial spine avulsion fractures.“ IEar-
tilaginous tibial eminence fractures have recently been
described and are defined by a double-PCL sign on MRI
in patients 5 to 3 years old.m IDue disadvantage of MRI
in pediatric patients is the possible need for sedation to
obtain high—quality images. Additionally, if surgery is
indicated for a displaced tibial spine fracture, evaluation
under anesthesia and diagnostic arthroscopy can directly
evaluate intra—articular injury, obviating the need for
MRI.
Treatment
The treatment of tibial spine avulsion fractures depends
on the amount of displacement, comminution, and asso-
ciated injuries. Nonsurgical treatment consisting of closed
reduction and immobilization in extension is recommend-
ed for type I fractures and type II fractures in which
adequate closed reduction is obtained. lClose follow-up
Drthopoedic Knowledge Update: Sports Medicine 5
 Section E: The Young Athlete

after closed reduction is needed to ensure maintenance of

reduction. Immobilization is recommended for 6 weeks,
followed by gradual and progressive range of motion.
Recently, two systematic reviews compared nonsurgi-
cal and surgical treatment of tibial spine avulsion frac-
tures. Pi. 2fl14 study reported that nonsurgical treatment
of completely displaced tibial spine fractures resulted in
a higher rate of nonunion as well as increased knee laxity
and greater loss of motion.“1 A ZEUS study echoed these
findings and reported clinical instability in Tfl‘lis of pa-
tients treated nonsurgically versus 14% clinical instability
in surgically treated patients.“ A higher rate of subsequent
ACL reconstruction was also reported in patients who
were treated nonsurgically.
Surgical treatment consists of either open or ar-
throscopic reduction and internal fixation. Arthroscop-
ically assisted tibial spine fracture treatment allows for
full evaluation of intra-articular contents and concomi-
tant procedures for other diagnosed pathology. Various
fixation options are available, including solid screws,
cannulated screws, bioabsorbable screws, suture fixation,
suture anchors, or any combination. Suture anchors have
become widely used in shoulder arthroscopy, and these
techniques and skills have been translated to the treatment
of tibial spine avulsion l-"racturesf‘ir‘M An advantage of
suture anchor fixation is the ability to spare the physis in
E skeletally immature patients. Another possible advantage
E includes the ability tn provide suture bridge compression
:5
:1: across the tibial spine fragment analogous to rotator cuff
Ch
E double-row repairs.“
S
3... Suture fixation of tibial spine avulsion fractures has illustration demonstrating suture fixation to
I1: repair a tibial eminence fracture. (Reproduced
.I:
'— been described since the mid 199lls, and the develop— from LaFrance HM, Giordano B, Goldblatt
rid ment of arthroscopic techniques using suture fixation are J. et al: Pediatric tibial eminence fractures:
continually refinedfir‘l" Using this technique, sutures are Evaluation and management. J Am Acad
flrthop Surg- 2D1D;IE[?]:395‘405.}
passed through the base of the ACL along with a chondral
fragment. These sutures are brought down through drill
holes in the proximal tibial metaphysis and tied over a
bone bridge or to a screw and post {Figure 6). Different polyethylene {UHMWPE} suture fixation was stronger
devices have been used for suture passage such as labral than polydioxanone suture {PBS} or single-screw fixa-
repair books or suture pa ssers along with meniscal repair tion and more consistent than suture anchor fixation.“
devices.“ Drill holes can be placed using a standard tibial Most recent studies support UHMWPE suture fixation
ACL guidefi'5 as having the strongest initial fixation strength combined
Biomecha nical studies have studied various screw, su- with cyclic loading strength to resist the rigors of early
ture, and suture anchor fixation techniques. Cine study mobilisation.
found antegrade screw fixation was better than suture
fixation in a cadaver model;“'" however, other studies I[Iomplicatio ns
have reported contemporary suture fixation techniques Iilommon complications after treatment of tibial spine
as superior to screw fixation.“-“9 In one study, fixation avulsion fractures include loss of motion, residual laxity,
was stronger with braided, nonabsorbable suture than growth arrest, and angular deformity. Nonunion has also
with 4.D-mm cannulated screw fixation with a washer.“iEI been reported.“ Residual laxity has been reported in 10%
A EMS study compared physeal—sparing suture fixation of knees managed surgically and 22% of knees managed
techniques and found that ultra-high—molecular—weight uonsurgicallyxi1 Loss of motion or arthrofibrosis after

firthnpaedic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons
 llilllapter 49: Patellofemnral Instability and |Either Coeumon Knee hence in the Skeletelly bnmature Athlete
tibial spine avulsion fracture is one of the most common
and difficult complications to treat. A 2012 study found
that early range of motion {within 4 weeks of surgery} re—
sulted in quicker return to activity and a 12-fold decrease
in the rate of arthrnlibrnsis.51 A 2010 study reported on
complications related to reoperation for arthrofibrosis
after treatment of tibial spine fractures.53' Distal femo-
ral physeal fracture and subsequent growth arrest were
described in 12.5% of patients who underwent manipu-
lation under anesthesia for arthrofibrosis following treat-
ment of tibial spine avulsinn fracture. This highlights two
important principles regarding arthrofibrosis after tibial
spine avulsion fracture: that prevention of stiffness after
surgical treatment is essential and requires stable fixation
with immediate rehabilitation, and arthroscopic lysis of
adhesions before manipulation is essential to help prevent
physeal fracture.
Discnid Lateral Meniscus
Discoid lateral meniscus is a common cause of knee symp-
toms in children. Young children with discoid lateral
meniscus can present with snapping knee syndrome, in
which an unstable discoid lateral meniscus causes inter-
mittent snapping nr popping of the knee. This condition
is often unaccompanied by a history of traumatic injury.
In young children, the snapping can be asymptomatic; in
older children, the snapping is more likely to cause pain
with activity.
Etiology
lCompared with the normal meniscus, the discoid me-
niscus has an abnormal shape, is inherently different at
a molecular level, and may have abnormal peripheral
attachments resulting in microinstability or macroinsta-
bility. The discoid meniscus encompasses more surface
area on top of the tibial articular surface compared with
a normal meniscus with a semilunar shape. The discoid
meniscus is also thicker than normal, especially within
its central aspect (away from the periphery] and is altered
at the molecular level with more haphaaardly arranged
circumferential collagen fibers compared with normal
menisci.“ The abnormal shape and morphology of the
discoid meniscus as well as the disorganization within
the collagen network can contribute to Ineniscal tears
and degeneration.
Classification
The 1EFatanabe classification, the most commonly used sys-
tem to classify discoid lateral menisci [Figure 2?], is based
on arthroscopic appearance and stability. Type I {com—
plete} discoid lateral meniscus is stable to arthroscopic
IE! Elilli American Academy of flrthopaedic Surgeons
Figure 3' Illustration depicts the Watanahe classification.
Type I. complete. Type II. incomplete. Type III.
Wrisberg variant [no meniscotibial attachments}.
probing, block-shaped, and covers the entire tibial plateau. F“?
Type II {incomplete} is stable to arthroscopic probing and
m
covers up to Bfl% of the tibial plateau. Type III {Wrisberg
EfI:
variant} is characterised by instability on probing. Type :I
a:
III is devoid of posterior meniscotibial attachments and is 1"
attached posteriorly only to the meniscofemoral ligament
Fl
E
as
of Wrisberg, resulting in posterior horn instability. m
F.
Instability of the discoid lateral meniscus is increas-
ingly recognised as an important aspect of arthroscopic
evaluation. A 2004 study reviewed 112 patients (123
knees} with a mean age of Hi years who underwent
arthroscopic evaluation and treatment of discoid lateral
meniscus? Peripheral rim instability was present in 23%
of discoid lateral menisci; instability was more common
in complete than in incomplete discoid lateral menisci
{33.9% versus 13.2%] and in younger patients (age, 8.2
years versus Ill? years}. Additionally, the most conunon
location for peripheral rim instability was the anterior
third {412%}, followed by the posterior third {33.9%}
and the middle third (11.1%}. In a 100? study, 23 con-
secutive patients underwent arthroscopic treatment of
discoid lateral meniscus?5 Meniscal instability was found
in T?% of knees, with anterior horn instability in 53%,
posterior instability in 16%. and combined anterior and
posterior instability in 6%. {if 23 unstable menisci, 2.2
were treated with arthroscopic saucerisation and suture
Drthopaedic Knowledge Update: Sports Medichte 5
 Sectictn B: The Young fldflete

Figure B Radiegraehs depict disceid lateral meniscus

A. AP view shews squaring at the lateral
femeral cendyle {E}, which is the amnunt ef
straight articular surface ef cendzrle {sh ert
line}, and cupping ef the lateral tibial plateau
{F}, measured frctm the tibial jeint line {lung
line} tn the presimal limit at the lateral tibial
plateau {anew}. A measurement greater than
1 mm is certsidered a pesititre resuft. I. Lateral
view shews the lateral femeral cendylar netch.
frem the tangential line {line}, which meets
the smeeth cunteur cf the articular surface
tn the netch. A value greater than 1 mm is
deemed pesititre. {Hepruduce-d with pennissien Figure 9 A, AP radiegraph demenstrates widened lateral
frem Cheri 5H. Ahn JH. Kim El, et al: Be the jeint space {thin arrew} and elevated tibular
racliegraphic findings at symptematic disceid head {thick arrewi. El. AP raeiegraph shews
lateral meniscus in d'tild ren differ tram nermal nermal lateral jeint spa ce {shnrt arrls-wlI and
central subjects? .lt'nee Surg Sperts Trams-taterr tibular head height {Icing arrew}. C, Cerenal
E Arthresc 2a1s:es[a]:112s=1 134.) MRI shews ce mplete type I disceid lateral
E meniscus larrew]. D. Carenal MRI shews nermal
:5 lateral meniscus shape. (Repreduced with
:1:
permissien trem Ehel 5H. Ahn JH. him till. et al:
stabilizatien. Careful intraeperatitre examinatien ef dis-
Us
E be the radiegraphic findings at symptematic
E
3... ceid lateral menisci is advecatecl, and meniscal stabilisa- disceid lateral meniscus in children differ from
I1: nermal centrel subjects? Knee Surg Sperrs
.I:
'— tien (in additien te saucerieatien and treating meniscal Traumatdl Arthmsc Elli Esflldlfltlfl-HSIH
c'ci tears} is recemntended when instabilityr is present.

Imaging directinn cf the shift cerrelated with the repair lecaticm.

Standard radiegraphs are usually nermal in children with
disceid lateral meniscus, althnugh there mat»r be subtle ra—
dius-graphic findings. 1When cnmpared with patients with-
eut defermity, children with disceid lateral menisci magi.r
have differences in the height cf the lateral tibial spine,
lateral jeint space distance, height cf the fibular head, and
ebliquitsr ef the lateral tibial plateau” {Figures 3 and 9}.
A 2t] 05‘ stud},F retrcispectitrel}F care mined knee MRIs ef
patients with disceid lateral meniscus whe were treated
with arthrescujpfr, and a new MRI classificaticm scheme
tn facilitate the diagnesis nf meniscal pathelciggf,F was pre—
pesed.” The patients’ MRI findings were described based
cm the relatic-nship ef the lateral meniscus tn the lateral
tibial plateau (nu shift, anterecentral shift, pesterecentral
shift, central shift]. These with a shift en preeperatitre
MRI were substantially,F mere likely tn have undergnne
meniscal repair during arthrescnpic treatment, and the
A retrespectire review ef 69 patients whe had under-
gene arthrescepic treatment ef disceid lateral menisci was
cenducted tn determine whether meniscal displacement er
defermatien en MRI was cert-elated with meniscus tear.fl
The afnrementiened prepnsed classificatieniE was medi—
fied and described the cencept cf “merphelegic change"
when diagnesing a tear in disceid lateral menisci. A mer-
phelngic change was diagnesed if a difference greater
than ?{l% was acted in meniscal thickness between the
anterieripcsterinr and medial!lateral pnrtiens cf the me-
niscus. A merphnlegic change was alsn diagnesed if the
meniscus cressed the lateral tibial spine en cerenal MRI
sequences er went beyend the tibial plateau margin en
sagittal sequences. All types cf tears {except radial tears]
found an arthrescep].r were asseciated with same sert ef
merphelegic change an preeperatitre MRI. When cem—
pared with signal intensit}r change an MRI, merphnlegic

firthnpaedic Knewledge Update: Sperts Medicine 5 fl lfllfi American Academy ef Orthepaedic Surge-ens
 llllllalzlter 49: Patellofemoral Instability and |Either Counmon Knee hsues iu the Skeletally humanrre Athlete
change was better at predicting the presence of a discoid
lateral meniscus tear in children.
Treatment
Support is increasing for meniscal reshaping andr'er partial
meniscectomy for the treatment of symptomatic discoid
lateral meniscus rather than total or subtotal excision.
Stabilization of the meniscus is increasingly recognized
as important if it is determined to be unstable during
arthroscopyfib” A retrospective case-control study of
.51 patients cempa red patients who were treated with ar-
throscopic meniscal saucerisation alone versus those who
underwent saucerixation plus stabilisation.” The average
patient age was 11.? years and the average follow—up was
15 months. No significant differences were noted between
treatment groups regarding postoperative knee range of
motion, complications, or self—reported functional scores.
Short-term clinical outcomes for patients with symptom-
atic disceid menisci requiring surgical intervention were
good, and most patients had complete relief of symptoms
and reliable restoration of both knee motion and function
with a relativelyr low complication rate. The addition of
meniscal sta bilisation did not affect the clinical outcomes
in those who demonstrated meniscal instability.
The timing of treatment can influence cartilage health
and meniscal reparability in patients with a discoid lateral
meniscus tear. A 2014 study investigated the relationship
between isolated disceid lateral meniscus tears and the
presence of articular cartilage lesions in 252 consecu—
tive patients!“1 Articular cartilage lesions were present in
26.6% of patients. Multivariable logistic regression anal—
ysis revealed that in addition to sex and body mass index,
preoperative symptoms lasting longer than 6 months in-
creased the likelihood of finding articular cartilage lesions
at arthroscopy. fisteochondritis dissecans {DIED} lesions
within the lateral femoral condyle can also be associated
with the presence of a discoid lateral meniscus.fl A 2fl13
study reviewed meniscal tear patterns in children and
adolescents and found that these treated within 3 months
of symptom onset were more likely to have reparable
tears compared with these who were treated more than
a months after onset.“3
Knee flstoethondresos
l[l‘steochondrosis is characterized by a disturbance in
endechendral ossification in a previously normal endo-
chondral growth center. Usteochondroses have been re—
ported in almost every growth center of the body. Two
common osteochondreses affecting the slteletallg,r imma-
ture knee are flsgeod—Scblatter disease and EL] disease
{although not a true osteochondrosis}, which affect the
IE! Ellie? American Academy of flrthopaeclic Surgeons
Degeed-Sehlatler ls"
lenon
Illustration depicts front and side views of
Dsgood-Schlatter tllsease.
tibial tubercle apophysis and the inferior pole of the pa—
tella, respectively. Both disorders have relatively predict-
able clinical presentations and are commonly self-limited
conditions. Ma naging patient and parent expectations are
as important as properly managing the condition itself. F“?
m
Osgood-Schlatter Disease
3‘I:
Osgood-Schlatter disease is a traction apephysitis of the :I
u:
tibial tubercle apophysis that commonly affects children I!"
who are undergoing rapid growth {Figure 10}. The exact
Fl
E
re
cause of Usgood-Schlatter disease is unknown but it is m
F.
likely an overuse syndrome in the developing skeleton.
The condition occurs when stress is placed on the devel-
oping tibial tubercle apephysis by the extensor mecha-
nism and commonly occurs in the running or jumping
athlete. A cross-sectional study of 955 adolescent stu-
dents between 12 and 15 years old found a 9.3% prev-
alence of Dsgood—Schlatter disease {113% in boys and
3.3% in girlsif" Using multivariable logistic regression
analysis, a significant association was found between
Dsgood-Schlatter disease and participation in sports ac-
tivity and rectus femoris tightness. This provides further
support for the proposed etiology of flsgoodHSchlatter
disease as an overuse syndrome as well as a rationale
for treatment with physical therapy—guided stretching
exercises.
Clinical Presentation
Patients with Illlsgood—E-lchlatter disease present with
pain and swelling over the tibial tubercle and may report
Drthopaedic Knowledge Update: Sports lvledichie 5
 Sectibn E: The Tbung Athlete
increased pain with running, jumping, and kneeling activ-
ities. Tenderness tb palpatibn, swelling, and prbminence
bf the tibial tubercle as well as tightness bf the quadriceps
and ha mstrings can be appreciated bn physical examina-
tibn. Pain can be reprbduced with resisted knee extension.
A detailed physical examinatibn is itnpbrtant tb differ—
entiate Dsgbbd-Schlatter disease frbm bther cbmmbn
cbnditibns that cause knee pain such as patellar tendinitis,
5L] disease, and pes anserine bursitis.
Althbugh IIZ'isgbbd-Schlatter disease can bften be diag-
nbsed clinically, plain radibgraphic imaging bf the knee
shbuld be bbtained tb rule but bther pbtential causes bf
knee pain, especially if the presentation is atypical. De-
pending bn the severity and chrbnicity bf the cbnditibn,
elevatibn, radiblucency, and fragmentatibn bf the tibial
tubercle can be seen en a lateral radibgraph. Advanced
imaging such as MRI is bften unnecessary tb establish
the diagnbsis.
Treatment
IJill'sgb-bd-Schlatter disease is generally a self-limited cbn-
ditibn and initial treatment shbuld fbcus bn symptbmatic
care {H5AIDs, analgesics}, activity mbdificatibn (rest,
avbiding aggravating activities), and physical therapy
[fbcusing bu quadriceps, hamstring, and ilibtibial band
stretching and strengthening}. The symptbms bf Os—
E gbbd-Schlatter disease can persist until clbsure bf the
E tibial tubemle apbphysis, and althbugh many patients will
:5
fl: be asymptbmatic after they reach adulthbbd, up tb 60%
Eh
E can still have sbrne residual pain bver the tibial tubercle
E
3... with lcneeling.‘55
I1:
.I:
'— Mbre invasive treatment can be cbnsidered fbr recal-
citi citrant |IlIlisgbbd-Schlatter disease. A large series bf male
military recruits reviewed the lbng-terru butcbmes after
surgical treatment fbr unresblved Osgbbd-E-chlatter dis-
ease.if The patients underwent isblated residual bssicle
rembval, isblated tibial tubercle resectibn, br cbmbined
bssicle rembval and tibial tubercle resectibn. After a me-
dian-duratibn fbllbw-up bf 10 years, 3?% bf patients
repbrted nb restrictibns in everyday activities br at wbrlc
and T5 {lib had returned tb their prebperative level bf spbrts
activity. Thirty-eight percent repbrted a cbmplete absence
bf pain with kneeling. Mbre recently, hyperbsmblar dex-
trbse injectibn was examined fbr the treatment bf recal-
citrant cases bf |ilillsgbbd-{ichlatter disease.“ In this study,
54 patients with refractbry Dsgbbd-Schlatter disease were
randbmly assigned tb either usual care {physical therapy}
br dbuble—blind injectibn bf 1% lidbcaine sblutibn with
br withbut 12% dextrbse. Injectibns were administered
mbnthly fbr 3 mbnths. At 1-year fbllbw-up, thbse whb re-
ceived injectibns that cbntained 12% dextrbse were mbre
likely tb be able tb participate in spbrts asymptbmatically
firthbpaedic Knbwlbdge Update: Spbrts Medicbie 5
cbmpa red with thbse whb were treated with 1% lidbcaine
injectibn albne br usual care.
5L1 Disease
5L] disease is analbgbus tb |[lisgbbd-Schlatter disease.
Dsgbbd-Schlatter disease is an bstebchbndrbsis bf the
tibial tubercle apbphysis; 5L] disease invblves the infe-
ribr pble bf the patella. Because there is ub apbphysis bf
the inferibr pble bf the patella, 5L] disease can be mbre
accurately described as an enthesitis rather than a true
bstebchbndrbsis. 5L] disease traditibnally presents in
slightly ybunger patients than Dsgbbd-Schlatter disease.
Clinical Presentatibn
Patients with 5L] disease typically have pain with activ-
ities that require running and jumping, similar tb thbse
with Dsgbbd-Schlatter disease. Symptbms are bnly pres-
ent during the bffending activity and bften resblve with
rest. Physical examinatibn reveals maximum tenderness
with br withbut swelling bver the inferibr pble bf the
patella lbcated bver the insertibn bf the patellar ligament.
Careful histbry shbuld assess the acuity bf symptbms and
physical examinatibn shbuld examine fbr any palpable
defect at this lbcatibn er the inability tb perfbrm a straight
leg raise. An acute br traumatic bnsct bf pain assbciated
with a palpable defect and inability tb perfbrm a straight
leg raise shbuld increase suspicibn fbr a patellar sleeve
fracture rather than 5L] disease.
Plain radibgraphic imaging bf the knee can reveal cal-
cificatibn br bssificatibn at the inferibr pble bf the patel-
la {Figure 11}. Radibgraphs can alsb help rule but bther
causes bf knee pain such as fractures, Usgbbd-SchlatEr
disease, and bipartite patella. As with Dsgbbd-Schlatter
disease, 5L] disease can usually be diagnbsed clinically and
advanced imaging such as MRI is usually nbt necessary.
Treatment
5L] disease bften has a self-limited cburse with resblu-
tibu bf symptbms after maturatibn bf the inferibr pble
bf the patella. As with Dsgbbd-Schlatter disease, treat-
ment shbuld fbcus bu symptbm cbntrbl with NSAIDs
br analgesic medicatibn, activity mbdificatibn, physical
therapy, and rest. A brief peribd bf immbbiliaatibn in a
cylinder cast br knee extensibn brace can be cbnsidered
fbr select patients. Late sequelae bf 5L] are rare and bne
case repbrt exists bf a fracture thrbugh a previbusly united
bssicle.“ Surgical excisibn bf symptbmatic, nbnunited
bssicles bf the inferibr pble bf the patella can be cbnsid-
ered fbr recalcitrant cases in adults. Tb date, nb study has
investigated the use bf injectibn therapy fbr the treatment
bf 5L] disease.
fl 21.1115 American Academy bf Cirrhbpaedic Surge-ens
 Chapter 49: Patellefemeral instability and Either Cathleen Knee beers in the Skeletally Immature Athlete
eff
Figure 11 Lateral radiegraph ef the knee ef a patient
with a histery ef Sinding-Larsen-Jehanssen
disease {anew}.
S u nt nt a ry
Patellefemeral instability in the child and adelescent ath-
lete is a cemmen cause ef knee dysfunctien. Preperly as-
sessing and treating the many facters that can centribute
te instability is essential re a successful eutceme. Tibial
spine avulsien fracture is a unique injury te the AC]. at-
tachment. Prempt diagnesis and treatment are essential
te restere nermal knee mechanics. Nensurgical treatment
is recemmended fer nendisplaeed fractures er fer these
that reduce anatemically with clesed reductien. Surgi-
cal interventien is recemmended fer displaced fractures
using varieus epen and arthrescepic techniques. Bieme-
chanical studies suppert the use ef all suture fiaatien.
Stable fisatien is needed te ensure the ability te begin
early range ef metien and rehabilitatien te prevent less
ef metien and artbrefibresis. Disceid lateral meniscus
is a petential cause ef knee pathelegy in the pediatric
patient. Histery and physical examinatien remain the
cernerstenes ef diagnesis: hewever, recent advances in
IE! lfllfi American Academy ef flrthepaedic Snrgeens
imaging techniques and interpretatien, specifically MRI,
can aid in evaluatien and treatment. Geed treatment
results have been ebtained with arthrescepic reshaping
{sauceriaatien} ef the disceid lateral meniscus re a mere
nermal centeur. Additienally, the impertance ef evalu-
ating fer and treating meniscal instability is increasingly
recegniaed and asseciated articular cartilage lesiens are
relatively cemmen. flsgeed-Schlatter disease and EL]
disease are cemmen cenditiens ef the knee in the juve~
nile athlete. Beth cenditiens typically have a self-limited
can rse and respend te a peried ef rest, anti-inflammatery
andl'er analgesic medicatien, activity medificatien, and
physical therapy. Symptems usually reselve by the time
patients reach skeletal maturity but surgery can be cena
sidered fer recalcitrant cases.
Hey Study Peints
- Respect ef physeal anatemy is impertant when
evaluating and treating patellefemeral instability
in skeletally immature athletes.
' Assessing and addressing meniscal instability is an
impertant aspect ef treating symptematic disceid
lateral meniscus.
I: Knee everuse syndremes in children and adeles-
cents are cemmen, and mast respend te nensurgical
treatment.
F“?
m
3‘I:
Annetated References :t
a:
1"
Fl
E
n:
1. 1|Waterman BR, Eelment P] Jr, flsvens ED: Patellar dis- m
F.
lecatien in the United States: Rule ef seer, age, race, and
athletic participatien. I Knee Sarg 3:111:15 [11:51—51
Medline D0]
The anthers ef this study queried The Natienal Eleetrenic
Injury Surveillance System fer all patellar dislecatiens
presenting te emergency departments frem Eli-US re 20 SE.
The incidence ef patellar dislecatien was 2.29 per 1Dfl,fl DU
persen-years in the US: equal rates were feund between
males and females with peak incidence between 1.5 and
19 years ef age and 51.9% eccurted during athletic ac—
tivity. Level ef evidence: II.
2. Lewallen Lilli; McIntesh AL, Dahm DL: Predicters ef
recurrent instability after acute patellefemeral dislecatien
in pediatric and adelescent patients. Am I Sparta Med
2013;41i3lsfifi-531.Mcdlinc D01
This case-central study cempared nensurgical treatment
with surgical treatment ef first-time patellar dislecatien
in pediatric and adelescent patients and reperted a 62%
success rate fer nensurgical treatment and a 31% success
rate in skeletally immature patients with trecbleat dys-
plasia. Fifty percent ef patients with recurrent instability
Drthepeedic Knewledge Update: Sperts Medicine 5
 Section E: The Young Athlete
required surgical intervention to gain stability. Level of
evidence: III.
. Howells NR, Eldridge JD: Medial patellofemoral ligament
reconstruction for patellar instability in patients with by-
permohility: A case control study. 1 Bone joint Surg Br
2fl12:94{lll:1655-1659. Mcdlinc D'UI
This case—control study examined the influence of hyper—
mobility on clinical outcome following MPFL reconstruc-
tion. Functional results were better in nonhypermobile
patients and although hyper-mobility is not a contraindica—
tion to MPFL reconstruction, patients with hypermobility
should be counseled on postoperative expectations. Level
of evidence: III.
Kepler CK, Bogner EA, Hammond S, Malcolmson U, Pot-
ter HG, Green DW: Zone of injury of the medial patello-
femoral ligament after acute patellar dislocation in children
and adolescents. Am I Sports Med 1011:39(?}:1444-1449.
Mediine DUI
This cohort study examined MPFL acme of injury after
acute patellar dislocation. The zone in the pediatric pop-
ulation was found to be the patellar attachment in 61%,
the femoral attachment in 12%, and both attachments in
11%. The remaining 15% had injury at multiple locations
or no identifiable injury. Leml of evidence: II.
. Fclus J, Kowalcayk E: Age-related differences in medial
patellofemotal ligament injury patterns in traumatic patel-
lar dislocation: |Ease series of Si} surgically treated children
and adolescents. An: ,i' Sports Med lfll 2;4fl{1|fl}:235 T—
E 2364. Medline DUI
E The authors examined preoperative and postoperative
:5 The study examined SUI consecutive patients {age range,
:1:
Ch
IDLE to 1.7.5 years] who underwent surgery for first-time
E patellar dislocation. MPFL injury was present in 94%,
S
3... most commonly at the patellar attachment (66%}, followed
I1:
.I:
by the midsubstance fiber area [50%] and the femoral
|_- attachment {32%}; 46% had injury in more than one lo-
id cation. Patcllar—side injury was more common in skeletally
immature versus mature patients HESS versus 54%}. Level
of evidence: IV.
. Nelita M, Dornacher D, Dreyhaupt J, Reichel H, Lipp-acher
S: The relation of the distal femoral physis and the medial
patellofemoral ligament. It"use Sarg Sports Traumosol
Attila-rose 2fl11;19{12]:2flE?-2fl?l. Medline DUI
This retrospective radiographic review of 2? patients who
had a history of patellofemoral instability {mean age,
14.3 years} examined the relationship of the femoral ori—
gin of the l'vIPFL to the medial aspect of the distal femoral
physis. The femoral origin of the MPFL was a median of
6.4 mm distal tn the physis. Level of evidence: IV.
Shea EU, Polouslcy JD, Jacobs F: Jr, et al: The relation-
ship of the femoral physis and the medial patellofemoral
ligament in children: A cadaveric study. ] Pedal-arr Urtbop
2U14;34{Sl:SflS-313.Medline DUI
This anatomic study examined the relationship of the dis-
tal femoral physis to the MPFL in six skeletaliy immature
cadaver knee specimens. All subjects had a center of MPFL
Urthopaedic Knowledge Update: Sports Ivledichie S
origin footprint at or below the distal femoral physis. The
proximal extent of the MPFL origin footprint was found
to extend above the physis in two older specimens.
Pennoclc AT, Alam M, Bastrom T: Variation in tibial
tubercle-trochlear groove measurement as a function of
age, sex, size, and patellar instability. An: 1 Sports Med
2014:42l2}:339-393.Medline DUI
This study examined TT-TU variations as a function of
patient age and size in a population with patellar instabil-
iry compared with those without instability. An elevated
TT-TG was found in both pediatric and adolescent patients
with patellar instability, with measurement varying as
a function of patient age and height {TT—TU increased
by {1.12 cm for each l-cm increase in height}. Level of
evidence: III.
lEamp CL, Stuart M], Krych A], et al: CT and MRI mea-
surements of tibial tubercle-trochlear groove distances
are not equivalent in patients with patellar instability. Ann
,I Sports Med lfllS;4l[S}:lSSS—lfl4fl. Medline DUI
This study examined the reliability of TT—TG distance
measurements on MRI and CT. Although TT-TU distance
can be measured with excellent interrater reliability on
both MRI and CT, MRI tended to underestimate TT—TG
distance compared with CT. Leml of evidence: II.
Ill. Lyltissas MG, Li T, Eismann as, Parilch SN: Does me-
dial patellofemoral ligament reconstruction decrease
patellar height? ill. preliminary report. J Pediatr Urtisop
someones—saunas: no:
lateral lmee radiographs of SS adolescents who underwent
MPFL reconstruction between Zflll‘i and Ellll. Patients
who underwent MPFL reconstruction showed a signifi-
cantly greater decrease in patellar height measurements
compared with control patients. Level of evidence: III.
11. Fabricant PIJ, Ladenhauf HN, Salvati EA, Green DW:
Medial patellofemoral ligament {MPFL} reconstruction
improves radiographic measures of patella alta in children.
Knee 2fl14:21[SJ:IISfl—llfl4. Medlinc DUI
The authors examined patellar height measurements [us-
ing the Insall-Salvati ratio, modified Insall-Salvati ratio,
and Uaton-Deschamps index} in 1? children [mean age,
14.9 years} who underwent isolated l'vIPFL reconstruction.
Preoperative and postoperative patellar height indices were
measured. Isolated .l'vIPFL reconstruction was associated
with consistently improved patellar height measurements
to within normal child hood ranges. Level of evidence: W.
12. Par]: MS, Uhung UT, Lee KM, Lee SH, Choi IH: Which
is the best method to determine the patellar height in
children and adolescents? Clio Urtlsop Relat Res
1D1fl;453[5}:1344—1351.Medline DUI
In this study, 1H3 children and adolescents were evaluated
using MRI and lateral lcnee radiographs. Insall—Salvati,
Blackburne-Peel, and Koshino -Sugimoto methods were
used to determine patellar height. The Insall- Salvati ratio
appeared most reliable in patients older than 13 years with
U 211115 American Academy of Orthopaedic Surgeons
 l[ilhallster 49: Patellofemoml Instability and Either Common Knee Issues in the Skeletally humeral-e Athlete
ahuost complete ossification. For younger patients, the
Husbino-Sugimoto method was the only applicable and
most reliable {but less valid} method. Level of evidence: I.
13. Eoshino T, Sugimoto E: New measurement of patel-
lar height in the knees of children using the epiphyseal
line midpoint. ] Pediatr Drrbop 1939;9{2}:216-213.
Mcdline DUI
14. Thévenin-Lemoine C, Ferrand l'vI, Courvoisier A, Dam-
sin JP, Ducou le Pointe H, 1|ii'ialle R: Is the Caton'Dev
schamps index a valuable ratio to investigate patellar
height in children? ,1 Bone Joint Surg Arr: 2911;93{3}:e35.
Mcdline DUI
The authors of this study examined lateral knee radio-
graphs of 3‘30 healthy patients divided into 111 groups
based on age. The mean Caton-Deschamps index was 1.06
:1: [L21 with excellent intra- and interobserver reliability.
The Caton~Descha mps index is a simple, reliable index for
evaluating patellar height in children and is an alternative
to the Insall— Salvati ratio and Koshino-Sugimoto method.
Level of evidence: I.
15. Hopper GP, Leach W], Rooney EP, Walker CR, Elyth M]:
Does degree of trochlear dysplasia and position of femoral
tunnel influence outcome after medial patellofemoral lig-
ament reconstruction? Am J Sports Med 2014;42{3}:?16-
222. Mcdline DUI
The anthers of this study examined the relationship be-
tween the degree of trocblear dysplasia and femoral tunnel
position on outcome after IlFL reconstruction in a 63
patients {22 knees}. Mean follow—up was 31.3 months.
Multivariable regression analysis demonstrated that the
distance of the femoral tunnel to the anatomic position
predicted clinical outcome. Additionally, all patients with
severe tmchlear dysplsia {N = 7"} had recurrent dislocation
compared with only 9.3% {N = 5} of patients with mild
dysplasia. Level of evidence: IV.
15. Petri M, Liodaltis E, Hofmeister M, et al: Uperative vs
conservative treatment of traumatic patellar dislocation:
Results of a prospective randomised controlled clinical
trial. ArchI Orthop Trauma Sarg 2fl13:133{2}:2{}9-213.
Medline DUI
This multicenter, randomized controlled trial compared
outcomes after nonsurgical and surgical treatment in 20
patients {mean age 24.5 years} after first-time patellar dis-
location. No significant difference was reported between
groups; however, a tendency toward better Kujala score
and lower dislocation rates existed for patients treated
surgically. Post hoc power analysis revealed that the study
was likely underpowered. Level of evidence: I.
1?. Hennrikus W, Pylawka T: Patellofemoral instability in she]-
etally immature athletes. Instr Course Leer 2fl13;62:445-
453. Medlinc
This report reviewed the evaluation and treatment of pa—
tellofemoral instability in sheletally immature athletes.
13. Cootjans K, Duiardin], Va ndenneuclser H, Bellemans J: A
surgical algorithm for the treatment of recurrent patellar
ID 21116 American Academy of flrtbopaeclic Surgeons
dislocation. Results at 5 year follow-up. Acta DrtIro-p Belg
2013;??{3}:313-323. Medline
This report retrospectively reviewed 11D patients who
underwent several procedures for recurrent patellofemoral
instability. Based on the results, an algorithm was de-
scribed using physeal status, Q angle, and TT—TG distance
when determining optimal surgical treatment. Level of
evidence: IV.
19. Luhmann S], IE'I‘Iironuell JC, Fubrhop 5: Outcomes after
patellar realignment surgery for recurrent patellar insta-
bility dislocations: A minimum 3-year follow-up study of
children and adolescents. I Psdiatr Drthop 2D11;31I[1}:65-
'21. Medline DUI
This study examined 23- pediatric and adolescent patients
{2? knees} who underwent patellar realignment surgery for
patellar instability. At a mean follow—up of 5 years, 53 Tu of
patients reported persistent improvement in knee function,
and pain and recurrent instability was infrequent (2%}.
Despite the low rate of recurrent instability, patient-rc-
ported outcome measures were lower than expected {mean
International Knee Documentation Committee {IKDC}
score, 65.5}. Level of evidence: III.
2D. Nelita l'vl, Dreyhaupt J, Reichel H, Woelfle J, Lippacher S:
Anatomic reconstruction of the medial patellofemoral liga-
ment in children and adolescents with open growth plates:
Surgical technique and clinical outcome. Ant 1 Sports Med
2DIS;41I{1}:SS-ES.Medline DUI
In this case series, 21 consecutive slteletall].r immature
patients with recurrent patellar instability underwent
physeal-respecting, double-bundle MPFL reconstruction.
F“?
The average age at surgery was 12.2 years, the average
follow-up was 2.3 years. Significantly improved Kujala m
scores were reported postoperatively compared with pre- E}:I:
operative scores. Level of evidence: IV. ::
ID
1"
21. Nelits IvI, 1ip‘ii'illiams SR: Anatomic reconstruction of the
Fl
E
n:
medial patellofemoral ligament in children and adolescents m
F.
using a pedicled quadriceps tendon graft. Arthrosc Tech
2fl14;3{2}:e3fl3-e3fl3.Medline DUI
The authors described an MPFL reconstruction technique
using a pedicled quadriceps tendon autograft. The advan-
tages of this technique include the avoidance of drilling
patellar tunnels, a single incision, and sparing of the ham-
string tendons for reconstruction of any future ligamen-
tous injuries. Level of evidence: W.
22. Yercan HS, Erltan S, Ultcu G, Dealp ET: A novel technique
for reconstruction of the medial patellofemoral ligament in
slteletally immature patients. ArchI Orthop Trauma Sat-g
2fl11;131[3}:1fl59-1fl65.Medline BID]
The authors present a technique for MPFL reconstruction
in skeletally immature patients using semitendinosis auto-
graft passed through patellar bone tunnels and tenodesed
to the adductor magnus tendon to avoid drilling tunnels
near the distal femoral physis. Level of evidence: IV.
23. Savarese E, Eisicchia S, Carotenuto F, Ippolito E: A tech-
nique for treating patello-femoral instability in immature
Drthopaedic Knowledge Update: Sports lvledichse S
 Section 3: The Turing Athlete
patients: The tihial tubercle perinsteum transfer. Musca-
fctsftefet Srrrg 2311;95 [21:39-94. Medline DUI
The anthers describe a distal realignment prncedure fer
treating patellnfemnral instability in skeletally immature
patients using transfer ef the tibial tubercle periusteun'i
instead e-f perfnrming tibial tubercle estentnmy. Level cf
evidence: I‘v’.
|IE'rrannatt K, Heywnrth BE, flgnnwnle D, Micheli L],
Kn-cher M3: Galeaaei semitendinnsus tenndesis fnr patel-
qemnral instability in skeletally immature patients. )7 Pe-
rft'an' Urrhep 2U]2:32{6}:621-625. Medline DUI
In this retrnspective review, 23 skeletally immature pa-
tients {34 knees} underwent the l«Galeaxxi prncednre fer
patellufemcrral instability between 1990 and 2036. Ap—
prnximately 329i: c-f patients experienced recurrent suhlux-
atinn er dislncatinn and 35% had secc-ndary interventinn.
Despite the high recurrence rate, the lEaleaexi prncednte
can still he a reasnnahle temperixing precedure hefnre
patients reach skeletal maturity. Lewl nf evidence: IV.
25. Uliva F, Runga I‘vI, Lengn UG, Testa ‘v', lCapasse I3, Maf—
fnlli N: The 3-in-1 prncednre fer recurrent dislncatien nf
the patella in skeletaily immature children and adnlescents.
Am ] Spnrts Med 2Gfl9:3?{9}:1314-I 321). Medline DDI
In this review, 25 skeletally immature patients [mean age
at nperatinn, 13.3 years} underwent surgical interventinn
with the 3-in-1 precednre {lateral release, vastns medialis
advancement, and medial transfer c-f lateral third nf the pa-
tellar ligament} fer recurrent patellar dislecatic-n. Pit mean
fnllnw-up cIf 3.3 years, patients had significant increases
E in pnstnperative Kujala scnres and mndified Cincinnati
E dysplasia and trechleeplasty was feund tn he a useful,
:5 sceres. Level e-f evidence: I‘v’.
:1:
Ch
E 26. Marsh J3, Daigneault JP, Sethi P, Pnlxhnfer GK: Treat-
3
3... ment nf recurrent patellar instability with a medificatien
III
.I:
nf the Rnnx-Gnldtbwait technique. I Pedintr Drthnp
'— 2336;26[4}:461-465.Medline DUI
lid
In this retrc-spective cnhert, 23' patients {33 knees} with
recurrent patellar instability underwent the mndified
Rnux-Gnldthwait precedure and lateral release. Mean
fnllnw-up was 6.2 years. Using Insall criteria, 26 knees
had excellent results, 3 were gciud, and 1 was fair. Level
nf evidence: IV.
2?. Eiglieni L, Finre I'vI, |III‘vnviellu IvI, Felli L: Patellar insta-
bility: |IEnmbined treatment with Gnldthwait technique
and arthrnscnpic lateral release. Museufnsiltefet 5mg
asit,ss{2}:ss—ss.srsslins nnt
In this retrnspective cehnrt, 19 adulescent patients {23
knees] underwent the Reux—Geldthwait precedure and
arthrnscnpic lateral release for treatment nf recurrent pa-
tellnfemnral instability. At a mean fellnw-up nf 6.3 years,
there were 11 excellent results, 6 gund, 2 fair, and 1 peer
based en the flex grading system and the Bray scnre. Level
nf evidence: IV.
23. Dejnur D, Eyn P, Ntaginpnnlns PG: The Lynn's snl-
cns-deepening trcrchlenplasty in previnns unsuccessn
patelluferneral surgery. Int firth-p 2013;32l3}:433—439.
Medline DDI
Drthnpaedic Knnwledge Update: Sparta Medicine 3
In this retrespective ce-hnrt, 22 patients {24 knees] un-
derwent trnchlenplasty fer recurrent patellar dislncatinn
asserciated with trechlear dysplasia. At a mean fnllew-up
cf 66 mnnths, pain decreased in 32% cf patients and
the apprehensien sign was negative in 25%. Significant
decreases were repnrted in snlcns angle, TT-TG distance,
and lateral patellar tilt cnmpared with prenp-erative mea-
surements. A significant increase in mean pesteperative
Kujala scnre was alsn repnrted. Level nf evidence: IV.
29. Nelits I'vI, Dreyhaupt], Lippacher 5: Cnmhined trechlen-
plasty and medial patellnfemnral ligament rectmstrnctinn
fnr recurrent patellar dislneatinns in severe trnchlear dys-
plasia: a. minimum 2—year fullnw—up study. An: I Spevts
Med 2313;4H5 MIDDLE-1012. Medline DUI
This study examined 23 patients [26 knees; mean age,
19.2 years} whn had patellnfemnral instability and severe
truchlear dysplasia treated with cumbined truchleuplas-
ty and MPFL recenstructinn. At a mean fellew-up nf
2.5 years, up recurrent dislncatitms were repnrted, and
Kuiala, IKDC, and visual analng scale senres all had sig-
nificant imprevenients cnmpared with preeperative values.
Lewl nf evidence: III.
3D. Fucentese 5F, Zingg PD, Schmitt J, Pfirrma rm CW, Mey-
er DC, Finch PP: IClassificati-nn nf trnchlear dysplasia as
predictnr crf clinical nutcnme after trnchlenplasty. Knee
Savg Sports Treavvretel Arrhresc 231 1:1 9(10}:1655- 1661.
Medline DDI
In this retrnspective review, 33 patients {44 l-tnees} nn-
derwent trnchlenplasty fcrr patellar instability. Patient
eutcumes were cumpared based en the type ef truchlear
reliable surgical technique tn imprnve patellnfemnral in-
stability in patients with trn-eblear dysplasia. The everall
results depended directly en the type ef dysplasia, with
a substantially betmr clinical nutcnme in types B and D.
Level nf evidence: III.
31. Parilxh 3N, Nathan 5T, 1|lilil'all E], Eismann EA: Cnmplica-
tinns nf medial patellnfemc-ral ligament recnnstrnctinrt in
yeung patients. Ass Jr Spa-rte Med 2013:41fi 1:1333-1333.
Medline DDI
In this retrnspective case series, all patients whn under-
went MPFL recnnstrnctinn between 2335 and 2311 were
examined fer pusteperative campiicatinus. A tutal nf 1??
knees were identified: 33 cemplicatinns were described in
29 ltnees {16.293}. Meier cemplicaticrns {34 nf 33} included
recurrent instability in 3 patients, stiffness in 3, patellar
fracture in 6, and patellnfemetal arthrusis andie-r pain in
5. Eighteen {42%} cnmplicatinns were determined tn be
secnndary tcr technical factnrs and cnnsidered preventable.
Level uf evidence: I‘v'.
32. Wagner D, Pfalxer F, Hingelbaum 5, Hnth J, Munch P,
Bauer G: The influence nf risl: facturs an clinical nutcemes
fell-swing anatnmical medial patellnfemnra] ligament
{MPFL} recnustrnctinn using the gracilis tendnn. Knee
Sarg Sports Traumatur' A'rtfivnsc 2313;21i2}:313-324.
Medline DDI
In this prespective case series, 511} patients with chronic
patellnfemnral instability underwent I'vIPFL recenstrnctinn.
fl 2316 American Academy nf Drthnpaedic Surge-ens
 liill'lapter 49: Patellofemoml Instability and Either Common Knee Issues in the Skeletally Immature Athlete
Clinical data, radiographs, and Mllls were prospectively
evaluated pre-operatively and postoperatively to detect
risk factors for patellofemotal instability. A low rate of
recurrent dislocation {2%} was reported. MRI showed
good integration of the reconstructed MPFL and a positive
effect on patellar tilt [decreased tilt}. a negative relation-
ship was found between the degree of trochlear dysplasia
and outcomes. Level of evidence: IV.
33. Matic GT, Magnussen RA, Kolovich GP, Flanigan DC:
Return to activity after medial patellofemoral ligament
repair or reconstruction. Arthroscopy 2fl14;3i}{3}:1013-
1025. Medline DUI
This systematic review examined return tn activity after
MPFL repair or reconstruction in If} articles and identi-
fied 402 patients who met inclusion criteria. Recurrent
dislocation was higher in patients who underwent MPFL
repair rather than reconstruction; however, repair and
reconstruction had similar postsurgical Tegner scores.
Level of evidence: IV.
34. Zionts L: Fractures and Dislocations about the Knee, in
IGreen HE, Swionltowski MR, eds: Slateleta:T Traarna in
bfdren .Philadelpbia, WB Saunders, 20119, pp 452-455.
DUI
3.5. Johnson AC, Wyatt JD, Treme G, Veitch A]: Incidence of
associated knee injury in pediatric tibial eminence frac-
tures. _}' Knee Sarg 2014:2?{3}:215-219. Medline
This retrospective case series reviewed pediatric tibial
eminence fractures to examine the incidence of associated
ltnee pathology. Twenty pediatric patients treated surgi—
cally for tibial eminence fracture over a Ill—year period at
a single institution were identified. Six patients {3 13%} had
associated meniscal tears with meniscal tear occurring
more commonly in type III versus type II fractures. Two
patients sustained associated ligamentons injury and none
had associated chnndral defects. Level of evidence: IV.
36. Shea KG, Grimm NL, Laor T, Wall E: Bone bruises
and meniscal tears on MRI in skeletally immature chil-
dren with tibial eminence fractures. _,i' Pediatr Orthop
lflll:31{2}:15fl-152.Medline DUI
In this retrospective case series, 30 skeletally immature
children with tibial eminence fractures underwent MRI
examination of the knee. Subchondral bone contusions
were seen in If! {9fl%}. Lesion location included the latr
eral femoral condyle i8fl%}, lateral tibial plateau {35%},
medial femoral condyle {60%}, and medial tibial plateau
{30%}. Meniscal tears were present in eight {40%} pa—
tients, four each in the medial and lateral menisci. Lavel
of evidence: IV.
3?. hrlitchell J], Sjostrnm R, Mansour AA, et al: Incidence of
meniscal injury and chnndral pathology in anterior tibial
spine fractures of children. I Pediatr Orthop _} Pediatr
Grtftop lfl'lfi;35{l}tl3{i-l35. Medline DD]
In this retrospective review, of 53 children who sustained
a tibial spine fracture between 1995 and 2011, 59% chil-
dren had an associated soft—tissue or other bony injury
diagnosed using MRI or arthroscopy. The most commonly
associated injuries were meniscal entrapment, meniscal
IE} tots American Academy of flrrhopaeclic Surgeons
team, and chnndral injury. No associated injuries with
type I fractures were reported. {If type II fractures, 19%
had meniscal entrapment, 33% had meniscal tears, and
17% demonstrated chnndral injury. Df type III fractures,
43% bad meniscal entrapment, 12% had meniscal tears,
and 3% had chnndral injury. Level of evidence: IV.
33. Meyers NIH, McKeever FI'vi: Fracture of the intercnndylar
eminence of the tibia. I Hone joint Snrg Ant 1959:41-
Ajl}:2fl9-22fl, discussion 220 -222. Medline
39. Zaricsnyj I3: Avulsinn fracture of the tibial eminence:
Treatment by open reduction and pinning. ] Bone Joint
Snrg slrn 19??;59[3}:1111—1114. Medlinc
4D. Chore] F, Seil R, Greiner P, IChatter l'vllvi, Eerard J, Raux
5: The difficult diagnosis of cartilaginous tibial eminence
fractures in young children. Knee Snrg Sports Traumatot'
Artfrrosc 2014;22i?}:1311-1516. Medline DUI
This retrospective case series described cartilaginous tibial
eminence fracture in six patients. Radiographs were nor-
mal in four and showed thin ossification in two. MRI was
negative for ACL rupture; however, four had a double-PCL
sign. Patients were referred for treatment at a median of
6 months {range, 2.5 to 43.42} months} after injury with
symptoms related to nonunion, ossification, and secondary
enlargement of the avulsed fragment. The authors em-
phasi ted a high index of suspicion when evaluating these
patients to avoid missed or delayed diagnosis of this rare
Iltity. Level of evidence: IV.
41. Gans I, Baldwin KD, Ganley T]: Treatment and man-
agement outcomes of tibial eminence fractures in pe- F“?
diatric patients: A. systematic review. Han _} Sports Med
2fl14t42{?}:1?43-1?5{i.Medline DUI m
E?I:
In this systematic review of studies examining tibial em- :I
inence fractures in children and adolescents, 26 articles a:
1"
were identified that met inclusion criteria, including 1 Fl
E
level III article and 25 level IV articles. The level of evi— n:
m
F.
dence supporting various treatments for tibial eminence
fractures in children and adolescents is low, with insuffi-
cient evidence to conclude the superiority of open versus
arthroscopic treatment or screw versus suture fixation
techniques. Type III and IV fractures heal with greater
laxity and greater loss of range of motion after treatment.
Level of evidence: IV.
41. Eogunovic L, Tarahichi M, Harris D, 1Wright R:Treato1ent
of tibial eminence fractures: h. systematic review. I Knee
Snrg 2fl15;23{3}:2554152. Medline DDI
This systematic review examined outcomes of nonsur-
gically and surgically treated tibial eminence fractures.
Sixteen studies met inclusion criteria. The pooled mean age
of patients was 23 years; mean follow-up was 35 months.
Clinical instability was seen in ?ll% of patients treated
nonsurgically and 14% of patients treated surgically. The
rate of ACL reconstruction was higher in nonsurgically
treated patients. Suture fixation was associated with im-
provements in clinical measures of stability and decreased
need for hardware removal compared with screw fixation;
however, no difference was reported in patient perceived
Drthopaedic Knowledge Update: Sports Medichie .‘i
 Section 3: The Young Athlete
stability and need for AEL reconstruction between the
two treatment methods. Level of evidence: IV.
43. Kim 11, Kwon JH, Seo DH, Soni SM, Murine M, Nha
KW: Arthroscopic hybrid fixation of a tibial eminence
fracture in children. Arthrosc Tech 2fl1352l2):e11?-e12fl.
Medlinc DUI
The authors describe an arthroscopic technique for
treating tibial eminence fractures in children by using
a bioabsorbable suture anchor in addition to all-inside
arthroscopic suture fixation to the intermeniscal ligament
and tibial periosteum.
Sawyer {3A, Hulstyn M], Anderson EC, Schiller J: Ar-
throscopic suture bridge fixation of tibial intercondylar
eminence fractures. Arthrosc Tech 2D13;2{4}:e315-e313.
Medline DUI
The authors describe an arthroscopic technique for treat—
ing tibial eminence fractures in children with an all-inside,
all-epiphyseal suture bridge technique using anchors.
45. l[Inchiai S, Hagino T, Watanabe ‘1", Senga 5, Hart.- H: Due
strategy for arthroscopic suture fixation of tibial inter-
condylar eminence fractures using the Meniscal Viper
Repair System. Sports Med Arthrosc Rehab-if Ther Tech-
uol 2311:3:1?. Medline [10]
In this retrospective case series, five patients {mean age
23.3 years} underwent arthroscopic suture fixation of
tibial eminence fractures using an all-inside meniscal re—
pair system. Surgical results were assessed using plain
radiographs, postoperative range of motion, and Lysholm
E scores. At latest follow-up, all fractures maintained reduc-
E spine: Epidemiology and outcome. Knee 2033:15{31:134-
:5 tion obtained at surgery and postoperative Lysholm scores
fl:
Eh
showed good results. Level of evidence: IV.
E
3 52. Patel NM, Park M], Sampson NR, |IGanley T]: Tibial
3... 46. Kluemper CT, Snyder GM, Coats AC, Johnson DL,
I1:
.I:
Mair SD: Arthroscopic suture fixation of tibial emi-
'—
nence fractures. Orthopedics 2013;36{11}:e14fll-e1406.
t'ti Medline DUI
This retrospective case series evaluated the clinical out-
comes of an arthroscopic suture fixation technique in I?
tibial eminence fractures treated between 1393 and 2313.
Average patient age was 13.3 years (range, 13 to 3? years}
and average follow-up was 25 months (range, 2. months to
13 years}. Postoperatively, all fractures were radiograph-
ically healed, and all patients had stable Lachman and
negative pivot shift test results. Two patients had 3" of
extension loss and one patient lost more than 10" of knee
flexion. Level of evidence: IV.
4?. Tsukada H, Ishibashi Y, Tsuda E, Hiraga Y, Toh S: A bio-
mechanical comparison of repair techniques for anterior
cruciate ligament tibial avulsion fracture under cyclic load-
ing. Arthroscopy 2005;21I,’101:113 7-1 201. Medlioe DUI
43. Bong MR, Romero A, Kubiak E, et al: Suture versus screw
fixation of displaced tibial eminence fractures: A biome-
chanical comparison. Arthroscopy 2DflS;21[1fl}:11?2-
1125. Medline D01
@ firthopaedic Knowledge Update: Sports Medicine 5
49. Anderson CH, Hyman JS, Mcflullough EA, et al:
Biomechanical evaluation of physeal-sparing fixation
methods in tibial eminence fractures. Arr: I Sports Med
1o13,41{v}:isss-1594.Means:- Do:
This biomechanical laboratory study of skeletally imma-
ture porcine knees examined the strength and resistance to
displacement of physeal-sparing techniques used to fix tib-
ial eminence fractures. Four treatment groups: UHMWPE
suture—suture button, suture anchor, PD S—suture butr
ton, and screw fixation. Physeal-sparing fixation of tibial
eminence fractures with UHMWPE suture button is bio—
mechanically superior to both PBS—suture button and
single-screw fixation at the time of surgery and provides
more consistent fixation than suture anchors.
SD. Abdelltafy A, Said HG: Neglected ununited tibial emi-
nence fractures in the skeletally immature: Arthroscop-
ic management. In: Orthop 2314;33{12J:2525—2532.
Medline DUI
In this prospective case series, 13 patients {average age [:e
SE] at surgery, III :e 2.6 years} with neglected, nonunited
tibial eminence fractures were treated with arthroscopic
reduction and suture fixation. At an average follow-up
of 131.3 months, 12 patients had grade A objective IKDC
score and 1 had grade B. All patients showed radiograph-
ic union and anatomic reduction at 12.4 weeks postop—
eratively. Eleven patients had clinical stability based on
Lachman, anterior drawer, and pivot shift test results
and no patient reported subjective instability. Level of
evidence: W.
51. Aderinto J, Waimsley P, Heating JP: Fractures of the tibial
16?. Medline IJIDI
eminence fractures in children: Earlier posttreattnent mo-
biliration results in improved outcomes. f Pediatr Orthop
2312;32l2]:139-144.Medline DUI
In this retrospective case-control study, 43 patients {43
knees; mean age, 12 years; range, 5 to 1? years) underwent
treatment of tibial eminence fractures. 1|When compared
with patients who initiated postoperative range of motion
within 4 weeks of treatment, those who started range of
motion later than 4 weeks required more days to return
to full activity and were 12 times more likely to devel—
op arthrofibrosis {P = 0.023}. Even when accounting for
other factors in multivariable regression analysis, earlier
initiation of range of motion was associated with earlier
return to full activity. After definitive treatment of tibial
eminence fractures, early range of motion results in a
more rapid return to full activity. Level of evidence: III.
53. Vander Have KL, Ganley TJ, Kocher MS, Price CT, Her-
rera— Soto JA: Arthrofibrosis after surgical fixation of tib-
ial eminence fractures in children and adolescents. Am
,7 Sports Med 2013:33l2]:293-301. Medline DUI
In this retrospective case series, 32 patients underwent
surgical treatment of tibial eminence fractures: 24 patients
required reoperation for loss of flexion {N = 3}, loss of
extension {N = 4}, or both [N = 11}. Manipulation under
fl 231:5 American Academy of Orthopaedic Surgeons
 lII'.31'Iapter 49: Patellefemural Instability and Either Gammon Knee hsues in the Skeletally Inmtarure Athlete
anesthesia resulted in distal femeral fractures and subse-
quent grewth arrest in 3 patients; 29 patients achieved
near-full knee metien at final fellew-up. Manipulatien
under anesthesia fer arthrnfibresis sheuld enly be per-
ftumed fellewing treatment ef tibial eminence fractures in
cenjunctien with lysis ef adhesiens. Level ef evidence: IV.
54. Papadepeules A, Kirkes JM, Kapetanes GA: Histe-
merphelegic study ef disceid meniscus. Arthrescepy
2Dfl9;25(3}:262-268.Medline Dfll
Intact, cnmplete lateral disceid meniscus samples were
examined frem If} patients whe had undergeue artbre-
scepic saucerizatien and cempared with centrel samples
ef intact lateral menisci excised during knee arthreplasty
precedures. Histemerphelegic scering shewed substantial
diserganizatien ef the circular cellagen netwerk in dis-
ceid menisci cempared with centml patients, especially
alnng the pesterinr third cf the specimens. Additinnally,
a heteregeneeus ceurse ef the circu mferentially arranged
cellagen fibers was shewn in the disceid meniscus greup.
Level ef evidence: I.
5.5. Klingele KE, Kecher M5, Hreske MT, Gerbine P, Mi-
cheli L]: Disceid lateral meniscus: Prevalence ef periph-
eral rim instability. I Pediatr Urtfiep 1004;24{1}:‘?9-31.
Medline DUI
56. (Seed CR, Green DW, Griffith il-I, Valen AW, 1|Iliiidmann
RF, Redee 5A: Arthrescepic treatment ef symptematic
disceid meniscus in children: Classificatien, technique, and
results. Arrhrescepy 2Dil?;13{2]:151153. Medline DUI
5?. Chei SH, Ahn jH, Kim KI, et al: De the radiegraphic
findings ef symptematic disceid lateral meniscus in chil-
dren differ frem nermal centre] subjectsiI Knee Snrg
Spur-ts Tram-natal Arrbresc 2fl15;23[4}:1123-1134.
Medline DUI
Radiegraphic findings were examined in T3 censecutive
children {91 knees] whe underwent arthrescepic surgery
fer disceid lateral meniscus. Substantial differences in the
mean height cf the lateral tibial spine, lateral jnint space
distance, height ef the fibular head, and ebliquity ef the
lateral tibial plateau were feund between these with a
disceid lateral meniscus and age- and sex-matched centrel
patients. Several plain radiegraphic findings in children
with symptem atic disceid lateral meniscus were different
than in matched centrel patients. Level ef evidence: II.
53. AtH, Lee Y5, Ha HG, ShimJE, Lim KS: A nevel mag-
netic resnnance imaging classificatinn nf discnid lateral
meniscus based en peripheral attachment. Am I Spnrts
Med lflflfltiSHfifid-Hfifi. Medline DUI
This tetrespective cehert study ef 6? patients {32 knees)
examined pteepetative l'vIRIs ef patients whe had undet-
gnne surgery fer disceid lateral meniscus. A new MRI
classificatien ef disceid lateral meniscus was prepesed
based en the peripheral attachment. An asseciatien was
neted between discnid lateral menisci classificatinn and
rate ef meniscus repair. Additinnally, meniscus repair le-
catien was asseciated with the type ef classificatien en
MRI. Lewl ef evidence: 11.
IE! lfllfi American Academy ef flrthepaedic Surgeens
.59. Tee W], Lee K, Meen H], et al: Meniscal merphelegic
changes en magnetic resenance imaging are asseciated
with symptematic disceid lateral meniscal tear in children.
Arthreseepy 2fl12;13{3]:33fl-336. Medline DUI
This retrnspective cnhnrt study ef 69 patients [T9 knees}
examined whether meniscal displacement er defermatien
en MRI was asseciated with meniscus tear in disceid
lateral meniscus. All tear types {except radial tears] feund
en arthrescep‘yr were assuciated with seme merphelegic
change in the disceid lateral meniscus as evaluated using
preeperative MRI. Merphelegic change as epp-esed te
signal intensity change en l'vIRI had greater sensitivity
fer detecting tears in disceid lateral menisci. Level ef
evidence: IV.
ED. Carter CW, Heellwarth J, 1'i'iii'eiss JM: Clinical eutcemes
as a functien ef meniscal stability in the disceid meniscus:
A preliminary repert. I Pediatr Dflhep 1fl12;31{1]:9-14.
Medline DUI
This retrnspective case-centre] study ef 51 patients [5?
knees: mean age, 11.?' years} cempared patients whe
underwent discnid lateral meniscus sauceriaatinn alene
versus saucerizatien + stabilizatien. At a mean fellnw-up
ef 1.5 menths, ne substantial difference was reported be-
tween the greups when evaluating pesteperative eutceme
measures ef range nf metien, cemplicatiens, and IKDC,
Tegner, and Lyshelm sceres. Ebert—term results fer patients
with symptematic disceid menisci requiring surgery are
favnrable and the additinn ef meniscal stabilisatinn fer
these with meniscal instability dnes net negatively affect
eutceme. Level ef evidence: III.
61. Fu D, Gue L, Yang L, Chen G, Duan 1E: Disceid lat- F“?
eral meniscus tears and cencemitant articular cartilage
m
lesiens in the knee. Artbrescnpy 2fl14;30{3}:311-313.
Medline DUI 3:I:
:I
In
This prespective case series nf 151 patients evaluated frem 1"
24310 te Zflll whe had undetgene surgery fer disceid Fl
E
lateral meniscus characterized articular cartilage lesiens n:
m
F.
fnund during arthrescepy. The mest cemmen lecatinn
ef cartilage lesiens was the lateral tibial plateau {11.6%}
and multiva riahle legistic regressien analysis shewed that
bedy mass index [=- 23 kgfmll, sex {female}, and ceurse
ef symptems {=- E menths} were asseciated with cartilage
lesiens. Level ef evidence: IV.
I51. Kamei G, Adachi bl, Deie M, et al: Characteristic shape {If
the lateral femeral cendyle in patients with esteechentlri-
tis dissecans accempanied by a disceid lateral meniscus.
] Urthep Sci ED12;1?{2}:124 413. Medline DUI
This retrnspective case—centrel study examining 53 pa-
tients (63 knees; mean age, 11? years} cen1pared knees
that had 0CD ef the lateral femeral cendyle and these
witheut DIED. The DIED greup had a significantly larger
intercendylar preminence ratie. Level ef evidence: III.
63. Shieh A, Eastrem T, Ree-craft J, Edmends EW, Penneck
AT: Meniscus tear patterns in relatien te skeletal imma-
turity: Children versus adelescents. Am ,1 Sperts Med
2D13;41{12}:2T?9-2?33.Medline DUI
Drthepaedic Knewledge Update: Sperts Medichte 5
 Seeders 3: The Turing Athlete
This retrnspective crnss-sectinnal study nf 293 patients
{age range, 11'] tn 19' years] cnmpared meniscal tear pat-
terns between children {npen grnwth plates} and adnles-
cents. I.iil'verall, 14% cf tears were cf the discnid meniscus
{N = 46}. Discnid tears cnmprised 15% nf tears in children
but nnly ?% nf tears in adnlescents. Children accnunted
fnr ?fl% nf all discnid meniscus tears and 41% required
peripheral rim repair in additinn tn sauceritatinn. {Inn-
cnmitant liga ment injury was mnre cnmmnn in adnlescents
{51% versus 23%}. Level nf evidence: III.
E4. de Lucena GL, dns Santns Gnmes C, Guerra RD: Preva-
lence and assnciated factnrs nf llC'isgnnd—Schlatter syndrnme
in a pnpulatinn—based sample nf Brazilian adnlescents. Am
] Sparta MEG. lfl11;39{21:415-42fl. Medline DUI
This crnss-sectinnal study examined 9.55 adnlescent stu-
dents {mean age I: SD}, 13.? 2 1.134 years} frnm Iflflfl tn
11109 in the schnnl system nf Natal, Brazil. The prevalence
nf Dsgnnd-Schlatter disease was 9.3%. Multivariahle 1n-
gistic regressinn analysis shnwed that factnrs significantly
assn-ciated with lifilsgnncl—Schlatter disease were regular
participatinn in spnrts and shnrtening cf the rectus femnris
muscle. Lewl nf evidence: III.
65. Krause BL, Williams JP, Carterall A: Natural histnry nf Gs-
gnnd-S-chlatter disease. 1 Pediatr Uri-“imp 1990;1fl{1]:65-
63. Medline DUI
6E. Pihlajamiilci HK, Mattila VM, Parviainen M, Kiuru M],
1li'isuri TI: Lnng—term nutcnme after surgical treatment nf
unresnlved ll2!sgnn::»d~5chlatter disease in ynung men. I Hesse
jnini Sarg Am Eflflflfllilfllflflfi-ESSS. Medline DUI
E
E This retrnspective cnhnrt study examined 111}? cnnsec-
:5 ntive military recruits {11? knees} whn had undergnne
:1:
Ch surgery for un resnlved |EI'Isgnnd-Schlatter disease. The rate
E
nf surgically treated, unresnlved nnnd-Schlatter disease
E
3...
I1:
.I:
'—
Ed
firthnpaedic Knnwledge Update: Spnrts Medicine 5
was 42 per lflfl,fl{li} military recruits. After a median
fnllnw-up nf 1|] years, 3?% repented nn restrictinns in
everyday activity nr at wnrk and ?5% returned tn their
prenperative level nf spurts. Six patients experienced mi-
nnr pnstnperative cnmplicatinns and turn had undergnne
renperatinn fnr treatment nf flsgnnd-Schlatter disease.
Level nf evidence: 11?.
6?. Tnpnl GA, Pn-desta LA, Reeves KL}, Raye MP, Fuller-
tnn ED, 'r'eh H‘W: Hypernsmnlar dextrnse injectinn
fnr recalcitrant flsgnnd-Schlatter disease. Pediatrics
2D11;123{5}:e1121—e1123.Medline DD]
This randnmiaed, cnntrnlled trial cf 54 patients {55 knees;
age range, 9 tn 1? years} with recalcitrant flsgnnd-Schlatter
disease cnmpared treatment with hypernsmnlar dextrnse
injectinn with placehn. Enth experimental and cnntrnl
grnups returned tn unaltered spnrt activity at 3 mnnths.
At 1 year, asymptnmatic spnrt was mnre cnmmnn in the
experimental grnup than the placehn grnup and usual
care. Hypernsmnlar dextrnse injectinn nver the apnphysis
and patellar tendnn nrigin was safe and well tnlerated in
this pnpulatinn and resulted in mnre rapid and frequent
achievement nf unaltered spnrt and asymptnmatic spnrt
cnmpared with usual care. Level nf evidence: I.
63. Freedman DIM, Knnn M, Jnhnsnn E-E: Pathnlngic patellar
fracture at the site nf an nld Sinding-Larsen—Jnhanssnn
lesinn: A case repnrt nf a 33—year—nld male. I Drifter:
Trauma Eflflfiflfilifllfifll-SBS. Medline DDI
l.l'irlen Reference
49.1: Ellis HE, 1|lfiiilsnn PL: 1iiiiden. A Surgical Technique far Me-
dici Patefinfemnrei Ligament Recnnsi‘rtrctfni: in the Sfieietafiy
Immature. Texas Scnttish Rite Hnspita], Dallas, TX, 1013.
fl 211115 American Academy nf Urrhnpaedic Surge-ens
Chapter 50
Special Considerations in Head
Injuries in Adolescent Athletes
Regina Kostyun. MSEd. ATC Carl W. Hissen. MD Imran Hafeer. MD
The perception of athletic head injuries is drastically
changing in youth sports. Although the majority of head
injuries are not life threatening, milder head injuries can
lead to long-lasting impairment if misdiagnosed or left
untreated. Clinicians are taking the lead in responding
to these head injuries with a conservative approach,
ensuring all symptoms and dysfunction have fully re-
solved before discussing return to sport. Coaches and
parents are being called on to increase their education
and awareness of these injuries, therefore helping to
increase quick identification of head injuries and de-
> crease the likelihood of further harm in young athletes.
Keywords: adolescent: head injury; concussion;
clinical management; return to school: return to
sport; concussion education
Introduction
Injuries sustained to the head during sports participation
fall along a spectrum of severity. Although most closed
head injuries are considered mild in nature with subse-
quent dysfunctions demonstrating transient characteris-
tics, life-threatening and catastrophic injuries do occur.
Physicians involved in the care of young athletes, especially
those engaged in on-ficld care and return-to-play decisions,
Dr. Nissan or an immediate family member serves as a
board member. owner; offices or committee member of
the American Cirthopaedic Society for Sports Medicine.
Neither of the following authors nor any immediate family
member has received anything of value from or has stock or
stock options held in a commercial company or institution
related directly or indirectly to the subject of this chapter:
Ms. Kostyun and Dr. Hafeec.
fl lflld American Academy of Drthopaedic Surgeons
must be vigilant and mindful of the head injury continuum
and implement a conservative management approach for
these adolescents. Although sports-related concussions are
the predominant head injury in a young athletic popula-
tion, physicians must remain attentive to the potential for
catastrophic head injuries and be able to execute seamless
provision of care during a life-threatening event.
Epidemiologyr
Participation in organized sports is increasing among
young individuals. The National Federation of State High
School Associations estimates that approximately 15
million high school student athletes participate annually
in organized sports. 1|i'lllhen middle school, youth, and
atajutu fiunoy, eu_|_ :g
recreational athletes are included, the number increas-
es to 2? million participants.I However, the increased
participation in organized sports has also contributed
to an increase in sport—related injuries. Injuries to the
head have long been recognized as a concern in contact
sports and account for approximately T343 of all sport-re-
lated injuries in young athletes}3 Dating baclc to the turn
of the century when American football, due to a series
of catastrophic injuries, was proposed to be banned by
President Roosevelt, these injuries, their recognition, and
appropriate treatment have been a topic of much concern.
With current increased knowledge and understanding of
these head injuries, along with the widespread availabil-
ity of modern radiologic techniques, the diagnosis and
management of these conditions has improved. Although
protective gear has improved drastically over the past
SCI years, intracranial bleeds appear to be on the rise in
the young athletic population for unexplained reasons.4
fine—third of adolescents who present to the emergency
department with intracranial hemorrhages and cervical
spine fractures sustain their injury while participating in
a sports" Although the concern over intracranial bleeds
remains high, even more concerning over the past decade
is the recognition of concussions in this age group. [n-
creased involvement in sports combined with improved
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectiun E: The Turing Athlete
identificatiun nf cuncussiun injuries has resulted in a 4.1-
fnld increase in the number nf diagnnsed cuncussinns
sustained at the high schuul level uver the past decade.‘5
During a similar time frame, emergency departments
have seen a rose. increase in the number cf adolescent
patients treated fur cuncussiuns"r with the must cummun
cause nf injury related tn spurts participatinn.“
The sharp increase nf diagnnsed spurts-related. cnncus-
sinns paired with the cuncern surruunding the pussible
lung-term cnnseqnences nf head injuries in the adules-
cent pnpulatinn has became a snurce nf public cnncern.
The amplified fucns frnm clinicians, researchers, and
spurts nrganizatiuns nn this injury has resulted in an
acute awareness uf cuucu ssiuns nut unly frum the medical
cnmmunity but alsu frnm the media and guvernment sec-
tnrs. This new era nf imprnved understanding regarding
head injuries has resulted in a new level nf scrutiny and
cuncern. This heightened awareness has established a
platfnrm nf educatinn and awareness with the gnal nf
reducing the severity uf head injuries.
Definitiun and Mechanism uf Injury
Head injuries can be defined as diffuse nr fucal, with
each classificatiun uf injury having its uwn unique clinical
sequelaefi" Diffuse injuries, such as shearing injuries, result
E in micrutranma tn the cnnnective system nf the brain;
E fncal injuries result in macrntrauma tn vessels and nther
:5
:1: tissues within the brain.
Ch
E Cnncussinns, diffuse head injuries, are defined as a
E
3... “trauma—induced transient alteratiun in mental status
I1:
.I:
'— that may ur may nut invulve luss uf cunsciunsness.”"-l
Eci Cnncussinns are caused by trauma, either direct nr indi-
rect. Direct trauma uccurs tn the head. Indirect trauma
is absurhed by the bndy and transferred tn the head.”
The resultant linear and rntatinnal fnrces sustained tn
the brain are thnught tn generate transient disturbances
in brain functiun.” This tempurary intrusiun in brain
functinn generally nccurs in the absence nf a structural
injury. Diffuse changes in metabulic functinn and subse—
quent energy imbalance results in the signs and symptnms
that make up the clinical presentatinn nf a cuncussiun.
Recent cuncern has been raised abuut the pussible
sequela fnllnwing subcuncussive impacts an individual
sustains, nut unly during a single spurts seasun but cu-
mulatively uver his ur her athletic career.” These putential
subcuncussive furces, as well as the cumulative number
uf impacts sustained uver a given seasun, have been mea—
sured in adulescent fuutball and ice huekey players.”-'5
Hnwever, a pathnlngic impact magnitude nr number nf
cumulative bluws has nut yet been identified and the ex—
act mechanism uf cuncussiun remains unclear. Impact
Drthnpaedic Knnwledge Update: Spurts Medicine 5
lucatiun has alsu been shuwn tu have puur prngnustic
and clinical value in an adulescent pnpulatinn.“
Fucal head injuries include intracranial hematumas,
such as subdural, epidural, intracerebral, nr snbarach-
nnid hemnrrhages {Figure I}. These injuries shuuld be
cunsidered in all instances nf head trauma, especially in
high-energy impacts tn the head. Subdnral hemurrhage,
bleeding between the dura mater and the brain, is must
cummunly seen in athletes whu participate in cuntact
spurts. Bleeding intn the space between the dura mater and
the inner surface nf the skull, nr epidural hemnrrhage, can
uccur when an unhelmeted athlete is struck in the head.
Intracerebral hemnrrhages nr cnntnsiuns cummunly seen
in the utbitufruntal lubes as a result uf a cuup—cuntrecuup
injury are rare in spurts-related trauma. Subarachnuid
hemnrrhage, nr bleeding in the subarachnnid space, is
cummunly caused by shearing stress between the arach—
nnid membrane and pia mater. Subarachnuid hemnrrhages
are nften assnciated with indirect trauma tn the head as
the resultant rutatiunal furces are transmitted frutn the
bndy tn the head.
Intracranial hemnrrhages can evnlve quickly and
withuut rapid identificatiun and treatment, substantial
mnrbidity can uccur. Althnngh these injuries are rare in
ynung athletes, certain cuntact and high-risk spurts are
mnre prune tu these pntentially catastruphic injuries." (if
the spurts cummunly played by ynung athletes, fuutball,
ice hnckey, lacrnssc, sncccr, gymnastics, diving, track and
field, and wrestling carry the highest risk uf life—threat-
ening injury tn the head.IH
ISin—Field Management and Initial [are
Sideline assessments uf injuries nu lunger fn-cus un se-
verity grading; instead, initial cvaluatinns are used tn
identify the presence nf a cuncussiun and as a screening
tuul tu detect cervical spine instability, intracranial hem—
nrrhaging, ur nther critical pathnlngies.”hm Differenti-
ating between emergent and nnnthreatening cnnditinns
can be challenging immediately fulluwing the injury.
A 2013 systematic review nf clinical tests used during
the assessment nf a head injury, either nn-field nr within
24 huurs nf the injury, suppnrts a cumprehensive, system~
atic, multifaceted apprnach fur the nn-field evaluatinn nf
an adulescent athlete tu impruve the chances uf a pusitive
nutcnme.“ Because the prngressinn uf injuries, especially
intracranial bleeds, can lead tn devastating nntcnmes, sub-
sequent assessments shuuld be cumpleted tu help identify
wnrsening symptnms nr a neurnlngic decline that wnuld
indicate a severe injury.
Initial evaluatinn nf the athlete shuuld begin with an
assessment nf airway, breathing, and circulatinn. The
fl lflle American Academy nf Drthnpaedic Surge-nns
 Chapter 5!]: Special Cnnsideratinns in Head Injuries in Adelescent Addetea

Figure 1 Magnetic resenance images ef intracranial hemerrhages. {All A large leftvside subdurai hematema with cellapse ef
the ventricle and rnidline shift. {B} A right-side acute epidural hematnma with midline shift. Nnte the snft—tissue
reactinn at the site nf the direct blew tn the head. {C} A right-side suba rachnnid hematnma.

need fer an artificial airway shnuld be determined, espe-

cially in an uncenscinus athlete. Less nf cnnscieusncss ___-
Cnmmnnly Used Sideline and Fellnw-
can place an athlete at increased risk nf aspiratinn as well
as impair breathing, which may lead tn hypnventilatien up Cnncussien Assessment Teels
and subsequent injury tn the central nervnus system?
On-Fielrl Assessments Pestdiagnersis Assessments
Evaluatinn nf the cervical spine shnuid nccur after the
Sperts Cencussien Pnst—Eencussien Symptem
athlete‘s airway, breathing, and circulatien have been
Assessment Tnnl Scale
assessed. Cervical instability nr spinal cerd injury shnuld {SEATS}
be assumed in an uncnnscinus athlete, and prnper stabi- Spnrts |I‘Znncussinn Balance Errnr Scnring F“?
lizatinn sheuld eccur befnre the athlete is transpnrted Assessment Tnnl fer System m
tn a higher level nf care. In the case nf either a cervical children {childSCATS}
3"I:
spine nr head injury, when the athlete is participating in a Standardized Hnu rncngnitivn telling :I
v:
helmetcd spnrt, the facemaslt shnuld be rcmnved and the Assessment nf 1"
helmet shnuld remain nn when the athlete is bearded and Enncussien Fl

E
as
transperted tn the nearest medical facility. This precedure Pest-(Zen cussien Immediate Pnst-Cencussien m
F.

alse shnuid be fnilnwed if the initial evaluatinn determines
that fecal neurnlngic impairments eicist.
Athletes with prelnnged less ef cnnscieusness, de-
creased mental status, severe headache, nr persistent
vnmiting fellnwing head trauma are suspected nf having
a fecal injury, such as an intracranial hemerrhage, and
shnuld undergn further evaluatien. The presence nf uni—
lateral signs nr symptnms er a lElasgnw I.Enma Scale {GCS}
scere nf 13 er lewer alse requires immediate acceleratinn
tn a higher level nf care.
Cnnscieus athletes withnut findings nf fecal neurnlngic
injuries shnuld be evaluated fer a cnncussinn fellnwing
head trauma. Understanding the mechanism nf injury,
recngnizing the presenting signs and symptems, and as-
sessing cngnitive impairments make the clinical diagnn—
sis nf a cnncussinn. The mest cnnunnnly used sideline
assessments include an inventery ef current signs and
symptnms, an assessment nf pnstural stability, and a brief
assessment nf cngnitive functinn in cnnjunctinn with a
Symptnm Scale and Eegnitive Testing
{ImPACT}
Balance Errnr Scnting Axen Sperts Eernputerized
System Cngnitive Assessment
Tnnl (ti-CAT}
King-Deviclt test Head Minder
thnrnugh histnry. Ne single ‘best’ tnnl is available fer the
diagnnsis ef a cnncussinn; therefere, spnrts medicine pre-
fessinnais shnuid use a cnmbinatinn nf assessment tnnls,
bnth en-field and during fellnw-up evaluatinns {Table 1}.
The symptnms ef a cencussinn can be classified intn fnur
dnmains: snmatic, cngnitive, emetinnal, and sleep. Symp-
tem checklists can be used during the en-fieid evaluatinn
as a systematic apprnach nf asking definitive yes-er—nn
questinns fer individual cnncussien symptnms despite the
cencern ef underreperting hy adelescent athletes}1 Twe
nf the mest cemmnnly used symptnm checklists include
the Pnst-Cnncussien Symptnm Scale and the symptnm

IE! lfllfi American Academy nf flrrhnpaedic Surgenns Drthnpeedic Knnwledge Update: Spnrts Medicine 5
 Section E: The Young Athlete
evaluation list in the Sports Concussion Assessment Tool
{SEATS} and SEATS for children ichildSCATSi. The most
commonly discussed and recognised sign of a concussion
on the field is a loss of postural control during the acute
phase of a concussion, with several medical societies rec-
ommending the use of postural assessments acutely."=”*“
The Balance Error Scoring System {BESS} is the most
widely used sideline assessment of static halanceflfl and
is included in the SEATS and childSCATS. However,
the BESS has been examined primarily in a collegiate
population, with little research conducted on athletes
of high school age and younger. In addition, the BESS
may he unsuccessful in identifying persistent balance
dysfunctions. A brief assessment of cognitive function,
although more challenging, is appropriate and included in
most sideline assessment tools. The use of computerized
neurocognitive testing for sideline assessment has not
been well investigated. Therefore, the application of these
tools during an on-field evaluation is not commonplace
and cannot be recommended at this time.“ The use of
the King-Devick test to assess oculomotor function in
collegiate and professional athletes is supported in the
literature,“=” although its use has not been investigated
in high school and younger athletes. immediate removal
from all physical activity should occur if signs or symp-
toms consistent with a concussion are present during the
E on-field evaluation following a traumatic event."-“
E Many youth sports and town leagues do not have access
:5
:1: to medical care on the sideline during practices or games.
In these situations, the clinicians in pediatric emergency
Ch
E
S
3... departments often provide the first medical evaluation
I1:
.I:
|_- of a young athlete with a suspected concussion. During
t'ti the past decade, emergency department providers have
substantially increased their awareness of concussions and
most physicians follow published guidelines when man-
aging concussion patients. These guidelines recommend
that serial follow—up assessments with a medical provider
should occur for continued care until the concussion has
resolved. Pediatric emergency department clinicians” and
athletic trainers11 have recently demonstrated similar re—
ferral patterns for adolescent patients to follow up with
their primary care providers for further management of
concussion symptoms. In many instances in the past, the
young athlete was simply watched by the athletic trainer
or told by emergency department personnel to rest for a
week and then return to play. This change in concussion
management is important because clinicians completing
the initial assessment are now recommending follow-up
care to ensure resolution of symptoms and recovery from
the injury instead of initially predicting recovery at the
moment of injury and recommending arbitrary dates for
return to school and return to play.
firthopaedic Knowledge Update: Sports Medicine 5
Concussion Management Team
Although concussions are considered mild in relation to
other head injuries, this does not diminish their com-
pleaity.'“'1"vi-fr13 As research continues to improve the un-
derstanding of this multifaceted injury, sports medicine
practitioners are being called on to collaborate with other
professionals to create a multidisciplinary concussion
management team to provide better care for adolescent
athletesJIJJ-Jfi-fl This team, composed of medical pro-
fessionals with experience in concussions, oversees the
education and awareness of concussions at the youth level,
provides a cohesive network to increase identification
of this injury, provides prompt implementation of rest,
and oversees a safe, successful return to academics as
well as athletics. This team supports the adolescent with
the emotional challenges of sustaining a concussion as
well as the social and mental difficulties associated with
persistent concussion symptoms.“ Since lfllfl, multiple
professional societies, including the American Medical
Society for Sports Medicine” and the American Academy
of Grthopaedic Surgeons,31 have released position state-
ments describing their role within this team.
The members of the concussion management team can
vary with an individual‘s recovery time. If an adolescent
recovers rapidly from his or her concussion, the team may
consist of only a few members. However, if an adoles-
cent experiences persistent symptoms with a protracted
recovery, the concussion management team will need to
include other medical professionals such as neurologists,
neuropsychologists, sports medicine physicians, psycholo—
gists, physical therapists, athletic trainers, school nurses,
school guidance counselors, and school faculty members.
Irrespective of the formal titles of the individuals com‘
prising the team, all members must remain current on
the literature given the rapid increase in understanding
of concussion and the noteworthy changes to the current
best practice management models for adolescentsfizru
In the secondary school setting, athletic trainers are the
best prepared and trained medical providers to evaluate
a head injury with a suspected concussion.33 The main
focus for athletic trainers should be to ensure the ado-
lescent athlete is properly assessed and receives guidance
and education regarding acute concussion management.
The establishment of a concussion management team and
written concussion policy within the school establishes
lines of communication between all involved team mem-
bers to ensure the health and safety of the student athlete
with a concussion.“*” The concussion management team
is essential for facilitating the smooth transition of the
student athlete with concussion back into the academic
environment.21 The possibility for a smooth return of the
fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 5!]: Special Ennsideralinns in Head Injmies in Adelescent Adfletes

student athlete tn the classrnnm is greatly enhanced with

a well-functinning and interactive management team,
_
Clinical Predictinn Rules fnr Patients
reducing the far-reaching, negative cnnsequences pnssible
in ynung athletes.“ "With Blunt Head Trauma

Canadian CT Head Rule Hevv Drleans CT Head

Clinical Management Criteria
Head ET is required fnr Head CT is required fnr
Imaging minnr head injury blunt trauma patients
Heurnim aging is a key factnr in determining the severity patients with any nne with LDC, GEE scnre
nf injury and the expediency with which medical care cf these findings 15, nnrmal neurnlngic
must be delivered fnr fecal head injuries. When assessing examinatinn. and
any cf the fnllnwing
head injury, the main indicatnrs fnr neurnimaging are fn— criteria:
cal neurnlngic deficit, altered mental stat us, vnmiting, and
GEE scnre c 15 at 2 Headaches
parental anxiety.” The cnncern nver radiatinn expnsure hnurs after injury
in adnlescents ever the past decade has led tn mnre specific Unmiting
Suspected npen
guidelines as tn when radinlngic evaluatinn is apprnpriate nr depressed skull
in instances nf head trauma. Clinical decisinn rules, such fracture
as the Canadian CT Head Rule and the New Drleans Any sign nf basal Age nlder than ED
Criteria, shnuld be used tn help determine the need fnr sltull fracture years
neu rnimaging fnllnwing blunt head trauma 1'Table 2]. {hemntympanum
"raccnnn eyes". Battle
1ifll'hen neurnimaging is required in a ynung athlete, MRI sign, ESF ntnrrheai'
may be a safer alternative tn CT; MRI has been shnwn tn rhinnrrhea}
be as sensitive as CT in detecting intracranial hemnrrhage Unm'rting a 2 episndes Drug nr alcnhnl
and reducing radiatinn eapnsure in pediatric patients.” intniticatinn
Standard neurnim aging prnvides essentially an clinical Age 65 years nr nld er Deficits in shnrt-tenn
infnrrnatinn regarding isnlated cnncussinn injuries. Alter— memnry
atinns in brain functinn as a result nf a cnncussinn have Amnesia befnre Physical evidence F“?
been thnught tn nccur in the absence nf structural injury impact a 3G minutes n'f trauma abnve the
m
due tn a substantial number nf nnrmal CT and MRI scans clavicles
EfI:
nbtained frnm these patients.”M Advancements in neurn- Dangernus mechanism Seizure :r
v:
imaging may snnn dispute this cnmmnnly accepted state— nf injury {fall frnm 1"
mentfi‘“r lIfjurrently, wnrlt is being cnmpleted tn investigate elevatinn, struck by Fl

E
vehicle] as
the rnle nf diffusinn tensnr imaging, functinnal MRI, and m
F.

magnetic resnna nce spectrnscnpy regarding cnncussinn mus-s sensitive. 60% 32% sensitive. 26%
specific”E specific"
management, specifically in the area nf quantifying the
ESF - carehrnspinal fluid, GEE - Elasgnw Cnma Scale. a - less at
severity nf injury.3E
cnnsclnusness.

Clinical Management Plan for Cnncussinns

Current recnm mendatinns fnr management after the ini-
tial diagnnsis include a series nf fnllnw—up assessments
until resnlutinn nf cnncussinn symptnms and impair-
ments, fnllnwed by a clnsely mnnitnred prngressinn bacl-t
tn full academic activity and unrestricted play tn ensure
a smnnth and safe recnvery."~1’5 Cngnitive and physical
activity mndificatinn is nften determined frnm the infers
matinn gained frnm these assessments as well as discus—
sinn with the adniescent athlete and his nr her parents.
Given the cnmpleicity nf cnncussinns, an individualized
management plan shnuld be created for each adniescent
athlete.
A shnrt—term perind nf rest from cngnitive and physical
esertinn fnllnwed by a gradual and systematic increase in
these activities cnntinues tn be the fnnndatinn nf apprn-
priate cnncussinn management.“ Student athletes whn dn
nnt rest and cnntinue tn engage in activities that prnvnlte
their cnncussinn symptnms have demnnstrated lnnger
recnvery tirnes.33""’ Ennversely, cnmplete abstinence frnm
cngnitive and light aernbic activities, especially fnr an
extended perind, has nnt been shnwn tn be beneficial}9
Return tn Learn
Adelescents with cnncussinns benefit frnm a gradual reen-
try plan tn help facilitate a smnnth return tn the academic
envirnnment.“ When a student athlete has been cleared
tn return tn the classrnnm, the individual may still be
affected by the cnncussinn, yet appears well tn teachers,

IE! Elilti American Academy nf flrthnpaedic Snrgenns Drtbnpaedic Knnwiedge Update: Spnrts Medichie 5
 Section E: The Young Athlete
school administrators, and peers.“ A reentry plan should
address classroom accommodations as well as environ-
mental adjustments, depending on the student athlete’s
symptoms and cognitive difficulties. The main focus for
the concussion management team during the return-to-
learn phase is to balance the need for the individual to be
in the classroom with the appropriate accommodations
and adjustments to decrease the potential for recurrent
or persistent symptoms.
Return to Play
Current return—to—play guidelines are based largely on
the resolution of concussion symptoms and progression
through increasingly demanding exertional exercise with
out provocation of symptoms. The potential exists for
adverse outcomes if an adolescent athlete is allowed to
return to contact or collision activities too soon. This
may be evident in the percentage of recurrent injuries
that occur within a short time from the original injuryfidfi
Recent investigations have found lingering motor per-
formance measurement deficits in adolescent concussion
patients who have appeared tn fully recover clinically
from their injury.‘”*"'3 This highlights the possibility that
motor control may have a different recovery trajectory
compared with symptom resolution or return of normal
neurocognitive function.
E Preseason Preparation
E Recovery Patterns
:5
fl: Adolescents may demonstrate longer recovery patterns
following a concussion than adults. It has been shown that
Eh
E
E
3... 63% to 93% of adolescent athletes will recover within 1
I1:
.I:
'— month from their concussion.‘l""‘"r However, a subset of
Ed patients will continue to experience concussion symptoms
longer than 4 weeks."'“="'i Females as well as adolescents
with a previous history of concussion, previous diagnosis
of migraine headaches, learning disability, or attention
deficit hyperactivity disorder may be predisposed to a
longer recovery coursefifir‘lii“E4 The substantial variation
in recovery length supports the implementation of an
individualized management plan. Concussions cannot be
generalized and each injury will be different.
Additional Management Strategies
For most adolescents who recover from a concussion
within a few weeks, the treatment plan may only need
to include a short period of rest and activity modification
until resolution of symptoms. In the situation in which
persistent symptoms or impairments continue to plague
the individual, additional treatment options including
medication, dietary changes, physical therapy, sub-thresh-
old exercise, and emotional support should be considered
and implemented into the management plan.
firthopaedic Knowledge Update: Sports Medichie 5
Medications have a limited but specific role in con-
cussion management if the individual continues to note
unrelenting symptoms that have persisted past the accept-
ed recovery length for an adolescent athlete, and if the
individualis symptoms negatively affect his or her quality
of life."=49 Given the lack of well-controlled studies on the
use of certain medications for symptom management, care
should be taken when prescribing these agents to a young
population.“ Sleep disturbances may be the most common
postconcussion symptom often treated with medications,
followed by persistent headaches, cognitive difficulties,
and emotional changes. The most recent International
Consensus Statement on Concussion in 2011“ notes the
unique situations in which pharmacologic therapies are
warranted during concussion management but strongly
warns against returning an athlete to contact or collision
activities if medications are still being used because of the
potential to cover or hide lingering symptoms.
Increasing evidence supports using subsymptom
threshold aerobic exercise as rehabilitation for a possible
physiologic dysfunction following a concussion.”51 In
addition, subsymptom threshold aerobic exercise can also
help ease feelings of depression or anxiety in adolescent
athletes who have been completely removed from their
team and have lost their sense of identity as an athlete.
An Emergency Action Plan is a document that outlines
how to triage a life—threatening or catastrophic event. An
Emergency Action Plan should be in place for every venue
that supports athletic play and reviewed by all members of
the medical and coaching staff on a yearly basis to ensure
a rapid and seamless execution of care if an adolescent
athlete is injured?
In many cases, use of a structured preparticipation
examination can enhance the management of an adoles-
cent athlete who suffers a concussion during a sporting
season. The preparticipation examination typically in-
cludes a screening neurologic examination along with
baseline neu rocoguitive assessments. Baseline assessments
are becoming increasingly prevalent in the secondary
school setting.22 In situations in which neurocognitive
baseline assessments are implemented in a group testing
environment, a standardised approach toward test admin-
istration, proper supervision of the testing environment,
and appropriate education of the student athlete on the
purpose of this type of testing is necessary to ensure valid
scores.5“-55 Even when these steps are taken to improve
the validity of the baseline examinations, the tests should
be reviewed by an experienced user of the neurocognitive
examinations to confirm their validity. Neurocognitive
baseline assessments completed in a group setting may
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 511]: Spa-rial Consideralions in Head Inimies in Adolescent Athletes
be inappropriate for certain adolescents, especially those
with a diagnosis of attention deficit hyperactivity disorder
or learning disabilitiesdflf
Specific Concerns in a South Population
Individuals with persistent symptoms following a con-
cussiun tend to be classified as having pustconcussiun
syndrume. However, pustconcussion syndrome is inad-
equately defined, the etiology is poorly understood, and
the term is commonly interchanged with “postconcussion
symptoms.” The argument has been made that the tra nsi—
tiun from cone ussiun tu pustcuncussiun syndrume should
occur at the point when typical concussion symptoms
should have resolved in the targeted populations":r Given
the fact that adolescent athletes have substantial variation
in recovery lengths, defining the point where concussion
symptoms should typically resolve is challenging.
Concerns exist for adolescent athletes returning to
spurts while still symptomatic from their concussions.
The National Center for Catastrophic Injury Research has
data that suggest a possible risk factor for a catastrophic
injury is the presence of a recent head injury?” Although
incredibly rare, second-impact syndrume should be con-
sidered by spurts medicine physicians given its relevance
to a youth population. Second—impact syndrome is typi—
cally a repeat injury that occurs when an athlete has nut
fully recovered from a previous injury, resulting in diffuse
cerebral swelling with delayed catastrophic deterioration,
and on occasion hraiustem herniatiun.” Second-impact
syndrome is a poorly understood injury because the only
literature that exists on this topic consists of case reports.
Second-impact syndrome has been documented in 14- to
15—year—olds in whom death occurs from diffuse cerebral
edema and possible herniatiun as the brain loses its ability
to auturegulate intracranial and cerebral perfusion pres-
sure. It has been assumed that several of these athletes
continued to participate in spurts while symptomatic from
a recent concussion when the structural injury was sus-
tained.“ To help prevent second—impact syndrume from
occurring, strict guidelines forbid athletes from partici-
pating in collision or contact activities while symptomatic
from a concussion. Although some experts refute the
presence of second-impact syndrume, spurts medicine
clinicians acknowledge concern about adverse louguterm
neurologic sequelae following repeat impacts to the head
in a symptomatic individual. This finding highlights the
need for proper education, especially for the athlete, to
disclose symptoms to those involved in his or her care.
Another concerning factor with prematurely returning
an adolescent athlete to contact and collision activities
is the risk of chronic traumatic encephalopathy {CTE}.
IE! lfllfi American Academy of flrthopaedic Surgeons
CTE, a neurodegenerative disease postulated to occur
from repetitive trauma, was originally identified in the
lfilfifls. Until recently, CTE has been diagnosed postmor-
tem in retired professional athletes and military personnel.
Current theory links CTE with chronic repetitive head
trauma, although causation has not yet been confirmed.
Research on CTE is in its infancy and current reports
represent a basic appearance of this injury within contact
sports.” Additional work in this area must identify risk
factors for the development of CTE.
Injury Prevention
Reducing the frequency of adolescent concussions con-
tinues to be a prevailing mission for sports medicine pru-
viders, researchers, and sports organizations. Although
improvements in helmet design have helped decreased the
risk of skull fractures,“ helmets as well as other types of
protective equipment {headbands, mouth guards} have not
been shown to result in decreased concussion occurrence
rates.fl Recent changes to contact and cullisiun activities
in youth hockey“ and similar proposed changes to youth
football and youth soccer may yield promising results, al-
though empirical data have not yet confirmed a reduction
in the overall number of sustained concussions. These
organizations are following the precedents of collegiate
football programs that have decreased the amount of F“?
contact that occurs during practices.
m
Concussion awareness paired with state legislation has
EfI:
recently become the main focus of protecting adolescent :I
u:
athletes.IM A national focus has been placed on appro- 1"
priate and conservative management of young student
Fl
E
re
athletes.” This emphasis has pushed for legislative guide- m
F.
lines to protect young athletes from the mismanagement
of cuncussiun injuries.“ As of November 2014, all states
have passed legislation on concussion management in
adolescent athletes. The laws in each state and the discus-
sion surrounding them have emphasized the importance
of creating protocols and concussion treatment plans.
Each law indicates that the athletes, coaches, pa rents, and
medical staff at the youth level are responsible for being
aware of the issues surrounding concussions and their
management.“ However, only 41 states require adoles-
cent athletes to complete formal cuncussiun education,
and 35' require parents to complete formal concussion
education. Educational programs exist and several states
have developed their own concussion education curricu-
lum. These programs as well as private programs often
include resources such as the US Centers for Disease Con-
trol and Preventiun’s Heads Up Toolkit, Sports Legacy
Institute Community Educators courses, ThinkFirst, and
Brain 101 and have been shown to increase awareness
Drthopaedic Knowledge Update: Sports Medichse S
 Sectinn E: The 1fusing Athlete
and early apprnpriate management in ynuth spnrts."5~""
These prngra ms nften have a specific pnpulatinn as their
target audience. The Heads Up Tnnlkit targets parents
and cnaches, and the Spnrt Legacy Institute prngram spe-
cifically targets athletes and prnvides real-life cnncussinn
experiences.
Adnlescent athletes, particularly thnse whn participate
in tnwn nr recreatinnal leagues, are usually nnt the target
pnpulatinn nf legislatinn and nften are nnt errpnsed tn the
same level nf educatinn. Parents nf fnntball athletes 5 tn
15 years nf age may struggle tn cnrrectly identify cnncus-
sinn symptnms, with mnst parents failing tn recngniae
sleep disturbances and emntinnal distress as resulting
frnm a cnncussinn.“
The extensive educatinnal prngrams in rnnst states
are directed in large part tnward high schnnl students.
The purpnse nf these prngtams is tn raise awareness and
imprnve the initial recngnitinn and treatment nf cnncus-
sinns because these student athletes are still reluctant tn
repnrt pnssible injury.fi*"""'fl Apprnitimately 50% nf student
athletes dn nnt repnrt their injuries tn cnaches nr med-
ical staff?1 Althnugh high schnnl student athletes can
cnrrectly identify certain cnncussinn symptnms such as
dizziness, headaches, and cnnfusinnfflfl nther symptnms
such as nausea, amnesia, sleep disturbances, emntinnal
nt persnnality changes, and the delayed nnset nf symp—
tnms are less well knnwn tn this pnpulatinnJEElJ'f'd1 Student
E
E athletes cnmmnnly cite self-misdiagnnsing a bell-ringer
:5
s1: nr cnncussinn injury as an injury nnt serinus ennugh tn
Eh
E warrant medical attentinn,” as well as internal pressure
E
3... tn avnid letting dnwn teammatesfld“ nr parents?5 as rea—
I1:
.I: snns fnr nnt repnrting their injury. Althnugh these ed-
|_-
id ucatinnal initiatives cannnt prevent all cnncussinns, the
hnpe is that early, prnpcr diagnnsis nf cnncussinns will
decrease the pnssibility and hnpefully the actual incidence
nf secnnd-impact, multiirnpact, and recurrent injuries, nr
nverlapping cnncussinn syndtnme. Therefnre, cnutin—
uatinn and imprnvement nf cnncussinn awareness and
educatinnal prngrams is impnrtant.
Recent studies have investigated the relatinnship be—
tween a student athlete’s sncinecnnnmic framewnrk and
disclnsure nf cnncussinn injuries.“W The sncinecnnnmic
framewnrk nf adnlescent athletes is EDII‘IPIEI and includes
the individual behavinrs and traits nf the athletes, the
strength nf their peer netwntks, their sncial euvirnn-
ment, and even the pnlicies nf their spntt’s nrga niaatinn.”
Cnaches whn are prnperly educated en the current man-
agement nf adnlescent athletes with a cnncussinn have the
ability tn nnt nnly increase identificatinn nf these injuries
but alsn ensure a spnrts envirnnrnent nf cnrnpliance nf the
athlete with apprnpriate and safe return tn play.“
firthnpaedic Knnwledge Update: Spnrts Ivledich'ie 5
Summary
Participatinn in athletic activities will always pnse a threat
nf head injury tn adnlescent athletes. Clinicians must be
prepared tn rapidly and effectively triage care fnr an adn-
lescent athlete whn suffers a life—threatening head injury.
In the case nf a spnrts-related cnncussinn, clinicians must
take a cnnservative stance nn apprnpriately resting and
slnwly prngressing an adnlescent athlete back tn cngni~
tive and physical activities nnce the cnncussinn has fully
resnlved. Given the difficulty nf eliminating the risk nf
head injuries during spnrt, clinicians can help educate
cnaches, parents, and athletes cm the prnper steps tn take
in the event nf a head injury in a ynung athlete tn mitigate
the chance nf further injury.
Hey Study Pnints
- Head injuries are cnmmnn in the adnlescent pnp-
ulatinn. Prnmpt recngnitinn nf catastrnphic versus
nnnemergent injuries and subsequent triage nf care
is paramnuut tn avniding lnng—term prnblems.
I A cnncise and structured apprnached tn an nn-field
assessment nf a head injury paired with the devel-
npnient and rehearsal nf an Emergency Actinn Plan
will help ensure smnnth and seamless delivery nf
care in the event nf a life-threatening event.
I Cnncussinns are cnmplest injuries that require a
multidisciplinary grnup nf health care prnfessinnals
tn nversee care and management until full resnlutinn
nf symptnms. The establishment nf a cnncussinn
management team at schnnl helps ensure the safe
and full return nf the student athlete with a cnncus-
sinn tn the classrnnm and the athletic field.
II Educatinn nf all invnlved in adnlescent spnrts, in-
cluding the athletes themselves, is perhaps the mnst
impnrtant area where imprnvements can be made
tnward preventinn nf head injury.
Annotated References
1. DiFinri JP, Benjamin H], Brenner], et al: Dveruse injuries
and burnnut in ynuth spurts: fl. pnsitinn statement frnm
the American Medical Snciety Int Spnrts Medicine. Cffrr
,l' Spnrt Med 2fl14;24{1J:3-2fl. Medline DUI
1. Kelly ED, Lissel I-IL, Rnwe EH, Vincenten 1a, Veal:—
lander DC: Spnrt and recreatinn-related head injuries
treated in the emergency department. lr: I Spnrt Med
lflfll;11{1j:??—31.Medline DUI
fl lflld American Academy nf Urthnpaedic Surge-nus
 Chapter 511]: Spa-rial Considerafieus in Head Iejte'ies in Adelesceut Athletes
This descriptive epidemielegic study eutlines the eccur;
rence ef spert-related injuries in adelescents frem data
cellected frem a narienwide sample ef emergency depart-
ments. During a single year, emergency department visits
fer cencussien care tetaled $154.3 millien.
. Halliah RP, Andersen IM, Lee MK, Rampa S, Allareddy
V, Allareddy if: Epidemielegy ef hespital-based emergency
department visits due re sperts injuries. Pedietr Emerg
Care 2014;30j3}:511-515. Medline DUI
. Ferbes JA, Zuclterman SL, He L, et al: Subdural hem-
errhage in twe high-scheel feetball players: Pest-inju-
ry helmet testing. Pedietr Neutesurg lfllS;49{1]:43-49.
Medline DUI
In this case reperr, the biemechanical testing results en
the feetball helmets were by twe athletes whe suffered
subdural hemerrhages during play revealed beth helmets
were deemed cempliant per Natienal Dperating Cemmit~
tee en Standards fer Athletic Equipment standards. The
anthers raise cencern that even with pretective equipment
passing helmet safety specificatiens, catastrephic head
injuries still eccur in high scheel feetball.
. Meehan WP 111, Mannie: R: A substantial prepertien ef
life-threatening injuries are spert-related. Pedierr Emerg
Care 2013;29j5j:614-52?. Medline Hill
This large retrespective study ef emergency department
visits ever a 10-year span revealed that 40% ef catastrepb-
ic injuries sustained by pediatric and adelescent patients
are related te sperts participatien. The anthers discuss the
pessibiliry ef preventing life—threatening injuries in this
pepulatiee by advecating fer rule changes, better ceach—
ing educatien, and preperly fitted pretective equipment.
. Linceln AE, Caswell 5V, Almquist IL, Dunn RE, Nerris
JB, Hinten RY: Trends in cencussien incidence in high
scheel sperts: A prespecrive 11-year study. Am I Sperts
Med 201 1;39{5}:953-963. Mcdliue DUI
This descriptive epidemielegical study prespectively gath-
cred cencussien injury rates fer 2.5 high scheels ever a
Ill-year peried. Their results revealed a 4.2—feld increase in
diagnesed cencussiens in 12 varsity sperts, with feetball
and girls seccer having the highest incidence rates.
. Eakhes LL, Leclt hart GR, Myers R, Linakis jG: Emergenv
cy department visits fer cencussien in yeung child athletes.
Pediatrics lfllflgllfifljmfifl-eSSE. Medline Dfll
This retrespective review reperts en data cellected by the
Natienal Electrenic Injury Surveillance System en It'll} US
based hespitals. Dvcr a 4-year cellectien peried, children
S te 19 years ef age acceunted fer Sfll,flflfl emergency
department visits with a diagnesis ef cencussien. Nearly
half ef all diagnesed cencussiens were sperts related.
. Simen TD, Eublira C, Hambidge 5]: External causes ef
pediatric injury-related emergency department visits in the
United States. Acad Emerg Merl.r 2UD4;11[1fl}:1fl41-1fl43.
Medline Dfll
IE! lfllfi American Academy ef flrrhepaedic Surgeena
9. Merris SA, Jenes WH, Precter MR, Day AL: Emergent
treatment ef athletes with brain injury. Nearesurgery
2fl14:?5{suppl 41:596r51fi5. Medline DUI
A cemprehensive review ef life-threatening head injuries in
athletes is presented. This article reviews current sideline
emergency management, transpertatien, and management
ef pretective equipment when caring fer an athlete with
a head injury.
1f). Ereglie SP, Cantu RC, Gieia GA, et al: Narienal Athletic
Trainer’s Asseciatien: Natienal Athletic Trainers’ Assecia-
tien pesitien statement: Management ef spert cencussien.
} Ariel Trees 3014:49(21:245-265. Medline DUI
11. McCrery P, Meeuwisse WH, Aubry M, et al: Censensus
statement en cencussien in spert: The 4th Internatienal
IIEenference en Cencussien in Spert, Zurich, Nevemher
ems. } ear Train 2013;43j4j:554—5?5.Medline eer
11. Harmen KG, Dreaner JA, Gammens M, et al: American
Medical Seciery fer Sperts Medicine pesitien statement:
lCencussien in spert. fir] Sperrs Med 2fl13;4?[1}:15-26.
Medline DUI
13. Stern RA, Riley DC}, Daneshvar DH, Newinslri C], Cantu
RC, McKee AC: Leng-term censequences ef repetitive
brain trauma: Ehrenic traumatic encephalepathy. PM R
2fl11:3{1fl, suppl 215450-5461 Medline DD]
This review article discusses the emerging evidence en
chrenic traumatic encephalepathy and highlights the need
fer addirienal research te help identify the pepulatiee at
risk as well as the clinical presentatien and evelutien ef
F“?
the disease.
m
14. Reed N, Ta ha T, Heightley M, et a1: Measurement ef head E?I:
impacts in yeuth ice heclcey players. Int ] Sperts Med :I
2010;31j11}:326-333.Medline DUI
e:
1"
Fl
The purpese ef this pilet study was te describe the bie- E
n:
mechanical measures ef head impacts, as measured by m
F.
the Head Impact Telemetry System, te yeung male ice
heckey athletes. A secendary purpese was te investigate
hew athlete and game characteristics may influence the
frequency and magnitude ef head impacts. The anthers
fellewed 13 13- re 14-year-eld ice hecltey athletes fer a
single seasen. Their findings shewed that the wing pesitien
demenstrated a significantly higher number ef impacts
te their heads {10.9 hits} than a defense {5.95 hits} and
centers (5.45} pesitien per game. The wing pesitien alse
experienced a significantly greater retatienal acceleratien
during hits than center pesitiens. mw magnitude hits with
a linear acceleratien less than 30 g cemprised the majerity
ef hits {33.1%} sustained at all pesitiens.
15. Ereglie SP, Martini D, Kasper L, Eckner JT, Kutcher JS:
Estimarien ef head impact expesure in high scheel feet-
ball: Implicatiens fer regulating centact practices. Am
] Sperts Med lfllS;41{12}:23??—2334. Medline DUI
Several feetball erganiaatiens have debated a rule change
that weuld reduce the weekly numb-er ef centact practices
in hepes ef mitigating the number ef subcencussive blews
sustained by athletes, yet limited data exist te suppert
Drthepaedic Knewledge Update: Sperts Medicine 5
 Section E: The Young Athlete
this movement. The authors of this cross-sectional study
examined magnitude and frequency data collected on 42
high school football athletes wearing the Head Impact
Telemetry System in their helmets over a single season.
Although athletes continue to sustain the greatest num-
ber and highest magnitude of blows to their head during
games, the findings of this study suggest an 13% reduction
in the number of sustained head blows when limiting
contact practice to once per week.
1S. Kerr Z'f, Collins CL, Mihalik JP, Marshall SW, Cuskiewics
KM, Comstnck RD: Impact locations and concussion out-
comes in high school football player—tn—player collisions.
Pediatrics 1014;134ES}:4SS—496. Medline DUI
The purpose of this study was to describe concussion out-
comes in terms of impact location during player-to-player
contact in high school football athletes. Data retrieve
from the RID system for the 2003—11113 high school
football seasons revealed 2,526 concussions that were
sustained from player-to-player contact. Impact location
had no association with injury recurrence, number of
reported symptoms, symptom resolution, or length of
time until return to play. Loss of consciousness was found
to occur more often with top-nf-the-head blnws, which
emphasizes the importance of proper tackling mechanics.
1?. Zemper ED: Catastrophic injuries among young athletes.
Br _i' Sports Med lfllflgssllJflS-li}. Medline DUI
This comprehensive review of catastrophic injuries sus-
tained by young athletes identified football, cheerleading,
ice hockey, gymnastics, wrestling, and lacrosse as the
E spurts that carry the highest risk of injury. Un average,
E 24 football athletes sustain a catastrophic injury every
.‘E year. Previous head injury, lack of appropriate protective
:1:
Ch gear, and inexperienced coaching have all been identified
E
as risk factors.
S
3...
I1:
.I: 13. Proctor MR, Cantu KC: Head and neck injuries in
|_-
young athletes. Clir: Sports Med EflflOHSHJmSS-HS.
t'ti
Medline DUI
19. Ellis M], Leddy J], 1iii'iller B: Physiological, vestibule-oc-
ular and cervicogenic post-concussion disorders: An
evidence—based classification system with directions for
treatment. Brain iisi 2015:29i2i:233~243. Medline DUI
This systematic review discusses an evidence-based ap-
proach toward treating physiologic, vestibulo-ncular, and
cervicogenic impairments and dysfunctions following a
concussion.
ll]. Eckner JT, Kutcher JS: Concussion symptom scales and
sideline assessment tools: A critical literature update. Carr
Sports Med Rep Efl1fl;9{1]:3-15. Medline DUI
Because of the complexity of concussion injuries, a single
assessment tool cannot accurately diagnosis a concussion.
Rather, a multifaceted assessment approach is advocated.
21. McCrea M, Iversou CL, Echemendia K], Makdissi M,
Raftery M: Day of injury assessment of sport-relat-
ed concussion. Br J Sports Med 2013;4Tl5}:2?2-234.
Medline DUI
Urthnpaerlic Knowledge Update: Sports Medicine S
This comprehensive review of assessment tools used during
the acute phase of a concussion suggests the diagnosis
of a concussion be made from the information obtained
from a cluster of tools instead of reliance on a single tool.
12. Williams RM, Welch CE, Weber ML, Parsons JT, VEIUVICI‘I
McLeod TC: Athletic trainers’ management practices and
referral patterns for adolescent athletes after sport-re-
lated concussion. Sports Health 2fl14;6{5}:434-439.
Medline DUI
An online survey of 351 athletic trainers in the secondary
school setting, with a response rate of 25.9%, revealed
TISSFS refer adolescent athletes with a concussion to a
physician for care. The authors note collaboration of care
within the secondary school setting can be improved be-
cause only 311% of athletic trainers shared concussion
management with the school nurse, and 11.5% were the
sole health care provider.
13. Cuskiewicz KM: Balance assessment in the management of
sport—related concussion. Clin Sports Med 201 1:3 fl{11:39'
102, ix. Medline DUI
Loss of postural control indicates neurologic impairment.
Therefore, an assessment of an athlete’s balance should
be incorporated into the clinical examination for a con-
cussion. Balance impairments, seen acutely following a
concussion, may resolve within a few days.
2.4. Caletta KM, Brandes LE, Maki K, et al: The King-De-
vick test and sports-related concussion: Study of a rapid
visual screening tool in a collegiate cohort. j Nearoi Sci
2011;3fl9l1-llt34-39.Medline DUI
This study compared preseason to postseason King-Devick
test scores in 219 collegiate athletes. Although a mild
learning effect was observed, as postseason scores were
better than preseason scores, in healthy collegiate athletes,
in 1|]I athletes who suffered a concussion during the playing
season their sideline King-Devick scores were significantly
worse than their preseason scores.
25. Galetta MS, Galetta KM, McCrnssin ], et al: Saccades
and memory: Baseline associations of the King—Devick
ancl SCATE SAC tests in professional ice hockey players.
I Near-oi Sci 1fl13;323:1-2}:23-31. Medline DUI
This prospective study describes the relationship be-
tween the Standard Assessment of Concussion {SAC} and
King-Devick tests during preseason baseline testing in
17 professional ice hockey players. The authors suggest
a relationship between immediate memory and saccadic
eye motion beca use lower SAC memory scores were found
with slower King-Devick time scores.
26. Cisa CC, Kutcher JS, Ashwal S, et al: Summary of evi-
dence-based guideline update: evaluation and management
of concussion in sports: report of the IGuideline Develop-
ment Subcommittee of the American Academy of Neurol—
ogy. Neurology ED13:SO[24}:2250-2151 Medline DUI
The authors present a systematic review of risk factors
for sustaining a concussion, the predictive abilities of di-
agnostic tools and clinical presentations in identifying
U lfllfi American Academy of Urthopaedic Surgeons
 Chapter 511]: Special Considerafians in Head Iajtu'ies in Adaleecent Athletes
severe ar pralanged itupairments, and interventiaus that
reduce recavery times.
1?. Kiunan'iau KA, Mannie RC, Camstack RD, Meeban WP
III: Management af pediatric patients with cancussiau
by emergency medicine physicians. Pediair Emerg Care
1fl14i3fliTjt453-461. Medlinc DUI
The purpase ef this study was ta identify strategies im—
plemented by emergency medicine physicians when caring
far yaung individuals with cancussians. The majarity af
physicians (31%] reparted using published guidelines fram
the American Academy af Neuralagy and the Internatiau-
al Canference an IEancussian in Spart when managing
cancussiau patients, and 363i: recammended fallaw-up
care ta ensure camplete resalutian af symptams.
23. Gusltiewicc KM, Register-Mihalilt J, McCrary P, et al:
Evidence-based appraach ta revising the SCATZ: Intra-
dnci ng the SEATS. iir I Sparts Med 2fl13:4?{51:239-293.
Medline DUI
The SCAT3 is a callectian cf the mast sensitive and reliable
cancussiau assessments currently available. A systematic
and streamlined way af assessing impairments fallawing
a cancussiau is pravidecl.
25". Halstead ME, Walter ED: Eauncil an Sparts Medicine
and Fitness: American Academy af Pediatrics. Clinical
repart—spart—related cancussiau in children and adales-
cents. Pediatrics lfllflglleiliififl'F-Eli Medline DDI
3b. Echemendia R], Iversan GL, McCrea M, et al: Role af
nen rapsychalagists in the evaluatian and management af
span-related cancussiau: An inter-arganisatian pasitian
statement. Arch Ciirs Neurapsycisai 2012;2T[1]:119-122.
Mcdline DUI
31. Herring SA, Cantu RC, Gusltiewica KM, et al; Amer-
ican lI'.'3allege af Sparts Medicine: Iiiiancussian {mild
traumatic brain injury} and the team physician: A can-
sensus statement—1011 update. Med Sci Sparta Esters
1011;43illjzl412-1411. Medline DUI
32. Mareau W], Nabhan DC: Develapment af the Hill
American Cbirapractic Eaard af Sparts Physicians pasi-
tian statement an cancussiau in athletics. j Cirirapr Med
2013;12i4]:169-1?3.Medline DDI
33. Meehan WP III, Taylar AM, Practar M: The pediatric
athlete: Taunger athletes with spurt-related cancussiau.
Ciiii Sparis Med lflllfifliljflfiS-Ha, 1:. Medline DD]
This review article highlights the lack af data an yanth
athletes and span-related cancussians. Given the differ-
ences and variatians af cancussians between adults and
adalescents, yanth athletes need ta be included as their
awn subgraup and require their awn set af management
strategies.
34. Dias AL, Wycltaff L]: NASH pasitian statement: Can-
cussians—the rule cf the schael nurse. NASH Sci: Nurse
1013;1fliljfllfi-IILMadline DUI
ID 2316 American Academy af Drehapaedic Surgeans
35. Raguslci M, Marel l3, Sweeney M, et al: Magnetic resa-
nance imaging as an alternative ta camputed tamagraphy
in select patients with traumatic brain injury: A retraspec-
tive camparisan. I Mattress-erg Pediair 2fl15;15[5}:523-S34.
Medline DUI
In this retraspective review af ST4 pediatric patients ad-
mitted ta an emergency department far head trauma and
wba subsequently underwent betb MRI and CT examina-
tians, anly 3U patients had pastivie findings. In the subset
af patients with pasitive findings, the authars shawed that
there was na significant difference between MRI and CT
in detecting intracranial injury.
36. Difiari JP, Giza CC: New techniques in cancussiau imag-
ing. Curr Sparts Med Rep lfllflgfiiljfiS -3S'. Medline DUI
1'Ii'isualiaing and quantifying cancussiau injuries cantinues
ta be challenging given the lack af infarmatian pravided
by standard neuraimaging. This review discusses the re-
cent advancements that have been made ta help pravide
clinicians with abjective data abtained fram innavative
neuraimaging techniques.
3?. I[Suban VA, Putultian M, Bayer {3, Dettwiler A: A diffu-
sian tensar imaging study an the white matter skeletan in
individuals with spans-related cancussianJNenratranma
2011;13[2}:139-1fl1. Mcdline DUI
Structural injuries fallawing a cancussiau are nat cam-
manly visualised an MRI and CT but may be detected
using diffusian tensar imaging IIDTI}. The autbars repart
the findings af using DTI an patients with cancussians,
maderate ta severe traumatic brain injury, and severe trau-
matic brain injury campared with age-matched cantrals. F“?
They suggest DTI may be sensitive enaugh ta detect mild
and severe injury ta white matter fiber tracks. m
E?I:
33. Maser RS, llifilatts C, Schatc P: Efficacy af immediate :I
a:
and delayed cagnitive and physical rest far treatment af 1"
spurts-related cancussiau. j Pediatr lflllfl aliSl:922-926.
Fl
E
n:
Medline DUI m
F.
This small retraspective study cf 45' high schaal and cal-
legiate athletes wha suffered a cancussiau demanstrated
a week af cagnitive and physical rest was beneficial in
reducing symptams regardless [if when the rest p-eriad
was implemented.
39. Majerske CW, Mibalilc JP, Ren D, et al: Cancussian in
sparts: Pastcaucussive activity levels, symptams, and neu-
racagnitive perfarmance. I Atiii Train lflflfl:43{3}:265-
2?4. Medline DD]
4D. Brawn H], Mannie; RC, Dilirien M], Gastine D, Callins
MW, Meehan WP III: Effect af cagnitive activity lev-
el an duratian af past—cancussiau symptams. Pediatrics
2fl14;133[21:e299-e3i}4. Medline DD]
The results af a praspective study an 335 adalescent and
yaung athletes being treated far a span-related cancus-
sian demanstrated these individuals wha did nat restrict
their cagnitive activities during the recavery phase ai their
cancussiau had a langer time until symptam resalutian
and clearance baclc ta spurt than individuals wha limited
their cagnitive invalvements. The anthers nate the results
Drtbapaedic Knawledge Update: Sparts Medicine 3
 Section E: The Young Athlete
of this study support the recommendation of cognitive
rest and highlight their results that complete abstinence
from cognitive activities was not associated with quicker
recovery times.
41. Halstead ME, Mcflvoy K, Devore CD, Carl R, Lee M,
Logan FE; Gonnci] on Sports Medicine and Fitness: Gouncil
on School Health: Returning to [es rning following a con-
cussion. Pediatrics 1013;132{5}:943-95 7". Medline DUI
42. Powers KC, Kaltnar JM, Cinelli ME: Recovery of
Static stability following a concussion. Gait Posture
2fl14;39{11:611-614. Medline I101
The authors set out to investigate center of pressure char—
acteristics during static stance in nine collegiate football
players cleared to return to play following concussion
and nine age- and position-matched healthy control
teammates. The football players who had clinically re-
covered from their concussion demonstrated persistent
anterior-posterior balance control deficits and may reflect
lingering vestibular impairments that are difficult tn detect
with current clinical assessments.
43. Howell DR, |Eistemig LR, Chou L5: Return tn activity
after concussion affects dual-task gait balance control
recovery. Med Sci Sports Esters 1015:4?{4}:6?3-ESO.
Medline BID]
The authors set out to investigate the center of mass char-
acteristics during a dual-task gait analysis in 19 adolescent
athletes with concussions and 19 uninjured matched con-
trols. At the time of clinical recovery and return to sport,
E the adolescents with concussion continued to demonstrate
E increased displacement and velocity during a dual-task gait
:5 compared with the healthy controls. The authors suggest
:1:
Ch
E
recovery of gait balance control may not coincide with
E symptom resolution and return of normal neurocognition.
3...
I1:
.I:
|_- Lan BC, Collins MW, Lovell MR: Cutoff scores in neu-
dd rocognitive testing and symptom clusters that predict
protracted recovery from concussions in high school ath-
Ietes. Neurosurgery 2fl12;?fl[2}:3?l-3?9, discussion 3-H.
Medline DUI
ImPACT scores of 103 male high school football athletes
were analysed to determine if certain symptom clusters
could identify athletes who demonstrated a protracted
recovery following their concussion. The results of this
study reveal certain symptom clusters may have prognostic
value in identifying resolution of symptoms and return of
working neurocognitive function following a concussion.
45. Meehan WP III, d’Hemecourt P, Comstock RD: High
school concussions in the soos-ssoe academic year:
Mechanism, symptoms, and management. Am J Sports
Med lfllfl;33{11}:24fl5-14fl9. Medline DUI
This descriptive epidemiologic study of S44 concussions
collected during a single academic year demonstrated high
school athletes were less likely to return to sport within 1
week of their injury when computerized neuropsychologi-
cal testing was implemented into the clinical management.
® firthnpaedic Knowledge Update: Sports Medichie 5
46. Inckerman 5L, Lee TM, IZldom MJ, Solomon (35, Forbes
JR, Sills AR: Recovery from sports-related concussion:
Days to return to neurocognitive baseline in adoles-
cents versus young adults. San-g Neurof int lflllgfiflflfl‘.
Medline Dfll
In this retrospective, observational study of lfli} high
school and lflfl collegiate athletes, neurocognitive recov-
ery was delayed in younger athletes compared with older
athletes. Postinjury ImPAET scores for verbal memory,
visual memory, reaction time, and symptoms for younger
athletes took longer to return back to baseline ImPRCT
scores than older athletes following a concussion injury.
4?. Eisenberg MA, Andrea J, Meehan W, Mannix R: Time
interval between concussions and symptom duration. Pe-
disrrirs 2D13:132[1l:3-1?. Medline [101
In this prospective cohort study of 2312} adolescents recov-
ering from a recent concussion, individuals with a previous
concussion were symptomatic for a longer period of time
than individuals experiencing their first concussion. The
authors of this study suggest proceeding with caution
when discussing return-to-play decisions given the risk of
prolonged symptoms during repeat injuries.
43. Castile L, Eollins CL, I'vIcIlvain HM, Comstock RD: The
epidemiology of new versus recurrent sports concussions
among high school athletes, 20 [1'5 -2[l1il. Br] Sports Med
1D11;4E{3J:603-61i}.Medline DUI
This study compared the epidemiology of first-time ver—
sus recurrent concussions in athletes at 100 high schools
nationally over a 5-year period. Data were collected on
2,41? concussions, of which 291 were repeat injuries. The
results suggest high school athletes who suffer multiple
concussions demonstrated a longer time until symptom
resolution and were withheld from sport participation
for a longer duration. A significant number of athletes
suffered a repeat concussion when returned to sport within
3 weeks of their original injury.
45'. Meehan WP III: Medical therapies for concussion. Cite
Sports Med Zfill;3fl{1}:115-124, ix. Medline DDI
This study reviewed the efficacy of pharmacological treat-
ment of a sport-related concussion. To date, medications
have not been shown to increase healing from a concussion
injury. Rather, certain medications may have usefulness in
aiding patients with chronic headaches, sleep disturbances,
and emotional changes as they recover from concussion.
SD. Baker JG, Freitas MS, Leddy JJ, Kozlowski RF, Willer ES:
Return to full functioning after graded exercise assessment
and progressive exercise treatment of postconc ussion syn-
drome. Rehohif Res Proet lflllfifll 2905309. Medline
The results of this small pilot study suggest individuals
with postconcussion syndrome may be experiencing
chronic symptoms that are not the result of ongoing physi-
ologic dysfunctions that occur during the initial onset of a
concussion. The authors suggest that postconcussion syn—
drome should be considered as a constellation of disorders.
fl lfllfi American Academy of Orthopaedic Surgeons
 Chapter 511]: Special Considerafiuns in Head Injtn'ies in Adulescent Athletes
51. Leddy JJ, lEnx JL, Baker JG, et al: Exercise treatment
fnr pnstcnncussinn syndrnme: A pilnt study nf changes
in functinnal magnetic resnnance imaging activatinn,
physinlngy, and symptnms. J Head Treasure.r Hebebif
2013;23{4}I:241-149.Medline n01
Clinicians have fnund pnstenncussinn syndrnme challeng—
ing tn treat, given the cnmplexity and lack nf a specific
erinlngy arnund the chrnnicity nf symptnms. The authnrs
nf this pilnt study snught tn understand hnw an aernbic
exercise treatment may influence brain activatinn patterns,
measured by functinnal MRI, in patients with pnst-cnn-
cussiun syndrnme. Five females with pnstcnncussinn syn-
drnme demenstrated functinnal Mfll aetivatinn patterns
similar tn age- and sex-matched cnntrnls during a math
task after cnmpleting twn sessinns [if the Belize treadmill
prntncnl. The results suggest a cnntrnlled prngressic-n nf
aernbic exercise may be beneficial at imprnving brain ac-
tivatinn in patients with pnstcnncussinn syndrnme.
52. Leddy J], Sandhu H, 5ndhi M, Baker JG, Willer B: Reha-
bilitatinn nf Cnncnssinn and Pnst-cnncussinn Syndrnme.
Spnrts Henitf: Eflll;4{2}l:14?—154.Medline net
This enmprehensive review an rehabilitatinn techniques
fnr cnncussinn symptnms and dysfunctinns identified there
apeutic benefits frnm certain types nf therapies, such as
cngnitive behaviural and aernbic exercise therapies, when
administered apprnpriately.
.53. Andersen J, Cnursnn KW, Kleiner DM, Mada TA:
Natinnal Athletic Trainers“ Assnciatinn Pnsitinn State-
ment: Emergency Planning in Athletics. I Add Thin
2Dfll;3?{1}:99-1fl4. Medline
54. Mnser R5, fichatz P, Neidtwski K, flirt 5D: Grnup versus
individual administratinn affects baseline neurncngnitive
test performance. Am J Spurts Med 2011;35{11}:2325-
233i]. Medline DID]
This study evaluated the differences in baseline neurn-
cngnitive testing in high schnnl athletes tested in a grnup
enmpared with an individual setting. Of the 331 athletes
whn cnmpleted baseline ImPACT testing, the 165 athletes
whn tested in a grnup setting demnnstrated significantly
lnwer scnres in all fnur cnmpnsites. The authnrs stressed
the impnrtance nf ensuring athletes cnmplete baseline test-
ing in prnperly supervised and quiet testing envirnnments.
55. 1'ii'aughan CG, Gerst EH, Sady MD, Newman JB, |Einia
GA: The relatinn between testing envirnnment and base-
line perfnrmance in child and adnlescent cnncussinn
assessment. Am I Spnrts Med lflld;42[?l:l?16-1?23.
Medline DDI
When prnperly trained test administratnrs fnllnw a stan-
dardized prntn-cnl and adequately supervise the testing
envirnnment, high schnnl athletes can effectively cnmplete
baseline neu rncngnitive testing in a grnup serting. The re-
sults nf this study demnnstrated nn significant differences
between ImPACT scnres fnr 313 athletes tested individu-
ally and 626 athletes tested in grnups nf 15.
56. Elbin R], Knntns AP, Hegel bl, Jnhnsnn E, Eurlthart 5,
Schatr. P: Individual and cnmbined effects nf LD and
ADHD nn cnmputerized nEurncngnitive cnncussinn test
IE! Eilli‘i American Academy nf flrthnpaedic Surgenns
perfnrmance: Evidence fnr separate nnrms. r'lircfiI Cfin
Nenrnpsycbni2013;13i5}:4?6-434. Mndline nix
Given the unknnwn pntential influence learning disabil-
ities and attentinn deficit disnrders may have em baseline
cnmpnterised neurncngnitive testing, the authnrs nf this
study cnmpared baseline scnres between athletes with and
withnut self-repnrted learning disabilities and attentinn
deficit disnrders. Athletes whn self-reperted either diagnn-
sis er a cnmbinatinn nf each demnnstrated lnwer cnmpnsite
scnres and repnrted a higher number nf symptnms.
5?. Jetwani V, Harmnn KG: Pnstenneussinn syndrnme
in athletes. Curr Spurrs Med Rep lfl]fl;9{1}:21-26.
Medline DUI
.58. Enden HP, Tacchetti RL, lCantu RC, Knnwles SE, Mueller
FD: lCatastrnphic head injuries in high schnnl and cnllege
fnntball players. Am J Speris Med lflflfidflflflflfi—lflfl 1.
Medline DID]
55. McCrnry P, Eerlrnvic 5: Secnnd impact syndrnme. Nee-
rnfngy 1993;5fli3}:6??—EB3. DUI
60'. Themas M, Haas T5, Dnerer JL et al: Epideminlngy nf
sudden death in ynung, cnmpetitive athletes due tn blunt
trauma. Pediatrics 1fl11;123{1}:e1-e3. Medline DUI
The authnrs analysed retrnspectively cnllected data ever
a fill-year perind with the aim nf determining the epide-
minlngy and frequency nf sudden death in athletes age
21 years and ynunger. Blunt trauma resulted in an aver-
age nf nine deaths per year, which the authnrs unted was
significantly less than cardinvascularrrelated deaths. The F“?
head and neck were the must cnmmnnly invnlvecl areas,
with fnntball cnntribnting the largest number nf deaths. m
3‘I:
El. McIntnsh A5, Andersen TE, Eahr R, et al: Spurts helmets :I
new and in the future. Br J Spnrts Med 1fl11;45{1ii}:12.'i3-
u:
1"
12-55. Mndline DUI Fl
E
as
The authnrs present a systematic review cf the current m
F.
literature nn helmet design, helmet standards, and the
cnnstraints arnund creating a helmet tn prevent cnncus-
sinns, and identified knnwledge deficits in several areas
and thus stressed the need fnr further research.
62.. Bensnn ET, McIntnsh A5, Maddncks D, Herring SA,
Raftery M, Dvnrdl-r J: What are the must effective risk-re-
ductinn strategies in spnrt cnncussinn? Br J Spnrts Med
1013;4?{5}:321—326. Medline net
This enmprehensive review presents evidence that demen-
strates prntective equipment and neck strengthening have
nut been pruven tn reduce the chance nf cnncussinn. The
authnrs stress the need fnr well-designed, spnrt—specific,
prnspective studies nn this tnpic.
63. Ernelts A, Lnud K], Brenner JS, et al; Cnuncil nn
Sports Medicine and Fimess: Reducing injury rislt frnm
bndy checking in bnys' ynuth ice hucltey. Pediatrics
2014;133{6J:1151-1151Medline Dfll
Drthnpaedic Knnwledge Update: Spnrts Medicine 5
 Section E: The Young Athlete
E4. Adler RH. Herring 5a: Changing the culture of concus-
sion: Education meets legislation. PM E lfllledllfl. Sup-
pl lifid-fifi-fi-Wl]. Medline DDI
65. Tomei KL. Doe C, Prestigiacomo C], Gandhi CI): Com-
parative analysis of state-level concussion legislation and
review of current practices in concussion. Neurosarg Fo-
cus 2012:33lfi}:E11. 1-9. Medline DUI
This study was a comparative analysis of 43 states with
existing concussion legislation. Legislation was direct-
ed specifically toward youth and school-aged athletes,
excluding athletes participating at the collegiate level.
The targeted population, education and training of indi-
viduals. and criteria for removal and return to play vary
significantly from state to state. Interestingly, no state
required the athlete to complete formal education. Rather.
responsibilities for athlete safety were placed on coaches,
parents, and appropriate health care providers.
6'5. Covassin T, Elbin R], Sarmiento K: Educating coach-
es about concussion in sports: evaluation of the CDC‘s
i“Heads Up: concussion in youth sports“ initiative. ] Sal's
Health 2012;32{SJ:133-233. Medline DUI
As increasingly more states are enacting legislation to pro-
tect youth athletes from the consequences of concussion
management. an increasing amount of responsibility is
being placed on youth spurt coaches. many of whom are
volunteers. The results of this survey of 335 youth sport
coaches support access to the Centers for Disease Con—
trol and Prevention's “Heads Up" tool kit for improved
concussion awareness and education as well as response
to concussions when they occur on the field.
E school athletes.I athletes with a promoting attitude toward
E
.‘E
:1: 6?. Eagley AF, Daneshvar DH, Schanker ED, et al: Effec-
Ch
E
tiveness of the SLICE Program for Youth Concussion
E Education. Ch'a ] Sport Med 2fl12:22{5]:335-339.
3... Mediine DUI
I1:
.I:
'— The SLICE program curriculum was shown to successfully
citi improve concussion recognition and athletes' response in
the event of a concussion injury during play when admin-
istered to elementary middle and high school students.
Females and athletes older than 13 years demonstrated
the greatest improvements between prepresentation and
postpresentation assessments.
EB. Mannings C. Ealynych C, Joseph MM. fimotherman C,
Kraemer DF: Knowledge assessment of sports-related cou-
cussion among parents of children aged 5 years to 15 years
enrolled in recreational tackle football. I Traama dense
Care Sarg QUEENS, suppl 11513-512. Medline DUI
This study evaluated the results of a survey on concussion
knowledge completed by parents with children playing
youth tackle football. There were no parents who were
able to correctly identify all signs and symptoms asso-
ciated with a concussion, despite half of the parents re-
porting they had received some form of formal education
on concussions.
65. Kerr ET, Register-Mihalik JK, Marshall 5W, Evenson KIL,
Iihalik JP. Cuskiendce KM: Disclosure and non-disclo-
sure of concussion and concussion symptoms in athletes:
Crthopaedic Knowledge Update: Sports Medicine 5
Review and application of the socio-ecological framework.
Brain Injlfll4:23f3]:1i}DQ-1fl21. Medliue DUI
The results of this literature review focused on the socio-
ecological framework for disclosing concussion. Although
the majority of research has been on the intrapersonal
and interpersonal factors. gaps in the literature exist on
the influence of policy levels on disclosure of concussion
symptoms.
TEL Register-MihalikJK, Guskiewics KM, McLeod TC, Lin-
nan LA, Mueller FCI, Marshall 5W: Knowledge. attitude,
and concussion-reporting behaviors among high school
athletes: .fi. preliminary study. ] Athf Train 2fl13;43{5 yeas-
653. Medline DUI
a survey of 16? high school athletes demonstrated that
increased concussion knowledge was associated with in-
creased reporting of symptoms to the school's medical staff
or parents. However, the authors reported that 40% of
concussions and 13% of bell-ringers are still unreported
as a result of the athlete undervaluing the severity of the
injury.
7'1. Register-Mihalik jK, Linnan LA, Marshall 5W, Valovich
McLeod TC, Mueller FD, Guskiewics KM: Using theory
to understand high school aged athletes’ intentions to
report sport-related concussion: Implications for concus-
sion education initiatives. Brain Inf lfll3;2?[?—3]:3T3-flflfi.
Medline [II-DI
The authors of this study sought to understand the chal-
lenges facing athletes when deciding whether or not to
disclose concussion symptoms. In a sample of 1d? high
concussion reporting as well as the positive influences from
coaches and teammates were identified as key factors for
concussion reporting. This highlights the need to not only
educate athletes about concussions, but suggests the need
for a sporting environment that promotes and rewards
I'EPDI'IIE'I'S.
3’2. Conrnoyer J, Tripp BL: Concussion knowledge in high
school football players. I Arhf Train 1fl14;49{5}:fi.54 «5.53.
Medline MI
The authors of this cross-sectional study administered a
survey to 334 varsity football athletes to determine the
level of understanding high schoolers in Florida had on
concussions following newly enacted concussion-edu—
cation legislation. The results of this study suggest that
concussion education on symptom identification and
ultimately consequences of mismanagement should not
be placed on the parents alone because 25% of athletes
reported never discussing concussions with their parents
and ED ‘i’n correctly identified brain hemorrhage and death
as possible consequences.
T3. Bloodgood B, Inokuchi D, Shawver W, et al: Exploration
of awareness. knowledge, and perceptions of traumatic
brain injury among American youth athletes and their par-
ents. j’ Adolese Health 2013:53{1}:34-39. Medline DUI
Educational endeavors aimed at increasing concussion
knowledge and highlighting the importance of early iden-
tification of symptoms in high school and youth athletes
C lfllfi American Academy of Orthopaedic Surgeons
 Chapter 511]: Special Considerafiens in Head Iujtu'ies in Adelescent Athletes
as well as their parents are en the rise. The anthers ef
this study surveyed 251 yeung athletes and 300 parents
te identify current views and knewledge regarding cen-
cussien injuries. Certain subgreups, specifically parents ef
children age 10 re 13 years, athletes age 13 re 15 years, and
methers and parents whe use the Internet several times a
day, seem re have mere awareness and cencern regarding
cencussien injuries.
5'4. Chrisman 5P, |Quiriqnit C, Rivara FF: Qualitative study
ef barriers te cencussive symptem reperting in high
scheel athletics. I Adeiesc Health 2fl13;52{3}:33fl-335.
e3. Medline DD]
Educatienal endeavers aimed at increasing cencussien
knewledge and highlighting the imperrance ef early iden-
tificatien ef symptems in high scheel athletes are en the
rise. The anthers ef this qualitative fecused grenp study
ef .511} high scheel athletes determined that althengh these
athletes had apprepriate knewledge regarding cencussien
injuries, withdrawal frem play er laclr. ef ceach appreach-
ability seemed te be barriers reward reperring sympterns.
T5. Sarmiente K, Mitchlce J. Klein C. Weng 5: Evaluatien
ef the Centers fer Disease Centrel and Prevenrien’s
cencussien initiative for high scheel ceaches: “Heads
IE! Eillfi American Academy ei' flrthepaedic Surgeens
Up: Cencussien in High Scheel Sperts”. ] Sci: Health
lfllflgflflfljrl 12-113. Mcdline DUI
High scheel ceaches whe cempleted the US Centers fer
Disease Centrel and Prevenrien's Heads Up teelltit be-
tween 2ilfl5 and 2006 were surveyed en their ltnewledge=I
attitudes, and behaviers reward cencussien injuries. High
scheel ceaches fen nd the teelkit te be cemprehensive and
useful, but neted their mest difficult barrier in dealing
with a cencussien injury was everly cemp-etitive athletes
and their parents whe viewed a cencussien as a weakness
and disputed the petential risks asseciated with centinued
play.
T6. Eeuida W, Marghli 5, Seuissi S, et al: Predictien value
ef the Canadian CT head rule and the New Clrleans cri-
teria fer pesitive head CT scan and acute neuresurgical
precede res in miner head trauma: A rnulticenter external
validatien study. Ann Emerg Med 2fl13;61[5}:511-51T.
Medline DUI
At the cenclusien ef this 3-year prespective study. the
results demenstrated that the Canadian CT Head Rule
had higher sensitivity and specificity ef predicting neu-
resurgical interventien than the New Clrleans Criteria
in patients with mild head injuries. The anthers suggest
the use ef such clinical decisien rules may help reduce the
frequency ef unnecessary CT.
F“?
re
3:I:
:r
a:
1"
Fl
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ta
re
P.
Drthepaedic Knewledge Update: Sperts Medichae 5
®
Chapter 51
Shoulder and Elbow Injuries in
the Skeletally Immature Athlete
Eric W. Edmonds. MD
The skeletally immature athlete is susceptible to a unique
set of injuries in the shoulder and elbow compared with
skeletally mature athletes; however, a few injuries are
shared that bridge the developmental distance, irre-
spective of physeal patency. The injuries that occur
in the skeletally immature shoulder and elbow can be
defined as overuse, fracture, or instability {with the clear
acknowledgment that these pathologies can overlap in
this young population, especially regarding etiology,
treatment, and outcomes}. Recent developments in
surgeons“ understanding of the assessment of these
injuries, treatment of these injuries, and even potential
} outcomes of injuries have been reported.
Keywords: childhood shoulder labrum and tendon
tears: capitellar 0CD; youth elbowr ulnar collateral
ligament Injury: imaging of child elbow; labral
tea rs: rotator cuff tea rs: osteoch ondritis disseca ns
Introduction
Defining skeletal immaturity is an important place to
begin the discussion of injuries in slceletally immature
athletes. The proximal humeral physis closes between age
14 and 1'? years in girls and between age It? and 13 years
in boys;1 the distal humeral physes and proximal forearm
physes have a wide range of variability that culminates in
Dr. Edmonds or an immediate family member is a mem—
ber of a speakers’ bureau or has made paid presentations
on behalf of Arthrex and firthopediatrics; has received
research or institutionalr support from inion; and serves as
a board member. owner, officer; or committee member
of the American Academy of Drthopaedic Surgeons. the
American Drthopaedic Society for Sports Medicine,- and the
Pediatric Orthopaedic Society of North America.
fl lflld American Academy of Drrbopaedic Surgeons
overall closure at approximately age 15 years.1 Therefore,
most of this chapter discusses children younger than 15
years.
When young athletes sustain an injury that is consid-
ered to be a result of overuse, they are most often engaged
in an activity involving overhead activity, including, but
not limited to, baseball, softball, volleyball, tennis, gym-
nastics, and water polo} However, the more traumatic
injuries that involve fractures and dislocations appear to
be associated with higher impact sports such as football,
wrestling, and batting in baseball. An additional concern
regarding the shoulder is a current trend that younger
children [mean age, 9 years} sustain proximal humerus
fractures, and teenagers {mean age, 15.5 years} sustain
dislocations and separationsr“
fiunoy, any :3
However, the spectrum of injury that can be seen with-
in this young cohort goes beyond simple fracture and
dislocation. In the shoulder, proximal humeral epiphys-
iolysis {Little Leaguer’s shoulder}, partial rotator cuff
tears, internal impingement pathology with labral tears,
ate|i
and complications associated with multidirectional insta-
bility can all be seen.1 Similarly, the elbow is susceptible
to medial epicondylitis ifLittle Leaguer’s elbow spectrum}
and valgus overload syndrome, ruptures of the anterior
bundle of the medial ulnar collateral ligament, capitellar
osteochondritis dissecans {DIED}, and Panner disease.1
With many of these periphyseal upper extremity inju-
ries, the skeletally immature athlete is at risk for growth
disruption and deformity if the pathology is not app—ro-
priately idEHtified and treatetlfI
Shoulder
Treatment of the shoulder requires an ability to assess
pathology within the joint itself. A study that evaluated
the intra-a rticular pathology seen arthroscopically in the
skeletally immature athlete found that 94% of children
treated using this approach had labral pathology pres-
ent.‘l Moreover, almost one—fourth {23%} of the labral
pathology involved the posterior labrum separately or in
Drthopaedic Knowledge Update: Sports Medicine 5
 Section E: The Young Athlete
conjunction with superior extension. In this same cohort,
23% had a partial rotator cuff tendon tear that predomi-
nantly involved the supraspinatus tendon. Although com—
plete rotator cuff tendon tears can occur in this age group,
none were seen within the study population.
Imaging of the shoulder in the skeletally immature
has not changed much in the past decade? Plain radio-
graphic films with contralateral images are recommended
for the assessment of proximal humerus epiphysiolysis
[also known as Little Leaguer’s shoulder], and MRI is
warranted to assess for injuries to the anterior and pos-
terior labrum. Additionally, the use of magnetic reso—
nance arthrography can help identify anterior labrum
periosteal sleeve avulsions and humeral avulsions of the
glenohumeral ligaments. Humeral avulsions of the glcno-
humeral ligaments can be missed during surgical assess-
ment; therefore, preoperative identification is important.
The evaluation of the shoulder via magnetic resonance
arthrography still has limitations. A study assessing the
ability to identify partial rotator cuff tendon tears in the
adolescent cohort demonstrated that the diagnostic ac-
curacy of magnetic resonance arthrography in this group
was ?2%.‘ A high false—negative rate suggested that the
study could be specific, but not sensitive, for diagnosis.
flveruse Injuries
E Most overuse injuries to the shoulder involve throwing
E or overhead activities, and most recent studies on this
:5
:1: subject involve baseball.” A lfllfl review highlighted
Ch
E some of the changes seen in overuse of the throwing arm
E
3... in the skeletally immature? With substantial time throw—
I1:
.I:
|_- ing, even in children as young as 3 years, an increase in
End external rotation and a decrease in internal rotation at
the shoulder can be clinically identified. Humeral remod-
eling can occur throughout development until the physis
closes. This remodeling can result in up to 15“ of humeral
retroversion at maturity compared with the contralateral
side, either by forcing rotation or reducing the amount
of normal rotational development. This change is consid-
ered by some studies to be beneficial to the mechanics of
throwing, but for this chapter, it highlights the torsional
force being applied to the proximal physis of the humerus.
This force could, at least in part, result in epiphysiolysis.
Epiphysiolysis tends to peak between age 13 and 16
years in boys,"' and the treatment is always nonsurgical.
Although described in boys, there is no reason the condi—
tion might not develop in girls, especially now that girls
are joining youth baseball leagues. These patients are pre—
vented from throwing for a period of 6 weeks to 3 months,
at which point a gradual throwing program is begun so
long as they remain symptom free. Most throwing pro—
grams start by increasing the distance thrown {long-toss
firthupaedic Knowledge Update: Sports Medicine 5
program}, followed by a short-toss program that increases
velocity. These programs are 90% successful in elimi-
nating symptoms indefinitely as long as rotator cuff and
periscapular muscle strengthening, capsular stretching
exercises, and good throwing mechanics are emphasized.T
Although it is important to recognize epiphysiolysis
and treat it appropriately to reduce the risk of physeal
closure, it is even more important to educate families
on how to avoid overusing the arm, thus preventing the
injury. A 10-year prospective study was performed to
help identify the risk factors associated with this injury.“
Pitchers between 9 and 14 years old were evaluated, and
the study found that pitching more than lflfl innings
within 1 calendar year was associated with a 15—fold
higher risk of injuring the arm. Although a trend toward
increased rates of injury in those who played both pitcher
and catcher positions was noted, this was not significant,
nor was the risk factor of throwing curveballs for those
younger than 13 years. The best educational approach
was to limit the number of innings pitched in 1 year and
to encourage play at positions other than pitcher and
catcher to reduce the risk of injury.
Fractures
Injuries to the osseous structures of the shoulder consist
predominantly of proximal humerus fractures, clavicle
fractures, and injuries associated with a Bankart lesion.
Treatment of clavicle fractures in the skeletally immature
patient is quite controversial and only one comparative
study published in lull} reported better radiographic
results in the surgical cohort than in the nonsurgical co—
hort.” Two studies attempted to evaluate the potentially
detrimental effects of leaving a displaced clavicle frac-
ture unreduced. Due study identified teenagers with a
malnnited clavicle fracture and tested them on a work
simulator machine, using the uninjured shoulder as an
internal control.1|fll At a mean follow—up of 2. years, no
differences were found in shoulder range of motion, but
slight decreases were noted in maximal shoulder external
rotation strength (3%; P = [LG-1) and abduction endurance
strength [11%; P = fl_fl4}_ However, all children returned
to at least their preinjury level of sports participation. In
a similar study performed on a slightly younger cohort
using a different work simulator, no substantial differ-
ence was detected in abduction or adduction torque or in
the power between affected and unaffected shoulders.11
In addition, minimal effects were seen via the outcome
questionnaire and only one child required corrective oste-
otomy. Further investigation will be required to determine
whether or not the skeletally immature athlete with a
displaced clavicle fracture will have any complications
with or without surgical management.
fl lfllui American Academy of Orthopaedic Surgeons
 Chapter 51: fihoulder and Elbow Injuries in [IIIE Skeletally Inunanlre Addete
In contrast to the clavicle, substantially more informa-
tion exists regarding the treatment of proximal humerus
fractures and their ability to remodel over time. A recent
study compared the outcomes of displaced proximal hu-
merus fractures {Heer grade III or IV} treated with and
without surgery.” This study found no difference in the
occurrence of complications, rate of return to activity,
or cosmetic satisfaction in a matched cohort of skeletally
immature patients [Figure 1}. However, a trend was noted
for seeing less than desirable outcomes in the nonsurgical
patients older than 12 years: for every 1-year increase in
age at the time of fracture, the likelihood increased by a
factor of 3.3 to have a less than desirable outcome.
The treatment has been updated for the adolescent
apophysis avulsion injury of the lesser tuberosity, which
is uncommon. Patients treated with either suture anchors
or transosseous sutures can achieve pain relief and expect
full return of intemal rotation strength, with a return to
sports activity at a mean of 4.4 months postoperatively,
although return of external rotation strength can be de-
layed until 6 months postoperatively.”
Instability
Many adolescent athletes at the cusp of skeletal maturity
will preferentially dislocate their shoulder rather than
sustain a fracture. A clear trend is noted in the North
American literature to treat patients of all ages with ar-
throscopic stabilization rather than with open surgical
intervention.“ A recent multicenter study evaluated the
potential complications associated with shoulder arthros-
copy in children.” Minor complications reported in this
population were consistent with readmission for pain
control, broken pain pump catheter, injury to the cephalic
vein, allergic reactions to skin prep, transient dysesthesias,
headaches, bronchitis, syncope, transient hypotension,
and uvula swelling. An additional procedure, outside of
the planned protocol, was performed in 2.5 '34:: of patients
for these minor complications.
Regarding the actual treatment of adolescent traumatic
anterior instability of the shoulder, a recent level III study
compared open and arthroscopic treatment in this age
group.” In 99 subjects {approximately two thirds were
treated arthroscopically], no substantial difference was
found between the two cohorts, and a 21% redislocation
rate was noted in this population. Irrespective of surgical
technique, a survival curve demonstrated that the repairs
have a 2-year survival rate of 86% and a 5-year survival
rate of only 49%. This young population, in contrast
to the historic results seen in the adult population, does
not seem to have successful outcomes regarding shoulder
instability. The reasons for this increased recurrent insta—
bility rate have not been proved, but it is possible that the
El rots American Academy of flrthopaedic Surgeons
Figure 1 AP radiographs of a displaced proximal
humerus fracture sustained after a fall in an
11-year-old boy. A. 1|v'ievv obtained after fall.
a. View obtained after 5 weeks of nonsurgical
treatment demonstrates ahunda nt callous and
remodeling. {Copyright San Diego Pediatric
Drthopedics, San Diego. CA.)
young age of the cohort has a tendency toward augmented
levels of physical activity {both a greater rate of activity
and an increased level of risk behavior].
Even the presence of benign hypermobility can be the
source of pathology and injury in the young shoulderJ-Ji F“?
In addition to lahral tears, adolescent shoulders appear
re
to be susceptible to partial rotator cuff tendon tears, in a
ElI:i
mechanism consistent with internal impingement. A 2013 :r
a:
study demonstrated evidence of 53 teenagers {15 girls, 1"
33 boys} with partial rotator cuff tears sustained from
Fl
E
at
overhead sports, including a large cohort of female water m
F.
polo players. Honsurgical management failed in almost
60% of tears; but, during surgery, ?D% of those tears in
which initial physical therapy treatment failed were found
to have associated pathology, including labral tears.”
As with the shoulder, the evaluation of injury in the skel-
etally immature elbow has been updated several times
during the past 5 years. The best approach to analyz-
ing the immature elbow in these athletes is to perform a
segmental analysis of the lateral, medial, and posterior
structures.” This allows assessment of the variety of po-
tentially injured structures (hone, ligaments, cartilage,
physes, and apophyses} in a systematic manner with less
risk of missing a potential site of pathology. The inju-
ries most pertinent to the orthopaedic surgeon includes
0CD, Little Leaguer‘s elbow {medial epicondylitis}, me-
dial epicondyle fractures, and ulnar collateral ligament
Drthopaedic Knowledge Update: Sports lvledichte 5
 Section E: The Young Athlete
injuries.” Many of these injuries can be included under
the umbrella of valgus overload: tension is placed on the
medial {and potentially, posterior] structures and com—
pression is placed on the lateral {and potentially, posterior)
structures.
A 2131!} study on assessing changes in the elbows of chil—
dren with a known throwing history and who were expe-
riencing medial-side pain demonstrated a difference in the
ability of plain radiography and MRI to help identify the
source of pain?” Although a few children demonstrated
slight hypertrophy [widening] of the medial epicondyle
apophysis and fragmentation, most MRIs demonstrated
those same changes as well as edema within the flexor-
prontator muscle mass tendon, strain to the ulnar collat—
eral ligament, and edema within the apophysis without
widening. However, even with these additional findings
noted on MRI, the clinical management was not altered.
Overuse Injuries
Although the medial structures get the most attention
regarding overuse, recent publications have focused on
the lateral side of the elbow and the treatment of capitellar
DCDFI'E“ Currently, a wide array of techniques seem to be
available for the treatment of symptomatic elbow DCD.
In 201 H, two studies were published regarding the best
treatment of the skeletally immature patient. Cine study
E indicated that arthroscopic débridement alone had good
E midterm outcomes (mean, 3.6 years} regarding symptoms
:5
:1: of pain and function.“ This assessment was based on the
Ch
E ability to return to sport and the mean Disabilities of the
E
3... Arm, Shoulder and Hand score {3.5 of lflfl], irrespective
I1:
.I:
'— of the lesion grade. However, the other study suggested
Ed that the removal of loose bodies alone was insufficient and
that establishing a good lateral shoulder to the capitellum
was more important."fl An osteochondral autograft from
the rib was used to reconstruct this aspect of the capi-
tellum when required. Substantially improved outcomes
were reported using a modified elbow rating system, but
some children did not return to sport and the overall
cohort had a reduced arc of motion.
|Either articles have been published examining different
surgical treatments in this skeletally immature cohort.
In lflll, an algorithmic treatment for DUI) lesions was
implemented that included retroarticular [transhumeraljl
drilling, fragment fixation, and débridement with good,
but not excellent, results.” In this small series, 20% of
elbows required a second surgery to manage symptom-
atic 0CD. In contrast to the lfllfl study on rib autograft
utilisation,11 the EH12 series” reported an improvement
in the postoperative elbow arc of motion, predominately
with extension. In 2fl13, the results of a slightly larger
series“ agreed with earlier publications that lateral-edge
firthnpaedic Knowledge Update: Sports Medicine 5
GED had worse outcomes, but also agreed with the more
recent EDIE publication that not every child does well
after 0CD treatment. This latest study used drilling to
stimulate healing in patients in the stable {3CD group
and incorporated an osteochondral autograft (essentially,
a mosaicplasty] to secure the unstable lesions. The arc
of motion was improved postoperatively, but only SD‘hE-
of children returned to sports at '1 year and 50% of the
lateral-edge OED cases required reoperatiou. The definite
treatment of capitellar UCD in the skeletally immature is
still undetermined, but these recent publications indicate
a need to identify the appropriate treatment of the specific
DIED [location and stability occupy divergent paths in
an algorithm}.
Fractures
The treatment of fractures of the humeral medial epicon-
dyle has been debated since the 19?fls, but some import-
ant developments have occurred within the past 5 years.
In 201B, two papers highlighted a problem in performing
accurate radiographic assessment of this fracture. The
first study reported poor interobserver and intraobserv-
er reliability in assessing fracture displacement.25 With
disagreement defined as a measurement difference of 2
mm or more, the study disagreed with 26% of its own
measurements, with 54% of its AP radiographic measure-
ments, with 3?% of its lateral radiographic measurements,
and with 64% of its oblique radiographic measurements.
Some recommendations were provided regarding the best
methodologl' to keep measurements consistent, but the
amount of perceived displacement should not be a crite‘
rion for choosing treatment of these fractures. The other
study suggested that although all literature on medial
epicondyle fractures uses AP radiographs, new evidence
using three-dimensional CT displaces this modality as
the primary methodology for measuring displacement.“
1When measuring displacement on plain radiography and
CT, significantly different findings were reported {Ta-
ble 1}, and AP and lateral radiographs were not sufficient
or accurate enough to measure medial epicondyle fracture
displacement. Therefore, these two papers potentially
negate any results or conclusions from outcome papers
published before Zfllfl.
In response, a study published in EMS evaluated the ca-
pability of the internal oblique radiographs to accurately
help define the displacement of humeral medial epicondyle
fractures. Dbservers were fifl‘b’u accurate in predicting
the true displacement on internal oblique films {when
position was controlled at 45“ and trigonometry was ap-
plied to the measured displacementlfii’ This methodology
is time—consuming and still not accurate, implying that
better methods for defining displacement are still needed
fl lfllfi American Academy of Orthopaedic Surgeons
 |Dhauter 51: Shoulder and Elbuw Injuries in the Skeletally bnmatu're Athlete

far this fracture type. A recent cadaver study suggests
that the use cf a new axial image can preside imprnved
understanding cf the true displacement“1 {Figure 2].
Despite nut having a validated, accurate, and law-radi-
aticn methcdclcgy for determining fracture displacement,
same data are available regarding the eutcnmes cf treat-
ment. Keeping in mind that the results cf past studies
using AP radingraphs tn define criteria fer treatment
should be questicined, the eutccimes frcim the treatment
cf children with minimally displaced fractures, but act
asseciated with a dislucaticin event, can puteutiallv be

_
Measurements cf Minimally Displaced
used. In a 2013 study comparing surgical and nensur-
gical treatment with a minimum 2-year fcllnw-up, as
differences were demunstrated in Disabilities cf the Arm,
Medial Epicnndyle Fractures Shnulder and Hand scares between the treatment cc:-
hurts}9 This study identified that nne half cf each cab-art
Plane of P required physical therapyr and that cine half cif surgical
Dlsplacement Hadlegraph 3D ET Value cases repnrted same transient numbness. Tn date, this
Cerenal {AP} 3.5 mm 3.3 mm «c 3.331 is the cnly cumparative studyr with cutcclmes between
Sagittal {lateral} 3.3 mm 3.3 mm c 3.331 treatment greups in the skeletallv immature patient with
Internal nblique 3.3 mm 3.3 mm 0.03? a medial epiccndyle fracture.
Substantial differences can be seen In measurements between
perceived displacement cm AP redid-graphs and actual measurements Instability
an three-dimensicnal [33-] CT scans cf minimally displaced medial Pntentially related tn everuse injuries, elbnw instabili-
eplcundyle fractures.
ty in the skeletally immature grnup is mere cummenly

F“?
m
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1"
Fl

E
as
m
F.

AF“ Internal Dbliq ue Lateral Distal Humarus Axial

Hadicg raphs and ph ntugraphs cbtained frum cadavers dem unstrate the elbdw views mare cum manly ubtained fer
medial epicendyle fracture assessment. Hate the inability tci accurately assess displacement that fellcws the muscle
vectcr pull. [Capyright San Diega Pediatric Drthnpedics, San Diegn, CA.)

ID 2316 American Academy bf flrthnpaedic Surgeens Drtbnpaedic Knnwledge Update: Spnrts Medicbse 5
 Section E: The Young Athlete

associated with a traumatic event. Injuries can occur

either mediallyall or laterally.31 A large study on the recon-
struction of medial ulnar collateral ligament tears (with
subcutaneous ulnar nerve transposition} reported that val-
gus stability could be restored and 33% of overhead ath-
letes returned to competition.” Perhaps more importantly,
at a minimum 2-year follow-up, complications were found
in lfl'iis of the cohort, 4% of which were major {ulnar
nerve injuries, medial epicoudyle fractures, and reoper-
ation for osteophyte formation}. Posterolateral rotatory
instability is much less com men. A series of nine children
reported that posterolateral rotatory instability was often
diagnosed in a delayed manner, and that any child with a
coutracture of nuclear etiology should be considered for
this pathology.“ Surgical correction is technically difficult Figure 3 Coronal T1 -weighted M RI demonstrates normal
attachment of the anterior bundle of the
[especially considering that often the surgery was initially medial ulnar collateral ligament {a rrows) on the
being performed for a coutracture release}, and ligament medial epicoudyle ossification. {Copyright San
reconstruction can risk injury to the lateral physes and Diego Pediatric Urthopedics, San Diego. {#1.}
apophyses. Therefore, preoperative identification of the
injury is paramount for safe treatment. Key Studyr Points
Two studies published in 1013 identified the normal
attachment of the anterior bundle of the medial ulnar I Using contralateral plain radiogra phs can help iden-
collateral ligament relative to the apophysis of the medial tify injuries to the physis or apophyses of either the
epicoudylefiflrl3 Both publications report that the liga- shoulder or elbow in the skeletally immature. MRI
ment inserts on the apophysis or epicoudyle itself, and can safely assess the injury if plain radiographs are
not on the condyle {Figure 3}. The importance of this not helpful.
E is not yet fully defined, but it could play a role in the I The treatment of capitellar DCD is evolving, but the
E decision-making process for treating displaced medial lateral shoulder {buttress} of the capitellum appears
:5
:1: epicoudyle fractures {especially if the epicoudyle fracture to be important to overall success in treatment.
Ch
E occurred secondary to an elbow dislocation event}. I The treatment of clavicle fractures and medial epi-
S
3...
I1:
coudyle fractures is still being evaluated and the
.I:
|_-
5 u mma ry definitive care in the skeletally immature is still
dd being debated.
The skeletally immature athlete is at risk for injury in
I Shoulder instability surgery in the adolescent cohort
the shoulder or elbow through overuse, fracture, or in-
may not result in the long-term success seen in the
stability. Most recent publications have highlighted the young adult population, perhaps because of the in-
understanding of radiographic assessment or lack thereof, creased activity level in this age group.
and have emphasised advancements in understanding
I Ulnar collateral ligament reconstruction has good
treatment of this young, extremely active group. Surgeons
outcomes for a large proportion of the young ath-
can translate adult pathology to the skeletally immature,
lete population, but families should be aware that
but they need to be cognizant of the physes and apoph-
approximately 20% may experience complications,
yses around the shoulder and elbow and how they play
require additional surgery, or not be able to return
a role in injury. MRI appears to be a good modality to
to a higher level of play.
help discover underlying injuries in this age group when
contralateral plain radiography is otherwise negative.

flrdsnpaedic Knowledge Update: Sports Medicb'ie 5 fl lflld American Academy of Orthopaedic Surgeons
 Chapter 51: Shoulder and Elbow Injuries in the Skeletally Immanire Athlete
Annotated References
. Chen F5, Diaa VA, Loeb-enberg M, Rosen JE: Shoulder
and elhow injuries in the skeletally immature athlete. I Am
Accd Urrhop Sarg lflflSflSiSiflfl-ISS. Medline
. Maylahn DJ, Fahey J]: Fractures of the elbow in children;
review of three hundred consecutive cases. I Am Med
Assoc ISSfltlfifiidltllfl-EES. Medline DUI
. Dashe J, Roocroft JH, Eastrom TP, Edmonds EW:
Spectrum of shoulder injuries in skeletally immature
patients. Urshop Elie: North Am 1013;44[4}:S41—551.
Medline DUI
This epidemiologic study of all children presenting to
a single institution describes the spectrum of shoulder
pathology seen, ranging from fractures to tumors. Level
of evidence: IV.
. Edmonds EW, Roocroft JI-I, Parilth SN: Spectrum of oper-
ative child hood intra-a rticular shoulder pathology. j Child
Drrhop lfll4;3{4}:33?—34i}. Medline DUI
This multicenter study evaluated the pathology spectrum
seen in skeletally immature patients treated with shoulder
arthroscopy. Level of evidence: IV.
. May MM, Bishop J'I': Shoulder injuries in young ath'
letes. Pedinrr Radio! 2013:43l5upp1 116135-5140.
Medline DUI
Increased levels of competition in younger athletes has
resulted in more shoulder injuries, and advances in cross—
sectional imaging is important in guiding treatment. Level
of evidence: IV.
. Edmonds E‘iV, Eisner EA, Ernie PG, Roocroft JH, Dwelt
JD: Diagnostic shortcomings of magnetic resonance
arthrography to evaluate partial rotator cuff tears in
adolescents. J Pediarr Urrhop 2015:35idir4UF-411.
Medline DUI
In this study, diagnostic accuracy of magnetic resonance
arthrography in adolescent partial rotator cuff injuries
was revs; therefore, clinical suspicion is an important
factor in determining management. Level of evidence: III.
. Lennard J, Hutchinson MR: Shoulder injuries in skeletal-
ly itnmature throwers: Review and current thoughts. Br
’1' Sports Med lfllfl:44[5}:306-31Il. Medline DUI
This review reported that although pediatric athletes sus-
tain soft-tissue injuries, growth plate injuries are much
more common. Therefore, injury prevention should targEt
proper throwing mechanics and reduced exposure. Level
of evidence: IV.
. Fleisig US, Andrews JR, Cutter GR, et al: Risk of seri-
ous injury for young hasehall pitchers: A III—year prov
spective study. Am ] Sports Med EfllltSflfliflSfi-ESF.
Medline DUI
In this study, risk of injury to young pitchers over 10 years
of activity was 5%. Reduction of innings pitched per year
IE! lfllii American Academy of firthopaeclic Surgeons
can be beneficial. Throwing curveballs does not appear to
directly affect risk of injury. Level of evidence: III.
Vander Have KL, Perdue AM, ISaird MS, Farley FA: Up-
erative versus nonoperative treatment of midshaft clavicle
fractures in adolescents. I Pediatt Urthop ED1D;3I]{4]I:30?—
312. Medline DUI
This retrospective review of adolescents treated surgically
{versus nonsurgically} reported that surgically treated clav-
icle fractures experienced significantly faster radiographic
union and that alignment and length were restored better,
placing patients in the nonsurgical cohort at risk for mal-
union. Leml of evidence: III.
If}. Schula J, Moor M, Roocroft J, Bastrom TP, Pen noclr AT:
Functional and radiographic outcomes of nonoperative
treatment of displaced adolescent clavicle fractures. I Home
joint Sorg Arr: 1013;95 (13}:1159-1 165. Medline DUI
In this study, no substantial deficiencies were found in
adolescent malunited clavicle fractures with intermedi-
ate follow-up, as measured using functional test results
and patient-derived outcome questionnaire. Level of
evidence: IV.
11. Bae D5, Shah AS, Kalish LA, Kwon JV, Waters PM: Shoul—
der motion, strength, and functional outcomes in children
with established malunion of the clavicle. 1 Pediatr Urthop
2013;33l5}:544-SSD.Medline DUI
Skeletally immature patients wild: malunited clavicle frac-
tures in this study did not have clinically meaningful loss
of shoulder motion or ahductionfadduction snength, and
indications for surgery need to be developed for this age F?
group. Level of evidence: IV.
m
E?I:
11. |Chaos GW, |Barry PM, Pishltenari AK, Hadley-Miller
::
N: versus nonoperative treatment of displaced proximal v:
humeral physeal fractures: A matched cohort. I Fediarr 1"
Fl
E
Urthop 2fl15;35{3l:234-239. MetlIine
n:
m
F.
This matched cohort study demonstrated no differences in
function, complications, return to full activity, or cosme-
sis of children treated either with or without surgery for
proximal humerus physeal fractures. However, a trend for
less-Idtao-desirable outcomes was noted in children older
than 12 years treated nonsurgically. Level of evidence: III.
13. Veaeridis PS, Eae DS, Kocher MS, Kramer DE, Yen TM,
1|Waters PM: Surgical treatment for av ulsion injuries of the
humeral lesser tuberosity apophysis in adolescents. I Home
joint Sorg Arr: 1fi11;93{101:ISSI—1333. Medline DUI
High—energy injuries sustained during sports can cause
avulsion fractures of the humeral lesser tuhetosity, and a
degree of clinical suspicion is necessary for diagnosis so
that surgical intervention can he performed in a timely
manner. Level of evidence: IV.
14-. Zhang AL, Montgomery SR, Ngo SS, Hame SL, 1|lillli'ang
JC, ISamradt SE: Arthroscopic versus open shoulder sta-
hilisation: Current practice patterns in the United States.
Arthroscopy lll14t3fll4jt43IS-443. Medlinc DUI
Urthopaedic Knowledge Update: Sports Medicine S
 Section E: The Young Athlete
Since EDGE, the incidence of shoulder stabilisation surgery
in the United States has doubled and almost 9'353 are
performed via arthroscopy. Level of evidence: IV.
15. Edmonds EW, Lewallen LW, Murphy M, Dahm D,
McIntosh AL: Peri-operative complications in pediatric
and adolescent shoulder arthroscopy. J Child Urthop
2U14;S{4}:341-344.Medline DUI
Using very strict criteria, this study reported a 2.5% rate
of major complications associated with shoulder arthros-
copy, must of which involved pain and complications with
anesthesia compared with direct surgical complications.
Level of evidence: IV.
Iii. Shymon S], Roocroft J, Edmonds ET: Traumatic anteri-
or instability of the pediatric shoulder: A comparison of
arthroscopic and open banltart repairs. 1 Pediatr Urtfzop
2fl15;35{1}:1-5.Medline DUI
In this comparison of arthroscopic and open treatment
of anterior traumatic shoulder instability, no substantial
differences in outcomes were seen. However, the rate of
redislocation was 21% in this adolescent cohort with a
5-year survival of only 49%, irrespective of technique.
Level of evidence: III.
1?. Eisner EH, Roocroft JH, Moor MA, Edmonds EW: Partial
rotator cuff tears in adolescents: Factors affecting out-
comes. I Pediatr Urthop 2013:33{1}:2-T. Medline DUI
This study reported that isolated partial articular-side ro-
tator cuff tendon injuries can be treated successfully with
physical therapy; however, in the presence of associated
E pathology, surgical intervention is often needed. Level of
E
:5 evidence: III.
fl:
Eh
E
IS. DweltJIt, Chung EB: A systematic method for evaluation
S
3... of pediatric sports injuries of the elbow. Pediatr Radiol
I1:
2fl13;43[Suppl 115120-5123. Medline DUI
.I:
'—
t'ti This study determined that the pediatric elbow is best
assessed by compartmentalising the radiographic evalu—
ation to the lateral. medial, and posterior compartments,
thereby separately considering all iniuries associated with
the common forces experienced at each location during
sports participation. Level of evidence: V.
19. clner B, May MM: Elbow iniuries in the young athlete—
an orthopedic perspective. Pediatr Radial 2013:43i5up-
pl I}:S129-5134. Medline DUI
In this report, valgus overload caused most elbow injuries
in the child athlete, with capitellar UCD, medial epicon—
dyle injuries and ulnar collateral ligament injuries become
more frequent. Level of evidence: IV.
2f]. 1|'lii'ei AS, Khana S, Limpisvasti U, Crues J, Podesta L,
Yocum LA: Clinical and magnetic resonance imaging
findings associated with Little League elbow. ] Pedietr
Urtfsop lfllfl;30{?}:?IS-?19. Medline DUI
This study reported that MRI demonstrates more pa-
thology than plain radiography in childhood baseball
players, but the findings do not appear to change clinical
management. Level of evidence: III.
Urthopaedic Knowledge Update: Sports Medicine 5
21. Schoch B, 1ifii'olf ER: Usteochondritis dissecans of the cap-
itellum: Minimum 1-year follow-up after arthroscopic
debridemeut. Arthroscopy lfllflfififllifld-SF-HTS.
Mfldlinc D'U'I
In this study, the treatment of capitellar {1CD in children
with isolated arthroscopic débridement resulted in im-
pmved outcome scores, but also a clear risk of reduced
activity level secondary to the elbow. Level of evidence: IV.
21. Mihara K, Suzuki K, lakiuchi D, Nishinalta N, Yama-
guchi It, Tsutsui H: Surgical treatment for osteochondritis
dissecans of the humeral capitellum. I Shoulder Elbow
Surg lfllfl;19{1}:31-3?. Medline DUI
The treatment of capitellar UCD in children with carti-
lage restoration, especially reconstruction of the lateral
margin, results in improved functional scores, but also
results in overall reduction in the postoperative total arc
of the elbow. Level of evidence: IV.
13. Tis JE, Edmonds EW, Eastrom T, Chambers HG: Short-
term results of arthroscopic treattnent of osteochondritis
dissecans in skeletally immature patients. 1 Pediatr Ur-
thop 2012:31l3lfllfi-231. Medline DUI
The treatment of capitellar UCD in children with ar-
throscopically assisted débridement and transhumeral
drilling of the lesion had good short—term outcomes for
resolution if the lesion was stable, but fixation and per-
sistent issues existed if the overlying cartilage was unsta-
ble. Level of evidence: IV.
24. Kosalta M, Hal-case J, Talcahashi R, et al: lUutcomes and
failure factors in surgical treatment for osteochondtitis dis-
secans of the capitellu m. 1 Pediatr Uri-“bop 3013:33{?}:?19-
?24. Medline DUI
The treatment of capitellar UCD in children with os-
teochondral peg fixation and osteochondral autograft
transplantation can improve outcome scores, but success
is inversely related to lesion size. Level of evidence: IV.
25. Pappas N, Lawrence JT, Donegan D, Ga nley T, Flynn JM:
Intraobserver and interobserver agreement in the measure-
ment of displaced humeral medial epicondyle fractures
in children. I Bone Joint Surg- Am 2010:92l2}:322-32?.
Medline DUI
Intra- and interobserver agreement is poor in measuring
humeral medial epicondyle fracture displacement on con-
ventional radiographs. Level of evidence: IV.
16. Edmonds EW: I-Iow displaced are “nondisplaced” fractures
of the medial humeral epicondyle in children? Results of a
three-dimensional computed tomography analysis. J Bone
joint Surg as: an1a;ss{1v}:sssscvs1. Medline not
Standard radiographs are not sufficient or accurate enough
to measure the medial displacement of medial humeral
epicondylar fractures because displacement occurs in the
anterior direction. Level of evidence: I.
1?. Gottschallt HP, Eastrom TP, Edmonds ET: Reliabili-
ty of internal oblique elbow radiographs for measuring
displacement of medial epicc-ndyle humerus fractures:
U lfllfi American Academy of Orthopaedic Surgeons
 Chapter 51: Shoulder and Eihnvv Injuries in the Skeletaily Iinmanire Athlete
A cadaveric study. ] Pediatr Urthnp 2fl13;33l1}:25-3I.
Medline DDI
Using a standard 43" internal ehlique radiegraph ef the
elhnw can help determine the displacement nf medial
humerus epicnndyle fractures when the measurement is
multiplied by 1.4, with gee-d cheerver reliability. Level nf
evidence: II.
23. Sender (ID, Fa rnswnrth EL, McNeil NP, Enmar JD, Ed-
mnnds 1333’: The Distal I-Iumetus Axial View: Assessment
cf Displacement in Medial Epicnndyle Fractures. ,l' Pediatr
Urthep 2015;35{EJ:449-454. Medline DUI
This cadaver study demnnstrated imprnved accuracy nf
measuring the displacement ef medial epicnndyle humerus
fractures using a newly described axial image ccrmpared
with the standard views {if the elhnw. Level nf evidence: [1.
29. Lawrence JT, Patel HM, Macknin J, et al: Return tn
cempetitive sperts after medial epicnndyle fractures in
adelescent athletes: Results ef eperative and nenepera-
tive treatment. An: I Sports Med 2fi13;41{5 }:1152-1151
Medliue DUI
This retrnspective cc-mparisnn r-EPDI'IZEd no difference in
eutcemes between surgical er nensurgical management
fnr medial epicnndyle humerus fractures. Hnwever, evi-
dence exists that fractures assnciated with a disl-ncatic-n
can be best treated surgically. Level ef evidence: IV.
31}. Cain EL jr, Andrews JR, Dugas jR, et al: Dutcnme nf
ulnar cellatera] ligament recenstructien ef the elhew
in 1231 athletes: Results in 243 athletes with minimum
2-year fnllnw-up. Am I Spurts Med 2D1fl;33{12]:2426-
2434. Medline DUI
ID 21116 American Academy nf flrthnpaedic Surgenns
Fnur-fifths nf adnlescents treated with ulnar cullateral
ligament recenstructinn and suhcutaneeus ulnar nerve
trauspnsitien returned tn their previeus level nf cempeti-
tinn nr higher in less than 1 year with stability. Level nf
evidence: IV.
31. Lattauaa LL, Geldfarh CA, Smucny l'vi, Hutchinsun DT:
Clinical presentatinn nf pesterelateral retatery insta-
bility of the elhnw in children. ] Herve faint 5mg Am
2fl13;95{15}:e1fl.5. Medline III-DI
This study repnrted that pnsternlateral mtatnry instabil-
ity can eceur in children, and the mast cemmc-n clinical
finding is elhcnv centracture. Iavel ef evidence: IV.
32. Larsen N, Ivinisan A, Witte D, et al: IvIediaI ulnar cellat-
eral ligament erigin in children and adelescents: An IvIRI
anatnmic study. I Pedfutr firthnp 2013;33l6}:fiE4-666.
Medline D01
This MRI study demnnstmted the insertien ef the anterie-r
bundle ef the medial ulnar cellateral ligament te be en the
medial epicnndyle (mean, 3.1 mm medial tn the physis].
Level nf evidence: IV.
33. Zell M, Dwell: JR, Edmcrnds EW: lDrigin cf the medial
ulnar cellateral ligament en the pediatric elhnw. I Child
firthep 2fl13;?{4]:323-333. Medlitle DUI
This IvIILI study en the anterier bundle ef the medial ul-
nar cnllateral ligament fnund it tn insert at a mean nf 3.1]
mm medial tn the physis and that buys had a wider ulnar
cellateral ligament than girls {4.115 mm versus 3.22 mm}.
Level ef evidence: IV.
F“?
m
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Drthepaedic Knnwledge Update: Spurts Medicine 5
Chapter 52
Strength Training and
Conditioning in Young Athletes
Tracy L. Zaslovr. MD. FAAP. CAQSM
Strength training programs may be implemented as
part of a comprehensive physical activity program
and can provide many benefits to the entire range of
youth when implemented properly. It is important for
sports medicine physicians to have an understanding
of srrength training and its common misconceptions,
and the health benefits of and current evidence-based
recommendations regarding strength training during
childhood and adolescence.
Keywords: youth; adolescents: young athlete:
strength training: weight training: resistance
training
Introduction
The current trends for child ren’s physical activity include
a wide spectrum from the high-level athlete at rislc for
overuse injury and overtraining to the inactive child at
risk for obesity and long-term health problems. Strength
training programs can provide many benefits to the
entire spectrum of youth when implemented properly.
This chapter defines strength training, discusses common
misconceptions, highlights the health benefits of and re-
views current evidence-based recommendations regarding
strength training during childhood and adolescence.
Physical Activity and Strength Training
Physical activity is essential for normal growth and dev
velopment in children and a physically active lifestyle
Neither Di: Easiovv nor any immediate famiiy member has
received anything of vaiue from or has stock or stock op-
tions heici in a commercial company or institution reiateo'
directiy or indirectiy to the subject of this chapter.
fl lflld American Academy of Drrhopaedic Surgeons
sets the foundation for lifelong activity and disease pre-
vention.1 The 1E.ii'i'orld Health Drganization recognizes
physical inactivity as the fourth-leading risk factor for
global mortality for noncommunicable diseases? Current-
ly it is recommended that children and adolescents [age
range, 6 to 1? years} participate in SCI minutes or more
of physical activity per days‘I Physical activity guidelines
recommend that age-appropriate physical activity include:
aerobic activity of ED minutes or more of moderate- to
vigorous-intensity physical activity {this can include either
moderate—intensity aerobic activity such as brisk walk—
ing, or vigorous-intensity activity such as running; and
strength training that should incorporate vigorous-inten-
sity activities, including those that strengthen muscle and
bone, at least three times per week {for this age group,
a1a|L|1tr fiunoy, ecu :g
bone-loading activities can be performed as part of play-
ing games, running, turning or jumping}.1
Strength [or resistance] training refers to a specialized
method of conditioning whereby an individual is work-
ing against a wide range of resistance loads to enhance
health, fitness, and performance.“1 Resistance training
includes exercises using body weight, weight machines,
free weights {barbells and dumbbells}, elastic bands, and
medicine balls. Resistance training should not be con-
fused with weight lifting, which involves explosive but
highly controlled movements that require technical skill}
Guidelines for youth strength training have been provided
by multiple organizations including the American Acade-
my of Pediatrics Council on Sports Medicine and Fitness,
the National Strength and Conditioning Association,
the American College of Sports Medicine, the American
Medical Society for Sports Medicine, the American Dr-
thopaedic Society for Sports Medicine, and the Nation-
al Athletic Trainers Association. Recommendations are
summarised throughout this chapter.
Is strength training safe and effective for children and
adolescents? Previously, strength training was discour-
aged in young athletes because of currently unsupported
concerns regarding growth plate injury, flexibility im~
pairment, and presumed ineffectiveness. Adverse effects
Drthopaedic Knowledge Update: Sports Medicine 5
 Section E: The Young Athlete
of strength training programs on growth have not been
demonstrated in children as young as E yearsf' De-
creased flexibility has only been confirmed in one study
that incorporated soccer agility training with strength
trainingf other studies have demonstrated improvedf-f“
or unchanged flexibility outcomes.”I Additionally, prior
concerns were based on limited injury rate data with
weight lifting or weight equipment that did not account
for proper supervision, proper use of weight equipment,
and type of training. Previous studies examining acute
resistance training injuries‘1 have highlighted the fact that
such injuries occur primarily with the implementation of
inappropriate training load, supervision by unqualified
instructors, or without adequate supervision.” Strength
training was not previously recommended because the
development of muscle strength was believed to be im-
possible without circulating androgen levels before pu—
berty; however, more recent strength training studies
using programs of adequate intensity and duration have
demonstrated strength gains substantially greater than
those expected from normal growth and maturation.”~”
Ultimately, substantial scientific evidence has estab-
lished that strength training provides health, perfor—
mance, and injury prevention benefits for children and
adolescents‘ldi“5 Because muscular strength is an essen-
tial component of motor skill performance,” developing
E competence and confidence to perform resistance exercise
E during growth years can have important long-term im-
:5
:1: plications for health fitness and performance.
Ch
E
E
3...
I1: Health Benefits of Strength Training
.I:
'—
titi Physical activity is essential for normal growth and devel-
opment through childhood and adolescence. Participation
in age-appropriate fitness programs can improve car-
diovascular health, aid weight management, strengthen
bone, improve psychosocial well—being, enhance motors
skills, and prevent sports-related injury. Developing con-
fidence, appropriate strength, and competence to perform
fundamental motor skills through activities that consol—
idate skill and health-related fitness can also provide the
foundation to maximise the efficacy of neuromuscular
conditioning during preadnlescence with long-term im-
plications for health, fitness, and sports performance.l3
Additionally, the inclusion of an appropriately super-
vised strength training program during physical education
classes does not have any adverse effects on after-school
performance in adolescent athletesd”
Cardiovascular Health
1illfith increasing rates of youth obesity, resistance training
is an important tool to potentially improve healthy body
firthopaedic Knowledge Update: Sports Medicine 5
composition. Traditionally, youth with obesity have been
encouraged to participate in aerobic activities; however,
excess weight limits their ability to perform high—impact
physical activity {such as running} and increases the risk
for musculoslreletal overuse injuries. Additionally, youth
with obesity often lack the motor skills and confidence
to pursue rigorous physical activity. Therefore, resistance
training can be an excellent entry point for this population
to enable them to build the strength, skills, and fitness to
enable further pursuit of more intense exercise.”
Several studies demonstrated that children and adoles-
cents with obesity or at risk for obesity and who partic'
ipated in resistance or circuit {combined resistance and
aerobic training} programs improved their body compo-
sition.‘l Resistance training programs have been shown
to not only decrease body fat but substantially increase
insulin sensitivity in adolescent males at risk for obesityf't1
Increased insulin sensitivity remained substantial after
adjustment for changes in total body fat and total lean
mass, indicating resistance training may have resulted in
qualitative skeletal muscle changes, enhancing insulin
activity.
Although no direct correlation exists between regular
physical activity and reducing blood pressure in normo-
tensive youth, limited data suggest that resistance training
using submaximal loads can be an effective intervention
for hypertensive adolescentsfiI1
The effects of resistance training on blood lipoproteins
in children and adolescents are not well documented.
Resistance training has been shown to have a positive
effect on blood lipid profile in children and adolescents
when compared with an inactive groupfi” However, rec-
ommendations to improve blood lipid profiles in youth
with dyslipidemia emphasises the importance of a com-
prehensive health program that includes regular physical
activity, nutrition education, and behavioral counseling.“
Bone Health
Previously, important and lilrely inappropriate concerns
existed regarding potential damage to growth plates from
resistance training and high-impact exercise; however, re-
sistance training has not been shown to have a detrimental
effect on linear growth in children and adolescents.” Not
only are these concerns not supported by the medical
literature, but these traditional feats have actually been
replaced by evidence indicating that the ideal time to build
bone mass is childhood and is achieved by participating
in weight-bearing activities?” Further evidence indicates
that mechanical stress applied to developing growth plates
from appropriate resistance training with moderate- to
high—intensity resistance exercise promotes bone growth
and formation to optimise bone mineral accrual during
fl Ellie American Academy of Orthopaedic Surgeons

childhood and adolescencefifl'i'“ Ultimately, although bone
mass is influenced by genetics, engaging in regular resis-
tance training in conjunction with adequate nutritional
intake (calcium, vitamin D, and calories} promotes nor-
mal bone formation and growth and can ma ximixe bone
mineral density during childhood and adolescence?!”
Developing healthy regular physical activity habits pro-
motes continuation of these habits into adulthood and
ultimately could reduce the risk of developing adult dis—
eases later in life.
Psychosocial Health
The medical literature examining the psychological
benefits of strength training is sparse and findings are
equivocal. Initial studies did not demonstrate resistance
training—induced psychologic benefits for healthy youth“;
however, other studies have demonstrated improvements
in psychologic well-being,31 mood, and self-appraisal”
in youth who engaged in physical activity programs that
included resistance training. Further research indicates
that self-concept and self-perception are related to an
individual’s physical activity level?“ Specific studies
evaluating self—concept and self—perception with specific
resistance training programs also demonstrated improve-
mentsfif!“ flverall, age-appropriate resistance training
focused on enjoyment and self-improvement positively
affects the psychologic well-being of youth.
However, intense training with excessive pressure
to perform at levels beyond their ability andior with—
out appropriate rest intervals, can negatively affect
youth. Furthermore, inappropriate coaching, unethical
training practices, or emphasis on lean physique can
result in abuse of performance-enhancing drugs,” re-
strictive eating behaviors,39 or burnout {overtraining
syndrome}.“~"’“
Injury Risk
Resistance training programs that are developmentally
appropriate and well supervised can be an excellent tool
to decrease injury. Children actually have a lower risk of
resistance training-related injuries such as strains and
sprains than adults;‘” however, appropriate supervision
with attention to postural alignment and technical com-
petency is essential. Physical inactivity is a known risk
factor for activityurelated inju ry;'“ thus, youth who regub
larly participate in age~appropriate fitness programs that
include resistance exercise may be less likely to sustain
injury. Building this essential foundation of physical fit—
ness is even more important in sedentary youth whose
musculoslreletal fitness may be ill-prepared for the de-
mands of recreational games and sports practiced“:
Additionally, for the highly competitive athlete,
IE! Elilti American Academy of flrrhopaedic Surgeons
Chapter 51: Strength Training and |Emsditioning in Yotmg Athletes
incorporating appropriate resistance training programs
into regular conditioning has been shown to decrease
injury risk in multiple sports including soccer, football,
and rugby.‘”'~‘HI Strength training programs have been
implemented to prevent specific overuse injuries such
as rotator cuff and scapular stabilisation for overhead
throwing athletes and quadricepsfhamstring exercises
for runningi'sprinting athletes. Well-supervised compre-
hensive resistance training programs designed to treat
abnormal biomecha nics that develop during adolescence,
especially in female athletes, have demon strated efficacy
for diminishing injury rates (specifically, anterior cruciate
ligament injury in female athletes}.‘5-""5 Resistance train-
ing programs implemented early in preadolescent girls
can induce an increase in muscle power, strength, and
coordination that mirrors the natural ueuromuscular
spurt that occurs in boys.“~“~‘”
Special Populations
Females have a natural propensity for the development of
poor ueuromuscular adaptations with muscular growth
during puberty that predispose female athletes to in—
creased injury risk.'3'5“ Participation in resistance training
by female athletes has been shown to demonstrate safer
movement mechanics and decreased injury rates."l~"*""i‘i Cer-
tain medical conditions can be exacerbated by strength F“?
training and must be considered before recommending
m
a strength training program51 '53 {Table 1]. Consultation
EfI:
with the appropriate specialist can help determine par- :I
u:
ticipation risks, which can be minimal and lower than 1"
those associated with a sedentary lifestyle.
Fl
E
as
m
F.
Guidelines for Strength Training
Prior to beginning a formal strength training program,
a medical evaluation {such as the Preparticipation Phys-
ical Evaluation} is recommended to evaluate injury risk
factors and medical history and to discuss training goals
and expectations.
Appropriate Exercises
Exercises incorporated into youth strength training pro-
grams must be specifically selected to be appropriate for
the developmental age and current fitness level for the
individual. Emphasis on technique fundamentals and
close supervision during training are essential. In addition
to selecting the appropriate exercises, equipment of the
correct size must be selected for the athlete to safely ex-
ecute correct technique; most strength training and gym
equipment are adult size and do not have weight incre-
ments appropriate for children. Therefore, although free
Drthopaedic Knowledge Update: Sports Medicine 5
 Seefien B: The Tewlg Athlete

——
Medical Cenditiens te Consider Befere Strength Training
Cemplex cengenital heart disease: These with mild cengenital heart disease may be safe fer all activities;
hewever, these with mederate te severe ferms er whe have undergene surgery may be mere limited.
Cardielegic censultatien is indicated befere clearance te participate in strength training and physical activity
pregra ms.
Cerenary artery anemalies
Hypertrephic cardiemyepathy: Disease manifestatien can change during adelescence and repeated
evaluatiens are recemmended.

Carditis: Inflammatien ef the heart can predispese te sudden death with exertien.
Systemic pulmenary hypertensien
Uncentrellecl hypertensien: These with hypertensien {:55 mm Hg higher than the 99"" percentile fer age, sex,
and height} sheuld aveid heavy weight lifting, pewer lifting, bedy building, and sperts with a high static
cempenent. Werltup is indicated fer these with :95“‘ percentile fer age, sex, and height.
Acquired heart disease including acute rheumatic fever with carditis
Underlying disease
Ehlers—Danles syndreme: The vascular ferm can predispese te cardievascular risks; all farms are at increased
risk fer ieint injury because ef asseciated Iigamenteus laxity.
lvlar'lan syndreme: Aertic aneurysm can cause sudden death.
Kawasaki disease [cerenary artery vasculitisl
Systemic er HLA-BET-asseciated arthritis requires cardievascular assessment fer pessible cardiac cemplicatiens
during exercise.
Juvenile dermatemyesitis er systemic lupus erythematesus with cardiac invelvement requires cardiac
assessment befere clearance.
Fever: Rarely, fever can accempany myecarditis er ether cenditiens that make typical exercise dangereus.
E
E Splenemegaly: Increased spleen size, especially when asseciated with menenucleesis. predispeses te increased
:5 risk ef splenic rupture.
fl:
L'Jll
E Anthracycline use: The cardietexic effects ef anthracycline increase risk ef cardiac preblems and resistance
E
3... training must be censidered with cautien: strength training that aveids isemetric centractiens may be
I1:
.I:
permittedfil“
'—
Ed Obesity: Because ef increased risk ef cardievascular strain and injury, apprepriate acclimatizatien and gradual
activity implementatien are impertant.

weights require better balance, centrel, and technique,
they can preside apprepriate weight increments and are
preferred fer yeung children in a supervised strength
training pregram.
When determining which exercises te incerperate inte
a pregram, many facters must he censidered, including
baseline fitness level, technical expertise, ceaching pre-
ficieucy, equipment availability, and training geals. Fer
children and adelcscents with a lew training age {that
is, minimal training experience andr'er peer technical
cempeteucy}, exercise pregrams sheuld be designed te
premete the develepment ef muscular strength and en-
hance everall fundamental sltill cempetency.j Neura-
muscular ceerdinatien is must susceptible te change
during childheed, resulting in the develepment ef
meter cempetencyfi‘l “Starter" pregrams can include
basic hedy weight exercises such as squatting, lunging,
pressing, and pulling mevcmcnts. After these technical
skills are mastered and apprepriate strength is devel-
eped, free weight exercises including weight lifting and
plyemetrics are incerperated. Fer technically cempe-
tent yeuth, free weight resistance training with clese
supervisien is recemmended ever machineubased re-
sistance training because adult equipment is eften net
sired apprepriately and weight increments are tee large
fer yeuth. Additienally, studies in the adult pepulatien
demenstrate less muscle activatien in machine-based
resistance training than in free weight resistance train-
ingyfid“ further supperting the recemmendatien te use
free weight resistance exercises.

firthepaedic Knewledge Update: Sperts Medicine 5 fl lflld American Academy ef Urthepaedic Surge-ens

aume and Intensity
Determining the apprnpriate vnlume and intensity nf a
strength training prngram is essential. aume refers tn
the number nf times an exercise is perfnrmed within a
training sessinn multiplied by the resistance used ('lci-
lngrams];1 Intensity refers tn the resistance tn be nver—
cnme during a repetitinn? Althnugh these variables are
inversely related, bnth must be cnnsidered tn develnp
an apprnpriate prngram that prnmntes technical skill
acquisitinn and strength while minimizing injury risk. If
intensity is tnn high, the participant is unlikely tn perfnrm
the exercise with cnrrect technique, increasing the risk nf
injury; if the vnlume is excessive, nvertraining can ncc ur.
An individual's nne repetitinn maximum HEM} is de—
fined as the maximum amnunt nf weight an individual can
displace at nne time. IRMs are used in research settings
tn assess baseline strength levels, and nne study demnn—
strated an injury with prnperly supervised IRM testing
in healthy children.” Currently, IRM strength testing is
nnt endnrsed as an apprnpriate measure befnre skeletal
maturity by the American Academy nf Pediatrics Cnuncil
nf Spnrts Medicine}1 Additinnally, IRM test results are
nnt a practical means nf assessment fnr physical educatinn
classes with a large number nf participants and minimal
time where supervisinn is limited. Simple field-based mea-
sures such as the vertical jump, lnng jump, and hand grip
Strength have been cnrrelated tn IRM strength values and
are a mnre practical means nf assessing muscular strength
in schnnl and recreatinnal settings.” Irrespective nf 1Rivt
lnad nr strength assessment evaluatinn measure chnsen,
ultimately, an individual’s technical cnmpetency {the abil—
ity tn perfnrm the exercise with apprnpriate technique] is
the mnst impnrtant factnr tn cnnsider when designing an
apprnpriate prngram.
Strength Training Prngram Progressinn
Training prngrams fnr ynuth withnut experience in re—
sistance training are recnmmended tn include a range
nf exercises and mnvement patterns and tn begin at lnw
vnlume (nne tn twn sets] and lnw tn mnderate training
intensities {up tn dfl‘h’: 1131M)?” Tn ensure safe, cnrrect
technique, it is recnmmended that ynuth initially per-
fnrm a lnw number nf repetitinns (nne tn three}, with
cnncurrent cueing during each repetitinn. Hnwever, nnt
all exercises need tn be perfnrmed fnr the same number nf
sets and repetitinns; the specific prngram design depends
an individual gnals and the level nf technical cnmpetency
and strength. As skills are mastered with cnrrect tech—
nique, the prngram can be advanced tn increase the sets,
the repetitinns per set, and the intensity; these prngram
changes must be made gradually tn minimize injury risk
and tn maximise learning and strength gains. Participants
IE! lfllfi American Academy nf flrthnpaedic Surgenns
Chapter 51: Strength Training and |l'ilt'niiditinning in Yntmg Athletes
must be supervised as the prngram prngresses tn mnnitnr
fnr fatigue and cnntinued technical cnmpetency during
training sessinns that can result in pnnr technique and
increased injury risk.
Rest Intervals During Training Sessinns
Rest intervals are an impnrtant cnmpnnent nf any train-
ing prngram. Rest is essential tn prevent fatigue-related,
pnnr implementatinn nf technique and increased risk fnr
injury. In a research setting, children recnver mnre quickly
frnm fatigue-inducing resistance training and are less
likely tn sustain muscle damage than adultsfiflr‘i‘ Current
recnmmendatinns are fnr rest perinds nf apprnximately
1 minute; hnwever, lnnger rest perinds flange, 2 tn 5
minutes] may be apprnpriate with increases in intensity
and exercises that require advanced technical skill, fnrce,
nr pnwer prnductinn {such as weightlifting nr plynmetric
exerciseslfi Additinnally, despite the faster recnvery rate
in children, ynuth must always be clnscly supervised tn
evaluate fnr cnntinued attentinn and executinn nf prnper
technique thrnughnut a training sessinn. Last, 8 hnurs
nr mnre nf sleep per night has been cnrrelated tn a lnwer
injury nccurrence rate, and thus, adequate sleep must be
encnuraged tn minimize injury risk.“
Training Frequency
Because ynuth are actively grnwing and develnping, al- F“?
lnwing apprnpriate rest and recnvery time is essential.
m
When develnping a resistance training prngram, the tim-
E?I:
ing frequency {number nf sessinns perfnrmed per week} :r
u:
must be selected carefully. Studies indicate that twn tn 1"
three sessinns per week enable muscular strength de-
Fl
E
as
velnpment in children and adnlescentsfl'” Training fre- m
F.
quency can increase as children prngress tn adulthnnd
and increase cnmpetitive intensity; hnwever, resistance
training prngrams shnuld be incnrpnrated tn cnmplement
the training prngram, and nnt as an additinnal training
sessinn, tn minimise nvertraining and nveruse injury.
Repetitinn Velncity
Repetitinn velncity refers tn hnw fast a specific mnvement
is perfnrmed. Initially, when training experience is limited
andi'nr a child is learning a new technique, the mnvement
is best perfnrmed at a mnderate rate tn ensure cnrrect
technique l[pnsture, pnsitinn, alignment} and maximize
cnntrnl. Hnwever, after a technique is mastered, great-
er mnvement velncities shnuld he used tn prnmnte the
develnpment nf mntnr recruitment patterns and firing
intensities.“ Additinnally, repetitinn velncities can vary
within a scssinn depending cm the gnal and experience
fnr each individual exercise. Ultimately, incnrpnrating
high-velncity mnvements is especially impnrtant during
Drthnpaedic Knnwledge Update: Spnrts Medicme 5
 Section E: The Young Athlete
the growing years when neural plasticity and motor co-
ordination are most sensitive to change.
5 u some ry
The health, fitness, and performance benefits of strength
training for children and adolescents are extensive. To
maximize the safety and efficacy of strength training
programs for youth, attention must focus on the fol-
lowing: Programs must include appropriate supervision
from qualified professionals; programs must address the
needs, goals, and abilities of younger populations; and
programs are ideally developed for the individual accord-
ing to biologic age, training age, motor skill competency,
psychosocial maturity, technical proficiency, and existing
strength levels.
The health and fitness benefits of strength training pro—
vide essential muscle strength and motor skills to decrease
the risk for poor health outcomes later in life. Addition-
ally, programs have been shown to reduce sports—related
injuries and are a key component of preparatory training
programs for aspiring young athletes. Ultimately, youth
strength training programs are an opportunity to enjoy
physical fitness while developing technical skill and com-
petency at an appropriate intensity and volume to build
a healthy fitness foundation for life.
E Christou M, Smilios I, Sotiropoulos K, Volaltlis K, Pilian-
E Rey Study Points
:5
s1:
Eh ‘I The myth that strength training is harmful has been
E
S dispelled.
3...
I1: I Strength training can be an important part of train—
.I:
'—
ing for young athletes, can promote lifelong fitness,
s'ti
and reduce sports-related injuries.
' Strength training programs must include appro-
priate supervision, address the needs of younger
populations, and be tailored to the biologic and
training age of the athlete.
Annotated References
1. Rowland TW: Promoting physical activity for chil-
dren’s health: Rationale and strategies. Sports Med
eastern 1}:919-936. Medline DIDI
2. World Health Drganieation: Global Recommendations
on Physical Activity for Health. Geneva, WHD Press,
lfllfl.
Activity recommendations for three age groups (ranges:
5 to 1? years, IE to 64 years, and 65 years and older} are
presented.
Drthopaedic Knowledge Update: Sports Medich'ie S
LLS. Department of Health and Human Services: Physical
Activity Guidelines for Americans. Washington, DC, US
Department of Health and Human Services, lflflfl.
Faigenbaum AD, Kraemer W], Blimltie C], et al: Youth
resistance training: Updated position statement paper
from the national strength and conditioning associa'
tion. j Strength Cored Res 2009:235, Suppl}:Stifl-S?S.
Medline DD]
An updated report is presented on recommendations
on youth resistance training regarding: potential risks
and concerns, potential health and fitness benefits, types
and amount of resistance training needed, and program
design considerations for optimizing long-term training
adaptations.
Lloyd RS, Faigenhaum AD, Stone MH, et al: Position
statement on youth resistance training: The 2014 Interna-
tional Consensus. Br] Sports Med 2014;4Sl7}:4SS-SDS.
Medline Dfll
Scientific evidence supports participation in appropriately
designed youth resistance training programs that are su-
pervised and instructed by qualified professionals. Health,
fitness, and performance benefits associated with training
for children and adolescents are outlined.
Ramsay JA, Blimltie C], Smith K, lCarrier S, l'vlacDou-
gall JD, Sale DG: Strength training effects in prepuhes-
cent boys. Med Sci Sports Exerc 1990:22i5}:6fl5-614.
Medline DDI
idis T, Toltmaltidis SP: Effects of resistance training on the
physical capacities of adolescent soccer players._,I Streisgtl:
Cored Res lflflfi:2fl{4}:?SS-?9L Medline
Lillegard WA, Brown EW, Wilson D], Henderson R, Lewis
E: Efficacy of strength training in prepubescent to early
postpubescent males and females: Effects of gender and
maturity. Pediat-r Relialril 199?:1{3]:14?—15?. Medline
Weltman A, Janney C, Rians CE, Strand K, Hatch Fl:
The effects of hydraulic—resistance strength training on
serum lipid levels in prepubertal boys. Am 1 Dis Child
193?;141{?}:??T-?Sfl. Medline
10. Faigenbaum AD, Milliken LA, Loud RL, Euralc BT,
Doherty CL, Westcott WL: Comparison of 1 and 2 days
per week of strength training in children. Res Q Esterc
Sport EflfllgTSl4l:4lfi-424. Medline DCII
11. Padres E, Eliakim A, ISostantini N, et al: The effect of
long-term resistance training on anthropometric measures,
muscle strength, and self-concept in pre-pubertal boys.
Psdiatr Esterc Sci El] 01:1 3:35T—S P2.
12. Paigenhaum AD, lvlyer GD: Resistance training among
young athletes: Safety, efficacy and injury prevention ef-
fects. Br ,1“ Sports Med 201G;44{1]:Sd-63. Medline DD]
Resistance training can be a safe, effective, and worth-
while activity for children and adolescents provided that
D lflld American Academy of Orthopaedic Surgeons

qualified prefessitinals supervise all training sessitins and
preside age-apprupriate instructinn nn prnper lifting prev
cedures and safe training guidelines.
13. Annesi I]. Westcctt WL, Faigenhaum AD, Unruh JL:
Effects {if a 12-week physical activity pram-cpl delivered
by YMCA after-schutil cnunselers i‘fnuth Fit fcrr Life}
un fitness and self-efficacy changes in 5-12-year—uld
buys and girls. Res Q Exerc Spcrt 2Dfl5:?fi{4i:463-4?fi.
Medline DUI
14. Behringer M, 1v'izim Heede A, Yue Z, Mester J: Effects {if re-
sistance training in children and adalescents: A meta-anal-
ysis. Pediatrics 21'] 10:1 2H5J:e1 199-e1210. Medline [191
A greater number nf training sessinns per week is assuci-
ated with greater strength gains after resistance training,
and lung-term interventicms are mere beneficial than shurt
cues. The ability tr: gain muscular strength currelates tu in-
crease with age and maturatinn status. Level cf evidence: 1.
15. American Enllege cf Sparta Medicine: ACSMs Guidelines
fer Exercise Testing and Prescriptinn, ed 8. Philadelphia,
PA, Lippinctitt Williams and Wilkins, 2fl1fl.
This manual summarizes recummended precedures fur
exercise testing and exercise prescripticn in healthy and
sick patients.
16. Behringer M, 1|titan Heede A, Matthews M, Mester J: Ef-
fects nf strength training an meter perfnrmance skills in
children and adulescents: A meta-analysis. Pediatr Exerc
Sci 2D]1,23[2}:136-2fld. Medline
After resistance training, yeunger patients and nunathletes
she-wed greater gains in mntnr perfnrmance. Thus, resis-
tance training can pruvide an effective way fer enhancing
mutar perfurmauce in children and adcrlescents. Level uf
evidence: I.
1?. Malina EM, Euuchard C, Ear—Cir U: Grettdii. Mantratiun
and Physical! Activity. Ehampaign, IL, Human Kinetics,
sass, pp 3-2:].
13. Myer GD, Faigeubaum AD, Straccinlini A, Hewett TE,
l'vlicheli L], Best TM: Exercise deficit disurder in yuuth:
A paradigm shift reward disease preventicm and cumpre-
hensive care. Ester Spurts Med Rep 291 3:12i4]:243-255.
Medline DD]
Exercise-deficient children need an be identified early in life
and treated with apprupriate exercise prngrams tc- target
muvement and physical prnblems. [f the uppartunity is
missed, later interventitms tn prumete healthy lifestyles
chuices will be mcrre difficult tn achieve.
19. Faigenhaum AD, McFarland JE, Buchanan E, Ratamess
NA, Kang J, Huffman jR: After-schuul fitness perfur-
mance is net altered after physical educatiun lessens in
adulescent athletes. ] Strength Chad Res 2fl1fl:24{3}:?65-
2TB. Medline D0]
The after-schucrl fitness perfurmauce cf 23‘ adclescent
athletes was assessed fciluwing three different physical
educatitm lessens [aembic training, resistance training,
and basketball skill training}. The study cuucluded that
IE! 2fllfi American Academy nf flrthnpaedic Surgenns
Chapter 52: Strength Training and Eflnflffiflfliflg in Young Athletes
an exercise lessen dues net have an adverse effect an after-
schc-ul fitness perfnrmance.
20. Sethern M5, Luftin JM, Udall JN, et al: Safety, feasibility,
and efficacy cf a resistance training program in preadnles-
cent nbese children. Am I Med Sci 2G00;319{E}:3?fl-3?5.
Medline DUI
21. Shaibi GQ, Cruz ML, Ball GD, et al: Effects uf resistance
training nu insulin sensitivity in uverweight Latinu adults-
cent males. Med Sci Sperts Exerc 2i] fld:33{?}:12{13-1215.
Medline DD]
22. Hagberg JM, Ehsani AA, Guldring D, Hernandez A, Sina-
ccire DR, Hullcrsay JD: Effect uf weight training an blend
pressure and heme-dynamics in hypertensive adulescents.
j Pedietr 1934:104i1}:H?—15L Medline DUI
23. Sung RY, Tu CW, Chang SK, Mu 5W, Wei-u H5, Lam
CW: Effects cf dietary interventiun and strength training
an hlucd lipid level in nhese children. Arci: Dis Chifd
2DD2;SE{E}:4fl?—410.Medline DID]
24-. Heelscher DM, Kirk 5, Ritchie L, Cunningham-Sabe- L;
Academy Pcsiticns Ccmmittee: Pcsiticn cf the Academy
cf Nutritieu and Dietetics: Interventinns fur the preventinn
and treatment [if pediatric uverweight and ubesity. f Acad
Nuts Diet 2D]3;113{10}:13?5~1394. Medline Dfll
Guidance and recummendatiuns are presented fur levels
cf interventicn targeting nbesity preventinn and treatment
frnm preschunl children tn adnlescents.
25. Malina RM: 1Weight training in yuuth—gmwth, matura- F“?
tiun, and safety: An evidence-based review. Ciirs I Spur-t in
Med 2flflE;1ii{E]-:4?3u43?. Medline DUI
SiI:
:I
26. Gunter KB, Almstedt Hi3, Jana KF: Physical activi- a:
1"
ty in childhuud may be the key tr: uptimiaing lifespan Fl
E
skeletal health. Exerc Spurs Sci Res 2G'12;4D[1}:13-21. n:
m
F.
Medline DUI
Physical activity during Chll-[lhflfid cnnveys nptimal bene-
fits tn bune mass, size, and structure. These benefits persist
beyund activity cessatien. Eurmntly, the must effective
interventinus te- enhance skeletal develnpment have been
schtml based.
2?. Vicente-Redriguee G: Haw dues exercise affect buue de-
veltipment during grnwth? Sparts Med 2flfl6;3d[?}:561-
559'. Medline DUI
23. Alvarez-San Emeteriu C, Antuiianu NP, Ldpea—Scrbab
er AM, Gentiles—Badillu J]: Effect uf strength training
and the practice cf Alpine skiing rm bane mass density,
grcwth, budy cumpesitiun, and the strength and puw-
er cf the legs nf adolescent skiers. I Strength {3q Res
2fl11:25{1fl]:2E?9-2390.Medline DD]
In this study, Alpine skiing cumbined with strength train-
ing pruved [D have a pc-sitive effect an the power and
percentage uf muscle mass in legs, as well as cm the bane
density in the lumbar spine cumpared with sedentary
individuals.
Drthnpaedic Knuwledge Update: Spurts Medicine 5
 Section E: The ”fusing Athlete
29. Hind K, Burruws M: 1iiii'eight—lzueating exercise and bone
mineral accrual in children and adnlescents: A review cf
ccntrcrlled trials. Bane 10D?;4fl{1j:14-2?. Medline DUI
30. Tu CC, Sung RT, 5n RC, et al: Effects nf strength training
an hudy cnmpcsitinn and hune mineral ccntent in children
whc are ubese. j’ Strength Bend Res lflfl5;19i3}:5616?§t.
Medline
31. Turner CH, Ruhling AG: Designing exercise regimens tu
increase h-nne strength. Exerc Spar: Sci Rest 2Ufl3;31{1}:45-
5i]. Medline DUI
31. Tu CC, Sung RY, Hau KT, Lam PK, Nelsen EA, 5n RE:
The effect cf diet and strength training an uhese chil-
dren’s physical self—cencept. ] Spurts Med Phys Fitness
lflflfl;43{1}:?6-32. Medline
33. Altintag A, Asci PH: Physical self-esteem cf adnlescents
with regard tn physical activity and pubertal status. Pe-
nna Exerc Sci asssnsinassass. Medline
34. Duntnn GF, Schneider M, lGraham D], et al: Physical
activity, fitness, and physical self—cuncept in adclescent
females. Pediatr Exerc Sci EDflE;13:24fl-2 51.
35. Knuwlcs AM, Niven AG, Fawkner 5G, Henretty JM: A
lnngitudinal examinaticn cf the influence of maturatinn nn
physical self-perceptinns and the relatinnship with physical
activity in early adulescent girls. ] Adeiesc 2i] DP:32{3}:555-
566. Medline DUI
E In this study, 15!] early adc-lescent girls were uhserved.
E A decrease in cwerall physical activity nver 11 mnnths
:5 was nnt influenced by age maturatic-n, hut variance in
:1:
Ch
E
physical activity was partially accnuuted fur by physical
E self-perceptinn.
3...
I1:
.I:
|_- 3d. Luhans DR, Aguiar EJ, Callister R: The effects nf free
4:33 weights and elastic tubing resistance training c-n physi-
cal self—perceptinn in adcrlescents. Psychnf Spcrt Exerc
Efllflglls4ST-5fl4. DUI
In this study, IDS adnlescents were divided intc: twu resis—
tance training gruups {free weights and elastic tubing] and
a centre] grnup. Thnse in the resistance training grnups
impruved their h-ndy ccmpusitiun. Resistance training
is feasible and effective fer impruving aspects cf health-
related fimess.
3?. Velez A, |IC‘aalem DL, Arent SM: The impact nf a 12-week
resistance training prngram nn strength, hudy cnmpnsi-
tiuu, and self-cuncept uf Hispanic adulescents. J Strength
Gun-d Res 2D]fl;24{4}:'lflES-IIJT3. Medline DUI
The health and fitness cf 23 Hispanic adcilescents {divided
randnmly intc: cuntrc-l and resistance training grnups}
was assessed hefnre and after interventinn. Resistance
training resulted in imparts nt psychnlugic and physielngic
improvement.
3E. Heffmau JR, Faigeubaum AD, Ratamess NA, Russ R,
Hang J, Tenenhaum G: Nutritinnal supplementation and
Urthnpaedic Knnwledge Update: Spurn-ts Medicine 5
anah-nlic sternid use in adclescents. Med Sci Spurts Exerc
lflflfl;4flj1}:15-24.Medline DDI
35'. Nattiv A, Luucks AB, Manure MM, Sanh—arn CF, Sund-
gcit-Enrgen ], 1Warren MP; American Cullege cf Sparta
Medicine: American |Curllege nf Spurts Medicine pnsitinn
stand. The female athlete triad. Med Sci Sperts Execs
lflfl?;39{10j:136?-1332. Medline
4'3. Brenner J5; American Academy cf Pediatrics Ceuucil nn
Spurts Medicine and Fitness. Uveruse injuries, nvertrain-
ing, and burn-nut in child and adnlescent athletes. Pediat-
rics lflfl?-119{6}:1242-1245.Medline DUI
41. Elnemers F, Cellard D, Paw MC, 'Uan Mechelen W, Twisk
J, Verhageu E: Physical inactivity is a risk fact-er fur phys-
ical activity-related injuries in children. Br I Sparts Med
1012;4E{91:669a6?4.Medline DUI
Sex, age, and level nf physical activity are independent risk
factcrs fur physical activity-related injuries in children. In-
jury rislt substantially declined with an increase in weekly
expcsure, the must active kids had the lnwest injury risk.
42. Myer GD, Fa igenhaum AD, Fnrd KR, Best TM, Bergercin
MF, Hewett TE: When tn initiate integrative neurnmuscu-
la: training tn reduce spcrts—related injuries and enhance
health in ynuth? Carr Spnrts Med Rep 2fl11:1fl[3}:153-
165. Medline DUI
Integrative neurnmuscular training {INTI may he must
beneficial if initiated during preadulescence. If main-
tained thruughuut childhucd and adelescence, INT will
likely imprcve mnvement hinmechanics, minimize risk
cf spurts-related injury, and prnmnte pct-sitive health nut-
cumes during adulthnnd.
43. Suligard T, Myklehust G, Steffen K, et al: Cumprehen—
sive warm—up prcgramme tc: prevent injuries in yuung
female fnnthallers: Cluster randcimised cnntrnlled trial.
BM] lflfl3;33?:a2463. Medline DUI
44. Emery CA, Meeuwisse WH: The effectiveness cf a neura-
muscular preventinn strategy tn reduce injuries in yuuth
succet: A cluster-ta ndumised ccntrulled trial. Br] Sputts
Med 2G10:44{3}I:355-562. Medline DUI
In this study, T44 ynuth snccer players were randumixed
int-n snccer-specific neurnmuscular prngram and central
grc-ups. The uverall injury rate was lnwer in the neuru~
muscular prugram grnup.
45. Myer GD, Ferd KR, McLean 5173, Hewett TE: The effects
c-f plynmetric versus dynamic stabilizatinn and balance
training an lnwer extremity hinmechanics. Am I Spurts
Med 20fl6;34(3}:445-455. Medline DUI
46. Myer GD, Sugimntu D, Thnmas 5, Hewett TE: The influ-
ence cf age en the effectiveness cf ueuremuscular training
tn reduce antericr cruciate ligament injury in female ath-
letes: A meta-a nalysis. An: I Spurts Med lfl13;41[1}:2fl3-
115. Medline DUI
D 211115 American Academy cf Urthnpaedic Surge-nus

Art asse-ciatinn was feund hetween neuremuscular train‘
ing and reductian af anteriar cruciate ligament injury
incidence. It may be nptimal te start with neuramuscular
prngrams during early adnlescence.
4?. Myer GD, Ferd KR, Palumhe JP, Hewett TE: Neuremus-
cular training impreyes performance and lnwer-extremity
hiamcchanics in female athletes. I Strength Cand Rea
EflflSil‘ir'jljifl-Sfl. Medline
4S. Hewett TE, Myer GD, Fard KR, et al: Eiamechanical
measures nf neuremuscular central and yalgus leading
cf the knee predict anterinr cruciate ligament injury risk
in female athletes: A prespectiye study. An: } Sparta Med
lflfljt33l4ji492-Sfl1.Medline DUI
4?. Fard KR, Shapite R, Myer GD, 1|Ii'an Den Begert A],
Hewett TE: Langitudinal sex differences during landing
in knee ahductinn in yeung athletes. Med Sci Sparta Exerc
aaia;42{1a]asas—1sai. Medline net
Fer this study, 315 subjects were tested in twe sessiens,
1 year apart. The knee abductien angle af females was
substantially increased during rapid adelescent grnwth, as
well as their knee ahductinn mntinn and mnments during
the subsequent year after rapid adelescent grewth, cemv
pared with males.
Si]. Hewett TE, Myer GD, Ferd KR: Decrease in neuremus-
cular cnntrel ahnut the knee with maturatien in female
athletes. J' Bette faint Surg Am lflfl4;SS—A{Sj:ISDI-ISDS.
Medline
51. Rice SG; American Academy af Pediatrics l[Zeuncil an
Sparta Medicine and Fitness: Medical canditiens affect-
ing spurts participatinn. Pediatrics Eflflfl;llll4]:341- 843.
Medline DUI
52. American Academy ef Pediatrics Cnuncil en Sperts
Medicine and Fitness, McCambridge TM, Stricker PR:
Strength training by children and ac'elescents. Pediatrics
2003;121i4}:SSS-S4fl.Medline DUI
SS. Steinhetr L], Steinhem PG, Tan ET, Heller G, Murphy
ML: Cardiac tnxicity 4 tn Ell years after cnmpleting an-
thracycline therapy. IAMA 1991,166i12jflSFI-ISTF.
Medline DUI
54. Burma J: The child and exercise: An ayeryiew. j Sparta Sci
1936;4{1}:S-20.Medline DUI
55. Schwanheclt S, flhilibeclr. PD, Einsted G: A camparisen
ef free weight squat ta Smith machine squat using electre-
myngraphy. I Strengti':I Band Rea 2009;23i9}:ZSSS-2591.
Medline DDI
Electramyagraphic activity was increased in the gastrec—
nemius, biceps femaris, and yastus medialis during the
free-weight squat yersus machine squat. Nu substantial
difference was reparted fur any ether muscles.
IE! ElIIii American Academy nf flrthapaedic Surgenna
Chapter 51: Strength Training and |iiienditiening in Yeung Athletes
.56. Schick EE, Cehurn JW, Brawn LE, et al: A camparisnn
af muscle activatien between a Smith machine and free
weight bench press. I Strength Cend Res 2fl10:24[3}:??9-
T34. Medline DD]
Subjects were tested in twn training sessinns. The free-
weight bench press demanstrated greater muscle activatian
than the Smith machine far muscle gteups tested.
5?. Faigcnbaum AD, Milliken LA, 1|I'ii'cstcett WL: Maximal
strength testing in healthy children. ,7 Strength Can-ii Res
Zflfl3;l?{1j:liSZ-IISS. Medline
SS. Castrn-Pifiere J, |Eirtega FE, Artern EG, et al: Assessing
muscular strength in ynuth: Usefulness nf standing lung
jump as a general index af muscular fitness. j StrengtiiI
Bend Rea EUID;E4{TJ:ISlfl-ISIT. Medline DUI
In this study, 94 children underwent upper andiar lawer
extremity strength tests. The standing leng jump {SLJ} was
strengly asseciatcd with lawer and upper bady muscular
strength tests. Thus, SLJ ceuld he censidered a general
index nf muscular fitness in ynuth.
SS. Ratamess NA, Altar BA, Eyetach TK, et al: American
Ililnllege nf Sparta Medicine: American Cellege ef Spnrts
Medicine pesitien stand. Pragressien medels in resis-
tance training far healthy adults. Med Sci Sparta Exerc
2UDS;4I[3}:ES?—TGS.Medline DUI
The nptimal characteristics nf strength-specific prngrams
include the use ef cnncentric, eccentric, and isnmetric
muscle actians and the perfarmaace af bilateral and uni-
lateral single- and multiple-jaint exercises. In additian, it
is recnmmended that strength prngrams sequence exercises F?
ta aptimiae the preservatien af exercise intensity.
m
61“.}. Faigcnbaum AD, Eatamess NA, McFarland J, et al: Effect ifI:
:I
af rest interyal length an bench press perfermance in bays, u:
teens, and men. Pedietr Exerc Sci 2DflS:Eflj4}:4ST—4SS. 1"
Fl
Medline E
a:
m
F.
SI. Zafeiridis A, Dalamitres A, Dipla H, Maneu V, |liSalanis
N, Kellis S: Receyery during high-intensity intermittent
anacrebic exercise in hays, teens, and men. Med Sci Sparta
Esterc lflfl5;3?{3}:SflS-S 12. Medline DUI
62.. Milcwski MD, Skaggs DL, Bishep EA, et a]: lE'Jhrenic
lack af sleep is assaciated with increased sparts injuries in
adelescent athletes. J7 Pediatr Drtbnp 1014;34j1jfllS-133.
Medline DID]
Heurs ef sleep per night and grade in scheal were the
best independent predicters af injury in this study. Sleep
deprivatinn was assnciated with injuries. Thus, premeting
adequate ameunt ef sleeping haurs may help in the pretee-
tian against spurts-related injuries. Leyel af evidence: III.
63. ‘t’eung WE: Transfer ef strength and pawer training
ta sperts perfarmance. Int ] Sparta Phyaiei Perform
2i] flS:I{1}:?4-Sl Medline
Drthapaedic Knawledge Update: Sparta Medicine S
tio » "
Chapter 53
MRI of the Glenohumeral Joint
Iarnes Derek Stensby, MD
Abstract
MRI and magnetic resonance arthrography of the
shoulder are valuable tools in the assessment of the
rotator cuff, labroligamentons complex, and rotator
interval. Knowledge of the added benefits of MRI in
comparison to other imaging modalities, the common
pitfalls and normal variants, and added benefit of in—
Ufa-articular contrast and abduction-external rotation
positioning strengthen the preoperative assessment in
patients presenting with shoulder pain and instability.
Keywords: glenohumeral joint: lahrum: MRI;
rotator cuff
Introduction
MRI of the glenohumeral joint is done without contrast,
with intravenous contrast as an indirect arthrogram, or
with intro-articular contrast. The choice of technique
varies by institution and clinical indication. In the typical
MRI protocol, images are acquired in the axial, ohlique
sagittal, and oblique coronal planes. Some institutions
use the oblique or angled axial plane tn target the antero-
inferior glenoid labrum. The benefits of intra-articular
administration of contrast in direct magnetic resonance
arthrography [ME A} include capsular distension, which
improves visualization of the labrum, capsule, ligaments,
biceps tendon, articular cartilage, and articular side of the
rotator cuff.1 MM also allows simultaneous administra-
tion of intra-atticular anesthetic and steroids to provide
diagnostic information and therapeutic benefit, without
decreasing the image contrast.1
The absolute contraindications to Mill’s include the
presence of cellulitis or joint infection or a history of
Neither Dr. Stan-shy nor any immediate family member has
received anything of value from or has stock or stock op—
tions held in a commercial company or institution related
directly or indirectly to the subject of this chapter.
fl lflld American Academy of Drthopaedic Surgeons
ipsilateral reflex sympathetic dystrophy. Anticoagulatinn
therapy and a history of contrast allergy are relative con-
traindications.‘ The most severe complication is joint in-
fection, which occurs in approximately 1 of every 4fl,flflfl
patients} The most common complication is pain, on
average beginning 16 hours after the injection and resolv-
ing over 2 days.‘ A survey of 202 patients who underwent
shoulder MBA found that 1% of patients described the
pain as worse than expected and 40% described Mite.
as more tolerable than MRI."
The Rotator Cuff
MRI and MBA are excellent tools for evaluating the
rotator cuff because they offer better soft—tissue contrast
than other imaging studies. A meta—analysis of the accu-
racy of preoperative imaging in detecting full-thickness
rotator cuff tears found sensitivity of 95.4% and speci-
ficity of 93.9% for MRA, compared with sensitivity of
92.1% and specificity of 91.9% for conventional MRIF
Preoperative identification of partial—thickness rotator
cuff tears was less robust; with MEA, sensitivity was
35.9% and specificity was 96%, and with conventional
MRI sensitivity was 53.6% and specificity was 91.?%.'5
Each of the imaging planes allows specific aspects of
the rotator cuff anatomy and pathology to be assessed.
Oblique sagittal images are best for assessing the anterior
fibers of the snpraspinatus tendon, the anterior-posterior
dimension of any rotator cuff tear, the cnracoacrnmial
arch, and the rotator cuff musculature. The oblique cor-
onal plane is best for the snpraspinatus and infraspinatus
tendons, the transverse dimension of any tear, retraction 1-9
of the myotendinous junction, and the medial extent of 3
Eu
a delaminating tear. The axial plane is host for assessing
:1
EL
the subscapulatis tendon. to
A full—thickness rotator cuff tear is identified if fiber
discontinuity spans the entire thickness of the tendon, with
the defect isointense to fluid on T2—weighted sequences or
matching gadolinium signal intensity on MBA? A partial
tear is diagnosed if the fluid- or gadolinium-filled area
of fiber discontinuity spans only a portion of the tendon
thiclcness.E Articular-side thickening of the snpraspinatus
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectinn 5": [lugging

and infraspinatus {presumably the rntatnr cable} nn imag-

es nbtained in the neutral pnsitinn was fnund tn suggest
the presence nf a partial—thickness articular—side rntatnr
cuff tear9 {Figure I). Cnnversely, the rntatnr cable was
reliably identified in the absence of a rntatnr cuff tear
nn images nbtained in the abductinn-eatcrnal rntatinn
(AB-ER) pnsitinn. The descriptinn nf a full-thickness tear
shnuld include its lc-catinn, the tendnns invnlved, its an-
terinr-pnsterinr sine, and the extent nf retractinn. The
descriptinn nf a partial-thickness tear shnuld include nnt
nnly lncatien and size but alsn the percentage nf tendnn
thickness that is affected and whether the tear invnlves
the articular nr bursal surface.”
Prenperative identificatinn nf rntatnr cuff pathnlngy
can be imprnved by understanding the features that dis—
tinguish rntatnr cuff tendinnpathy frnm tendnn tears,
the must cnmmnn lncatinn nf rntatnr cuff tears, and
the pitfalls nf MRJ nf the rntatnr cuff. Du MRI, rntatnr
cuff tendinnpathy appears as increased thickness and
increased signal intensity. TZ-weighted fat—suppressed Figure 1 {Jbliuue tnrnnal TE-weighted fat-suppressed
sequences are useful fnr distinguishing tendinnpath‘}.r frnm magnetic resenance image shnws articular—side
a tendnn tear, which is isnintense tn fluid. An evaluatinn thickening {a rrnvv} at the presumed rntatnr
cable. indicating a partial-thickness articular-
nf degenerative tears in 360 shnulders fnund the rntatnr side tear. This finding was cenfirmed at
cuff segment 15 tn 16 mm pnsterinr tn the rntatnr cuff arthrnscnpy. The patient was a Elli—yea r—nld man
interval tn he the must cnmmnu lncatinn nf tears.11 This with prng ressive sheulder pain exacerbated by
nverhead activities.
segment’s lncatinn in the center nf the rntatnr crescent
may make it mnre prnne tn tearing and initiatinn nf a
degenerative tear.
Recent studies identified several MRI pitfalls. Ina
The Labrum and Labral lr'istabilitj,r
creased signal intensity in the substance cf the tendnn
cannnt be used in isnlatinn tn diagnnse rntatnr cuff pa— The fihrncartilaginnus labrum assists in stabilizing the
tbnlngy because increased signal may result frnm vari- glennhumeral jnint by increasing the surface area nf the
atinns in histnlngy er the magic angle artifact, which articulatinn, deepening the articular cavity, and serving as
usually is seen in the distal tendnn.” MRI evaluatinn a site nf attachment fur the capsulnligamentnus cnmple}:
nf the subscapularis tendnn was fnund tn be less rnbust and biceps tendnn. The nnrmal labrum has unifnrm lnw
than MRI evaluatinn nf ether rntatnr cuff tendnns.” signal intensity with a rnughly triangular cnnfiguratinn
Specificity and pnsitive predictive value fnr su bscapula ris em all MRI sequences. The labrum may have a sharp nr
tears bnth were lflfl‘i’rii cnmpared with arthrnscnpy, but rnunded free edge. Increased signal within the labrum
sensitivity was duly 39% and accuracy was nnly 69%.” may be an artifact caused by vnlume averaging er magic
These data suppnrt the premise that MRA, fat suppres— angle {nn shnrt echn time sequences]. The labrum is best
sinn, and image interpretatinn by a fellnwship-trained assessed with MIRA, which increases the cnnspicuity nf
tn musculnskeletal radinlngist are useful in the prenperative tears with a cnmhinatinn nf juint distensinn, separatinn
.5
en diagnnsis nf subscapularis tears. Identificatinn nf a cyst nf the snft—tissue suppnrt structures, and extensinn nf
in
E in nr adjacent tn the lesser tubernsitjyr shnuld prnmpt a cnntrast intn any defect. The superinr and inferinr as-
careful assessment cf the subscapularis.” The difficulties pects nf the labrum are best assessed nn nblique cnrn-
é;

in evaluating the subscapularis tendnn include vnlume
averaging cf the superinr margin cf the tendnn and the
adjacent rntatnr cuff interval mimicking a tear, difficulty
in differentiating an intrasubstance nr cnncealed tear
frnm an articular-side tear, and an irregular cnntnur cf
the tendnn surface caused by tendinnpathy and leading
tn a false-pnsitive diagnnsis nf a tear.”
nal images, and aerial images nffer the best views nf the
anterinr and pusterinr labrum. Angled er nblique asial
images may yield the best views nf the anterninferinr and
pnsternsuperinr aspects nf the labrum. The glennhumeral
ligaments are best evaluated using a cnmhinatinn nf ax-
ial and sagittal images. Any anterninferinr bnne less is
best detected nn nblique sagittal images. MRI is slightly

firthnpaedic Knnwledge Update: Spurts Medich'ie 5 fl lflld American Academy nf Cirrhnpaedic Surge-ens
 Chapter 53: Mill bf the Glebbhumeral JbiJIt

Figure 2 Magnetic resbnance images shbw nbrr'nal labr'al Iuariants {arrbws}. A, A thin curvilinear cbntrast extensibn
between the glenbid and superibr labrurnr anteribr tb the biceps anchbr, which is cbnsistent with a sublabral
sulcus. B. A sublabral fbrarnen with centrast extensibn between the glenbid and anterbsu peribr Iabru m, abbve
the midglenbid. c. A Bufbrd temples with an absent anterbsuperibr labrurn and a thick middle glenbhumeral 1-9
ligament. D. A hypertrbphic pbsterbinferibr la brurn sis-tbnclanlr tb mild glenbicl hyp-bplasia. 3
cu
:1
EL

inferibr tb CT fbr assessing glenbid bbne lbss when cbm—
pared tb arthrbsc'bpicall].r preven defects.”
An understanding bf the man}r nbrrnal 1rariants bf the
labrnm can prevent a false-pbsititre diagnbsis bf a labral
tear. Mast labral variants are fbund in the supetibr and
anterbsuperibr labrum. The sublabral sulcus br recess is
a cbmmbn variant that can be mistaken fer a superibr
LI]
labrum anteribr and pbsteribr rear. The sulcus, which
is seen in as manyr as T3913 bf patients, has a smbbth,
well—defined margin, parallels the glenbid and dbes nbt
extend pbsteribr tb the biceps-labral anchbrl"r (Figure 2,
A}. If the cbntrast br abnbrmal signal extends mm the
substance bf the superibr labrum, it can be preblznerati'lieI].r
distinguished frbm a tear {Figure 3}. In the anterbsuperibr

IE! lfllfi American Academy bf flrchapaeclic Surgebns Drthbpaedic Knbwledge Update: Spbrts Medicine 5
 SEEl'ifll't 5": Imaging
Figure 3 TE-weighted magnetic resonance arthrogram
demonstrating abnormal contrast extension
into the substance of the superior labrum
{arrow} compatible with a superior labrum
anterior to posterior tea r. The patient was a
ED-year-old man who presented with a 3-month
history of right shoulder pain that worsened
with abduction. The patient underwent
arthroscopic repair after conservative
management failed.
quadrant, the labrum may not be firmly adherent to the
glenoid, and contrast or fluid can be interposed into this
sublabral foramen {Figure 2, B}. The sublabral foramen
may extend and become contiguous with the sublabral
recess, but it should not extend into the biceps—labral
anchor or anteriorly below the midglenoid. The Buford
complex, another anterosuperior labral variant, is found
on arthroscopy in 1.5% of patients as a focally absent
labrnm in the anterosnperior quadrant with a thick, cord-
lilte middle glenohumeral ligament” {Figure 2, C}. An
additional variant that may be encountered in the eval—
uation of the labrum is labral hypertrophy in the setting
of posterior glenoid hypoplasia {Figure 1, D).
Several imaging techniques can be used in evaluating
the anteroinferior labrum. The most complete evaluation
on is obtained with MBA in both the standard and ABER
.E
on positions. The Perthes lesion, a nondisplaced avulsion of
l'fl
E the labrum with stripping of the medial periosteum, is
best seen on sequences obtained in the AEER position11m
é;
{Figure 4}. The anterior labral periosteal sleeve avulsion
lesion, which is a medially displaced avulsion of the la-
brum and attached glenohumeral ligament with intact
scapular periosteum, is best identified on MRI in the
standard position.” Although hail-1A has been the stan-
dard for evaluation of the labrum, a recent comparison
study found that multideteetor computed tomographic
firthopaedic Knowledge Update: Sports Mediehie 5
Tl-weighted magnetic resonance arthrogram
of the anteroinferior labrum in the standard
{A} and abduction-external rotation ill
positions. Linear T1 hyperintense contrast
{arrow} interposed between the glenoid and
the nondisplaced labrun'i in {I} is compatible
only with a Perthes lesion. The patient was an
13-year-old worn an who played volleyball and
had shoulder pain. swelling, and a popping
sensation.
arthrography {ETA} offered better evaluation of the
labroligamentous complex, cartilage, and osseous inju-
ries than MBA.“ The authors concluded that although
ETA is less expensive, has fewer contraindications, and
requires less time than MBA, it does not offer a complete
evaluation of the extra-articular structures, is less reliable
than MBA for evaluating the middle glenohumeral liga-
ment, and exposes the patient to radiation.
There has been recent emphasis on preoperative iden-
tification of a humeral avulsion of the glenohumeral liga-
ment {HAUL} because this lesion may be a cause of failed
surgery to correct shoulder instability {Figure 5}. The
difficulty of identifying a HAGL lesion arthroscopically
increases the importance of preoperative imaging detec-
tion.22 Unfortunately, HAGL lesions often are not detect—
ed on MRI. A recent study reported that 26% of HAGL
lesions could not be identified on MRI despite knowledge
of the surgical findings.” All of the patients had a history
of anterior dislocation or instability. Additional injuries,
the most common of which were Hill-Sachs fracture
and subscapularis tendon tear, were identified in 95%
of patients. In a patient with relevant history or after
noncontributory conventional MRI, MR5 can aid in the
preoperative diagnosis of a HAUL lesion.”113
The BiEEps Tendon and Rotator Cuff Interval
Lesions of the biceps tendon and rotator cuff interval
can be a source of pain. These lesions usually occur in
conjunction with rotator cuff pathology, but they also
fl lflld American Aeadmny of Orthopaedic Surgeons

Figure 5 Dbligue coronal TE-weighted fat-suppressed
magnetic resonance arthrogram shows a
tear of the inferior glenohumeral ligament
at its humeral attachment. which has led to
an abnormal double contour {arrow}. Edema
in the humeral head {asteriskl resulted from
dislocation and anterior impaction. The patient
was a 21-year-old man who played hockey, had
a history of Iabral repair. and had a recurrent
dislocation.
can occur in isolation. Proton density—weighted sequences
with fat suppression have the greatest sensitivity for de-
tecting tendon degeneration, although tendon caliber
change is more specific.“ Diagnosing partial tears of the
biceps tendon at the entrance to the bicipital groove can
be challenging on MRI or MRA without directed effort.
Biceps tendon partial tears at the groove entrance show
abnormal signal intensity, but half have an associated
caliber change, and evaluation in all imaging planes aids
in identification of a biceps groove entrance lesion.” The
biceps pulley, which is composed of the superior gleno-
humeral ligament and coracohnmeral ligament in com—
bination with the subscapularis, holds the biceps tendon
in place. MRA was found to have sensitivity of 32% to
sees and specificity of fl?% to 93% in the evaluation of
the biceps pulley.“ Diagnostic criteria included nonvisu-
aliaation or discontinuity of the superior glcnohumctal
ligament, medial subluxation of the biceps tendon on
axial images, biceps tendinopathy, and inferior displace-
ment on oblique sagittal images.
The rotator cuff interval is a triangular region bound-
ed medially by the coracoid process, superiorly by the
anterior margin of the supraspinatus, and inferiorly by
the superior margin of the subscapularis. In the rotator
IE! lfllli American Academy of flrthopaedic Surgeons
Chapter 53: MRI of the Glenohurneral Joint
lElblicjue sagittal Tl-weighted magnetic
resonance image shows loss of fat signal
intensity in the su bcoracoid fat {arrow}. The
patient was a 53-year-old woman with clinical
signs of adhesive capsulitis.
cuff interval the anterior capsule is supported by both the
superior glenohumeral ligament and the coracohnmeral
ligament. The biceps tendon traverses the rotator cuff in-
terval, where it is held in place by the biceps pulley, before
exiting the joint via the hicipital groove. The complex
anatomy of the rotator cuff interval is best assessed with
MR3. because joint distension can separate the compo-
nents of the rotator cuff interval. Abnormalities of the ro-
tator cuff interval can lead to a restricted range of motion
or instability. Adhesive capsulitis is a common condition
characterized by painful and restricted range of motion
that is exacerbated at night. The MRI findings in adhe-
sive capsulitis include thickening of at least 4 mm in the
coracohumeral ligament, thickening of the joint capsule
in the rotator cuff interval, and obliteration of the sub-
coracoid fat” [Figure 6}. Conversely, a capacious rotator
cuff interval capsule may be seen in the setting of instabil- 1-9
ity. 1"With MRA all five patients with a surgically identified 3
cu
rotator cuff interval lesion had contrast extension to the
:1
EL
undersurfacc of the coracoid process“ {Figure TI"). The to
rotator cuff interval was found to be significantly larger
in patients with chronic anterior instability.”
S u m ma ry
MRI and MRA offer an excellent means of assessing
internal derangement of the glenohumeral joint and the
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectien 9: imaging
Annotated References
Figure? Del-due cerenaIT‘l-weighted magnetic
resonance arthregrarn shews a capacieus
capsule in the tetatet cuff interval with
ce ntrast eatensien te the uncle rsurface ef the
cure ceid anterierly. The patient was a 14-year-
eld girl whe had been injured in a cheerleading
accident. Preeperative eaaminatien under
anesthesia cenfi rmed heth anterier and
pesterier instability.
tetatet cuff, and they can he helstered by tailering the
technique re the specific clinical cencern. Knewledge ef
MRI techniques, artifacts, nermal variants, and pitfalls
adds pewet te this clinical reel.
Key Study Peints
I MRA impreves sensitivity and specificity fer beth
full {95.4% I 39.9% versus 91.1% f 92.9%} and
partial {35.9% {96% versus 63.6% .3 913%] in
cemparisen with arthrescepy.
It MRA in the AEER pesitien impteves evaluatien
ef the inferier lahrum and identificatien ef Perthes
lesiens.
en
.5
en
l Preeperative assessment ef the suhscapularis, the
l'fl
humeral attachment ef the glenehumeral ligament,
E
é;
and the biceps tenden at its entrance re the hicipital
greeve is challenging.
1' Knewledge ef the nermal lahral variants impreves
the preeperative MRI evaluatien.
l MRI findings ef adhesive capsulitis include thicken—
ing ef the cetacehumeral ligament, thickening ef the
ieint capsule in the tetatet interval, and ehliteratien
ef suh-ceraceid fat.
firthnpaedic Knewledge Update: Sperts Medicine 5
. Rhee RB, Chan KK, Lieu JG, Kim ES, Steinhach L5: MR
and CT arthregraphy ef the sheulder. Semis: Masculin—
shale: Radfef lflllflfiilifl-H. Medlinc DUI
MEAL technique, indicatiens, centraindicatiens, and im-
aging pretecels were reviewed, with relevant anatemy
and pathelegy.
. Ugas MA, Huynh EH, Fest MG, Pattie JT, Gaskin CM:
MR. arthregraphy: Impact ef stcreids, lecal anesthet-
ics, and iedinated centrast material en gadelininm sig-
nal intensity in phantems at 1.5 and 3.0 T. Rndr'elegy
2014;2T2i1}:4?5-433.Medline DUI
The signal intensity ef M11135. phantems centaining varying
cencentratiens ef gadelinium, iedinated centrast, lecal
anesthetic, and certicestereids were studied.
. Newherg flH, Munn CS, Rehhins AH: Cemplicatiens
ef arthregraphy. Radiefegy 1935;155-[31-tEDS-EDE.
Medline DD]
. Giaceni JC, Linlt TM, Vail TP, et a1: Merhidity ef direct
MR arthregraphy. AIR first] Reevrtgenei 1fl11;196{4}:363-
H954. Mcdlinc DDI
A survey ef 155 censecutive patients determined the fre-
quency, intensity, and time ceurse ef pain after direct
. Binltert CA, Zanetti M, Hedler J: Patient‘s assessment
ef discemfert during MR. arthregraphy ef the sheulder.
Radfelegy lflfl];231{3i:??5-??3. Medline DUI
. de Jesus JG, Parlter L, Franges A], Naearian LN: Accu-
racy ef MRI, MR arthregraphy, and ultraseund in the
diagnesis ef tetatet cuff tears: A meta-a nalysis. AIR Arr:
,7 Reenrgenel2909;191i6}:1?fl1—1?fl1 Medline DUI
A meta-analysis ef 65 studies evaluated the sensitivity and
specificity ef direct MBA, standard MRI, and ultraseund
in the evaluatien nf full- and partial-thickness tetatet
cuff tears.
. Farley TE, Neumann CH, Steinhach L5, jahnke A], Pe-
tersen SS: Full—thickness teats ef the tetatet cuff ef the
sheulder: Diagnesis with MR imaging. AJR Am ] Reent-
3'm 1991;153fllr34T-351. Medline DUI
. Kassarjian a, Bencardine JT, Palmer 1|iiii'E: MP. imaging ef
the tetatet cuff. Eadie! Effie Netti: Am 2Dfll5;44{4}:5{13-
523, vii—viii. Medline DUI
. Sheah K, Bredella Milt, 1'ifl'i'arner j], Halpetn EF, Palmer
WE: Transverse thickening aleng the articular surface ef
the tetatet cuff censistent with the tetatet cable: Identifi-
catien with MR arthregraphy and relevance in retater cuff
evaluatien. AJR Am I Reenrgenef 20 [19,1 93(3):!ST9-536.
Medline DO!
A retrespcctive review cf 54 patients cempatcd arthres—
cepy with MRA in standard and ABEF. pesitiens fer
fl lfllfi American Academy ef Drthepaedic Surge-ens

identificatien ef the retater cable as an indicate-r ef reta-
ter cuff tears.
Id. Ellman H: Diagnesis and treatment of incemplete reta-
ter cuff tears. Elia Urtbep Refer Res 199fl;254:64-?4.
Medline
11. Kim HM, Dahiya N, Teefey EA, et al: Lecatien and ini-
tiatien ef degenerative retater cuff tears: An analysis ef
three hundred and sixtyT sheulders. J Hens faint Surg Am
lfllflfllfilflflEE-Iflflfi.Medline DUI
A retrespective review ef 315i] sheulder ultraseund exam-
inatiens determined the mast cernmen lecatien ef partial-
and full—thickness retater cuff tears.
12. Tuite M]: Magnetic resnnance imaging ef retater cuff
disease and external impingement. Mega Resen Imaging
(Hit: N Am lflllglfliflflfiilflfl, ix. Medline DUI
External impingement and its MRI characteristics were
reviewed.
13. Adams CR, Scheelfield JD, Burl-c ha rt 55: Accuracy ef
preeperative magnetic resnnance imaging in predicting a
subscapularis tenden tear based en arthrescepy. Artbres-
cepy lfllflt2fill 1}:142?—1433. Medline DUI
A retrespective review cempared the sensitivity and
specificity ef MRI and arthrescepy fer the diagnesis ef
subscapularis tears in 90 censecutive patients. Level ef
evidence: III.
14. Wissman RD, Kapur 5, Alters J, Crimmins J, Ting J, Laer
T: Cysts within and adjacent tn the lesser tuberesity and
their asseciatien with retater cuff abnarmalities. AJR Am
J Reentganef lflfl9;193{fi}:lfifl3—lfiflfi. Medline DUI
A retrespective review nf 1,Ili}fl sheulder MRI examinas
tiens cerrelated the presence ef MRI-visualised humeral
head cysts in varieus lecatiens with the presence ef retater
cuff tears.
1.5. Gyftepeules S, U'Dnnnell J, Shah NP, Gess J, Babb J,
Recht MP: Cerrelatien ef MRI with arthrescepy fer the
evaluatien ef the subscapularis tenden: A musculeslteletal
divisien’s experience. Skeletal Radial 2013:42[9}:1269-
127'5. Medline DUI
A retrespective review ef 236 patients cempared the sen-
sitivity and specificity ef MRI and arthrescepy in the
evaluatien ef the subscapularis. Discerdant findings were
reviewed te identify pitfalls in the MRI evaluatien.
16. Lee RE, Griffith JP, Teng MM, Sharma N, Yung P: Gle-
nnid hene less: Assessment with MR imaging. Radfefng'y
2013;16?{1):496—5fl2. Medline DUI
A rettespective study cempared MRI ef gleneid bene less
with CT and arthrescepy in 166 patients.
1?. Smith DBL, {Zhepp TM, Aufdemertc TE, Witkewslti EG,
Jenes RC: Sublabral recess ef the snperier gleneid labrurn:
Study ef cadavers with cunventienal nenenhanced ME itn-
aging, MR. arthregraphy, anatemic dissectien, and limited
IE! lfllfi American Academy ef Urthepaedic Surgeens
Chapter 53: Mill ef the Gleuehumeral Jeint
histelegic examinatien. Radfefeg'y 1995;2fl1{1}:251-256.
Medline DUI
13. 1|Williams MM, Snyder SJ, Buferd D Jr: The Buferd cem-
plex: The “cerd-lilte” middle glenehumeral ligament and
absent anteresuperier labrurn cemplex. A nermal ana-
temic capsulelabral variant. Artbrescepy 1994;1fli3]:141-
24?. Medline DUI
19. Tian CY, Cui GU, Zheng ZZZ, Ren AH: The added value
ef ABER pesitien fer the detectien and classificatien ef
antereinferier lahreligamenteus lesiens in MR arthreg-
raphy ef the sheulder. Eur] Eadie!1fl13;32{4}:551-651
Medline DUI
A retrespective study cempared geld-standard arthres-
cepy with MRI in the standard and ABER pesitiens fer
evaluatien ef the antereinferier labrurn.
ED. Wischer TE, Eredella MA, |Genant HK, Steller DW,
lilcrst PW, Tirman PF: Perthes lesien {a variant cf the
Bankart lesien}: MR imaging and MR arthtegtaphic
findings with surgical cerrelatien. AIR Am I fiesetgeeef
Zflfl2;1?3{1}:233-23?.Medline DUI
21. Acid 5, Le lIEerreller T, Aswad II, Pauly V, Champsaur
P: Preeperative imaging ef anterier sheulder instability:
Diagnestic effectiveness ef MDCT arthregraphy and cem-
parisen with MP. arthregraphy and arthrescepy. AJE Am
J Reentgerref 2012;193I3}:fifil-661 Medline DUI
A retrespective study cernpared direct MRI and ETA in
the evaluatien ef anterier instability. Arthrescepy was
censidered the geld standard.
12. ll3eetge M5, Khaaaam M, Kuhn JE: Humeral avulsien
ef glenehumeral ligaments. J Am Acad Urtfaep Surg
2fl11:19{3}:12?-133. Medline
Clinical findings, imaging findings, and treatment ef
HAGL lesiens were reviewed.
13. Magee T: Prevalence ef HAUL lesiens and asseciated ab-
nermalities en sheulder MR examinatien. Skefetal Radfef
2fl14;43{3}:3fl?-313.Medline DUI
Imaging findings and asseciated injuries in 23 censecutive
patients with surgically cenfirtned HAUL lesiens were
retrespectively reviewed.
24-. Buck FM, Grehn H, Hilb-e M, P'firrtnann CW, Manaanell
S, Hedler J: Degeneratien ef the leng biceps tenden: Cem-
parisen ef MRI with grass anatemy and histelegy. AIR 1-9
Am] Reentgenef lflfififl 93(5 3:136T-13'FS. Medline DUI
3
a:
MRI and histelegic findings ef biceps tendinepathy in 15
:1
EL
cadaver specimens were cempared. LI]
15. IGasltin CM, Andersen MW, Cheudhri A, Diduch DR:
Fecal partial tears ef the leng head ef the biceps brachii
tenden at the entrance tn the bicipital greeve: MR imaging
findings, surgical cerrelatien, and clinical significance.
Skeletef Radfeflflfl9:33{1fll:959—965. Medline net
Urtbepaedic Knewledge Update: Sperts Medicine 5
 Section 5": [lugging
A tettnspectiye study ctunpated atthtnscnpy and MRI
nf partial tears cf the biceps tendnn at the biceps gnu-aye
entrance in 16 patients.
16. Schaef'feler C, Waldt S, Helsapfel K, et al: Lesinns cf the
biceps pulley: Diagnostic accuracy crf MR arthrngraphy
nf the sheulder and evaluatien nf preyinusly described and
new diagnnstic signs. Rndieingy 1012;264il}:5fl4-513.
Medline DUI
A retrnspectiye study evaluated the accuracy at MBA in
the disgnnsis nf lesinns nf the biceps pulley in 30 tense-c—
utive patients, in cnmparisnn with arthrnscnpy.
tn
.E
can
l'fl
E
é;
firthnpasdic Knnwledge Update: Spnrts Medich'ie 5
2?. Mengisrdi B, Pfirrmsnn CW, Gerber E, Hndlet J, Eanetti
M: Frusen shnulcler: MR arthrngraphic findings. Radial-
Dg'y Iflfl4;233{1}:436-492. Medline DUI
23. Vinsnn EN, Majnr NM, Higgins LD: Magnetic resnnance
imaging findings assn-ciated with surgically prayen rata-
ttu' interval lesinns. Skeletal Radial Eflfl?;36{5i:4fl5-4lfl.
Medline DD]
25'. Kim KC, Rhee K], Shin HD, Kim TM: Estimating the
dimensinns cf the tntatnr interval with use nf mag-
netic resnnance arthrcrgraphy. ] Bane faint Surg Am
lflfl?;39{11j:245D—1455.Medline DUI
fl lfllfi American Headmny nf Urthnpaedic Surge-ens
Chapter 54
MRI of the Elbow
Nicholas C. Natty. MD
Radiography, CT, ultrasound, and MRI all are used
in elbow imaging to assess patients with pain. How—
ever, MRI is the best imaging modality for evaluating
soft-tissue structures in the elbow. The common flexori'
entensor tendons, biceps tendon, collateral ligaments,
and nerves all are commonly injured structures that are
easily evaluated with MRI.
Keywords: elbow: MHI
Introduction
Radiography, CT, ultrasound, and MRI each have a
role in elbow imaging. Radiographs of the elbow should
be obtained if the patient has acute traumatic injury or
chronic pain. CT can be helpful in identifying mineralized
intra-articular loose bodies or delineating the anatomy of
a complex intra-articular fracture. Ultrasound soft-tissue
evaluation in the elbow is most useful in evaluating the
distal biceps and the common flexor and entensor ten-
dons.1 Ultrasound allows dynamic imaging, which may
be useful in evaluating for ulnar nerve subluitation or a
snapping triceps.
In general, MRI is the imaging modality best suited for
evaluating soft—tissue structures in the elbow including
ligaments, tendons, cartilage, and nerves. Conventional
MRI sequences should be obtained in all three planes
using Tl-weighted and fluid—sensitive sequences {short
tau inversion recovery or Til-weighted sequences with fat
suppression}. Magnetic resonance arthrography {MBA} is
particularly beneficial in the evaluation of osteochondral
Neither Dr. Nacey nor any immediate famiiy member has
received anything of value from or has stuck or stock op-
tions heici in a commercial company or institution reiateo'
ti‘irettiyr or indirectiy to the subject of this chapter
fl lflld American Academy of [irrhopaedic Surgeons
lesions, loose bodies, and ulnar collateral ligament [UCLj
injury in a throwing athletes! Coronal studies should be
obtained along a line connecting the medial and lateral
epicondyles, and sagittal studies should be perpendicular
to the coronal studies.J MRI units with a 3—Tesla magnets
ic field strength can generate high signal-to-noise ratios
and are able to demonstrate a more detailed depiction of
normal anatomy compared to a 1.5-Tesla unit. Caution
is necessary, however, because 3-Tesla imaging can show
mild signal alterations of tendons, ligaments, and nerves
of the elbow that may not be symptomatic.4
The common eaten sot and flexor tendons are best seen on
fluid-sensitive coronal and axial studies. Normal tendon
should be hypointense on all sequences, except that sop
called magic angle artifact occasionally occurs on short
echo time sequences, such as Tl—weighted and proton
density sequences, when normal tendon fibers are oriented
55" from the main magnetic field. Mildly hyperintense or
intermediate signal on fluid-sensitive studies within one
of these tendons is consistent with tendinosis. A diagnosis
of tendinosis on the basis of short echo time sequences
requires caution because of the potential for false diagno-
sis related to magic angle artifact. The presence of magic
angle artifact can be confi rmed by identifying the normal
hypointense appearance of the tendon on T2-weighted
or short tau inversion recovery sequences. Hyperintense
signal that matches the signal intensity of joint fluid is 1-9
consistent with tendon tearingi {Figure 1}. Muscle edema 3
Eu
from an associated strain may be seen adjacent to an
:1
EL
area of common extensorufleitor tendinosis or tearing. to
High signal intensity from reactive edema in the adjacent
bone sometimes can be seen but need not be present.
The extensor carpi radialis brevis is the most commonly
injured component of the common entensor tendon, and
the pronator tame and flexor carpi radialis are the most
commonly injured components of the conunon flesor
tendon. Evaluating the underlying collateral ligament is
Drthopaedic Knowledge Update: Sports Medicine 5
 SEEEifln 9: Imaging
. .I ll
“ IZ-rfiw
Figure 1 A cerenal fluid-sensitive MRI study showing an
internal cleft cit fluid in the cummun extensur
tenden iarrewll, censistent with a high-grade
partial tear. The untern pertiens ef the tend-an
are thickened and shuw internal intermediate
signal that is net as bright as the fluid signal at
the tear, censistent with underlying tendincisis.
critical because tendun débridernent in the presence cif an
undetected ligament injury can lead ti} elb-uw instability!
The distal biceps tendcin lies antericir tn the brachialis
tendun and has a much lunger tendcin segment} Axial
studies shuuld extend just distal tn the radial tuberusity
te ensure that the entire tendcn insertien is included.
Absence cf the biceps tendun at its insertion is cunsistent
with a complete rupture {Figure 2}. The distal biceps
tendcin may have a bifurcated appearance near its inser-
tinn cm the radial tubercsity because pf separatic-n cf the
chart and lung heads.El Distal biceps tendun tears may
en preximally retract if there is injury as the lacertus fibre-
.E
can sus. Fur presurgical planning, sagittal MRI studies can
l'fl
E easily measure the extent uf tendun stump retracticm?
Tendinpsis and a partial tear cf the distal biceps tendun
é;
can uccur. The distal biceps tendun has nci tendun sheath
but instead a bicipitcradial bursa is interpcsed between
the tended and underlying bune. The bursa may becc-me
enlarged and inflamed if there is assuciated biceps pa-
theicgyflE The curving distal biceps tend-an sc-metimcs has
intermediate signal cm Tl— ur prc-tcin density—weighted
studies as a result pf magic angle artifact; this artifact
firthepaedic Knewledge Update: Sparta Medichte 5
An axial fluid-sensitive MRI study shuwing the
absence cf the ncrmal distal biceps insertiun
ente the radial tuberusity I{scilid arruw) with
surrciu nding edema in the antecubital fessa,
compatible with cun'iplete distal biceps rupture.
Mere medially. the inserticin ef the brachialis
tendun can be seen near the ulnar tuberusity
{clashed arrewil
is net seen an Tl-weighted studies.ml Pcsiticning the pa-
tient in elbuw flexicm, shuulder abductiun, and furearm
supinaticn {the FABS pcsiticnl can imprcye yisualisaticn
cf the biceps tEflElflflF The triceps tended nurmally has a
striated appearance because three muscular cumpunents
ccntribute tc its fibers.”| Triceps tears usually are best
seen an sagittal studies near the insertiun cf the triceps
en the ulecranun. Small ayulsicin fractures ur fractured
enthesciphytes often are present but are best seen an
radiugraphs.“~”
The anterier bundle cf the UCL, which is the primary
stabilizer cf the medial side cf the elbciw, ciften is injured in
thruwing athletes. The anteriur bundle is best seen cm cur—
unal studies. The humeral attachment typically is breader
than the distal attachment en the sublime tubercle cf the
ulnal The pustericir bundle cf the UCL is less ciften injured
than the antericr bundle and is best seen an axial studies
as the finer cf the cubital tunnel just deep tn the ulnar
nerve. With MRA, a tear cf the UCL appears as ligament
thinning er thickening with asseciated Tl-weighted hy-
perintense fluid signal cur Tl—weighted hyperintense signal
from gadulinium cuntrast. In a full-thickness tear, fluid 01'
fl lflld American Academy cif Urrhupaedic Surge-ens

Figure El A coronal fluid—sensitive MRI study showing
hyperintense fluidlike signal extending across
the entire thickness of the ulnar collateral
ligament anterior bundle near its humeral
attachment {arrow}. consistent with a full-
thickness tea r. The distal insertion of the
ligament on the sublime tubercle of the ulnar
appears intact.
contrast extends across the entire thickness of the ligament
and possibly into the adjacent soft tissues” [Figure 3}.
Contrast extending between the distal attachment of the
UCL anterior bundle and the sublime tubercle [called a T
sign} is compatible with a partial-thickness undersurface
tear in throwing athletes with media] instability” {Fig-
ure 4}. However, anatomic correlation studies found that
the T sign can be a normal variant if the gap is less than
3 mm, especially if the patient is older than T5 years.”-”
In a reconstructed UCL, an enlarged appearance may
be normal, with internal intermediate signal of the graft
relative to the native UCL. Graft interruption and laxity
with a Til-weighted hyperintense fluid signal or gadolini-
um contrast extending across the graft is compatible with
recurrent tearing, however.”*”
The lateral ligament complex consists of the radial
collateral ligament {REL}, lateral ulnar collateral ligament
{LUCL}, and annular ligament. The proximal attachment
of the REL and LUCL to the humerus lies just deep to
the common extensor tendon, with the REL just ante-
rior to the LUCL origin. The RCL extends distally to
attach to the annular ligament. The LUCL passes along
IE! lfllfi American Academy of flrthopaedic Surgeons
IShapter 54: MRI of the Elbow
Figure 4 A coronal T1 -weighted fat-suppressed
postarthrography MRI study showing T1—
weighted hyperintense signal from gadolinium
contrast extending between the distal insertion
of the ulnar collateral ligament anterior
bundle and the sublime tubercle {arrow}. The
presence of the T sign suggests partial-thickness
unde rsurface tearing.
the posterior aspect of the radial head and neck and the
annular ligament to eventually insert on the supinator
crest of the ulnar" The distal aspect of the LUCL can be
difficult to see on MRI because of its oblique course; most
LUCL tears occur at the humeral attachment, however"5
(Figure 5}. RCL and LUCL tears appear as fluid signal
or gadolinium contrast extending across a portion of the
ligament in a partial-thickness tear or the entire thickness
of the ligament in a full-thickness tear. LUCL injury often
is associated with posterolateral rotatory instability or a
prior elbow dislocationJfli'
A synovial fringe {a symptomatic plica] sometimes can 1-9
be found in the radiocapitellar compartment. The diag- 3
cu
nostic use of MRI can be problematic because the synovial
:1
EL
fringe sometimes has a similar appearance in people with to
and without symptoms.21 A synovial fringe thickness of
more than 3 mm and coverage of more than one third of
the radial head are believed to be the most specific signs
of synovial fringe syndrome. Possible associated findings
include increased signal within the plica, signal changes
in the surrounding bone marrow, and radiocapitellar
chondral lossfi2
Drtbopaedic Knowledge Update: Sports Medicbie 5
 SEEEiDIl 5": Imaging

Figure 5 A coronal fluid-sensitive lv'lFiI study showing

a tear at the humeral attachment of the
lateral ulnar collateral ligament {solid arrow]
with irregular and distally retracted ligament
fibers. The overlying common eatensor tendon
is thinned, compatible with partial tearing
id ashed arrow).

Bones and Cartilage

Two normal, common osseous elbow variants of the el-
bow are important to note. Cortical irregularity some—
times is seen along the posterior aspect of the capitellum
at the bare area without overlying cartilage. This variant,
sometimes called a capitellar pseudodefect, can mimic an
osteochondral lesion on far-posterior coronal MELHJ“ In
addition, a central trochlear ridge that is devoid of over-
lying cartilage can be seen on sagittal MRI and should
not be mistaken for a chondral defectflfl“
An osteochondral lesion often occurs in the capitellom
more anteriorly than the capitellar pseudodefect, typi-
call},r in older children with fused physes.” A capitellar
on osteochondral lesion is seen on MRI as abnormal signal
.E
on intensityr in the subchondral bone with potential overly—
l'fl
E ing chondral abnormality. Stabilityr of the osteochondral
lesion is determined by the presence of focal cartilage
é;
r3. sagittal fluid—sensitive MRI study through
the radiocapitellar compartment of the
elbow showing an unstable osteochondral
fragment {solid arrow] involving both the
bright hyaline cartilage and dark subchondral
bone plate. Instability is indicated by cartilage
fissures at the margins of the osteochondral
fragment with Tlivveighted hypen' ntense fluid
signal tracking along the deep aspect of the
lesion. The osteochonriral fragment is on the
anterior aspect of the capitellum. A normal
pseudodefect of the capitellum is seen as an
irregular area of bone more posteriorly on the
capitellum whe re there is no overlying cartilage
{dashed arrow}.

interruption and fluid signal or cystic change along the
deep aspect of the lesion in the subchondral hone2f {Fig-
ure ii]. MRA can be used to determine fragment insta—
bility; extension of Tl-weighted hyperintense signal from
gadolinium contrast along the deep aspect of the lesion is
indicative of instability. In children with unfused physes,
Panner disease is an osteochondrosis caused by necrosis
and regeneration of the unfusecl capitellar ossification
center. Heterogeneous T1- and Til-weighted signals with
associated fragmentation of the capitellar ossification
center are characteristic MRI findings in Panner disease.“
MRI may be clinically indicated to evaluate for radio-
graphically occult or subtle fractures, most commonly in
the radial head or neck in adults and the supracondylar

firthopaedic Knowledge Update: Sports Medich'ie 5 fl lflld American Academy of Orthopaedic Surgeons

Figure 3‘ en atrial fluid-sensitive l‘v'lFil study shuwing
edema within the medial epicendylar apephysis
{anew} in a yummy patient with an unfused
physis, campatihle with stress change in Little
Leaguer's elbow.
regien in children.” Bene centusiens eften are present
after dislecatinn and can be seen an l'vIRI.2 An avulsive
stress iniury tn the medial epicendyle, semetimes called
Little Leaguer’s elbcrw, can eccur befere physeal fusien
in a young threwing athlete.” Edemalike signal frnm
recurrent avulsive stress can be seen en fluid—sensitive
MRI within the medial epicendylar apephysis as well as
its asseciated physis {Figure 7'}. The physis may appear
to be abnermally widened.
Cartilage abnernialities can be seen an MRI, altheugh
they may be difficult te diagnese because ef the intrin—
sically thin nature of elbew cartilage. In threwing ath-
letes, cartilage defects andfur esteephyte fermatinn can
be seen aleng the medial aspect ef the elecranen with
pesteremedial elecranen impingement as a cempenent ef
valgus everlead syndrcime.” Intra-articular lease bedies
are easily seen en cenventienal MRI sequences er M11251.
Nerves
The ulnar nerve is the nerve mest cemmenly entrapped
at the elbuw. The ulnar nerve ceurses th reugh the cu-
bital tunnel farmed anterierly by the medial epicendyle
and UCL pestericir bundle, laterally by the elecrannn,
and pesterierly by the arc uate ligament. The ulnar nerve
travels between the humeral and ulnar heads ef the Hester
carpi ulnaris muscles aleng the distal aspect ef the cubital
tunnel; in the mere prescimal pertien there sheuld truly
be thin, law-signal {ie, dark} arcuate ligament aleng the
superficial aspect ef the tunnel witheut any everlying
muscle fibers. Any muscle fibers in this area are frem an
accesse muscle knewn as the anceneus epitrechlearis,
IE! Efllfi American Academy ei' flrchepaedic Surgeens
IShapter 54: Mill ef the Elbevr
Figure E An axial T1 weighted MRI study shewing
striated muscle fibers traversing the superficial
aspect ed the cubital tunnel {dashed arrevv},
censiste at with an anccr neus epitruchlearls.
The ulnar nerve {selid arrew} lies deep tn the
anccineus epitrechlearis. where it can became
entrapped. resulting in ulnar neurepathy.
which can be asseciated with ulnar neurnpathy” {Fig-
ure 3}. Any mass lesic-n within the cubital tunnel, such as
a ganglieu cyst er esteephytes, creates a predispesitien tn
neurepathy. The ulnar nerve alse is subject tn neurepathy
frern a mechanical etielegy because at valgus everlcrad
in threwing athletes.” The ulnar nerve nermally shews
mild hyperintensity en Tit-weighted studies in individuals
witheut symptems. Any nerve enlargement, distertien ef
the nermal nerve fascicles, er extreme hyperintensity en
Til-weighted studies suggests neurepathyfii' Ulnar nerve
abnermalities are best seen an axial studies. If scanning is
continued distally inte the ferearm, denervaticrn changes
consisting ef muscle edemalike signal er fatty atrcrphy can
be seen in the fleaer carpi ulnaris and the ulnar half ef
the flatter digiterum prefundus.”
The radial nerve ceurses just deep tn the brachicira-
dialis muscle until it appreaches the prescimal aspect ef
the supinater muscle {the arcade nf Frehse}. At this lev-
el, the nerve splits intu an anterier superficial sensery 1-9
branch and a pesterier deep meter branch {alse called 3
tu
the pesterier interesseeus nerve}. MRI can be helpful in
:
EL
identifying an underlying mass causing neurepathy, such tci
as a lipema er ganglien cyst. Either cemmen causes ef
radial neurepathy are difficult tc- distinguish an MRI
and include a thickened arcade ef Frehse and preminent
radial recurrent arteries [the leash at Henry}? A nermal
radial nerve can be difficult ta see an cenventienal MRI
sequences, but because [if underlying neurepathy may
be mere visible if it becemes pathnlegically enlarged er
Drthepaedic Knnwledge Update: Specie Medicine 5
 SEEl'ifll't 5": Imaging
Figure 9 An axial fluid-sensitive lv'IFtl study shevving an
abnnrmal radial nerve. The nerve is markedlyr
hyperintense {a rrew} frem neure pathy,
erebably caused by a thickened arcade ef
Frehse as the nerve passes the presimal aspect
ef the su pinater muscle. A nermal radial nerve
can be difficult te identify.
hyperintense with T2 weighting {Figure 9}. Deuervatien
changes may be seen in the innervated territery ef the
supinater and extenser musculature.“
The median nerve eeurses threugh the anteremedial
elbew aleng with the brachial artery and vein. Cemmen
causes ef median neurepathy include entrapment between
the twe heads ef the prenater teres muscle, a thickened
bicipital apeneuresis, and a fibreus arch ef the Heater
digiterum superficialis muscle, all ef which are difficult
te see en MRI.” Due abnermality that can be detected
by imaging is a nermal-variant supracendylar spur with
an associated Struthers ligament. The supracendylar spur
can be well seen en radiegraphs, and the relatienship
between the spur and the Struthers ligament with the
median nerve can he deciphered using iteiilitl.23 The me-
dian nerve gives eff a meter branch called the anterier
interesseeus nerve, which innervates the {letter pellicis
lengus, prenater quadratus, and radial half at the flexer
digiterum prefundus.”13'” Pathelegy within the anterier
interesseeus nerve itself can be difficult te directly ebserve
en an MRI, but denervatien changes censisting ef edema
.5
en andfer fatty atrephy within the innervated muscles can
l'fl
E suggest the diagnesis {Figure 1D].
é;
5 u re ma ry
MRI is the imaging medality best suited fer evaluating
seft-tissue structures in the elbew. Cemmen indicatiens
include cemmen flexer er extenser tendinepathy, distal
biceps tear, UCL er lateral ligamenteus cempleic injuries,
esteechendral lesien evaluatien, and nerve pathelegy.
firthepaedic Knewledge Update: Sperts lvledich'ie 5
1-
Figure 1D I'm asial T1—weighted MR! study ef the distal
ferea rm just preicimal te the wrist shevving
fatty atrephy ef the prenater quad ratus
muscle {a new}. Prebably caused by chrenic
denervatien irem an ab nermality ef the
anterier interesseeus nerve.
MBA is particularly beneficial in the evaluatien ef es-
teechendral lesiens, leese bedies, and UCL injury in a
threwing athlete.
Icey Etudy Peints
I The erigins ef the cem men flexer and extenser ten-
dens sheuld be hemegeneusly hypeintense en all
sequences; intermediately hyperintense signal with-
in the tenden erigin en a fluid-sensitive sequence is
seen in tendinesis, whereas signal hyperiutensiry ap-
preaching that ef jeint fluid is censistent with tearing.
I Partial-thickness UCL anterier bundle tears
demenstrate ligament thinning er thickening with
asseciated Tl-weighted hyperintense fluid signal
er Tl-weighted hyperintense signal f-rem gadelin-
ium centrast if MBA is perfermed. Gadelinium
tracking deep te the anterier bundle insertieu en
the sublime tubercle can be seen as a subtle finding
ef partial—thickness undersurface tears seen enly
with MEAL. In a full-thickness tear, fluid er centrast
extends acress the entire thickness ef the ligament
and pessibly inte the adjacent seft tissues.
1' MRI can accurately demenstrate denervatien find-
ings in the musculature ef the elbew and prestimal
ferearm. Hewever, MRI is eften unable te detect
the precise pathelegy within the affected nerve,
particularly in the radial and median nerves.
fl lflld American Academy ef Cirrhepaedic Surge-ens

Annatated References
. Radun-ayic G, Vlad V, Micu MC, et al: Ultrascrnnd as-
sessment cf the elbaw. Merl Ulirasart 2fl11;14[1j:141-146.
Medline
The use af ultrasaund in elbaw imaging was reviewed,
with an emphasis an narmal tendun and ligament appear-
ance and pathalagy as well as dynamic maneuvers used
in elbaw imaging.
. Dewan AK, Chbabra AE, Khanna A], Andersen MW,
Bruntan LM: MRI cf the elbaw: Techniques and spectrum
cf disease. I Bane Iain: Satrg Am 2fl13;95{14}:e99, 1-13.
Medline DUI
Cummcn MRI findings in the clbuw were uutlined, with
an emphasis an recent articles and clinical experience.
. Terada H, Yamada H, Tayama ‘t': The appearance cf the
lateral ulnar callateral ligament an magnetic resanance
imaging. ,r Slranlcler Eraser Surg aaaannateta-ats.
Medline DUI
. Del Grande F, Ara M, Faraha ni 5], Wilclcens J, Casgarea
A, Catrina JA: Three-Tesla MR imaging at“ the elbaw in
nan-symptamatic prafessianal baseball pitchers. Sleeleral
Radial 2fl15;44{1j:115-113. Medline DUI
A retraspectiye analysis described cnmman findings an
3-Tesla elbaw MRI in asymptematic prefessic-nal base—
ball pitchers, including callateral ligament thickening and
ulnar nerve abnarmalities.
. Wale DM, Newman JS, Kanin GP, Russ G: Epicandyli-
tis: Pathugenesis, imaging, and treatment. Radiagraplrics
lfllfl;3fl{1}:ltST-1S4.Medline DUI
The narmal anatamy cf the camman flexar and extensar
tendans was described, with pathalagic findings as seen
an MRI and ultrasuund as well as treatment aptians.
. Hayter CL, Adler RS: Injuries cf the elbaw and the cur-
rent treatment af tendan disease. AIR Am] Raertt‘gerral
1012;199lfljfi46-551Medline nat
Cumman elbcrw pathalagic findings an MRI were de—
scribed, with percutaneaus treatment aptians including
carticnsternid injectinn, percutanecrus tenctnmy, and
platelet—rich plasma injectian.
. Chew ML, Ginffri: EM: Disnrders cf the distal biceps
brachii tendan. Radicgrapbics lflflfinIS Hear—123?.
Medline DUI
. Dirim E, Erauha SS, Pretterltlieber ML, et al: Terminal
bifurcatian cf the biceps brachii muscle and tendan: An-
atu-mic cansideratic-ns and clinical implicatinns. AJR Am
_,l Ruentgertel 2Dfl3;191[6}:W243-W255. Medlitte DUI
. Elease S, Staller D, Safran M, Li A, Fritz R: The elbaw, in
Staller D, ed: Magnetic Resartartce imaging in {Sir-rhepae-
dics and Sparta Medicine, ed 3. Baltimare, MD, Walters
Klnwer, lflfl'i’, pp 1463-1525.
ID H116 American Academy ai' flrtbapaedic Surgeans
|iiihapter S4tMRJaftheElbuw
11“.}. Mallisee TA, Bnyntc-n MD, Ericksan S], Daniels DL: Nar-
ntal MR imaging anatamy cf the clbc-w. Magi: Resart
Imaging Claire N Am 199?:5l3}:451-4?9. Medline
11. Kaplas ME, Schneider E, Sundaram M: Prevalence cf tri-
ceps tendan tears an MRI cf the elbaw and clinical carrela-
tiun. Skeletal Radial 2011;431:51531594. Medline DUI
A retrnspectiye study faund a higher than expected 3.3%
rate cf triceps tendan injury in patients referred far elbaw
MRI. Mast injuries cansisted af a partial tear.
12. Sheehan SE, Dyer GS, Sadicltsan AD, Patel KI, Khurana
E: Traumatic elbuw injuries: 1it'illhat the urthapedic sur-
genn wants ta knew. Radiagrapiaics 1013;33l3]:369—3 33.
Medline DUI
Radiagraphic findings in cantman elbaw fractures were
described, with apprapriate use af crass-sectianal imaging.
It is critical far the radialagist tcr canyey certain elbnw
trauma findings tn the crrhapaedic surgean.
13. Beltran L5, Eencardinn JT, Beltran J: Imaging pf spurts
ligamentaus injuries cf the elbaw. Seasin Masculasltelei
Radial 2013;1Tlfilt4SS-4ES. Medline DUI
The imaging manifestatians af spans-related injuries tn
the medial and lateral callateral ligament cample‘x were
reviewed, with narmal anatamy, injury biamechanics, and
apprapriate treatment.
14. Guellette H, Eredella M, Labis J, Palmer WE, Tarriani
M: MR imaging cf the elbaw in baseball pitchers. Skeletal
Radial 20fl3;3?{2j:115-121. Medline DD]
15. Mnnshi M, Pretterltlieber ML, Chung CB, et al: Ante-
rinr bundle {if ulnar callateral ligament: Evaluatirtn [if
anatcmic relatianships by using MR imaging, MR at-
thrcgrapby, and grass anatamic and histalagic analysis.
Radialagy 2004;231l3}:?9?-303. Medline DUI
16. Hughes T, lIEhung C: Elbuw ligaments and instability, in
Chung C, Steinbach L, eds: MRI aftlee Upper Extremity:
Sbaalder, Elbara, Wrist, and Hand. Philadelphia, PA,
Walters Kluwer, 201i], pp 402-43fl.
This tharaugh textbaalr facuses an upper extremity MRI.
1?. Wear SA, Tharntan DD, Schwartz ML, Weissmann RC III,
Cain EL, Andrews JR: MRI cf the recanstructed ulnar cal-
lateral ligament. AjR Am I Raenrgertal1011;19?{S}:1193-
121.14. Medline DID]
Despite the camplex appearance cf the recanstructed 1-9
UCL, MRI can shaw ligament discantinuiry campatible 3
cu
with pastsnrgical tear. MRA generally shuttld be used
:1
EL
ta increase jaint distentian and shew any insinuatian cf LI]
Enganarticular gadalinium cantrast thraugh the ligament
E! BEL
18. MacMaban P], Murphy DT, Zaga AC, aanagh EC:
Pnstnperatiye imaging cf the elbc-w, wrist, and hand.
Semin Muscalaaleelet Radial 1fl11515{4j:34fl-356.
Medline D0]
Drtbapaedic Knawledge Update: Sparta Medicine S
 Section 5": [lugging
Surgery of the elbow, wrist, and hand were reviewed for ra-
diologists, with the postsurgical appearance. There is par-
ticular focus on ulnar collateral ligament reconstruction.
19. Schaeffeler C, 1it'lllaldt S, 1illiloertler K: Traumatic instability
of the elbow: Anatomy, pathomechanisms and presen-
tation on imaging. Ear Radial lfllSflSlflin'lSSE-ESSS.
Medline DUI
The types of elbow instability and their imaging manifes-
tations were discussed, including posterolateral rotatory
instability, valgus instability, complex instability, and
dislocation injuries.
Ill. Sch reiher J], Patter HG, Warren RF, Hetchkiss RN, Da-
luiski A: Magnetic resonance imaging findings in acute
elbow dislocation: Insight into mechanism. _l Hand Strrg
Arr: 2fl14;39{2}:199-105. Medline DUI
A retrospective study of patients with elhew dislocation
found that complete ligameoteus tears were more common
on the medial than the lateral side. On the lateral side,
tears were more common in the LUCL than in the REL.
21. Ruiz de Lueuriaga EC, Helms CA, Kosinski AS, Vinson
EH: Elhew MR imaging findings in patients with synovia]
fringe syndreme. Skeletal Radial 2D13:42{S}:S?S'liflfl.
Medliue DUI
This small retrospective study compared MRI findings in
patients with diagnosed syuovial fringe syndrome with
these in normal control subjects. He findings were statis—
tically significantly different between the groups, although
there was a notable difference in plica thickness; thickness
greater than 2.6 mm was associated with synevial fringe
syndrome.
Eeresal L, Redrigues-Sammartine M, Canga A, et al:
Elbow synovial fold syndrome. AJR Am I Roentgertol
2U13;201{1]:WSfl-W95.Medline DD]
The clinical presentation, imaging findings, and treatment
of synevial fold synd reme were reviewed. Synovial fold
syndrome can he clinically confused with ether causes of
lateral elbow pain, such as lateral epicondylitis, and it also
can he misdiagnosed on imaging because of its variable
appearance, which often is net related to symptoms.
13. Stein JM, Coal: TS, Simonsen S, Kim W: Normal and vari-
ant anatemy of the elbow on magnetic resonance imaging.
Magi: Resort Imaging Clin N Am 2911;19l3iail19-519.
Medline DUI
on
.E The normal anatomy of the elbow on MRI was reviewed,
on with an emphasis on esseeus and neneeseous variants that
l'fl
E
é;
can mimic pathology.
firthopaedic Knowledge Update: Sports Medicine 5
34. Sampaie ML, Schweitzer ME: Elhew magnetic resonance
irnagiug variants and pitfalls. Magi: Resort Imaging Eli-rt
N Am lfllflflfll‘lkfidd-fi‘fl. Medlinc D'CII
Common findings on MRI of the elbow can he misin.
terpreted as pathologic by an inexperienced interpreter.
25. Bancroft LW, Pettis C, ‘Illllasyliw C, Varich L: Daren-chen—
dral lesions of the elhew. Sevnin Mascaleskelet Radial
2fl13;1?{5}:44E-4S4.Medline DUI
A pictorial review shows radiographic and MRI findings
of osteochondral lesions of the elbow, particularly in the
capitellum, with an emphasis on relevant classification
systems.
26. I-{ijowski R, De Smet AA: MRI findings of osteeehendritis
dissecaus of the capitellum with surgical correlation. A}R
Am] Roentgerrol 2005;135lfi}:1453-I459. Medline DDI
1?. Helms C, Major H, finderson M, Kaplan P, Dussault R:
Elbow, in Mascalosheletal MR .l, ed 2. Philadelphia, PA,
Elsevier, EDGE-3, pp 224—243.
23. Linda DD, Harish S, Stewart HG, Finlay R, Parasu H,
Rehelle RP: Multimodality imaging of peripheral neurepa-
thies of the upper limb and hrachial plexus. Radiographias
lfllfl;3fl{5}:13?3-14lifl.Medline not
Anatomy, clinical findings, and imaging findings associ-
ated with common neurepathies of the upper extremity
were reviewed, with the use of ultrasound or MRI in con-
junction with electrophysiologic resting.
19'. Rndreisek G, ICrook DW, Burg D, Marincek B, Weishaupt
D: Peripheral neuropathies of the median, radial, and
ulnar nerves: MR. imaging features. Radiograplries
lflflfitlfiliitllIST-IEET.Medliue DUI
SD. Kim S], Hang 5H,]un TS, et al: MR imaging mapping of
skeletal muscle denervation in entrapment and compres-
sive neuropathies. Radiograplaics lflll;31{2}:319—<332.
Medline D-DI
Distinguishing intrinsic abnormalities within small nerves
may he difficult on MRI, hut denervation changes con-
sisting of edema andlor fatty atrophy can be seen within
the innervated distrihutien. Herve distribution maps were
reviewed for commonly affected nerves throughout the
body, including the elbow.
fl lfllfi American Academy of Orthopaedic Surgeons
Chapter 55
Imaging of the Hip
Iennifer I Piers:e, MD
Abstract
Understanding the imaging of the hip joint can provide
further detail and information needed to accurately di-
agnose the complexity of hip pain. MRI is an important
modality for the evaluation of both intta—atticular eti—
ologies of hip pain such as labrochondral abnormalities
and extra-articular etiologies such as ischiofemoral and
iliopsoas impingements.
Keywords: acetabular Iabrum: femoroacetabular
impingement; hip cartilage; hip imaging; MRI
Introduction
Imaging of the hip has evolved substantially as a result
of new concepts in hip morphology and biomechanics as
well as the increasing number of arthroscopic hip proce-
dures being performed.1 Radiography, CT, ultrasound,
and MRI are valuable diagnostic tools. Specific consid-
erations are pertinent in evaluating a painful hip joint in
patients who may have ischiofemoral impingement, ilio-
psoas impingement, or an abnormality of the hip labrum
or cartilage in femoroacetabular impingement {FAIL
lschiofemoral lmpingement
Pain and other symptoms of ischiofemoral impingement
syndrome are caused by entrapment of the quadratus
femoris muscle between the ischial tuberosity and the
lesser trochanter.1 Narrowing of the ischiofemoral space
can result from variable positioning of the lower extrem-
ity or a congenital or acquired deformity as with fine--
ture, bursitis, or enthesopathy at the lesser trochanter
Neither Dr. Pierce nor any immediate family member has
received anything of value from or has stock or stock op-
tions held in a commercial company or institution related
directly or indirectly to the subject of this chapter.
fl lflld American Academy of Drthopaedic Surgeons
or ischial tuberosity.“ Because competitive sports often
require repetitive, complex movements and great hip EI-
ertion, ischiofemoral impingement commonly occurs in
athletes?“4 Multiple studies found substantial narrowing
of the ischiofemoral space in patients with abnormal im-
pingement of the quadratus femoris.“*-~“-~5 The normal lesser
trochanter—ischial tuberosity interval has been reported
to be approximately 2 cm; this distance allows rotation of
the femur without improper friction or contact with the
ischial tuberosity, hamstrings, and quadratus femoris}
However, data are limited and vary on normal values for
the ischiofemoral space or abnormal values that warrant
a diagnosis of ischiofemoral impingement. With internal
rotation of the hip, ischiofemoral space was measured
at 13 mm {a 5 mm} in patients with ischiofemoral im-
pingement, compared with 23 mm is: fl mm} in control
subjects.1 1illlhen the interval was measured with the hip
in neutral position, the ischiofemoral space was 12.9 mm
($3.?I mm} in patients with symptoms and 29.3 mm is: 5.9
mm} in control subjects.“1
Radiographs in patients with ischiofemoral impinge-
ment typically are normal. Bone production, sclerosis, or
cystic change occasionally can be seen along the ischi-
al tuberosity or lesser trochanter. MRI is the preferred
modality for revealing ischiofemoral space narrowing
and edema of the quadratus femoris muscle. Axial flu-
id-sensitive images, such as TE—weighted fat—suppressed
and short tau inversion recovery studies, are especially
useful for this purposef' Dther MRI findings associated
with ischiofemoral impingement include bursae forma-
tion along the quadratus femoris or obturator enternus,
ischial tuberosity or lesser trochanter bone changes, and 1-9
abnormality of the hamstring tendonsb4 (Figure 1]. Mus~ 3
cu
cle strain and tearing of the quadratus femoris can appear
:1
EL
similar to that of ischiofemoral impingement and should to
be considered if there is no narrowing of the ischiofem-
oral space}
Iliopsoas lmpingement
Iliopsoas impingement is a source of hip pain from ilio-
psoas inflammation and an anterior labral tear caused
Drthopaedic Knowledge Update: Sports Medieh'ie 5
 Section 9: Imaging

Figure 1 Axial TI-weighted fat-suppressed MFlls demonstrate findings of ischiofemoral impingement. A. Muscle edema
in the ouadratus femoris with a narrow ischiofemoral interval {arrowheads} and associated ischial tuberosity
bursitis with partial tearing of the hamstring tend on complex (arrow) are shown. B, Development of an obturator
esternus bursa with mild muscle edema in the quadratus femoris [arrows] is shown.

Figure 1 Images show iliopsoas impingement. A. Dbligue axial TI-weighted magnetic resonance arthrogram shows an
anterior la bral tear {arrow} directly suhjace at to the iliopsoas tendon Ila rrowh ead}. B. Axial T2-weighted fat-
su ppressed MRI at a position inferior to the image in A shows increased signal surrounding the ilio psoas tendon
on {arrowhead}, which represents edema and bursitis.
.E
on
l'fl
E
by abnormal iliopsoas tendon traction. The lahral tear inflamed, adherent, and thickened iliopsoas tendon can
é;

is present in a specific, focal anterior location in the hip
labrum at the iliopsoas notch and directly suhjacent to
the iliopsoas tendon {3 o'clock positionif" This location
is distinctly lower than that of labral iniuries associated
with femoroacetahular impingement {FAI}, hip dyspla-
sia, or trauma, which were described as occurring at the
anterosuperior quadrant {1—1 o’clock position}.El A tight,
lead to iliopsoas impingement or produce a traction in-
jury to the lahrum and capsule? {Figure 2). A relatively
narrow width and lateral dip or oblique orientation of the
iliopsoas tendon, which are common in women, also can
be associated with iliopsoas impingement.til
The symptoms of iliopsoas impingement include hip
or groin pain, snapping hip (cor-ta saltans interna}, and

firthopaodic Knowledge Update: Sports Medicine 5 fl lflld American Academy of Orthopaedic Surgeons
 Chapter 55: Imaging of the Hip

focal tenderness over the iliopsoas tendon at the anterior

joint line. The diagnosis can be confirmed with an ultra-
sound—guided injection into the iliopsoas bursa, which
also can provide long-term relief of symptoms.” Pain
relief after the injection predicts a favorable outcome after
surgical release of the iliopsoas tendon."

Hip Labrum Abnormality

The diagnosis of FAI is increasingly common, and hip
arthroscopy techniques are advancing. As a result, im—
aging of the hip has become more accurate and detailed.”
The acetabular labrum provides hip joint stability by
deepening the acetabular cup, increasing the joint surface
area, absorbing pressure or shock, distributing pressure,
and sealing the joint to keep synovial fluid within the ar-
ticular cartilaginous surface. In the absence of the labru m,
the articular cartilage is subjected to an increase in contact
stress of up to 92%, which leads to early degenerationJ“
Labral tissue is composed of type I collagen and fi-
brocartilage. A triangular labral shape is common, but
rounded, flattened, and other shapes are normal and are
most likely to occur as patients age.“I A labral tear can
form through the substance of the labrum, at the cartilage
junction, or at the osseous attachment. Most tears occur
as a detachment of the labrum from the labral chondral
junction or bony acetabulum.1 The anterosuperior labrum
is the typical location of a tear, especially as related to FA]
{Figure 3]. In FAI, the morphologic osseous changes of Figure 3 Sagittal TE-weighted fat—suppressed magnetic
resonance arthrogram shows a labral tear in FAI
a cam deformity, acetahular retroversion, or acetabular with detachment at the la bral osseous junction
overcoverage increase the forces across the anterosuperior in the anterosuperior quadrant {arrow}.
hip joint.
Routine MRI of the hip is less accurate than magnetic
resonance arthrography {MRA} for detecting labral tears. such as a cam or pincer deformity, is necessary. Because
In comparison with arthroscopy as the gold standard, of the invasiveness, cost, and time requirement of MBA,
MRA was found to have sensitivity of 91% to lflfl'i’f- and improvements in the quality of noncontrast or conven-
accuracy of 93% to 96% for detecting labral tears.11 A tional hip MRI are the subject of ongoing study. Early
2fl11 meta-analysis reported that comparisons of MRA data suggested that 3-Tesla {T} noncontra st MRI is more
and noncontrast MRI found varied sensitivity and spec- effective than 1.5-T MRA for the early detection of chon-
ificity values for the detection of labral pathology.” Re— dral and labral pathology and that its use is cost—effective
ceiver operating characteristic analyses proved that the and improves patients’ experience.”
diagnostic accuracy of MRA was superior to that of non- Although there are well-known normal variants in 1-9
contrast MRI of the hip. Likewise, CT arthrography with shoulder labral anatomy, sublabral sulci or recesses in the 3
tu
multiplanar reconstruction also can he used to detect hip labrum have only been widely reported beginning in
:1
EL

labral tears; it offers excellent spatial resolution when
iodinated contrast undermines or penetrates the labrum,
indicating tear.‘~MI However, CT is inferior to MRI for the
evaluation of intrasubstance labral changes, periarticular
soft tissues, and edema'like marrow changes. At most in-
stitutions, CT arthregraphy is used to evaluate the labrum
if the patient has a contraindication to the use of MRI or
if a preoperative assessment of an osseous abnormality,
El] 0435'” A labroligamentous sulcus is created when fluid to
distends the junction of the labrum and the transverse
ligament, especially anteriorly. Therefore, this normal
variant can be seen with fluid distension of MRA and
should not be mistaken for a tear.
Sublabral sulci are found to be present in approximate-
ly 20% to 24% of hips.”=” Although a posteroinferior
sublabral sulcus (Figure 4] initially was described as a

IE! lfllli American Academy of flrthopaeclic Surgeons Drthopaedic Knowledge Update: Sports Medicine 5
 Sectinn 5": [nagging

potential pitfall in the diagnnsis cf lahral tears,“5 sulci near-cnmplete depth nf ccintrast cit fluid undermining cf
were found at all leeatic-ns and quadrants cf the acetahu- the turn lahrurn, have a nuulinear appearance, and can
lar lahrum. Sulci were mnst ccimmc-n in the antcrciinferinr he assnciatcd with a paralahral cyst or ussenus abnnr-
and pnsterinr quadrants.“r Distinguishing lahral tears malitymfl (Figure E}.
frem sublahral sulei requires a detailed eyaluatien ef the
depth and mcrphnlngy nf lahral detachment frcim hcine,
the subjacent nssecius changes, and paralabral cysts. 0n
MRA, suhlahral sulei have incemplete lahral undermining
by cnntrast nr fluid at the lahral hasc—bnnc ju ncticin, have
linear mnrphc-lcigy, and are less than 1 mm thick. In addi-
tien, suhlahral sulei lack suhiacent nsseeus changes such
as nstcnphytcs, suhchnndral cysts, sclernsis, and martcm.r
edema {Figure 5}. In cnntrast, lahral tears typically are
Incated in the antercisupericir quadrant, haye cnmplete tn

Figure 5 Cnrcnal Ti-weighted fat-suppressed magnetic

Figure 4 Dhlique atrial TI—weighted magnetic rescinance
arth rngram shnws a fecal, smcicith -ma rgined
nermal-uariant pesterier sulcus iarrewl and
nc-rmal suhjacent hcne.
resenance arthregrarn shews linear partial
undermining by high-signal gadnlinium at the
Iahral-chnnd ral junctictn {a rrcw}. The subjecent
hene, surreuriding pericapsular structures. and
cartilage are nnrmal.

tn
.5
cu
l'fl
E
é;

Figure E A, Cnrnnal T1 -weighted fat-suppressed magnetic resnnance arthrcgram shnws a chnndral defect {arrnwhead}
and irregular Iahral undermining by gadnlinium [army-ii}. B. Enrnnal T1-weighted magnetic rescinance arthrngram
shuws suhchcindral cysts iarrewi arid deficient cartilage at the la braI-chendral interface. These findings suggest
the presence at a lahrai tear rather than a suhlahral sulcus.

firthupaedic Knewledge Update: Spurts Medichte 5 fl lflld American Academy at Urthnpaedic Surge-ans

Hip Cartilage Abnormality
Imaging and cad aver studies revealed that the greatest hip
cartilage thickness is along the superolatetal acctabulum
and the anterosuperior femoral head.”~3” Appropriately,
these areas must absorb the greatest force during weight
bearing and walking. Chondral damage was found in
3% of patients with a labral tear.“ Therefore, the de-
tection of chondral abnormality should lead to careful
evaluation of the labrum, and vice versa. Ninety-four
percent of chondral damage was found to occur at the
labral—chondral junction, especially in the anterosupe—
riot acetabular labrum, and the presence of labral tears
doubled the risk of chondral damage. Relatively young
patients were found to have an isolated labral tear, but
older patients had both labral and chondral lesions; there-
fore, it was postulated that labral tears can precede and
lead to chondral damage.11
Early detection of cartilage disease is preferable, and
imaging can be used to provide a noninvasive assess-
ment of chondral areas at risk before irreversible degen-
erative joint disease occurs. Radiography, GT, and MRI
for evaluating articular cartilage traditionally depicted
only morphologic defects.“ However, new MRI carti-
lage-mapping techniques make it possible to assess the
biochemical ultrastructure and health of cartilage before
the development of distinct macroscopic defects}ll The
new techniques include T2 mapping, delayed gadolin-
ium—enhanced MRI of cartilage jdGEMRIC}, Tlrrho
MRI, sodium imaging, and diffusion tensor imaging.”
Proton-density fast spin—echo and T2—weighted se—
quences are commonly used in the evaluation of cartilage.
Both of these fluid-sensitive sequences show excellent con-
trast between the osseou s, chondral, and fluid interfaces.
The associated subchondral cysts and bone marrow ede-
ma pattern are most accurately seen in these sequences”
{Figure T}. MRA is widely used for evaluating articular
cartilage in the hip. The distention of the joint with fluid
and gadolinium contrast improves the evaluation of the
thin and tightly congruent chondral surfaces of the femo—
ral head and acetabulum. Additional joint distraction can
be accomplished by applying traction to the hip or lower
leg during MRI by using MRI-compatible weights?“14
1"i'i'ilhen 6 kg of traction was used in MRA, an average
1.? mm of separation along the femoral and acetabular
surfaces improved detection of chondral defects such as
delamination.“ Noneontrast MRI can be used for the
evaluation of cartilage, but relatively few studies have
been published.” Nonarthrographic MRI of the hip was
found to be 33% to 93% sensitive and Hit» to sva. spe-
cific for the detection of arthroscopy—proved cartilage
defects?
IE! lfllti American Academy of flrthopaedic Surgeons
Chapter 55: Imaging of the Hip
i
Figure if Ssqittal Tl—weighted fat-Suppressed magnetic
resonance arthrog ram shows chondral
delamination with subjacent bone marrow
edema. This fluidvsensitive sequence shows
fluid undermining a flap of aceta bular cartilage
{arrows} and abnormal reactive edemalilte
signal in the suhchondral bone suhjatent to the
cartilage defect {arrowheads}.
T2 mapping is sensitive for the collagen and extracel—
lular matrix components of cartilage. Degraded cartilage
has a disruption of collagen fiber architecture, decreased
concentration of collagen, and increased free water con-
tent.” Therefore, degenerating cartilage typically produc-
es higher TE values than normal, healthy cartilage. The
use of dGEMRIC sequences provides information on the
proteoglycan-glycosaminoglycan {GAG} content of carti-
lage. The large, negatively charged GAG molecule draws
in positively charged sodium ions and binds water into
the extracellular matrix of cartilage. Lilte GAG, gadopen-
tetate dimeglumine has a negative charge, and increased
concentrations of gadolinium are distributed into areas
with a low GAG density and, therefore, into cartilage that
is abnormal and unhealthy.“ Du Tl—weighted sequenc-
es, this increased or concentrated uptake of gadolinium
has shorter T1 values and can be distinguished from the
remainder of the chondral surface.“ Before dGEMRIC
sequences are obtained, an intravenous dose of gadolini-
um is administered. The patient exercises for 15 minutes [-9
to aid gadolinium delivery to the hip joint, and a subse- 3
tu
quent SCI-minute delay allows uptake and concentration
:1
EL
of gadolinium in the cartilage. Intravenous gadolinium to
enters the cartilage from blood perfusion at both the
synovium-eartilage and bone-cartilage interfaces.”
S u m ma ry
Imaging of the hip, especially using MRI, can help dis-
tinguish intra-articular and extra-articular etiologies of
Drthopaedic Knowledge Update: Sports Medichse .‘i
 Section 5": [lugging
pain. The diagnosis and treatment of FAI is becoming
more prevalent; therefore, understanding hip labral nor-
mal variants and pitfalls are crucial for accurate diag—
nosis. Also, new MRI sequences and technology appear
promising for earl].r detection of cartilage degeneration.
Ischiofemoral and iliopsoas impingement syndromes need
to be distinguished from FAI, and imaging with MRI
allows for direct visualization of the regions of interest.
Hey iitudpr Points
I The ischiofemoral inter val measurement varies with
internal and external rotation of the leg. The diag—
nosis is made when there is impingement type pain
and abnormal edemalfluid in the muscle traversing
the ischiofemoral space.
It MRI findings of iliopsoas impingement are edema;l
fluid surrounding the iliopsoas tendon and lower an—
terior labral tears. Fluoroscopic or ultrasound-guid-
ed injection of the iliopsoas bursa is an important
diagnostic test and treatment option.
' Hip labral normal variants and sublabral sulci and
clefts have been described throughout the labrnm.
These normal variants will not have complete deat-
tachment of the labrum, adjacent chondral defects,
or osseous changes.
Annotated References
1. Sutter R, Zanetti M, Pfirrmann CW: New develop-
ments in hip imaging. Radiology 2fl12:264{3):551—561
Medline DID]
Technical advances in hip imaging and recent anatomic
and pathologic insights were reviewed as related to hip
diagnoses.
2. Torriani M, Souto 5C, Thomas E], Uuellette H, Eredella
MA: Ischiofemoral impingement syndrome: An entity
with hip pain and abnormalities of the quadratus femo-
ris muscle. AJR Am: J Roentgenol 2Gfl9:193{1):135-19fl.
Medline DUI
on
.E The author reviewed the anatomy of the ischiofemoral
on
l'fl interval, along with results of internal or external position
E
é;
of the leg.
3. Ali AM, 1illi'hitwell D, Dstlere 5]: Imaging and surgical
treatment of a snapping hip due to ischiofemoral impinge-
ment. Skeletal Radiol 1011:4[ll5]I:d53-656. Medline DUI
The clinical, anatomic, and imaging aspects of ischiofem—
oral impingement were discussed in this case report.
firthnpaedic Knowledge Update: Sports Medicine 5
4. Tosun CI, Algin D, Yalcin N, Cay N, Dealtoglu G,
Karaogla noglu M: Iscbiofemoral impingement: Evaluation
with new MRI parameters and assessment of their reliabil-
ity. Skeletal Radiol 2fl12541{5]:5?5-53?. Medline DUI
Substantial narrowing of the ischiofemoral space was re—
ported in patients with hip pain and muscle changes to the
quadratus femoris, compared with asymptomatic control
subjects. MRI with the hip in neutral position detected
differences in ischiofemoral space intervals compared with
studies with the hip in internal rotation.
. Blankenbalter DG, Tuite M]: Non-femoroacetabular im-
pingement. Semis: Mascnlosltelet Radlol lflldflfidhlfil-
135. Modline DD]
Hip pain caused by ischiofemoral, anteroinferior iliac
spine or subspine, or iliopsoas impingement was reviewed,
with a focus on MRI findings and pathophysiology.
. Taneja AK, Bredella MA, Torriani M: Ischiofemo-
ral impingement. Magi-t Reson Imaging Clin N Am
1013;21j1j:65-?3.Med1ine DUI
The anatomic and clinical background of ischiofemoral
impingement was reviewed. Ischiofemoral impingement is
difficult to diagnosis on radiographs and CT. MRI is the
preferred modality for seeing a narrowed ischiofemoral
space and quadratus femoris muscle edema changes.
. Domb EG, Shindle MK, McArthur E, 1|iloos JE, Magennis
EM, Kelly ET: Iliopsoas impingement: A newly identified
cause of labral pathology in the hip. H55] 2011;?{2H45-
150. Medline DUI
Iliopsoas impingement causes labral tearing directly sub-
jacent to the iliopsoas tendon at the level of the iliopsoas
notch. An inflamed, adherent iliopsoas tendon can cause
impingement or traction injury to the labrum and capsule.
. Elanltenbalter DE, Tuite M], Keene J5, del Rio AM: Labral
injuries due to iliopsoas impingement: Can they be di-
agnosed on MR arthrographyiI AjR Am I Roentgenol
2312;"199l4jtflfl'4-900.Medline DUI
A review of arthroscopically proved iliopsoas impingement
found that related labral tears were focally present at the
3 o’clock position. This position is lower than the typical
1 to 2 o’clock labral tears in FAI or osteoarthritis. Espe-
cially in women, a narrow width and oblique orientation
of die iliopsoas tendon may be associated with iliopsoas
impingement.
. Thomas JD, Li Z, Agur AM, Robinson P: Imaging of
the acetahular labrnm. Semis: Mascalosltelet Radial
2fl13;1?{3}:143-25?.Medline DUI
Imaging of labral tears was reviewed with a focus on MRI.
Labral tears resulting from FAI, hip hypermobility, degen-
eration, dysplasia, and trauma were discussed, with pitfalls
in labral imaging, such as suhlahral sulci. The effectiveness
of noncontrast 3-T MRI was compared with that of 1.5 -T
MILA. Early data suggest that 3-T noncontrast MRI is
preferable to 1.5-T MRA.
fl lflld American Academy of Orthopaedic Surgeons

1f}. Fergusen 5], Bryant JT, Gant R, Ite K: The influence
ef the acetabular lahrum en hip jeint cartilage ceasel-
idatien: A pereelastic finite element medel. ] Biemecf?
2Dflfl;33{3}:953-96fl.Medliue DUI
11. Leceuvet FE, 1|Infande Berg EC, Malghem ], et al: MR imaging
ef the acetabular labrum: 1Flfariatiens in lflfl asymptematic
hips. AJR Au: } Resutgeaei 1996:16?{4}:1025 -1l}23.
Medline DUI
12. Beaule FE, U’Neill M, Rakhra K: Acetahular lahral tears.
I Benefeirn‘. Stag Am: 2009;91L‘3lflfll-T1fl. Medline DUI
This study cempared the accuracy ef MBA te arthrescepy
as the geld standard fer labral tears.
13. Smith TU, Hilten G, Tems AP, Denell ST, Hing CE: The
diagnestic accuracy ef acetabular lahral tears using mag-
netic resenance imaging and magnetic resenance arthreg-
raphy: A meta-analysis. Eur iliaa'ielI 2fl11;21[4}:363-BT4.
Medline DUI
This meta—analysis included 19 articles and a tetal ef 331
hips. Altheugh there was a wide range ef sensitivities and
specificities fer the use ef nencenuast MRI and MBA, the
diagnestic accuracy ef MRA was feund te be superier.
14. Llepis E, Fernandez E, Cereaal L: MR and CT arthregra-
phy ef the hip. Semiu Mascaieshefet Raa'iei 2fl12;16{1}:4l-
56. Medline DUI
MRI and CT arthregraphy ef the hip were reviewed, with
imaging findings related te several intra-articular hip pa-
thelegies, especially lahral tears and chendral defects.
1.5. Rebinsen P: Cenventienal 3-T MRI and 1.5-T MR ar-
thregraphy ef femereacetabular impingement. AIR Am
] Resutgenel 2fl12:199{3]:5l}9—515. Medline DUI
The cencept ef FM and the MRI findings asseciated with
FAI were reviewed. The current status ef 1.5-T MBA was
described and cempared with nencentrast 3-T MRI. With
its increasing availability, pewerful new sequences, and
neninvasive nature, nencentrast 3-T MRI has the petential
te be superier te 1.5-T MBA.
16. Dinauer PA, Murphy KP, Carrell JP: Suhlahral sulcus at
the pesterein ferier acetabulum: A petential pitfall in MR
arthregraphy diagnesis ef acetahular lahral tears. AJR Am
I Ruaargaaai 2004:133lfi}:1?45-1?53. Medline DUI
1?. Saddil: D, Treupis J, Tirman P, U’Dennell J, Hewells R:
Prevalence and lecatien ef acetahular suhlahral sulci at
hip arthrescepy with retrespective MRI review. AJR Am
J ReeutgenefEDDE:IBT[5}:W.SDT-11. Medline DUI
13. Studler Ll, Kalberer F, Leunig M, et al: MR arthregraphy
ef the hip: Differentiatien behaeeu an anterier suhlabral
recess as a nermal variant and a lahral tear. Radieiegy
Eflfl3;149{3]:94?-954.Medline DUI
ID lfllfi American Academy ef Urthepaeclic Surgeena
Ifiil'layllter 55: Imaging ef the Hip
19. Kurrat H], Uberliinder W: The thickness ef the cartilage
in the hip jeint. ,1 Heat 19?E:116{Pt 11:145-135. Medline
If}. Petchprapa CH, Recht MP: Imaging ef chendral lesiens
including femereacetahular impingement. Samia Masca-
feskefet Eadie! 2D13;1?{3}:253-2?1. Medline DUI
The functien and structure ef cartilage were empha-
sized te impreve understanding ef traditienal MRI ef
the physical, merphelegic defects ef cartilage and new,
hiechemically based MRI sequences for evaluating the
ultrastructure ef cartilage.
21. McCarthy JG, Neble PC, Schuclt MR, Wright J, Lee]:
The rele ef labral lesiens te develepment ef early degener-
ative hip disease. Elia U-rtftup Raiat Res 2D01;393:25-3?.
Medline DUI
23. Strickland CD, Kijewski R: Merphelegic imaging ef
articular cartilage. Magi: Resets Imaging Ciia N Am
2011:19(2}:229-243.Medline DUI
MRI sequences and their ability te shew hip cartilage
were discussed.
13. blishii T, Haltanishi K, Sugane N, Masuhara K, Uhaene
K, Uchi T: Articular cartilage evaluatien in esteearthritis
ef the hip with MR. imaging under centinueus leg tractien.
Mags: Reset: Imaging 1993:16{3]:3?1—fl?5. Medline DUI
24-. Llepis E, CEIEEEIl L, Kassarjian A, Higueras V, Fernan-
dea E: Direct MR. arthregraphy ef the hip with leg trac-
tien: Feasibility fer assessing articular cartilage. AIR Am
] Resatgeaef 2003:190l4}:1124-1123. Medliue DUI
Centinueus tractien previded with 6-kg MRI-cempati—
ble weights achieved 1.6 mm ef separatien between the
acetabular and femeral chendral surfaces. The increased
separatien may impreve detectien ef chendral defects
such as delaminatien.
.15. Mint: DH, Heeper T, Cennell D, Euly R, Padgett DE,
Fetter HG: Magnetic resenance imaging ef the hip:
Detectien ef lahral and chendral ahnermalities using
nencentrast imaging. Artbrescepy 2fl05:21[4}:335-393.
Medline DUI
26. Mesher T], Dardainslti B]: Cartilage MRI T2 relaxatiun
time mapping: Uverview and applicatiens. Semis: Mus-
cafeskelst Radial 10fl4;3{4}:355-363. Medline DUI
2?. Burstein D, Gray M, Mesher T, Dardainslci E: Measures ef
melecular cempesitien and structure in esteea rthritis. Ra- 1-9
diei Ciin Netti? Am EDD 9,4?{4hti F5453 5. Medline DUI 3
tu
This article reviews new specialised magnetic resenance :1
EL
LI]!
sequences te evaluate the ultrastructure ef cartilage te
detect early cartilage degeneratien and change.
Urthepaedic Knuwledge Update: Sperts Medicine 5
Chapter 56
Imaging of the Knee
Meredith C. Northam. MD
The knee is one of the most commonly injured joints in
the body and is also a common source of chronic pain.
The menisci, articular cartilage, and major ligaments of
the knee may be injured and require surgical exploration
andior intervention. These structures are well evaluated
with MRI so this can be a useful tool for preoperative
planning or when diagnosis is uncertain. Familiarity
with the appearance of these key structures and their
injuries on MRI can be beneficial to the clinical practice
of the orthopaedic surgeon.
Keywords: anterior cmciate ligament: cartilage;
knee imaging; MRI: meniscus; posterior cruciate
ligament
Introduction
The knee is one of the most important joints in the hu-
man body and knee pain is a common complaint among
patients. Although an orthopaedic surgeon gathers a great
deal of clinical information from the patient and by per-
forming a physical examination, a basic understanding
of the appearance of the knee on MRI can be extremely
beneficial. In addition, it is important for the orthopaedic
surgeon to review the appearance of the major structures
of the knee and the appearance of common injuries on
MRI.
The Anterior |Cruciate Ligament
The anterior cruciate ligament {ACLJ is the most com-
monly injured major ligament of the knee. The ACL sta—
bilizes the knee primarily by resisting anterior translation
Neither Du Northern nor any immediate family member
has received anything of value from or has stock or stock
options held in a commercial company or institution related
directiy or indirectly to the subject of this chapter.
@ lfllfi American Academy of Drthnpaedic Surgeons
Figure 1 Sagittal Tit-weighted fat—suppressed MRI of the
anterior cruciate ligament {AEL}. A. A normal
ACL with homogenous low signal intensity and
intact fibers paralleling the intercondylar roof.
B. An intrasubstance tear of the ACL.
and secondarily by resisting varus and valgus forces.1
Approximately 90% of ACL tears can be diagnosed based
on the patient’s clinical history and a thorough physical
examination. MRI is the imaging study of choice for
diagnosing pathology and tears in the ACL as well as
associated injuries. The accuracy of MRI for ACL tears
was found to be 95% to 10fl%.1 To avoid magic angle
artifact, which can mimic a tear, TZHweighted sequences
are recommended for evaluation of the ACL rather than
Tl-weighted sequences. An intact MIL usually is seen as
taut fibers paralleling the intercondylar roof on sagittal
MRI studies, but confirmation on axial and coronal views
is recommended {Figure l, A}. ACL tears most commonly
involve the intrasubstance fibers {approximately Ffl‘hi), but
This to 20% occur proximally at the femoral attachment 1"?
of the AEL and 3% to 10% occur distally at the tibial E
insertion.“
fil
“E.
n
Du MRI, the primary sign of a complete tear of the in
ACL is complete disruption of the fibers {Figure 1, B}.
flccasionally the ACL is completely torn, although the
fibers initially appear to be intact on MRI. The fibers are
wavy in appearance and have a relatively horizontal or flat
angle with respect tn the intercondylar roof, and this subtle
appearance is consistent with a tear. Secondary MRI signs
of an ACL tear also have been reported. Pivot-shift bone
Orthopaedic Knowledge Update: Sports Medicine 5
 Sectiun 5': Imaging

cuntusiuns uften are seen as bune marruw edema in the lat-

eral femural cundyle and pustercllateral tibial plateau. The
cuntusiun uccurs when the tibia is displaced anteriurly and
impacts untu the lateral femural cundyle. This mechanism
alsu can pruduce an impactiun fracture (the su—called deep
femural nutch sign}.if A cuntrecuup bone cuntusiun in the
pusterumedial tibial plateau, a Seguncl fracture is small
avulsiun fracture cf the lateral tibial plateau related tn the
meniscutibial ligament andfur slips from the iliutibial band
ur lateral cullateral ligament}, and anteriur translatiuu cf
the tibia alsu have been described?” Patients with an ACL
rear with a curtical depressiun fracture were repurted tu
have an increased incidence uf meniscal tears in the same
knee as well as a relatively puur clinical uutcume 1 year
after ACL recunstructiun.“ In the same study, an increased
vulume uf bune marruw edema withuut fracture was uur
assuciated with a peer pustuperative clinical uutcume.
A partial ACL tear usually is treated nunsurgically.
There are relatively few published studies un this type
cf tear because it is net cummun and can be difficult tu
diagnuse clinically ur radiugraphically. MRI findings sug-
gesting a partial tear include an increased T2 signal alung
the cuurse cf the ligament, with preduminantly intact
fibers; unexpected fucal angulatiun uf intact fibers; and,
in a chrunic tear, attenuatiun cf the fibers.2 Narruwing
cf the transverse dimensiun with a nurmal anteriur—pus— Figure 1 Sagittal TE-vveighted fat-suppressed MRI
teriur dimensiun an atrial imaging has been described in shuws an anteriur cruciate ligament gangliun
a stable partial tear; the absence cf the anterumedial ur with a glubular, masslike hyperintense signal
abn urmal'rtyr within the ligament, with intact
pusterc-lateral bundle suggests an unstable partial tearf” fibers.
New imaging planes have been suggested fur use in the
diagnusis uf partial ACL tears. A recent study repurterl
that 32% uf suspected ACL injuries were selective bundle
The Pusteriur Cruciate Ligament
tears, and there were three times as many anterumedial
bundle tears as pusterulateral bundle tears.” The study The pusteriur cruciate ligament {PCLJ is nut uften turn.
alsu fuund that 3*Tesla {HHTJ imaging in the ublique cur“ The PCL else is infrequently repaired ur recunstructed,
unal plane yielded significantly greater specificity [92% althuugh surgical currectiun is becnming mure cummun.
re 96%} fur selective bundle tears than imaging in cun- 0n MRI, the nurmal PCL is seen curving intu the inter-
ventiunal urthugunal lsagittal and cur-anal} planes {6?‘iiil. ccmdylar nutch, is usually less than 6 mm thick in the
The use uf this imaging appruach can be beneficial in anteriur—pesteriur dimensiun {as measured un T2—weight~
eclective ACL bundle recunstructiuns. ed sagittal images}, and has a luw signal intensity un
Pitfalls in the diagnosis cf ACL tears are related tu in- all sequences.” The PCL is unusual in that the fibers
m creased Til—weighted signal abnurmality alung the cuurse must uften du nut frankly disrupt with tearing, althuugh
.E cf the ligament that results frurn mncuid degeneratiun ur cumplete intrasubstance tears and avulsiuns are pussible
U"!
nu
E an ACL gangliun. These patients usually have rm instabili- {Figure 3]. Instead, the ligament stretches significantly
ty, may have nu symptoms, and uccasicmally have a histu— and subsequently becumes structurally incumpetent.”
a

ry uf swelling ur fullness in the knee. An ACL gangliun is
best identified an MRI as a glubular mass-like cyst within
the ACL, althuugh with intact fibers {Figure 2}. An ACL
gangliun is difficult tu diagnuse thruugh an arthruscupic
anteriur purtal because it is difficult tu see superficially ur
anteriurly. Prubing ur aspirating from a pusteriur portal
usually is required.”"3
Du MRI, a turn PCL ligament appears as thickened tu
mere than ? mm, with a sensitivity cf 94% and specificity
cf 92%, and usually the T1- and prutun density—weight—
ed intrasubstance signal abnurmality is greater than the
Til-weighted signal abnurmality.” Unlike uther ligament
tears, fur unknuwn reasuns PCL tears unly rarely have a
significantly increased Tl-weighted intrasubstance signal

flrfltupaedic Knuwledge Update: Spurrs Medicine 5 El ll] 16 American AcadMy uf Drrhupaedic Surge-nus

Sagittsl TE-weighted fat-suppressed MRI shows
a complete posterior cruciate ligament tear
with disruption of the fibers.
abnormality. Because of these features, radiologists some
times miss the diagnosis of PCL tear.
MRI can suggest mucoid degeneration of the PCL, as
in the ii't'CL.‘5 1i'n'ii'ith mucoid degeneration, the PCL usually
is thickened and has increased TE- and proton density—
weighted signal abnormality {although the intensity of
the signal abnormality is less than in a tear}. The sirnir
larity of these findings to those for a PCL tear can lead
to confusion. A so-called tram-track appearance of the
PCL on MRI helps to distinguish mucoid degeneration
from a PCL rear. The tram-track appearance is associated
with a functionally intact ligament and is described as
a homogeneous longitudinal T2- and proton density—
weighted intrasuhstance signal abnormality that usually
extends along the course of the entire ligament, with
intact fibers coursing through the signal abnormality on
all three planes and an adjacent peripheral rim of intact
hypnintense ligament fibers.”
The Menisci and Hyaline Cartilage
MRI is the most accurate imaging modality for diag—
nosing a meniscal tear. The menisci are C- shaped and
Eb Ifllti American Academy of Urthnpaedic Surgeons
Chapter 56: Imaging of the Knee
thicker at the periphery than at the center. The posterior
horn of the medial meniscus is larger than the anterior
horn, and the horns are roughly equal in size to those of
the lateral meniscus. A meniscus should be seen as having
a homogeneously low signal intensity on all imaging se=
quences, although some mildly increased intrasubstance
signal in the posterior horn of the medial meniscus is
normal in children and young adults and is related tn nor
mal vascularity. Dlder adults may have a predominantly
intrasubstance signal abnormality that does not extend
tn the articular surface. This finding represents mucoid
degeneration, which is not always a source of pain and
does not always lead tn a meniscal tear but is mentioned
in imaging reports tn acknowledge signal abnormality
that does not represent a tear?”
Several variants should he noted when evaluating the
menisci. Meniscal flounce usually occurs along the free
edge of the medial meniscus and typically is secondary
to fleainn and redundancy of the free edge. A meniscal
ossicle is of uncertain etiology and can be congenital,
posttraurnatic, or degenerative. The nssicle most often
is seen in the posterior horn of the medial meniscus and
should not be called a loose body. A discnid meniscus is
most common in the lateral meniscus and is a central est-
tension of the meniscal fibrocartilage tn cover the central
tibial plateau. A discoid extension can be diagnosed if
the body of the meniscus measures 15 mm or more on a
relevant central cnrnnal image or if three or more bowtie
shapes are identified on contiguous [4—mm—thicltl sagittal
images (Figure 4). Chondrocalcinosis also can been seen
on MRI, and it is important tn correlate the images with
corresponding radiographs.”
A meniscal tear has been defined as a “distortion in
the absence of prior surgery or increased intrasuhstance
signal intensity unequivocally contacting the articular
surface.”5
If the signal is seen on two cnntigunus slices, the positive
predictive value for a tear is 94% in the medial meniscus
and 95% in the lateral meniscus.” l'vleniscal tears are best
diagnosed on MRI sequences with a low echo time, such
as T1- and proton density-weighted sequences. Iflblique,
horizontal, longitudinal, radial, complex, and root me- 1"?
niscal tears can occur. A horizontal tear runs parallel tn 3
fit
the tibial articular surface and divides the meniscus into “2.
n
superior and inferior halves {Figure 5). These tears most to
often are degenerative and often are associated with a
parameniscal cyst. A longitudinal tear runs perpendicular
to the tibial articular surface and divides the meniscus into
peripheral and central halves. These tears usually occur
in relatively young patients after a traumatic event, and
they are strongly associated with ACL tears. A radial tear
is both perpendicular and parallel to the tibial articular
Drrhnpaedic Knowledge Update: Sports Medicine .5
 Sectien 5': Imaging

Figure 4 MRI shaws a discaid lateral meniscus. A. lIIIclrclnal Til—weighted fat-suppressed sequence. B, Sagittal pruten density—
weighted fat—suppressed sequence.

I V .1. ‘u I.“
ll,.:! l
I. ' . r'h' '
l I I

A
Figure 5 Mfil shews a herizental tear ed the medial meniscus with an adjacent parameniscal cyst. A. Itic-renal preten
m density—weighted sequence- I. Axial Tseighted fat-suppressed sequence.
.E
5'!
na
E
surface; it disrupts the heap strength of the meniscus, The indirect signs [if a meniscal tear include a parame-
a

causing significant less ef meniscal functicnn. A rec-t tear
typically is a type at radial tear, and it can result in menis-
cal extrusien ef mere than 3 nnn heyend the tibial plateau
{Figure 6}. These tears are well knewn for being missed an
MRI and during arthrescepy. The cerenal pla ue is best fer
diagnesing a rent tear. A cemplen tear is a cemhinatien
uf heriaenta], vertical, and radial tearsfi”
niseal cyst, a meniscal extrusien, and suhehendral hene
marrew edema. Parameniscal cysts are strengly asseci-
ated with an underlying meniscal tear, and the likelihood
at an underlying meniscal tear varies with the lucatien
ef the pa rameniscal cyst.” Specifically, 10fl% ef patients
with a lateral parameniscal cyst adjacent tn the hedy and
pasterier hern ef the lateral meniscus had an underlying

flrdiupaedic Knewledge Update: Sparta Medicine 5 El 1016 American deadeniy at Dnhnpaedie Surge-ans

”'5-
Figure 5 MRI shows a posterior root tea r. A. llZoronal TE-vveighted fat-suppressed sequence showing a complete tear of
the posterior root of the medial meniscus. E. A mo re anterior sequence shows associated meniscal extrusion and
severe osteoa rth rosis.
meniscal tear, but an underlying meniscal tear was not
present in 36% of the patients with a parameniscal cyst
adjacent to the anterior horn—body region of the lateral
meniscus.” It is necessary to be aware that a parame-
niscal cyst within the region of the anterior horn of the
lateral meniscus is less likely to have underlying tear than
a parameniscal cyst elsewhere in the knee.
Meniscal root tears reportedly are difficult to diag-
nose on MRI or during arthroscopy. These tears were
described using 3-T MRI correlated with dissection pho-
tographs of cadaver knee specimens.“ Posterior root tears
of the lateral meniscus were found to be associated with
meniscal extrusion and ACL tears.” The posterior root of
the lateral meniscus does not have the isosceles triangular
configuration seen elsewhere in the menisci. The usefulr
ness of MRI in diagnosing a tear of the posterior root of
the lateral meniscus was evaluated, with the question of
whether an associated ACL tear alters diagnostic accura-
cy.'t”'-I The standard criteria for diagnosing meniscal tears
were found to be adequate to diagnose a posterior toot
tear of the lateral meniscus, and the presence or absence
of an ACL tear did not affect the ability to diagnose a
meniscal toot tear.
An association between medial meniscal root tears
and medial tibiofemoral cartilage loss has primarily been
described in small studies. An association between medial
meniscal root tears and the development or worsening of
medial tibiofemoral chondrosis was found in a study that
Eb Ifllti American Academy of flrdiopaedic Surgeons
Chapter Ed: Imaging of the Knee
used a longitudinal design.21 The significantly greater
prevalence of severe chondral loss in patients with a root
tear than in those without a meniscal root tear supported
the theory that meniscal root tears have a pseudomenis-
cectomy—like effect}1
Hyaline cartilage is an extremely important intrawar-
ticular tissue that supports joints and often is injured by
trauma or degenerative change in the knee. Damaged
cartilage rarely heals spontaneously, and its subsequent
degeneration leads to osteoarthrosis of the knee. Surgical
and pha rmacologic advancements have become extremely
important in the treatment of damaged cartilage. MRI is
the most important and widely used imaging modality
for evaluating cartilage because of its superior contrast
resolution. Multiple grading systems can be used for car-
tilage abnormalities, but for clinical purposes it is best
to describe the abnormality in terms of focal abnormal
signal, surface fibrillation, partial- or fullvthickness chon- 1"?
dral loss, and underlying bone marrow signal abnormal- 3
fl!
ity. It is also important to note any delamination, which “2.
o
appears as high—signal abnormality at the bone—cartilage to
interface.1
Many sequences can be used for cartilage evaluation,
but the most common are the two dimensional fast spin-
echo proton density—weighted and T1—weighted imag-
ing sequences, with or without fat suppression. Many
institutions prefer an intermediate—weighted sequence
that combines the contrast advantage of proton density
Drthopaedic Knowledge Update: Sports Medicine 5
 Sectien 5': Imaging
weighting with that cf T2 weighting by using an eche time
cf 33 te El} msec. Tl-weighted sequences de net previde
adequate centtast between the jeint fluid and the cartilage
and shnuld net be the primary type nf sequence.
The field strength ef the imaging magnet has imperta nt
implicatiens for the assessment ef hyaline cartilage. In
patients with symptems, 3-T MRI cffered better diagnes-
tic perfermance than 1.5—T MRI fer assessing articular
cartilage.11 The specificity and accuracy ef 3-T MRI was
greater fer detecting cartilage lesiens, but it did net have
greater sensitivity than 1.5-T imaging. In additien, 3-T
imaging had greater accuracy than 1.5'T imaging for
grading articular surfaces and cartilage lesiens.” Addi-
tienal sequences alse are being studied fer the evaluatien
ef cartilage; with 3-T MRI, T2 mapping was shewn te
impreye sensitivity in the detectien ef cartilage lesiens
within the knee frem T4.6% te 33.9%.” The greatest
imprevement in sensitivity was neted in patients with
early cartilage degeneratien, and this sequence can have
a significant effect en early detectien and pessibly pre—
ventien ef further cartilage degeneratien.”
The knee jeint is a cemmen senrce ef pain in patients
presenting te an erthepaedic clinic. The ACI. and PCL
are twe ef the majer ligaments ef the knee; the fermer
being cemmenly injured and the latter being infrequently
tern. The ACL may be cempletely er partially tern, er
may have a bulheus appearance suggestive ef muceid
degeneratien. The PCL may be tern with seemingly intact
thickened fibers en MRI er be disrupted andfer avulsed.
The appearance ef muceid degeneratien ef the PCL has
recently been described as a tram-track appearance with
increased preten density and T2 signal abnermality difu
fnsely aleng its ceurse. Signal ahnermality within the
meniscus that extends tn the articular surface en at least
twe images is suggestive ef tear. Many types ef meniscal
tears have been described and include ebliquefheriaental,
vertical, radial and cemplea tea rs. Parameniscal cysts are
a secendary sign ef meniscal tear, but may net always
m be when lecated aleng the anterier hern ef the lateral
.E meniscus. Hyaline cartilage is best evaluated en preten
5'!
re
E density- and TIL-weighted images with er witheut fat
saturatien, and diagnestic accuracy is increased when
a
imaging en a 3-T magnet.
flrtltepaedic Knewledge Update: Sperts Medicine 5
Key Study Peints
1* The ACL may be cempletely er partially tern, er
may have a bulheus appearance suggestive ef mu—
ceid degeneratien.
I The PCL may be tern with seemingly intact thick-
ened fibers en MRI er be disrupted andfer avulsed.
I Parameniscal cysts are eften a secendaryr sign ef
meniscal tear.
' Hyaline cartilage is best evaluated en preten den-
sity— and Til-weighted images with er witheut fat
saturatinn; imaging en a 3-T magnet increases di-
agnestic accuracy.
Annotated References
1. Swensnn TM, Harner CD: Knee ligament and menis-
cal injuries: Current cencepts. firtbep lr: Nertfr Am
1995:26{3l:529-546. Medlinc
2. Helms C, Majer N, Andersen M, Kaplan P, Dussault R:
Mnscrrfuslrelstal MRI .Philadclphia, PA, Saunders, NUS.
3. Resnick D, Kmnsderf M: HERE and Jefnt Imaging .Phil-
adelphia, Pa, Saunders, 1004.
4. Renter EM, Fitzgerald SW, Friedman H, Regers LF, Hen-
dria KW, Schafer MF: Anterier cruciate ligament injury:
MR imaging diagnesis and patterns ef injury. Radiegrapfr-
it's 1992;12{5j:9D1-915. Medline DUI
5. Kaplan PA, Walker CW, Kilceyne RF, Brewn DE, Tusek
D, Dussault RG: Clccult fracture patterns ef the knee
asseciated with anterier cruciate ligament tears: Assess-
ment with MR imaging. Radieiegy 1992;133l3]:335-338.
Medline DD]
6. Earth 1|illl'P‘lr, Green J, Heuse MA: The lateral netch sign
asseciated with acute anterier cruciate ligament disrup-
tien. Am } Sperts Med 2Dflfl;23(1}|:63-?3. Medline
'3'. Campes JC, Chung CE, Lektrakul H, et al: Pathegenesis ef
the Segend fracture: Anatemic and MR imaging evidence
ef an ilietibial tract er anterier ebliquc band avulsien.
Radiefegy lflfll;219[2}l:331-336. Medline DC“
3. Kijnwski R, Sanege ML, Lee HS, et a1: Ebert-term clinical
impertance ef esseeus injuries diagnesed at MR. imaging
in patients with anterier cruciate ligament tear. Radfelegy
lfl]2;264{1):531-541.Medline net
This retrespective study evaluated patients with an ACL
tear and a depressinn fracture. Clinical eutceme sceres
were decreased 1 year after ACL recenstructien surgery.
Eene marrew edema velume was net asseciated with the
decrease in clinical eutceme sceres.
El 1016 American AcadMy ef Drthepaedic Surge-ens

9. Roychowdhury S, Fitzgerald 5W, Sonin AH. Peduto A],
Miller FH, Hoff FL: Using MR. imaging to diagnose par-
tial tears of the anterior cruciate ligament: Value of axial
images. AJR Am ,I' Roentgenoi 199?;16Eilfiifl4ET-1491.
Medline [ll-DI
10. Park H], Kim 55, Lee 5?, et a1: Comparison between
arthroscopic findings and 1.5-T and 3-T MRI of oblique
coronal and sagittal planes of the knee for evaluation of se-
lective bundle injury of the anterior cruciate ligament. AJR
Am] Roentgenoi 2014;203{2}I:W1 99-316. Medline DUI
In this study, the oblique coronal plane and the combina—
tion of the orthogonal planes and both sagitra] oblique
and coronal oblique planes provide better diagnostic infor-
mation with increased specificity on 3-T MRI compared
with orthogonal views alone for the diagnosis of selective
bundle tears. The results were not similar for 1.5-T MRI.
11. McIntyre J. Moelleken 5. Tirman F: Mucoid degeneration
of the anterior cruciate ligament mistaken for ligamentous
tears. Sheietni Rodin! 2001;3li{5}:311-315. Medline DUI
12. Fealy 5, Kenter K, Dines J5, Warren RF: Mucoicl degen-
eration of the anterior cruciate ligament. Arthroscopy
lflfll;1?{9}:E3?.Medline DUI
13. Eergin D, Morrison WE, Carrino Jill, Nailamshetty 5N,
Bartoloaai AR: Anterior cruciate ligament ganglia and
mucoid degeneration: |Iiiloesistence and clinical correla-
tion. EUR Am ] Roentgenoi Zflfi4;132{5}:1233-1231
Medline [ll-DI
14. Rodriguez W Jr, 1lil'inson EN, Helms CA, Toth AP: MRI
appearance of posterior cruciate ligament tears. AJR Am
I Roentgefloi lflflfl;l91{4}:lflfll. Medline DDI
1.5. McMonagle J5, Helms CA, Garrett WE Jr, Vinson EH:
Tram-track appearance of the posterior cruciate ligament
[PCL]: Correlations with mucoid degeneration, ligamen-
tous stability, and differentiation from PCL tears. AIR
Aer: ,I' Roentgenoi lfl13;201{2}:394-399. Medline DUI
Dn MRI, PEEL tears and findings suggestive of mucoid
degeneration show intrasuhstance signal abnormality
and ligament thickening. Tram-track appearance with
peripheral rim of hypointense signal is seen with mucoid
degeneration. Patients with mucoid degeneration usually
are asympmmstic and have no instability.
16. Nguyen JC, De Smet as. Graf EH. Rosas HG: MP. imag-
ing-based diagnosis and classification of meniscal tears.
Radiographies 1fl14;34{4}:931-999. Medline DUI
The MRI findings of meniscal tearing of the knee were
reviewed in this study.
1?. De Smet AA, Graf BK, del Rio AM: Association of
parameniscal cysts with underlying meniscal tears as
Eb Ifllii American Academy of flrflropaedie Surgeons
Chapter 56: Imaging of the Knee
identified on MRI and arthroscopy. AIR An: I Roentge-
rsoi 2D11;196[2}:W18fl-6. Medline DUI
Compared with parameniscal cysts associated with the
medial meniscus or other locations in the lateral meniscus,
parameniscal cysts adjacent to the anterior horn or root of
the lateral meniscus are less likely to have an underlying
meniscal tear.
13. Brody JM, Hulstyn M], Fleming BC, Tung GA: The me-
niscal roots: Gross anatomic correlation with 3-T MRI
findings. AIR Am ] Roentgenoi lflfl?;133{5}:W4-46‘5[i.
Medline DUI
19. Brody JM, Lin HM, Hulstyn M], Tung GA: Lateral 111c-
niscus root tear and meniscus extrusion with anterior
cruciate ligament tear. Radioiogy 20fl6;239{3]:305-310.
Medline DUI
2.0. De Smet AA, Blankenbaker DG, Kijowski FL, Graf BK,
Shinki K: MR diagnosis of posterior root tears of the
lateral meniscus using arthroscopy as the reference
standard. 1UP. Am J Roentgenoi lflfl9:192{2}:430-436.
Medline DUI
Standard imaging findings suggesting a meniscal tear can
be used to diagnose root tears of the lateral meniscus.
The concurrent presence of an ACL tear did not decrease
diagnostic accuracy for a lateral root tear.
21. Guermasi a, Hayashi D, Jarraya M. et al: Medial pos-
terior meniscal root tears are associated with devel-
opment or worsening of medial tibiofemoral cartilage
damage: The multicenter osteoarthritis study. Radiology
2013:263i3}:314-321.Medline DUI
Isolated medial meniscal root tears are associated with
the development and progression of medial tibiofemotal
cartilage loss.
22. Kijowski R, Blankenbaker DE, Davis KW, Shinki K, Ka-
plan LI), De Smet AA: Comparison of 1.5- and iii-T MR
imaging for evaluating the articular cartilage of the knee
joint. Radioiogy lflfl9:25fl{3i:339-34E. Medline III-DI
The use of 3-T MRI has improved the diagnostic perfor-
mance of MRI {in specificity and accuracy but not sensi-
tivity} in evaluation of the articular cartilage compared
with 1.5-T MRI.
13. Kijowski R, Blankenhaker DG, Munos Del Rio A, Eaer G5.
Graf BK: Evaluation of the articular cartilage of the knee
joint: 1|IJ'alue of adding a T2 mapping sequence to a routine
MR imaging protocol. Rodioiogy 1013;269'l2}:5l13-513. 1"?
Medline DC}! 3
fl!
'9.
The addition of a T2 mapping sequence to routine 3-T n
no
MEI protocols improved sensitivity for cartilage lesions of
the knee, with the greatest effect in the detection of early
cartilage deterioration, from 94.6% to 33.9%. There was
a small reduction in specificity.
Drthopaedic Knowledge Update: Sports Medicine 5
Chapter 57
Diagnostic Ultrasound and
Ultrasound— Guided Procedures
Jennifer L. Pierce. MD Nicholas C. Nacey. MD
Ultrasound can provide valuable information in many
musculoslceletal disorders. Its low cost, nonioniaing
multiplanar imaging, easy accessibility, and dynamic
real-time imaging malrc ultrasound attractive for use
in patients with a sports injury or another joint-related
condition. With knowledge of musculoskeletal anatomy,
pathophysiology, and specific ultrasound techniques,
diagnosis and effective therapeutic intervention can
be performed.
Keywords: calclfic tendinitis: foreign bodies: joint
aspiration: musculoskeletal ultrasound: tendinosis:
tendon tears; ultrasound; ultrasound-guided
interventions
Introduction
Musculoslceletal ultrasound increasingly is used in both
diagnostic and interventional applications. Ultrasound
offers several advantages for musculoslceletal evaluation,
including the absence of exposure to ionizing radiation,
good soft—tissue resolution, potential for dynamic imag—
ing, easy comparison with the contralateral side, safety
for patients who cannot undergo MRI {such as those
with a pacemaker}, and low cost.“1 Ultrasound also has
several disadvantages, however. Ultrasound provides
a more limited field-of-view examination than other
cross-sectional techniques, it has limited ability to show
some structures {particularly bones and cartilage} that
are easily observable on MRI, the examination is time
Neither of the following authors nor any immediate familyr
member has received any-“thingI of value from or has stock or
stock options held in a commercial company or institution
related directly or indirectly to the subject of this chapter:
Dr. Pierce and Dr. Naceg
fl lflld American Academy of Drthopaedic Surgeons
consuming, and the examination quality depends on the
slcill of the technician.1 Although ultrasound can be used
to complete a systematic examination of an entire joint, it
is most effective when used to answer a particular clinical
question or to examine a focal area.
Choosing the appropriate ultrasound transducer is
critical {Figure l]. A high-frequency probe produces a
higher resolution image of superficial structures, but a
lower frequency probe is necessary to penetrate into deep
tissues, as in the hip. A small-footprint, high-frequency
transducer (a so—called hockey stick transducer} is used
to obtain high-resolution images of superficial structures
in the hands and feet or ankles. A linear high-frequency
probe can be used to obtain high—resolution images of
superficial structures and yields a larger field of view than
the small-footprint transducer. A curved, lower frequency
transducer is used to produce images of deep tissues with
an even larger field of view.1
Modern ultrasound machines incorporate a wide array
of parameters that can be used to obtain an optimal im-
aging examination.‘ After the appropriate transducer is
chosen, a presetting is selected for the body part to be ex-
amined. The appropriate imaging depth allows the chosen
structure to be studied but does not include unnecessary
deeper tissues. The focal zone should be adjusted so that
it lies at the targeted structure. The gain setting can be
adjusted to obtain the appropriate image brightness, and
time gain compensation can be adjusted so that the image
brightness is homogenous throughout the superficial and
deep aspects of the image. The color and power Doppler 1-9
settings show an increase in blood flow and may be ben- 3
run
eficial in detecting areas of hyperemia within inflamed
:1
EL
tissues? Many units offer extended fielduofuview imaging cc:
in which the probe can be moved and multiple images can
be stitched together to produce an image that is much
larger than the intrinsic field of view of the transducer. A
structure can be described as being hyperechoic {bright},
hypoechoic {dark}, or anechoic [black and typical of sim-
ple fluid}. Assessment of the echogenicity, or brightness,
of a structure is a critical component of the examination
Drrhnpaedic Knowledge Update: Sports Medicine 5
 Section 9: Imaging
Figure 1 Photograph showing ultraseund probes used
for mustuloslceletal applications. A 15-MH2
small‘footprint hoclcey stlclt probe [left] is best
used for imaging small su perficial structures
of the hand and wrist or foot and anltle. A
El- to 12-MH: intermediate-frequency linear
transducer {middle} provides a slightly larger
field of view for structures such as the shoulder.
elbow. or knee. A S-MHa low-freq uenty curved
transducer {rig ht} provides the largest field of
view and deeper penetration but the lowest
resolution. and its best use is in large patients
or in deep locations such as the hip.
that can be adversely affected by inappropriate settings.
Many potential ultrasound artifacts must be con-
sidered. Anisotropy, which is most commonly seen in
tendons, is an artifact unique to musculoskeletal ultra-
sound.“3 Tendon imaging must be done with the ultra-
sound beam aimed perpendicular to the course of the
tendon to show the normal echogenic, fibrillar pattern
of the tendon. If the probe is not perpendicular to the
tendon, the tendon will appear to be hypoechoic, and
tendinosis could mistakenly be diagnosed.
The presence of air reduces the ability of ultrasound
to obtain images, and therefore it is critical to use a suf-
ficient quantity of ultrasound gel and to maintain skin
contact with the entire ultrasound transducer. The hand
holding the transducer can be kept in contact with the
or patient‘s skin to improve stability. Images should be ob-
.E
or tained in orthogonal planes to confirm an abnormality
l'fl
E in any targeted structure. Most interventions are done
using a freehand technique in which one hand holds the
é;
probe and the other holds the needle. The needle is in
the plane along the long axis of the transducer so that its
entire course can be seen until it reaches the target.“l It is
critical to observe the needle tip to avoid advancing more
deeply than expected. Some small joints can be reached
with a needle using an out—of—plane approach in which
only a small cross-section of the needle is observed.1
firthcrpaedic Knowledge Update: Sports Medicine 5
Shoulder Ultrasound
|Due of the primary uses of musculoslceletal ultrasound
is to evaluate the shoulder and in particular the rotator
cuff. Ultrasound is particularly beneficial in patients who
cannot undergo MRI because of claustrophobia or an
implanted medical device. MRI and ultrasound by an
experienced technician both have approximately 95%
sensitivity and specificity for detecting a rotator cuff tear,
in comparison with arthroscopy.5 Shoulder ultrasound is
limited by its dependence on the skill of the technician
because of the difficulty of appropriately scanning the
complicated shoulder anatomy. MRI remains the test of
choice for evaluating the bones, cartilage, labrum, and
intra-articular portion of the biceps because these struc-
tures cannot be well seen using ultrasound.
The supraspinatus is the most commonly torn rotator
cuff tendon. Positioning the patient’s hand with an an-
terior-facing palm along the ipsilateral lower back {the
modified Crass position} moves the tendon out from
under the acromion and aids visualisation“ {Figure 2}.
The criteria for diagnosing a rotator cuff rear include
nonvisualisation of the tendon, partial— or full—thick—
ness tendon interruption with or without a hypoechoic
defect, focal tendon thinning, and loss of the normal
bursal surface tendon convexity? Tendinosis appears as
hypoechoic enlargement of the tendon with loss of its
normal fibrillar echotexture, although care must be taken
to distinguish this appearance from anisotropy artifact.5
The infraspinatus and teres minor tendons are best seen
from the posterior aspect of the shoulder, with the hand
crossing the chest and touching the contralateral shoul-
der.“ The criteria for diagnosing tears of these tendons
are similar to those for diagnosing a supraspinatus tear.
The nondistended subacromial-subdeltoid bursa can be
seen as a thin echogenic line representing the potential
space between the deltoid and supraspinatus; in bursitis,
anechoic fluid is present in this space?
The subscapularis tendon and extra-articular portion
of the biceps tendon can be seen on ultrasound by placing
the transducer along the anterior aspect of the shoul-
der {Figure 3}. The anatomy in this area is most easily
identified with the patient’s shoulder externally rotated
and the transducer in a horizontal position to produce a
short-axis image of the biceps tendon and a long-axis im--
age of the subscapularis tendon, similar to an axial MRI
imagefi Abnormal findings in the biceps tendon include
surrounding fluid from tenosynovitis, focal anechoic slits
or tendon splitting in a partial tear, and nonvisualisation
of the tendon in a complete disruption.j Subscapularis
tendon tearing can be diagnosed using the criteria for a
supraspinatus tear, except that the subscapularis tendon
fl lfllfi American Academy of Orthopaedic Surgeons

Figure 2 Ultrasound image of the rotator cuff obtained
with the patient in the modified Crass position
and the transducer along the long axis of the
supraspinatus tendon. showing the normal
fi brillar appearance of the tendon (solid arrow}
and its attachment on the greater tu berosity.
Posterior shad owing from the acromion
{da shed arrow} can increase the difficulty of
im aging the medial portion of the tendon.
has a multipeunate appearance on short-axis images from
its multiple tendon slips, which should not be misinter-
preted as a tear.“
Ultrasound of the shoulder has multiple interventional
applications. Ultrasound can be used as an alternative to
fluoroscopy to guide injections into the glenohumeral or
acromioclavicular joint. Subacromial—subdeltoid bursa
injection can be done under ultrasound guidance as an
alternative to fluoroscopy- or palpation—guided injection.
The biceps tendon sheath can he quickly located with I.Il-
trasound for a peritendinous injection. lSaleific tendinitis
can be treated using a unique interventional application
of ultrasound in the shoulder [Figure 4}. Ultrasound can
ezatguisitelj.r reveal hyperechoic foci from calcium depos-
its. Both single— and double—needle techniques have been
described?” A needle is inserted into the calcific depos-
it, and saline andfor anesthetic are introduced to break
up the calcium, which is aspirated. After the procedure,
Steroids should be injected into the snbacromial bursa to
decrease reactive inflammation.“ Usually it is not possible
to remove all of the calcium, but at 1-year follow-up 9fl%
of patients had improvement in symptoms and calcifica-
tions even if no calcium was removed.”
Elbow Ultrasound
Because of the superficial location of the distal biceps ten-
don, ultrasound is able to accurately diagnose a tear and
determine the extent of proximal retraction of the tendon
stump {Figure 5]. Specific techniques may be necessary to
IE! lfllfi American Academy of flrthopaedic Surgeons
Chapter 5?: Diagnostic Ultrasound and Ultrasound-Guided Procedures
Ultrasound image obtained across the short
axis of the biceps tendon {arrow} within the
biceps groove along the proximal humerus.
Minimal hypoechogenicitjlr surrounding the
tendon represents the normal tendon sheath
with a small amount of physiologic fluid, which
is a potential target of therapeutic injection.
Figure-4 .Jltrasound image of the supraspinatus
tendon, {dashed arrow}, showing a markedly
hy perec hoic focus (solid arrow} with posterior
acoustic shadowing representing calcium
hydroxyapatite deposition. A hyperechoic
needle can be seen entering the calcium from
the left side of the image for therapeutic
calcium fenestration and aspiration.
observe the distal aspect of the tendon as it courses deep
to its insertion at an oblique angle and is predisposed to
anisotropy.” During imaging in the long axis of the ten- 1-9
don, the application of additional pressure to the distal 3
cu
aspect of the transducer {the so-called heel-toe maneu-
:1
EL
ver} can help keep the transducer parallel to the tendon. LI]
The long axis of the distal biceps also can be observed
by flexing the elbow and positioning the transducer in
the coronal plane from a lateral or medial approach.“
Complete tears are seen as tendon discontinuity with
a gap between the tendon stump and radial tuberosiry.
Fluid andfor hemorrhage can be seen in the tendon gap.
A partial tear may be more challenging to diagnose than
Drthopaedic Knowledge Update: Sports Medicine 5
 Section 9: Imaging
I'll.-
ngth 11.2 cm
.......
.......
I.-
ear-r - . I
Figure 5 An extended field-of-view ultrasound image of
the anterior elbow in the sagittal plane shows
a proximally retracted tendon stump {arrow}
resulting from a complete biceps rupture,
with a small amount of surrounding anechoic
fluid. Extended field-of-view imaging allows
measurement of the distance from the tendon
stump to the radial tuberoslty {line extending
from x to x}.
a complete tear, but tendon thinning, irregularity, or by-
poechogenieity may be observable, sometimes with fluid
in the bicipitoradial bursa.”
Long-axis images of the common flexor or extensor
tendon can be obtained by placing the probe in the core-
nal plane of the flexed elbow along the medial or lateral
epicondyle, respectively” {Figure 6). Tendinosis in either
tendon appears as hypoechoic swelling without fiber dis-
ruption, cortical irregularity of adiacent bone, increased
Doppler blood flow, or intratendinous caleifieations.”
Focal anechoic areas with fiber disruption are seen with
tearing of the common l'lexor or extensor tendon.” Im-
aging in the same plane can he used during peritendinous
steroid injection, dry tenotomy, or platelet—rich plasma
injection. The collateral ligaments can be seen underlying
the common extensor and flexor tendons. Ultrasound is
not commonly used specifically to evaluate these liga—
ments, but they should be evaluated concurrently with
the overlying tendons because their disruption can cause
persistent symptoms after the tendinopathy is treated.”
Elbow neuropathy can be observed under ultrasound
on as enlargement of the nerve cross-sectional area and loss
.E
on of the normal fascicular pattern. The ulnar nerve is easily
l'fl
E seen in its short axis by placing the transducer transversely
across the cubital tunnel.” As the elbow flexes, dynamic
é;
subluxation of the ulnar nerve can be seen across the
apex of the medial epicondyle. If the medial head of the
triceps moves along with the ulnar nerve, snapping triceps
syndrome can be diagnosed” The median and radial
nerves also can be observed more anteriorly in the elbow if
neuropathy is suspected, although an underlying etiology
usually is difficult to identify in these sites.13
firthopaedic Knowledge Update: Sports Medicine 5
4
Figure 5 a coronal ultrasound image along the lateral
aspect of the elbow shows a normal common
extensor tendon {arrow} along its long axis.
The lateral epicondyle origin is in the lower
right side of the image. The proximal radius is
in the lower left side of the image. The fibers
of the radial collateral ligament blend with the
undersu rface fibers of the common extensor
tendon and can be difficult to distinguish.
Wrist and Hand Ultrasound
High-resolution images of wrist and hand tendons are
easy to obtain because of their superficial location. Peri-
tendinous injection can be effecdvely done under ultra-
sound guidance.” Tendon rupture can occur as a result of
trauma, chronic irritation caused by adjacent hardware,
or an underlying inflammatory condition such as rheu-
matoid arthritis.” The torn tendon stump and extent of
retraction are readily identifiable with ultrasound, which
may aid in presu rgical planning [Figure 3"}. In chronic tens
don rupture, scar tissue along the path of the torn tendon
can form a pseudotendon, which is a pitfall in ultrasound
interpretation. However, the structured fibrillar—appear—
ing collagen fibers of normal tendon usually are absent if
scar tissue has replaced the normal tendon.“
Supporting soft—tissue structures in the fingers can
be evaluated with ultrasound. Direct observation of a
disrupted sagittal band can be difficult, but dynamic
imaging with the hand in a clenched-fist position can
show subluxation of the tendon away from the side of the
ruptured sagittal band?1 A flexor tendon pulley injury can
produce tendon bowstringing, particularly in the flexed
position. a distance of 1 mm between the phalanx and
flexor tendon at the location of a pulley was suggested
as the maximal normal distance in the flexed position,
with a higher value suggesting a pulley injury.“ Patients
with trigger finger may have a thickened, hypervascular
A1 pulley with associated tendinosis or tenosynovitis of
fl lflld American Academy of Orthopaedic Surgeons

Figure '1 A l'iigh-resolution ultrasound image along
the long axis of the left flexor pollicis longus
tendon at the level of the distal radius after
surgical plate fixation. fln the right side of the
image, a normal fibrillar tendon pattern can
be seen. However. the tendon is progressively
enlarged and hypoechoic secondary to
tendinosis {right to left] until eventually it
terminates in an abmpt stump [arrowheads]
at the level of the plate because of a template
tendon rupture.
the underlying flexor tendon and possibly thickening of
the volar platc.‘-""-33 Dynamic imaging clone longitudinal-
ly along the affected tendon may show loss of normal
smooth tendon gliding at the level of the A1 pulley with
catching of the tendon adjacent to the pulley.” Collateral
ligaments of the fingers, particularly the ulnar collateral
ligament of the thumb, can be examined with ultrasound.
Ultrasound accurately shows pmximal retraction of a rup—
tured ulnar collateral ligament in patients with a Stener
lesion.“ Flexing the thumb at the interphalaugeal joint
produces motion of the adductor aponeurosis and is use-
ful for distinguishing the adductor aponeurosis from the
underlying ulnar collateral ligament.”
Rheumatologic evaluation can be done with ultra—
sound. ]oint effusion appears as anechoic compressible
fluid signal; in comparison, synovitis has a more hetero-
geneous appearance and is noncompressiblefiifi Synovitis
also can be distinguished from effusion on Doppler im-
aging by the demonstration of internal vascularity within
areas of synovitis, whereas vascularity is not present in
an effusion. Erosions can be identified as focal areas of
cortical disruption that appear in two planes.16 A survey
of multiple joints can be done to assess for disease severity
or progression. A patient with a crystal deposition disease
such as gout may have effusion and synovitis as well as
small hyperechoic foci within the area of synovitis or
along the cartilage surface secondary to uric acid crystal
deposition” {Figure 3}.
Ultrasound can be used to confirm a suspected di-
agnosis of ganglion cyst in the hand or wrist. Ganglia
appear as rounded, sometimes multilocular, anechoic foci,
sometimes with a small neck extending toward a joint or
El lfllfi American Academy of flrchopaeclic Surgeons
Chapter 57: Diagnostic Ultrasound and Ultrasouudefluided Procedures
Figure B a longitudinal ultrasound image across a
painful metacarpophalangeal joint showing
linear hype rech ogenicity {solid arrow} layered
on top of anechoic cartilage {dashed arrow}.
which is highly specific for uric acid crystal
deposition in gout. The underlying cortex and
subch ondral bone plate of the meta carpal
{arrowhead} appear hyperechoic, as expected.
Figure 9 A color Doppler image obtained in the region
at a palpable abnormality clinically suspected
to be a ganglion cyst. Color flow in a rounded
lesion is compatible with blood flow in a
radial artery pseudoa neurysm. The echogenic
material in the remainder of the mass probably
represents thrombus. A ganglion cyst would he
expected to be anech oic (black) and not show
any internal Doppler color flow. A = artery. U =
vein.
tendon sheath. |IEolor Doppler imaging is mandatory to
exclude the possibility of an arterial aneurysm or pseu- 1-9
doaneurysm mimicking a ganglion cyst, particularly if 3
cu
aspiration is being considered {Figure 9}. The presence of
:1
EL
blood flow or echogenic signal within the lesion suggests cc:
the presence of a solid mass rather than a ganglion. Gan-
gliou cyst fenestration and aspiration, with or without
steroid injection, is effective in 39% of patients, although
the lesion may reccur.IE
Ultrasound is promising for the evaluation of carpal
tunnel syndrome when used in combination with clinical
examination and nerve conduction velocity studies. The
Drthopaedic Knowledge Update: Sports Medicbse 5
 Section 9: Imaging
Figure 1D .i'i. transverse ultrasound image of the wrist
just proximal to the carpal tunnel shows the
median nerve in its short axis {M N}- The nerve
has an enlarged, 22—mm3 cross-sectional area.
The enlarged size of the nerve in combination
with loss of its normal fascicular architecture
(ho neycomb appea rance} strongly suggests
carpal tunnel syndrome.
median nerve can be distinguished from the tendons of
the carpal tunnel because of its honeycomb appearance
and because it does not show as much loss in echogenicity
with anisotropy as do the adjacent fleaor tendons. A nerve
cross-sectional area of less than S minl can be considered
normal, and a cross-sectional area of more than 12 turn1
can be considered abnormalEH {Figure 10}.
Although radiography is the first-line imaging mo-
dality for the detection of foreign bodies, some foreign
bodies {such as those made of glass or wood} are radio-
graphically occult. Ultrasound is effective in screening
for radiolucent foreign bodies. Most foreign bodies are
echogenic, and many show posterior shadowing25f {Fig-
ure 11]. Hypoechoic tissue from a reactive inflammatory
or granulomatous reaction can be seen surrounding the
foreign body. Complications such as abscess formation
or tendon rupture also can be detected.
Hip Ultrasound
The evaluation of patients with hip pain is elusive and
challenging because of the many structures in the area
on and many potential pain sources. The pain may arise in
.E
on superficial or deep structures, and therefore finding the
l'fl
E optimal ultrasound transducer is important. High-fre-
quency transducers {s- 10 MHz} are ideal for examining
é;
superficial structures, but lower frequency and curvilinear
transducers should be considered for the deep structures
of the hip.
Placing the transducer along the anterior hip parallel
to the long axis of the femoral neck allows a relative sag-
ittal—plane image of the acetabulum, femoral head, and
femoral neck to be obtained, and this location is best for
flrdtopaedic Knowledge Update: Sports Medicine 5
i3. high-resolution ultrasound image of a finger
in its short axis showing a linear hyperechoic
focus just beneath the skin surface. as is
compatible with the presence of a glass
foreign body {solid arrow}. The foreign body
was not visible on radiographs. Minimal
hypoechogenicity surrounding the foreign
hotly is compatible with inflammatory change.
The foreign body is in contact with the adjacent
fleuor tendon [dashed arrow], but the tendon
appears intact.
the evaluation of fluid or synovitis in the hip joint. Nor-
mally the anterior joint capsule of the hip is concave and
will bow with convexity when distended with fluid. With
this location and transducer orientation, the hip may be
accessed for joint aspiration or synovial biopsy to detect
infection, inflammatory arthritis, or a metal hardware
complication (Figure 12}. Superficial to the anterior hip
capsule is the thin tendon and bulky muscle of the ilio-
psoas. By turning the transducer 9D" and moving supe—
riorly, an atrial- or transverse-plane image of the femoral
head is produced, and the oval echogenic iliopsoas tendon
can be seen directly anterior to the femoral head [Fig-
ure 13}. The iliopsoas tendon can be dynamically assessed
for snapping or internal coita saltans in the transverse
plane with Her-don, abduction, and internal rotation. Ilio-
psoas tendinosis and, rarely, bursitis can he detectedf'f'ti'1
Although surgical release is the definitive treatment, an
initial successful response from steroid injection may be
a predictor of favorable surgical outcome.32
Evaluation of the lateral hip over the greater trochan—
ter is essential, particularly if gluteal tendon pathology
fl lflld American Academy of Orthopaedic Surgeons
 Chapter 5?: Diagnostic [Huasuund and Ultrasound-Guided Procedures

Figure 12 Ultrasound images in the longitudinal plane of the anterior hip with the transducer parallel to the femoral neck.
A. Normal hip joint without effusion, showing the concave anterior joint capsule {arrowheads}, femoral head (FHJ,
and femoral neclt {FM}. I. A so-called bowed-out anterior capsule (arrows) with convert contours caused by a large
joint effusion and syn ovitis seconda rv to an adverse reaction to metal-on-metal hip arthroplasty.

subgluteus maximus bursa.fl Areas of thickening and

Femoral Head
Figure 13 Ultrasound image of the anterior hip in the
transverse or arial plane. The oval hyperechoic
iliopsoas tendon (a rrow} is directly anterior
to the superior femoral head. The dashed
line represents the typical needle course for
ilio psoas tendon or hu rsa injection from a
lateral-to-medial approach along the anterior
hip. Femoral vessels {‘9'} also can be seen.
is suspected. The patient is placed in the lateral decubi-
tus position on the opposite hip, and the transducer is
placed in the transverse plane over the lateral hip and
bony protuberance of the greater trochanter. With move-
hypoechogenicity represent tendinosis or tearing. At these
attachment sites on the greater trochanter, calcific ten-
dinitis and osseous spurring with enthesopathic changes
are common pain generators that can be treated with
ultrasound—guided aspiration or lavage or with steroid
injection, respectivelyfihu
1With the patient prone, the piriformis and the ham-
string complex can be seen using a curvilinear probe that
is less than 1D MHz. To locate the piriformis, the trans-
ducer is placed in the transverse plane along the inferior
sacroiliac joint. As the transducer is moved caudally and
laterally toward the greater trochanter, the region of the
greater sciatic notch with the piriformis is seen. Passive
internal and external rotation of the hip dynamically
moves the piriformis muscle and confirms its location
on the ultrasound image. The sciatic nerve is a large oval
hypoechoic multifasciculated structure seen deep to the
gluteus maximus. An ultrasound-guided piriformis injec-
tion can be done in this transverse plane with the needle
coursing medial to lateral (Figure 14}. A cadaver study
found that ultrasound-guided piriformis injections had
a 95% accuracy rate {19 of El] injections were correctly
placed into the pitiformis muscle belly], compared with a
30% rate for fluoroscopy-guided iuiectious [o of 20 were 1-9
correctly placed). Many of the fluoroscopic injections 3
tu
were erroneously placed into the gluteus mastimus, and in
:1
EL

ment slightly anterior to posterolateral on the greater tron
chanter, it is possible to see the gluteal tendons and their
corresponding bursae: the gluteus minimus attachment at
the anterior facet with the subjacent subgluteus minimus
bursa, the gluteus medius attachment onto the lateral and
superoposterior facets with the subgluteus medius bursa
below it, and the large gluteus mauimus attachment on
the posterior facet with the interposed trochanteric or
one patient the placement was within the sciatic nerve?“I to
The hamstring complex, composed of the semimem-
branosus, semitendinosus, and biceps femoris, can be
evaluated by ultrasound starting in the transverse plane
at the level of the ischial tuherosity near the lower but-
tock or gluteal fold region. At the ischial tuberosity, the
conjoined tendon of the semitendinosus and the biceps
femoris inserts medially; the semimembranosus tendon

IE! lfllfi American Academy of flrthopaedic Surgeons Drthopoedic Knowledge Update: Sports Medicine 5
 Section 9: Imaging
. fl -...
,._ .. if
at _.F
Figure 14 Transverse or axial ultrasound image of the
pestericir hip at the sciatic netch just caudal
and lateral to the sacroiliac joint. The piriformis
is the he ndliite muscle and tendon {outlined}.
The sciatic nerve {arrow} is an oval hypeechoic
structure deep to the gluteus maximus. The
dashed line represents the typical needle path
for piriferrnis injection from a medial-te-Iateral
approach along the posterior hip.
is lateral and slightly deeper. The sciatic nerve is lateral
to the hamstring tendons in a region of surrounding fat
at the level of the ischial tuherosity. Hypoechoic enlarge-
ment of tendon represents tendinosis and degeneraticn,
and anechoic fluid filling a gap between disrupted, frayed
tendons is diagnostic of a tendon tear.
Knee Ultrasound
Although the intra-a rticular and osseous structures of the
knee are best evaluated using MRI, the super ficiai tendons
and soft tissues are ideal for ultrasou nd examination.
The normal hyperechoic and fihrillar appearance of the
quadriceps and patellar tendons can he evaluated using a
linear transducer of approximately 10 MHz in the sagittal
plane, parallel to the extensor mechanism. The ability to
dynamically evaluate the quadriceps and patellar tendons
in fleaion-extension motion is a unique advantage of al-
trasound. Tendinosis of the quadriceps or patellar tendon
is seen as hypoechoic thickening or swelling of the tendon
m with observable continuous fibers. lWell-deli ned anechoic
.E
or defects suggest tea ring of the tendon fihers; occasionally,
l'fl
E neovascularity and hyperemia are seen and are best de-
picted with power Doppler ultrasound imaging.
é;
Just deep tn the quadriceps tendon is the suprapatellar
recess, which is preferentially distended by fluid in the
knee. This location can he used to obtain joint aspirations
in both native and postarthroplasty knee joints. 1'i'iiii'ith the
knee in slight flexion and the transducer placed transverse
to the knee, the superolateral aspect of the knee adjacent
to the patella is the ideal location for joint aspiration, even
firthapaedie Knowledge Update: Sports Medicine 5
Greater
enter}
Ultrasound image in the transverse or
axial plane of the anterior Icnee along the
superalateral suprapatellar recess. With the
lcnee in slight 'ilertio n, fluid is preferentially
present in the superolate rel aspect of the
knee. Needle placement {arrowheads} for joint
aspiration is recommended at this location,
especially if little or no fluid is seen.
when little or no joint effusion has been seen (Figure 15 i.
This location also can he used fer knee injections if ul-
trasound guidance is necessary.
A joint effusion can communicate posteromedially into
a Baker cyst {a semimemhranosus-medial gastrocnemius
bursa). A Baker cyst is diagnosed by location and has
a small neck arising between the tendons of the semi-
memhranosus and the medial head of the gastrocnemius.
Identification of this anatomic position and relationship
is critical to confirming the diagnosis of a Baker cyst and
differentiating it from a heterogeneous, cystic soft-tissue
neoplasm. Aspiration and injection of steroids and local
anesthetic can he done if a Baker cyst is symptomatic,
although fluid may reaccumulate. Ultrasound guidance
of Baker cyst aspiration and injection is ideal because it
provides real-time visualization of needle placement and
vessel location {Figure 16}.
Foot and Ankle Ultrasound
The Achilles tendon is best evaluated from a posterior
approach with the patient prone. A high—frequency
transducer {:- lfl MHZ] can he used because of the su~
perficial location of the tendon. In the sagittal plane or
parallel to the long arcis of the tendon fibers, the Achil‘
les tendon is a large uniformly hyperechoic, fibrillar
tendon approximately 5 mm thick. The tendon should
be scanned proximally from the gastrocnemius—soleus
mnsculotendinous junction and distally to the calcaneal
fl lflld American Academy of Orthopaedic Surgeons

Figure 15 Ultrasound split image in the longitudinal plane
along the posteromedial knee—popliteal fossa
showing a predominately anechoic Baker cyst
between the tendons of the semimemb ranosus
and the medial head of the gastrocnemius.
Internal debris, septations, and synovial
thickening often are present in a Baker cyst.
insertion. Hypoechogenicity and fusiform thickening in-
dicate chronic tendinosis and degeneration, which typi-
cally occur 5 to 6 cm proximal to the calcaneal insertion.
The dynamic capabilities of ultrasound allow the Achilles
tendon to be evaluated with dorsiflexion or plantar flexion
of the foot, which can assist in the evaluation of tendon
disruption or gliding dysfunction within the paratenon
{Figure 1?}. Turning the transducer 90" produces an axi-
al-plane image of the Achilles tendon, in which the tendon
should maintain a flat to concave anterior border and not
be diffusely convex. Like other ultrasound examinations
of tendons, the Achilles tendon evaluation requires care
to reduce anisotropy artifact and should be implemented
with a back-and-forth toggle of the transducer in the
transverse plane and a heel-toe maneuver in the longi-
tudinal plane.E
The plantar fascia or aponeurosis is seen by placing
a linear—frequency transducer along the plantarmedial
aspect of the heel in the longitudinal plane. The normal
fascia is uniformly hyperechoic and less than 4 mm in
thickness.“ Thickening and hypoechoic regions near the
caleaneal attachment are a common finding in patients
with plantar fasciitis. Comparison with an asymptomatic
contralateral plantar fascia can be helpful. The transducer
is turned 9C!" perpendicular to the long axis of the foot.
An evaluation in the transversebaxial plane also should be
done. Corticosteroid iniection or needle tenotomy of the
plantar fascia can be done in the transverse plane, with
the needle entrance along the medial or lateral aspect of
the heel to avoid penetrating the more sensitive plantar
surface of the foot.
The superficial nature of the foot and ankle tendons
and ligaments makes them well suited to ultrasound
ID Elilli American Academy of flrthopaedic Surgeons
Chapter 5?: Diagnostic Lflnasuund and Ultraseund-Guided Procedures
Figure 1? Extended field-of-view ultrasound images of
the Achilles tendon in the longitudinal plane.
A. A normal Achilles tendon {arrows} from the
musculotendinous junction to the calca neal
attachment. The tendon is uniform in size and
thickness as well as echogenlcity. B. A complete
tear of a severely thickened and hypoechoic
Achilles tendon. A gap is demarcated by the
torn edges of the tendon {arrows}. Fluid.
hemorrhage. and hyperechc-ic blood clot
{asterisks} fill the gap.
evaluation, especially with the addition of dynamic testing
with motion or stressing of ligaments. Unlike postoper-
ative MRI or CT of the foot, ultrasound of tendons and
soft tissues around hardware is not degraded by metal
artifact. Fluid collections and nerve or tendon impinge-
ment by adjacent plates and screws can be detected with
ultrasound.
High—resolution ultrasound transducers are excellent
for the evaluation of most peripheral nerves.” Ultrasound
can reveal nerve abnormalities caused by entrapment
syndromes. Dynamic testing depicts nerve impingment,
abnormal motion, and nerve enlargement indicating
neuritis. Ultrasound-guided local injection with corti- 1-9
costeroids and local anesthetic around the nerve can be 3
tu
beneficial for both the diagnosis and treatment of nerve
:1
EL
entrapment or neuritis. to
At the posteromedial ankle, abnormalities in the fi-
bro-osseous tarsal tunnel can cause tarsal tunnel syn-
drome from impingement on the tibial nerve. The tibial
nerve is large {similar in caliber to a small tendon}, and it
is recognised by multiple tiny hypoechoic nerve fascicles
as well as its location superficial to the flexor hallucis
longus. The distal phalanx of the great toe can he flexed
Drtbopaedic Knowledge Update: Sports Medicine 5
 SEEl'ifln 5": Imaging

Figure 1E dlLrasbuncl images in the transverse br axial plane bi the pbsterbmeclial anlrle at the tarsal tunnel- A, The
flerrbr retinaculum {arrbwheads} butlines the tarsal tunnel. 1v'lrfithin the tarsal tunnel, the bval, echbgenic, and
multitasciculatecl tibial nerve [cl ashed circle} cburses adjacent tb vessels. The flesbr hailucis lbng us (FH L} is subjacent
tn the tibial nerve. a. Cbmbined perineural injectien bf cbrticbsterbid and bupivacaine, which is hypbechbic
(asterisks). The needle {errbwheetisi cbu rses enteribr tb pesteribr near the tibial nerve.

tb bhserve the cbntractibu bf the fleI-tbr hallucis lbngus
tendbn-muscle {Figure 13}. The tibial nerve divides intb
the medial and lateral plantar nerves albng its cbursc
thrbugh the tarsal tunnel. If there is clinical cbncern abbur
nerve entrapment bf the branches bf the tibial nerve, such
as the first branch bf the lateral plantar nerve (the Banter
nerve}, ultrasbund-guided injectibns are mere effective
than injectibns dbne withbut guidance b: with flubrb-
scbpic guidance.“
Ultrasbu nd has advantages that alibw it tb play an impbrr-
ant rble in the diagnbsis and management bf many mu scu—
lbslceletal disbrders. Its lbvl.r cbst, nbnibniaing multiplanar
imaging, easy accessibility, and dynamic real-time imag-
ing make ultrasbund attractive fbr use in patients with
a spbrts injury br anbther jbint-related cbnditibn. w-
an ever, ultrasbund can be significantly time cbnsuming, is
.E
can heavily technician dependent, and requires a steep initial
l'fl
E learning curve. Knbwledge bf musculbskeletal anatbmy,
pathbphysiblbgy, and specific techniques are required fbr
é;
l-tey Study Pbints
- Higher frequency prbbes {:r 9 MHz] are ideal fbr the
evaluatibn bf superficial musculbskeletal structures.
A lbwer frequency curvilinear prbbe [5-6 MHz}
aids in the evaluatibn bf deeper structures and is
rbcbmmended fbr hip ultrasbund examinatibns.
I The nbrmal tendbns exhibit a well-defined very
linear fibrillar pattern bf fibers. Tendinbsis is di-
agnbscd when there is fusifbrm cnla rgemcnt, hypbe-
chbgenicity, and lbss bf the fibillar pattern. If there
is an anechbic gap in the tendbn with separatibn bf
tendbn fibers, tendbn tear is highly likely.
1- Anistrbpy is an impbrtanr artifact in musculb-
skeletal ultrasbund that can mimic pathblbgy, such
as tendbn tear br tendinbsis. Subtle mbvements bf
the transducer can eliminate anisbtrbpy, such as
“tbggling” back and fbrth in the transverse plane
and “heel-tbeing” in the lbngitudinal plane. Ultra-
sbund by an experienced technician has apprenti-
matcly 95% sensitivity and specificity fbr detecting
a rbtatbr cuff tear in cbmparisbn with arthrbscbpy,

accurate diagnbsis and effective therapeutic interventibn
in all musculbskeletal ultrasbund examinatibns.
similar tb the sensitivity and specificity bf MRI.
' Ultrasbund can be used as real-time guidance fbr
musculbskeletal pcrcutanebus interventibns and
injectibns with significant imprbvemcnt in accu-
rate needle placement as cbmparecl re the “blind
apprbach” and flubrbscbpy.

firtbbpaedic Knbwledge Update: Spbrts Medicine 5 fl lflld American Academy bf Cirrhbpaedic Surge-ens

Annntated References
Smith J, Finnnff JT: Diagnnstic and interventinnal
musculnslteletal ultrasnund: Part 1. Fundamentals. PM
E 2Dfl9:1{1}:-54-?5. Mcdline DUI
This review article prevides infnrmatien en the physics nf
ultrasnund, a descriptinn nf basic techniques nf imaging
the musculnslteletal system with ultrasnund, and describes
the nnrmal appearance nf structures such as tendnns, mus-
cles, and nerves.
Naaarian LN: The tap 1|] reasnns musculnslceletal
snnngraphy is an impnrtant cnmplementary at al-
ternative technique tn MRI. AIR Ans ,7 Rneufgerrnf
Zflflfl;l§fl{d}:ldEI—1626.Mcdlinc DUI
Lin J, Fessell DP, Jacnbsnn JA, Weadnclc W], Hayes CW:
An illustrated tutnrial nf musculnskeletal snnngraphy: Part
I. Intrndnctinn and general principles. AJR Am I Rnerri-
gerrnf lflflfl;1?5{3}:53?-645. Medline DUI
Lnuis L]: Musculnslceletal ultrasnund interventinn: Princi-
ples and advances. Eadie! Ciiu hie-rib Arr: 20033631515-
533, vi. Medline DUI
1i’ablnn (SM, Eedi A, Mnrag Y, Jacnbsnu jA: Ultrasnnng-
raphy cf the shnulder with arthrnscnpic cnrrelatinn. Ciirr
Sperrs Med 2013;32{3]:391—4flfl. Medline DUI
This review fnr nrthnpaedic snrgenns describes nnrmal
rntatnr cuff anatnmy, cnmmnn patbnlngic findings, and
cnmmnn pitfalls in shnulder ultrasnnngraphy.
Jacnbsnn jA: Shnulder U5: Anatnmy, technique, and scan—
ning pitfalls. Radinfngy lfl’l 1:26fl{1]:E-16. Medline DUI
The authnr discusses technique and pnsitinning fer a thnr-
nugh shnulder ultrasnnnd examinatinn.
Rutten M], Jager G], Elickman jG: US cf the rntatnr
cuff: Pitfalls, limitatic-ns, and artifacts. Radicgrnpfrfcs
2Dflfi;15{2}:539-604. Mcdline DUI
Jamadar DA, Rnbertsnn EL, Jacnbsnn JA, et al: Muscu-
lnskeletal snnngraphy: Impnrtant imaging pitfalls. AIR
Arrr } Rnerrigerrnf lfllflglfidmfllfi-EES. Medline DUI
A review nf cnmmnn ultrasnund pitfalls for an inexperi-
enced musculnslceletal snnngrapher is presented, with an
emphasis nn anisntrnpy.
Lee K5, Rnsas HG: Musculnskeletal ultrasnund: Hnw
tn treat calcific tendinitis cf the rntatnr cuff by ultra-
snund-guided single-needle lavage technique. AIR Arrr
,l Rnerrigerrnf 2D1fl;195[3}:633. Medline DUI
The technique fnr single—needle injectinn nr aspiratinn nf
rntatnr cuff calcific tendinitis is described.
ll]. Serafini G, Scnnfienaa LM, Lacelli F, Silvestri E, Aliprandi
A, Sardanelli F: Entatnr cuff calcific tendnnitis: Shnrt-
term and Ill-year nutcnmes after twn-needle LIE-guided
IE! lfllfi American Academy nf firthnpaedic Surgenns
lElbatster 5?: Diagnostic Lilnasnnnd and Ultrasnund-Guided Pmce-dures
percutanenus treatment. Nnnrandnmiced cnntrnlled trial.
Radiningj: 2009;252{1}:15?-164. Medline DDI
This lfl—year study nu patients treated fnr rntatnr cuff
calcific tendinitis demnnstrated that treated patients had
imprnve nutcnmes cnmpared tn nnntreated patients at
1 year; hnwever, nutcnmes were similar at 5 and 1%} years
whether nr net rntatnr cuff calcific tendinitis aspiratinn
was perfnrmed.
11. Bureau bl]: Calcific tendinepathy cf the shnulder. Semis
Muserrfnshefei Radini 2D13;1?{1}:30-34. Mediine DUI
The imaging mauifestatinns cf shnulder calcific tendinnsis
are discussed, including its stages nf development and
interventinnal injectinn nr aspiratinn using a single-needle
technique.
12. clel IEura jL, are 1, Zabala R, Legdrburu A: Snungraph-
icalIy guided percutanenus needle lavage in calcil'ic ten-
dinitis nf the shnulder: Shnrt— and inng-term results. AIR
Arr: ] Rnenrgerrni 200?:139i3}:W123-34. Medline DUI
13. Knnin GP, Haaarian LN, 1illi'ala DM: U5 cf the elbnw:
Indicatinns, technique, unrmal anatnrny, and pathnlng-
ic cnnditinns. Rddingrapfrfcs 2013;33H}:E115-E14?.
Medline DUI
binrmal anatnmy and the technique fnr an elbnw ultra-
snund eaaminatinn are described. as well as pathnlngic
findings with an emphasis nn distal biceps, cnmmnn fnre-
arm flexnr—elctensnr, and nerve pathnlngy.
14-. Brigidn MK, De Maeseneer M, Mnrag Y: Distal biceps
brachii. Semis: Mascainskeier Radini' ED13;1?{1]:2fl-11
Medline DUI
Ultrasnund cf the distal biceps tendnn is described, with
an emphasis nn techniques used tn identify the distal as-
pect nf the tendnn. lIl'lnmmnn pathnlngic entities including
tendinnsis and tears are discussed.
15. Radunnvic G, Vlad V, Mien MC, et al: Ultrasnund as—
sessment cf the elbnw. Med Uirrasnr: lflllfldflhlfl-Hd.
Medline
The elbnw anterinr, pnsterinr, medial, and lateral reginns
are described, with a discussinn nf anatc-my and pathnlngy
in each reginn.
16. ajniewiea AM: US fnr diagnnsis nf musculnskeletal
cnnditinus in the ynung athlete: Emphasis nn dynam-
ic assessment. Rddfngrdpfrr'cs 2014;34i5}:1145-1162.
Medline DUI 1-9
3
This review articles describes multiple scenarins in which Eu
dynamic maneuvers can be perfnrmed when perfnrming :1
EL
LI]
musculnskeletal ultrasnund. Mnst cf these maneuvers are
nnt pnssible with crnss-sectinnal imaging, thus prnviding a
pntential advantage nf ultrasnund cnmpared tn crass-sec-
tinnal mndalities.
1?. Khnury V, Cardinal E, Bureau N]: Musculnslteletal
snnngraphy: A dynamic tnn] fnr usual and unusual
disnrders. AIR Arr: ,7 Rnerrigerrnf lflfl?;1flfl[l}:W63-?3.
Medline DUI
Drtbnpaedic Knnwledge Update: Spnrrs Medicine 5
 Section 5": [lugging
13. Urlaudi D, Carazaa A, Silvestri E, et al: Ultrasaund-guided
prncednres arnnnd the wrist and hand: Hnw tU dts. Ear
I Radial 2014;33{?J:1231-1133. Medline DUI
Techniques fur cnmmnn ultrasnnnd—guided prucedures are
described, with an emphasis nu injectiun nf small jnints,
DeQuervain tenusynuvitis, and trigger finger.
15. Bad-at M, Fullertan B: Ultrasnnngraphy nf the hand, wrist,
and elbuw. Plsys Med Reliabil Clis: N Ass: lfllfl;21{3}:5fl9-
531. Medline DUI
This review intended ftsr physiatrists describes diagnustic
imaging and interventicms in the hand, wrist, and elbnw.
1i]. Pappas bl, Gay AN, Meier bi, Enaentlta D: Case re-
pert: Pseudcitendein farmatien after a type III flestnr
digittsrnm prufnndus avnlsinn. Clis: Drtlsnp its-la: Res
2fl11;459{3}:2335a2333.Medline DUI
This case repnrt describes the MRI appearance nf a
pseudntendnu that farmed after a camplete finger teudan
disruptie-n.
1]. Lopez-Ben R, Lee DH, Nicaladi D]: Easter knuckle {injury
nf the extensur hand with esrtensur tendtsn sublnstatitsn}:
Diagnnsis with dynamic US. Repnrt nf three cases. Ra-
dialagy lflfl3;223[3}:642—64ii. Medline DUI
Klauser A, Frauscher F, Endner G, et a1: Finger pulley
injuries in extreme rack climbers: Depictinn with dynamic
U5. Radialagy 20fl2;212{3}:?55 3:51. Medline DUI
23. Guerini H, Pessis E, Theumann N, et a1: Snnegraph-
ic appearance nf trigger fingers. I Ultrasnstssd Merl
lflfl351?(1fl}:l4i}?—1413. Medline
Ebrahim F5, De Maeseneer M, Jager T, Marcelis 5, Ja-
madar DA, Jacebsan IA: US diagnusis af UCL tears ef
the thumb and Stener lesians: Technique, pattern-based
appruach, and differential diagnnsis. Radingraplsias
20D6;26i4}:1flfl?—1fl2fl.Medline nu:
15. Martinnli C, Peres: MM, Bigntstti E, et al: Imaging finger
iuint instability with ultrasuund. Sesssis: Mascalusleelei
Radial 2313:1Tl5}:4fifi-4?fi. Medline DUI
The use nf ultraseund is described fer the evaluatinn c-f
finger instability, with an emphasis cin ctsllateral ligament
and palmar plate injuries.
Iii. |Crainger A], Rnwbntham EL: Rheumatuid arthritis. Semis:
an
.E Mascalasltelel Radial 2013;l?{1}:69-?3. Medline DUI
can
I'D
Cummun nltrasaund findings in patients with rheuma-
E taid arthritis are described, with discussian af pntential
é;
advancements in ultrasnund and cnmparistsn with tsther
mudalities.
2T. Cll'Cnnnnr P]: Crystal depnsititsn disease and pseriatic
arthritis. Semis: Masealaskelet Radial 2D13;1?[1}:?4—?9.
Medline DUI
Urthtipaedic Knnwledge Update: Sparta Medicine 5
Ultraseund findings pertaining ta crystal depasitian dis-
ease are described, with emphasis tsn gtsnt and psuriatic
arthritis.
23. Peetrtsns PA, Derbali W: Carpal tunnel syndrnme. Semis:
Musculuslrelei Radial lfl]3;1?{1}:23 -33. Mediine DCI'I
The use nf nltrasnund in evaluatinn uf carpal tunnel syn—
drnme is described, and multiple studies were synthesized
tn suggest a median nerve cruss-sectinnal area belnw 3
mm1 as nurrnal and above 11 mml as abnnrmal.
19. Jarraya M, Hayashi D, de Villiers EV, et al: Multime-
daliry imaging uf fnreign bndies cf the musculuslreletal
system. AIR Ass: I Resurgessal 2914;203{1]:W92-1i}2.
Medline DUI
The use tsf radingraphy, nltrasnund, and MRI is described
fur the evaluatinn nf ftsreign bin-dies, with the clinical im-
plicatinns nf metal, glass, and weed fureign hadies.
3i]. Deslandes M, Cuillin R, Cardinal E, Hrsbden R, Bu--
reau bi]: The snapping ilinpsnas tendnn: New mecha-
nisms using dynamic senegraphy. AIR Ass: I Raeatgeaal
lDflfl;lBfli3}:5Tfi-531.Medline DUI
31. Blankenbalter DC, De Smet AA, Keene J5: Sunugraphy uf
the ilinpsuas tendcin and iniectitsn nf the iliupsuas bursa
fur diagnc—sis and management nf the painful snapping
hip. Skeletal Radial 1006:35{31:565-57'1. Medline DCI'I
32. Pfirrmann CW, Chung CB, Theumann NH, Trudell D],
Resniclt D: Greater trtschanter uf the hip: Attachment
uf the abductnr mechanism and a cumples: nf three bur-
sae. MR imaging and MR hursagraphy in cadavers and
MR imaging in asymptamatic vc-lunteers. Radiology
lflfllglllill:469-4TT.Medline DUI
33. Labrtssse JM, Cardinal E, Lednc BE, et al: Effectiveness
nf ultrasnund-guided cnrticnsternid iniectinn fur the treat-
ment of glutens medius tendinc-pathy. AIR Ass: I Raessi-
gessnl 2U]fl;194l1}:2{ll-lflfi. Medline DUI
In a pruspective study, 54 patients with a clinical diagnesis
tsf glutens medius tendinusis were evaluated after ultra-
suund-guided peritendinuus injectinn with tria mcinulune
and bupivacaine. An average 55% reducticin in pain was
repurted, and EDDIE nf patients were satisfied. with the
results uf the injectiun. Peritendinuus ultrasnund—guided
curticnsteruid injectinns may be an effective treatment nf
glutens medias tendinnpathy.
34. Finnaff JT, Hurdle MP, Smith J: Accuracy elf ultra-
suund-gnided versus flutsrnscnpically guided cun-
trast-cnntrnlled pirifnrmis injectiuns: A cadaveric study.
I Ultrasound Med EDGE;ET{3}:I 1511163. Medline
35. Cardinal E, Chbem ELK, Beauregard CG, Anbin B, Pelletier
M: Plantar fasciitis: Sanagraphic evaluatien. Radialagy
1996:3DIiI}:25?—359. Medline
36. Chiuu H], Chen TH, Chiuu ET, Lin IE, Chang CY: Pe-
ripheral nerve lesiuns: Rule tsf high-resnlntinn US. Radiu-
gsaplsics Ell 03;13{fi}:e1 5. Medline DUI
U lfllfi American Academy nf Urthtspaedic Surge-ens
 l[Shapter 5?: Diagnostic Ultrasound and Llltraeuund-Guided Prueedures

37. Presley JG, Maida E, Pawlina W, I'vl'tnrth}.T N, Rysstnan

DB, Smith]: Suungraphic visualizati-an uf the first branch
cf the lateral plantar netve {Baxter nerve}: Technique and
validatiun using perineutal injections in a cadavetic Il'lIDElEl.
I Ultras-cured Med 1fl13g32{9}:lfi43-1652.Medlinc DDI
Twelve ankle—fact cadaver specimens underwent ultra-
scund-guided Baxter nerve perineural injectiuns with di-
luted calmed later-t. An uptitnal lucatinn fur the petineutal
injecticin was fpund tn be at the abductcn' hallucis—quae
dratus plantae interval. Surgical dissectiuu was perfcrrmed
tti assess injectic-n lecatiun, and all 12 injectitins were
funnel tn have accuratelyr placed the injectate amund the
Easter nerve.

1-9
3
tu
:1
EL

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IE! lfllfi American Academy pf flrthnpaedic Surgerina Drthupaedic Knawledge Update: Sparta Medicine 5 ®
 Index
Page numbers with f indicate figures Acute abdomen, 6111 American Medical Association Code of
Page numbers with t indicate tables Acute boutcnniére defonnity, 1114 Medical Ethics, 4?1
Acyclovir, 535', 391] American flrthopacdit: Society for
ADAMTS-S, 4.99
A Adductor brevis muscle
Sports Medicine (AUSSMj, 436
American Psychological Association
Ab Deer, 33?—393, 4113
avnlsion, 163,1“ {APA}, SS3
Ab Flex, 39?—393
medial thigh compartment, 164 American Spinal Injury Association
Al} Revolutionieer, 39?-393
Adductor longus muscle, 164 {ASIA}, 433
Ab Rocker, 39?-339, 4111
Adductor strain Amittiptyline, 41 9
Ab Roller, 3361, 33?—333
clinical presentation, 16? Amniotic stem cell transplants, knee,
Ah Shape]; SST—393
complications, 163 13'i]|
Ab Slide, 396;: 3S?-4flil, 4001
imaging of, 16? Amoxicillin, for bronchitis, 395
Ab Twister, 35‘?—3 3'3
pathoanatom5 166—16? Analysis of variance jANflVA}, 434—
Ab Vice, SST—3 Elli
rehabilitation, 163 435
Abdominal bracing, say-ass treatment of, 161-163 Antoneus epitrochlea ris, ?33, ?33f
Abdominal crunches, 33315 401}:
Adenosine ttiphasphate {ATP}, creation Andrews-Carson scores, postoperative,
Abdominal cutaneous reflex, 43S
of, i4?t 3?
Abdominal hollowing, 394-395
Adenoviruses Anechoic, definition of, ?SS
Abdominal injuries, 615-630
bronchitis and, 594—395 Anisotropy, ultrasound, ?36
Abdominal wall
conjunctivitis and, 5'31 e
fascia] attachments, 16?)“
Adhesive capsulitis, Tl? chronic instability
injuries, 61?—613
causes of, SS evidence-based practice, 3661'
musculature of, 163-164
diagnosis of, 33—36 exercise, 333
Abduction and external rotation
far-suppressed l‘vfi’ti, ?1?f taping, 333—339
{ABERj
nonsurgical treatment of, S6 exercise, 334
MR1, 5f, Tf surgical treatment of, 56—5? injuries, 1??-1SS
rctatot cuff tear imaging, ?14
Adipose cells, in tendincpatby, 496 lateral aspect, 1?El—1lifl
Abrasion artliroplasty, 113
Adolescents. See nfso Pediatric patients; medial aspect, 1313-131, 1311f
Abrasioos, facial, 6114
Skeletally immature athletes ligaments, 1?Sf
Acetabular dysplasia, 113, 133}r
head injuries in, 635—699 rehabilitation, 333—391
Acetabnlnm
head injury prevention, 691—691 sprains, 1??
labral tears, 11?—119, 11?!“
patellofemoral instability, 665* evidence-based practice, 36???
hamstring allograft, 1151'
Advanced Throwet's Ten Exercise manual therapy, 33?—3SS
physical examination, 113i.“
Program, 345 overview, 33?
treatment, 113
Advanced trauma life support, spinal risk of, 1T9
Acetaminophen, 141-141. See ofso injuries and, 416 stability of, 1??—1?S
Honstetoidal anti-inflammatory
African Americans, GED rates in, 641 ultrasound evaluation of, ?61-?64
drugs [HSAIDsj
Age, rotator cuff tears and, 34f Ankle impingement syndromes, 133—
Achilles tendinopatl'ty, 493-499
Air, effect on ultrasound, ?56 13?
evidence-based practice, 336i
Alcohol intake, sports psycltology and, Annular ligament attachment, ?33
exercise, 336-33?
555—556 Anorexia nervosa, 356
insertional, 196f
Allen test, 1113 Antalgic gait
manual therapy, 336
Allegrafts, 515-51.15 after ACL injuries, 355'
overview, 3S6
autografts versus, 516-51? in lIIiTPS, 141
risk factors, 336
availability of, S15 Anterior apprehension test, 1311'
taping, 3E6
dermal, 516 Anterior body impingement, ESE—1.36
Achilles tendon
for Hill-Sachs lesions, ii Anterior center-edge angle [ACEA], 13D
acute rupture, 193
irradiation of, S13 Anterior cruciate ligament [AELj
contractores, 13?
tendon, 511i anatomy of, ITS—TF6, ITEfi 1??f,
disorders of, 194-196, 1353‘
overuse injuries, 195-196
Allop-atch HD, 513 sssf
Allo‘iPash process, 513 associated injuries, 65.5
ultrasound evaluation of, ?61-?63
Alternative hypotheses {H,}, 4311 basic science, 139
Acromioclavicular joint
Aluminum chloride, 59] biomedianics of, 1?S—1?6
injuries, 1?—11
Amantadine, 411i| femoral footprint, 1?6, 1?6f
classification of, 13, 19:
complications, 11
Amenorrhea, female atltlete triad and, imaging of, ?4?—?43, reef
5?5—531 skeletally immature athletes, 6.55
management of, 13-11
American Association for the Surgery of injuries to, 1715-1 rs
mechanism of, 13
Trauma {AASTL 613 approach algorithm for, 6331‘
postoperative rehabilitation, 11-11
American Association of Tissue lianks, diagnosis of, 1?6—1??
”Pairs Elf 513 graft selection, 1?S-1?S|'
typm of separation, 15,:
American Heart Association {AI-1A], mechanisms of, 654—635
Actinomyces. SSS
cardiac screening, 361-363, 3611. reconstruction techniques, 63?f
Acupuncture, 141

l@11116 American Academy of flrrliopaedic Surgeons Orthopaedic Knowledge Update: Sports Medicine 3 @

Al
 rehabilitation after, 1'13
return to sport, 113'
revision surgery, 1'33
risk factors for, 655
surgical outcomes, 3 natural history of, 111
surgical trmnnenr, 113—1 1'3
outoames of, 335'
patient education in, 363
patient fear of teiniury, 36D
pitfiical examination
skeletally immature athletes, 633
reconstruction of, 361t
grafts in, 313—317:r
rehabilitation concepts, 339-333
soreness rules, 364:
skelerally immature athletes, 633
tears
nonsurgical management, 633-636
in skeletally immature athletes,
633—664
surgical management, 636-633ll
Anterior drawer test, 633
Anterior impingement test, 113, 1311';r
Anterior inferior iliae spine [A115], 136-
13?, 15st
Anterior labral periosteal sleeve lesions,
T16
Anterior talofihular ligament {ATFL},
173-133, 173f
Anteroinl'erior tibiofibular ligament
{AITFLL 131
Antipronation taping, 333-334
foot and anltle, 333f
in plantar fasciin's, 334—333
Anulus fibrnsus, failure of, 433
Anxiety disorders, 333, 331r
Aortic rupture, 36?
Apley test, 134
Apolipoproteiu E, 433
Aponeurosis, evaluation of, 163
Apprehension sign, 113
patellar irtstability and, .113?
for posterior shoulder instability, 3
shoulder instability and, 4
Arcade of Frnhse, T33
Artn suspension, 63f
Arrhythmogenic right ventricular
cardiomyopathy [ARVC], 361—363
Arthroscopic capsular release, 3?
Arthroscopic débridement and lavage,
143
Arthroscopic: drilling, IHAT lesions, 134
Arthroscopy
elbow, 6?’-3ill
conn'aindications for, 6?
indications for, 6'?
hip
complications of, 1161'
indications for, 113—1 1?
portals, llfif
Articular cartilage
basic science, 111
\
16 American Academy of flrthopaedic Surgeons
knee, 111-136 tibial spine, 613-613
lesions, 113 maMy of, 613—631
clinical evaluation, 111 biomeehanics of, 6313-631
Epidemiology, 11.1 complications. 611-613
diagnosis, 613—611
treatment of, 111—1517r treannent, 611—611
Association for Applied Sport Avulsion injuries
Psychology {AASP}, 333 hamstring, 133—136
Athletes ischeal tuberosity, 154,6
cardiac issues in, 361—331 proximal thigh, 131-161
classification of sports, 366f quadriceps, 136-133
dietary requirement foe 343-343 Atithromycin, 333, 336
female athlete niad, 313—3 31
financial effect on, 433
glenohumeral instability in, 3-16
hip injuries Babinslei maneuver, 436
evaluation of, 131 Babinslri sign, 433
rehabilitation and, 334—333 Baciihss cererts, GI infections, 336
return—to-play oinsiderations, 333 Bactroban, 333
identity of, 333 Baker cysts, 161
infectious diseases in, 335-6131 Balance Error Scoring System {BESS},
proximal thigh injuries, 131-131 413,15. 633
sport psychology and, 333—333 Ballet, rehabilitation concerns, 333
Athletes, young. See aiso Skeletally Bani-tart lesions
immature athletes description of, 3
conditioning, 111-113 skeletally immature athletes, 131-133
training, v1 1—119 Bankart repair
Athlete’s foot, 593-531 arthroscopic, 6
The Athlete‘s Plates, 346:“ use“, 6, 1
Athletic heart syndrome, 363 for shoulder instability, 3, 6f
Athletic pubalgia, 163—111 Barton bandage, 6331’
diagnostic injections, 163 Bassett ligament, 336
FA] and, 166, 166!“ Battle sign, 634
imaging in, 163 Baxter nerve, 137Jr
pathnanatomy, 163—164 Beighton hypermohility score, 13".?
physical examination of, 164—163 Benign hypermobility, shoulder, 1'33
postoperative complications, 166 Bennet fracture, 131, 131f
presentation, 164 Bent—knee sit-up, 333—3 36, 331,6. 411m,
radiograph, 1651f 464
rehabilitation, 166 Benaoyl peroxide, 333
treannenr of, 163—166 Berndt and Hardy classification system,
Atlantoaxial instability, 433'r 643—646
Atlantoaxial rotatory subluxation Bemdt-Hardy-Lnomer radiographic
jAARSj, 443—446, 443j" system, 133
Atlanto-dens interval {A131}, 43 T, 443f Bernese periacetabular osteotomy, 113
Aurieular hematomas, 633 Beta-triealcium phosphate {firTCF},
Autografts 333-331
allografts versus, 316—311Ir Biceps crease interval test, 36
hinmeel'tanics of, 514—313 Biceps femoris
Autologous chondrocyte implantation rerouting, 1311f
jAEI}, 113—113, 111;“ tenderness in, 133
cell-seeded, 11? Biceps tendon
for chondral lesions, 35" attachment, 43yF
microfracture parses. 119-133 complete rupture of, 1331‘
DAT sersas, 133 lesions, 316—113
rehabilitation after, 113—313 partial tear of, 11?
Autologous tenocyte injections, 493 tendinopathy, 43-34
Automated Neuropsychological ultrasound evaluation of, 136, 1'3?
Assessment Metrics {AHAM}, 416 Bilateral acetabular retroversion, 131f
Autopsy-negative sudden unexplained Binge eating disorders, 336
death {AN-31.113}, 366 Bladder dysfunction, 433
Avolsion fractures Bladder injuries, 613-614
Orthopaedic Knowledge Update: Sports Medicine 3

Bladder rupture, 623—624 Calcilic tendinitis, nltrasuund treatment
Ii-lu-nd flaw, hear dissipatiun and, 632 uf, 2'5?
li-ltunensaat line, 190, 195 Calcium humcustasis, stress fractures
Blunt ahdnminal trauma {EAT} and, 267'r
general sideline appruach, 616-612 Cam defurmity, imaging uf, 133,:r
in spurts, 615—616, 6161’ Cam impingement, 12E
Blunt head trauma, 6391‘. Cnmpyfnbncter
Handy mass index {ii-Ml] etiulngy, 592:
Achilles pathulugy and, 336 CI infectinns, 696
law, 26? Canadian C—Epine Rule, 43'?
Budy temperature Capitellar ussificatiun center. unfusetl,
heat illness and, 631-632 234
regularinn nf, 631 Capitellar pseudndefect, 234
Bails. See Furunculusis Capitellum, recnuslructinn cf, 2|]4
Bane age assessment, 654f Capsular shift, 1 I
Bane health Carbohydrates
female athlete niad and, 52?, 5'29 athlete’s dietary requirements, 546
strength training and, 212-213 during exercise, 649
Bette marruw Cardiac issues
edema, 169 in athletes, 561—52'1
sfimulafiun uf, 223, 252-25 6, 234 prep-articipatin-n examinaliun fut;
suhchundral edema, 169 561—563
Bane ntarrutv edema, 266, 2433’ Cardiuvascular health
Hunt mineral density (EMU), 262, heat illness and, 632
595—5 62 strength training and, 212
Bane murphugenetic prutein {EMF}, Carpal tunnel syndrume, 259—266, 2613f
51f} Carpumetacarpal [Ch-{C} fractures, 162
Bnne scans, 4517'r Cartilage. See nfsu Chundral lesinus;
Bunc-patellar tendun-hune {EPTB} graft, Chundral resurfacing
524—62? elhuvv, 234—235
Ennes, clbnw, 234—235 GAG cnntent, 243
Burdetelln permssis, 594-595 Case repurts, 430'
Butulinum tuxin A iniectiuns, 269 Case studies, 43!]
Buntnnniére defurmity, 164, 105;" Case-central studim, 43 D, 431, 432
ael dysfunction, herniated disks and, Catechulatninergic pulymurphic
453 ventricular tachycardia [CPVTL 566
Buxer’s fractures, It'll-162 Catechulatninugeric pulyventricular
aer’s knuckle, 1134 tachycardia {CP‘U’TL 561i
Hrachial plexus injuries, 434 Categurical variables, 433, 4343‘
Bracing Catun-Deschamps index, 2‘33, 203};
ahduminal, 394—395 sssf
fur knee usteuarthritis, 240-241, 24H Caulifluwer car, 6133
Brainstem herniatiun, 691 Cavnvarus fact defurmity, 232
Bridges exercise, after ACL injury, 362 Ceftriaxnne, 596-592
Brnnchitis, in athletes, 594—6 95 Cellular therapies, 511—612
Brustt'cim prucedure, 2313 Central curd syndr-ume, 435
Brudsinslri sign, 593 Central slip injuries, 1!]4
Brugada syndrutne, 566 Cephalexin, 53?, 593—594
Bucket-handle sign, 254f Cerebruspinal fluid [CSFL 606
Eufnrd cumplex, 44, 9'26 Cervical cancer, I-IP‘i.ir and, 596
Bulhncavernusus reflexes, 435 Cervical cellar, 434, 43?
Bulimia nervusa, 556 Cervical nerve rant injuries, 434
Burners, 425—426, 426;: 434 Cervical ruut impingement, 425—426
Burns, eye, 61f! Cervical spine
Burst fractures, spine, 424 acute injuries, 433-434
Butt bluclring, 424 histury, 434s
clayr shuveler’s fracture, 433
cnmpressiun fractures, 43B
C cungnita] anutnalies, 441
Caicaneal stress Eactures, 23? dish: herniatiun, 441—443, 442,]Ir
Calcaneulibtllar ligament {CPL}, 22E, disltstatiuns, 425
229f facet capsule injuries, 43E
l@2616 American Academy uf Clrthnpaedic Surgenns
1'
Indcx
flexinn teardrop fractures, 439;If
fractures, 425, 43Fr
imaging uf
cumputed tumugraphy, 436-43?"r
MRI, 43?
plain radingraphy, 436
intrnuhilizatiuu cf, 434
incidence uf, 424
injuries
snhacnte presentaliuns, 435-436
types cf, 432—441
kyphusis, 444
inched facer dislncatinn, 433
less nf lnrdusis, 444
pusttraumatic findings, 444—445
spear taclder spine, 444, 444,!
sprains, 441
stenusis, 444
strains, 441
suhaxia] injuries, 43 2—439, 4391’
Cervical Spine Research Suciety, 42.9
Chair sign, E3
Child-SCr'LTir, 414
Chi—square inf} test, 43.5
Chinnydin trachnmntfs, 596
Chfnmyrfuphifc pnenmunfae, 594-595
Chnlanginpancreatngraphy, magnetic
resnnance, 625
Chundral lesiuns
iatrugenic injuries, 116
shutdder, 5?
nunsurgical treatment, 52
palliative treatment, 52
repararive treannenr, 52
resturative treatment, .5?
surgical treatment, 5?"
Chandra] rmnrfacing
platelet—rich plasma in, 5fl9
stem cells in, 511-512
Chundrucalcinusis, 249
Chrnnic cxertinnal cutnparttnent
syndrume [CECSL 26 9—220
diagnnsis uf, 269
surgical management, 269—221]I
symptums nf, 269
lChrunic traumatic encephal-npatlmyr
[CT'E], 691
Cigarette smelting, 122
Clavicle
fractures, 22—25
classificarinn uf, 22—23 ,’
cumplicatiuns uf, 23—25
management uf, 23-25
mechanisms uf injury, 22-23
pnstnpcrative rehahilitaIi-nn, 25—26
usteulysis, 22
Clay shnveler‘s fracture, 433, 4391’
Clindamycin, 53 3, 593-594
Clinical psyehnlngy, athletic injury and,
555-552
Clnsed kinetic chain exercises, 361
Cinstrt'a'fttnt difjfin'fe, 596, 592t
Crthnpaedic Knnwledge Update: Spurts Medicine 5 @
 Cfostridfum perfi'fngens, 33
Clotrimasole, 333
Cock robin totticnllis pnsiti
44sf
Codmau pendulum
Cohort studies, 431}, 4‘ ”1—432, 432,!"
Collagens, 231, 2321*
cross-linking, 133
implanm, 233
type I, 433, 433
type II], 494
type W, 433
Collegiate sports, 334—333
Common estensor tendon
elbow.r stability and, 31
fluid in, ran
long-axis image of, 233
ultrasound image of. 233f
Common flesor tendon, 31
Commotio cerebri. See Concussions
Commotio cordis, 366, 36 3—353
Competition, eating during, 343-343I
Complex elbovlr instability, 33—33
Compression plates, stress fracmres,
263
Computed tomographic arthrography
{UTA}, 2213
Computed tomographic myelogr‘apby,
433
Computed tomography
cervical spine imaging, 436—43?
patellofemoral dysfunction, 233-211
spine imaging, 427-423
in spondylolysis, 43i"
Computerized Cognitive Assessanent
TDDl {ccarg 41s
Concussion, 41 1-422. See abo Head
injuries
in adolescents
clinical management, 633-631
head injuries and, 633—633
management teams, 333-ti 33'
assessment of, 413-413, 6321‘
biomechanical forces, 412
classification of, 413
computer-based evaluation, 4113
definition of, 411-412
education programs, 632
ethical decisions, 423—424
evaluation tools, 413-413, 414:
management, 412-413
modifiers, 413t
patbophysiology, 412—413
postconcussion syndrome, 413-413
return to play after, 41s, 419:
second—impact syndrome, 413—423
Conditioning, young athletes, 211-213
Conduction, heat dissipation, 632f
Cone drills, after ACL injury, 363
Confidentiality issues, 422-423
Conflicts of interest, 4211—421
Conjoint tendon, 163—164
i,
a 16 American Academy of Drthopaedic Surgeons
Conjunctivitis, 33 1—332
allergic, 332
bacterial, 332
viral, saa, 332f
Contact sports, shoulder instability
and, 4
Continuous variables, 433, 434,,
Contralateral straight leg raise, 432
Contrecoup injury, 411
Contusions
facial, 6114
proximal thigh, 131-161
Coraeoclavicular {CC} ligaments
iniurr to. 13
reconsu'uction of, 23'
reps]: 111'
Cord blood stem cell transplants, 233
Core body temperature, 1336
Core muscles
importance of, 333
stability and, 333—334
stabilisation esercises, 333-433
benefits of, 334
nonnaditiona], 333—432
risks of, 334
traditional, 333-432
Cornea] abrasions, 6113
Coronary artery anontalies, SIS“,if
Coronoid fracture fisation, 34
Correlation coefficients, 433
Corticosteroids
artbrograpbic ioiut distension with, 313
for knee osteoarthritis, 242
for lateral epicondylitis, 34
NFL on, 133
with platelet-rim plasma, 133
ultrasound-guided injections, 143
Commit-attenuate, 333
Cotton test, 232
Coup-contrecoup injuries, adolescent,
3313
Cost proportional hazard modeling, 433
Conn saltans externa, 1413-143r
Costa saltans interna, 143-146, 743
imaging, 146
presentation of, 14-3
treatment of, 146
Cossackie virus, 333
lCraig classification, 22
Creatine supplements, 342'
Cribriform plate fractures, 636
Crossed—leg gravity stress tests, 232
EEDEEl I], 333—336
Crossover sign, 131']I
Cross—sectional studies, 433, 431
ICruciate ligament injuries, 123—132.
See also Anterior cruciate ligament
iACL}; Posterior cruciate ligament
[FCLJ-
ICrunches
abdominal exercises, 433::
after ACL injury, 362
Orthopaedic Knowledge Update: Sports Medicine 3
bent-knee sit-up L'Efflfl', 434
muscle recruitment in, 434
Crunches, reverse, 336, 3333‘; 434
Cryotberapy
for genital warts, 336
for molluscum contagiosum, 333
Cryptosporidium port's-Ht, 333, 33‘?!-
CuffPatcb, 32.3
Cullen sign, 613
Curettage
for molluscum contagiosum, 333
lClAT lesions, 234
Curl—up exercises, 333
Cutting drills, after ACL injury, 334!-
Cyclists, handlebar palsy, 133
Cycloplegics, 633
Cystography, 323
D
DANE T] method, 23
Daptomycin, 3315
de lQuersain tenosynovitis, 1316-13?
Death, mandatory reporting of, 363—
364
Deep squat tests, 333
Dehydration, preesercise, 633
Dejonr classification, 233—233, 2331f
Deltoid ligament, 231
Deltotrapeeial fascia injuries, 13
Dental injuries, 613
Depressive disorders, 336
Dermal allografts, 323
Dermoscopy, for verrucae, 333
Descriptive statistics, 4133
Descriptive studies, 431]
Deaamethasonefiodine drops, 332
Diabetes mellitus, 314—313, 632
Diaphragmatic rupture, 326:
Diaphragmatic spasm, 611"
Diclosacillin, 33?
Dienst portal, 116
Diet, requirements for athletes, 343—343
Dietary Supplement Health and
Education Act of 1334, 333
Dietary supplements, 3313—3 31
Dijit classification, 233
Disabilities of the Arm, Shoulder and
Hand {DASH} assessment, 33
Discogeoic pain, thoracolurubar, 431—
432
Discoid lateral meniscus, 633—623
classification of, 523—624
etiology, 623
imaging of, 624—623
radiographs, 6241f
treatment of, I323
Discoid meniscus, 243
Discrete variables, 433
Dislt herniation
bowel dysfunction and, 433
cervical spine, 441-443, 442:r
 Indcx

lumbar spine, 453—456, 454i; 455f pustuperative, 166 Entsmairus genus, 593
imaging of, 454 Edinburgh classificatiun, 21—13 Entltescpathy, 494
presentaticn cf, 454 Elders—Danica syndrume, 11? Enyirumnent, humidity in, 6.31
treatment cf, 455-456 Elastin, crussslinlting, 1315I Epicundylitis, rehabilitation, 341i!
surgical treatment, 441 Elbuw Epidermal grcwth facter, 51.15
thuracic spine acutei'uauruadc injuries nf, 31—33 Epidural hematuma, MRI, ti3Tr'f
epidemiclegy cf, 452-453 anatcmy cf, 31 Epipbysiclysis, skeletally immature
presentatiun, 452-453 arthruscupy ed", ET-Efl athletes, T113
Disltectumy, lumbar, 455—456 cumplicau'uns, 69—11] Epistasis, 636
Discrtlerecl eating, female athlelze triad ccutraindicalicns fun, ti? Epstein—Barr virus, 534
an cl, 515-532 indicatinns int, 6? Equinus—cnnsu'aint taping, 336
Distal biceps tendun patient pusitinning, E3, 63f Erythrnmycin, 53?, 533
anatnmy uf, T31 purtal placement, 33—59, 63]!“ Escherichia ceii
injuries tn, 36—3? specific precedures, 33-?1 enterchemnrrhagic, 596, 59?:
diagnusis cf, 36 bnnes, imaging cf, 1'34—1'35 etinlngy, 53?:-
mechanisms cf, 36 cartilage, imaging 01", T34—1'35 Essex-cresti injuries, 31
uutccunes, 315 chrunic discrders, 31—99 Estrogen, ElviD and, 5'Fti—S5'"?
treannent, 36 cumplex instability, 33-35 Ethics
insertiun, 3'32!" fractures, F34—Tfl5 cnnfidentiality, 411-473
Distal radial tuhernsity cumpressinn injuries cunilicts cf interest, 4111—431
test, 315 rehabilitatiun, 313-349, 33th? iufnrmed cnnsent, 4??
Distal triceps tendcrn skeletally immature athletes, patient autunumy, 4'31 471
avulsiuns, 35—36 5'3 1—539 cd' spurts medicine, 463—4???
injuries, 35—36 instability, THE—TIDE Eustachian tube dysfuncn'un, 5131
ruptures, 35 ME] cf, T31-1'33 Exercise. See aisc Specific exercises
Distensinn arthrugi'aphy, 5ti nerves, 735-1315 eating after, 549-553
apler ultrasuund, F59, T53?" GED nf, 344—1545, 645]“- eating during, 543
Dnrsal scapular artery, ED imflsins: 54? eccentric, 496
Dnrsal scapular nerve, fifl treatment cf, 645 immune functiun and, 535
Dursal wrist gangliun, 13? uveruse disurders, 31—319 fur knee csteuarthritis, 233-233
Dnuble-leg lifts, .351 pnsteriur mubiliaalicn nf, 331f fur rutatur cuff pathulugy, 311—3 13
DnubIe-leg wall jumps, 3E5f pnstetulateral rutatnry instability Exercise tubing, elbuw, 335f
aycycline, 535 iPLEJi, 33 Exercise-assuciated cullapse iEACi, 633
Draw Tight, 53,".l radiucapitellar cumparnnent, F34f Exercise-assuciated hypunatremia
Drnp arm test, 3.5 simple dislncatinns, 31-33 {EAl—I}, E36
Drup sign, 31, 33f stability cf, 31 Exertiunal heat-related illness {El-1111i,
Drug abuse, 556 tendinupathy, 91 631
Dual energy x—ray absurptiumetry tendcns, 131—131 Exertinnal heatstrnite [EH3], 533—634
{cm}, are terrible u'iad, 34—35 Experimental studies, 43!]
Duct tape ncclusiun, fur verrucae, 539 ultrasuund cf, IVE-1'53 Extensnr carpi radialis brevis {ECEEJ
Duncan leaps, 534 varus PMRI, 35 angiufibruplastic hyperplasia, I’D—Fl
Dynamic bug, 314f Elbuw extensinn test, 31 tlébridement cf, 4913f
Dynamic ltnee valgus, 333 Electrical stimulatinn injuries, 731
Dynamic stability training, elbnw, 334f fur adductur strain, 16? lateral epiccndylitis and, 34
Dynema, 5 34 fur ltnee ustecartbrilia, E41 resectiun at, 3'5
Dysmc-rpbia, 5515 Electtucardingram {ECG} Exteuscir carpi ulnaris [ECU]
Dysplastic sp-untlylulisthesis, 4631’ cardiac screening with, 56 1-563, 5152.! subluxatiun, 1'33
in myucarditis, 5E? tendinitis, wrist pain in, 131L133
Electrcmycgraphic {EMS} analysis Extenscrr tendcn injuries
nf cure muscle activity, 396 buutunniére injurifi, 1134, 1135f
Est injuries, 533 medial epic-sndylitis, 91 central slip injury, 104
Early Arthritis Therapies {EARTH}, 436 Electrctherapy, fur adhesive capsulitis, mallet finger, 1.34
Eastern Asscciaticrn fur the Surgery Bf 56 sagittal band injury, 104
Trauma [EAST], s1 9 Eimslie-Trillat nsteutnmy, 213 External eblique fascia, 163—164
Eating disurders, 555, 556 Elsnn tests, 134 External eblique muscles, 163-164, 336
Ecchymesis, pnsteriur buttnclts, 153 Energy availability External rutaticn exercises, 314, 3153‘;
Echccardiugrapby, 56‘? fur athletes, 545-543 31?f
Echuvirus, 593 calculatic-n cf, 54?: External rutatiun lag sign, 35
Edema in the female athlete triad, 535—532 External retariun stress test, 131
bane marrnw, 156 luw, svs, ass-ass Extra-articular impingement, 113
M31 signal, 731, 7351f Eatnmneba bistuiytica, 536, 59.71 Extracurpcreal sbuclt wave therapy
perinsteal, 2456 Enteruhemurrhagic E. cnl'i, 536, 59H {ES‘WT}

@1315 American Academy cf Drd'iupaedic Surgenns Drtbnpaedic Knuwledge Update: Sparta Medicine 5 ®

1'
 for adhesive capsulitis, 55
in GTPS, 143
fnr lateral epicnndylitis,
for medial tibial su'ess fume, 155
for stress fractures,
in tendinopamy, 493
Eye injuries, EDS-513
Eye protection, 51 l
Eyelids, laceration of, 535
{A
F r
F et capsule injuries, cervical spine,
433
Facet joint syndrnme, 4113
Facetumediated pain, thoraculumh-ar,
451—451
Facial trauma, 533-513, 5113f
fractures, 535-533
initial assessment of, 533-534
preventinn nf, 511
suft-tissue injuries, 594—535
FAB-IR {flea-Lion, adduction, internal
rotation} test, 144, 154—155
Farnciclnvir, 59f}
Fascia, abdominal wall, 153-154
Fast—Fist 353', 535
Fat, dietary requirements, 543
Federal Educational Rights and Privacyr
Act, 413
Female athlete triad, 515—531
diagn—s cf, 511-513, 5131
features of, 515-51?
prevention of, 519—533
return tn play, 530—531, 5311.“
risk assessment, 5 3'3:
screening for 51?, 513:
treatment of, 519
Female Athlete Triad Cnalitinn, 15'?
Femoral condyle, GED, 541, 541?] 5431“,
5443‘
Femoral head-neck juncn‘ort, 1345f
Fem-era] neclt
stress fracture, 51?!"
ultrasound images, 1511f
Femnral nerve stretch test, 451
Femoral truchlea, trochleoplasty, 559-
513'
Femoral version, 113
Femnruacctahular impingement {FM},
111—143, 143
arthroscopic indications, 115
athletic puhalgia and, 155, 15-5f, 1519f
etiology of, I11Ir
hip rehabilitation, 351-353
history, 113—1 19
imaging, 129—134
CT, 133
Mill, 131—133
radingrapha, 119-131
management, 134—135
outcomes, 135-13?
15 American Academy of flrthopaedic Surgeons
physical examination, 119 rygomatic, 53?
treatment, 351—351 Frozen shoulder. See Adhesive capsulitis
types of, 111—113 Fullterson procedure, 559'
FiberWire, 533, 534 Fullerson osteototny, 113
Fibrillin, 493 Fungal infections, sltin, 593-5 91
Fibroblast growth factors {FGFs}, 5D5, Funuteulosia, 531—5 33
510
Fibrochondrocytes, mertiscal cell type,
151 G
Fibular head, 514f Gagey test, 4
Fifth metatarsal fractures, 191-193,. Galeaeai prncedttre, 559'
1911‘, 193f Ganglion cysts, 159
FINER criteria, 419—4 33, 431” Gastroenteritis, 595—595, 59TH.“
Fingers, dislucations, 131-1 I13 Gastrnhiteslinal infections, 595-595
Pierrot carpi tadialis, 91 Gastrointestinal tract injuries, 515-515
Fleaor carpi radialis tendinitis, 1117»r Gender
Floater hallucia lnngns tfilliilflfl'mflifllfl, {3CD rates and, 541
153-154, 154,1" peak height velneity and, 553
Fletmr pollicis longus, 1591' stress fractures and, 157:I
Fleaor tendon injuries Genetic testing, 415
Jere-r fir-sea 1'15 Genital 1warts, 595
pulley ruptures, 135, 1353‘" Genituurinary infectinns, 595,. 591'
scaphoid fractures, 135—135 Genomics, ethical issues, 415
Flemr—prnnatnr tnass injuries, 14 Gthrdia lmnhlia, 595, 59 1t
Flertor-pronator tendinitis, 339-341 Glasgnw Coma Scale scnre, 531Ir
Fluorescein dye, 539-513 Glenohumetal exercises, 314—315
Fluoroquinolones, 591 Glenohumeral instability, 3—15
Focused Assessment with Snnngraplrty Glennhumeral internal rotation deficit
for Trauma {FAST}, 511r (BIRD), 333
Folliculitis, 531—533 Glenohumeral juint
Food and Drug Administration, 553 dynamic stability of, 33—34
Feet 51111 of, res—rac-
disorders, 131-191 RDM exercises, 313-311
exercise, 334 Glenohumeral ligaments
rehabilitatiort, 333—391 avnlainn nf, 4f
ultrasound evaluation of, 151-154 evaluation of, 114
Football linebackers, 3—9 humeral avulsiun of, 3
Fnreartn, radial tnhernsity level, 31f Glcnoid anchors, 53 1—531
Forearm cuunterforce straps, 95 Glennid hnne
Foreign bodies augmentation of, 1-3
corneal, 559 hmofi?
imaging nf, 1513 Glenoid dysplasia, healing of, 13f
ultrasound of, 7511f Glennid lahrum
Fractures anatomy of, 43-44
avnlsinn, tibial spine, 513—5'13 micrufracture treamieor, 53f
cervical spine, 415, 431' Glide test, 131, 1fl3f
clavicular, 11-15 Glucosamine andfor chondroitin sulfate,
dental, 513 141
elhnvv, Tfl4 Gluteal tendinosis, 141
facial, 535-593 Gluteus medics.I insertion of, 141., 1411‘
fifth metatarsal, 191-193, 191,1; 193f' Gluteus minimus
mandibular, 5117'r insertion of, 141, 141]“
maxillary, 595—53? uln'asnnnd evaluation of, 151
medial malleolus, 194 IElyceryl trinitrate, 493
nasal, 535 ttansdermal patches, 95
occipital condyle, 43'.Tr Glycosantinoglycans {GAG}, 495—495
udunmid, 43‘? Golfers
orbital blowout, 531 medial epicondylitis and, 91-91
radial head, 31—31 rehabilitation concerns, 355
shoulder, 131-153 Gout, uric acid crystals, 159f
tarsal naviculat, 193-194, 194,1‘" Gracilis muscle, 154
tibial stress-type, 155—159 Graftjacl-tet, 513
Orthopaedic Knowledge Update: Sports Medicine 5

|Grafts
hiumechanics of, .514
harvest nf, 515
stability tests, 515
synthetic, 515‘
types ef, 515—51'?
Greater n'nchanter, anatnmy nf, 141,1”
|L'ireater tre-chanteric pain syndrnme
{GTPS}, '1 41—144
causes nf, 141—141
esaluatien nf, 141
imaging nf, 141-143
n'eannent, 143—144
Grnin injuries, 153—111
Greup A fl-hemelytic strepte-ce-ccus
{GABHEL 593—594
Grewm faster therapy, 5113—510, 503—
511. See misc Platelet-rich plasmas
Specific facturs
Grewth fasters
isnlated, 5111—511
fnr ltnee esteuarthritis, 141-143
Gruwth plates, functien nf, 1553
Guyen canal, 103
H pathnphysinlegy nf, 153 1—631
Haemapfriitts influences, 591, 595
Haglund defnrmity, 1915
Hammer syndreme, lflfi
Hamstring
anatnrny nf, 153
ayulsinns, 153-156
hisrury ef injuries, 153
imaging ef, 153—154
injuries
arulsien 1with retractiert, 1551’
classificatien nf, 154
pnstnperatiye care, 155
reiJljuries, 15I5
surgical indicatiens, 1515
treatment pretecel, 154—156, 154]“
Wnnd classificatinn nf, 1551
physical examinatinn nf, 153
preximal d1igh injuries, 151-1151
snains, 153—1 56
strength testing, 153f
Hamstring grafts, quadrupled, 515
Hamstring tendnn cemplex, 1411f;
1151—151.
Hand
injuries m, 1111—111
ultrasnund nf, 153—?6fl
Handlebar palsy, 1113
Hanging strap exercises, 397, 3931';
4113—4114
Hangman fracture, 43?
Harris Hip scnres, 1311
Hastings classificatinn, 1fl3
Head injuries. See aise Cnneussinns
in adolescents, ESE-I599
definitiens, tiiiti
@1015 American Academy ef flrdmpaedic Surgeries
epidemiulegy nf, 635-636
initial care in, ESE—ESE
mechanisms nf injury, ESE
Inn-field management, 636-635
preseasen preparatien, 639‘
presentien cf, 691—691
recuyery patterns, 63?
secend-impacr syndrutne, 691-1591
clinical predictien rules, 659:
diffuse, 63E.
fecal, 6315
mental status and, 1536
Health Insurance Pertahility and
Accnuntahility Act {HIPAA}, 413
Heart
hypertrepic catdiemwpathy, ififif
nnrmal anatnrny, 51115,?r
Heat, dissipatien nf, 1'1?a~
Heat edema, E33
Heat exhaustien, sss
Heat illnesses
background, 631
epidemielegy nf, E31
hydratinn and, 631—633
management ef, 635-6315
medicarien and risk nf, E31:
prevenfinn nf, 636-531
rislr factnrs, 631-1533
spectrum nf, 533—635, ti35f'
Heat rash, 533
Heat syncepe, E33
Heatstreke, death frem, 631
Heel drep exercises, 496, 491;“
Heel pain, plantar fasciitis and, 131-133
Heel prep exercise, 3:111r
Heel slides, 111, 361
Heel—tne maneuver, 151'
Helmets, fnethall, 423-414
Hematemas, fnrmatinn nf, "151
Hepatitis E virus transmissiun, 595
Hepatitis C virus transmissinn, 593
Herniated disk, See Disk herniatinn
Herpes gladiatarum, 539
Herpes simplex 1trirus Iii-1511'}, 535‘
Herpes tester, 539, 55“], 59W
High-intensity neuremuscular electrical
sthnulatien, 361
HillrSaehs lesinns
descriptinn nf, 3
humeral head, 3'4
management nf, Ii
recurrence, ti
Hip
anatem:.r, 163
arthrnplasty, pnstnperatiye issues, 353
arthruscnpy, 115-11?
cemplicatiues, 116-111, 1161
athletic injuries, 115—116
hiumechanics nf, 311
cartilage ahnermality, 143
cartridge lesiens, 35-i-
Drthepaedic Knnwledge Update: Sperrs Medichse 5
1'
Indcx
chundral degeneratiun, 1341
chundral injuries, 136
extra-articular diserders ef, 141—150
imaging ef, 139—145
impaired strenglfl nf, intereentinns,
31H
injuries, athletic puhalgia, 1153-1?!
instability, 119-111
atraumatic, 110
rislr facters fer, 1131*
iahral tests, 134
repairs, 13i
ligaments, 11:11
pain, differential diagnnses, 141
peripheral turnparnnent, 13E
prusdmal thigh injuries, 151-161
rehahilitafinn, 351-353
stahilisers, l 19
strains, 151
strengthening prugrams, 351-353
ultrasenegraphy, 150—1151
ultraseund images, 1151f
Hip abductinn straight leg raise, 3'13f
I-Iip braces, 15E
Hip Iahrum, ahnurrnality, 141—?41
Hip lag sign, 141
Hip |iiirutcnme Scares, 355
HW transmissinn, 593
Huffman sign, 4315, 436:
Heel: ef hamate fractures, [[16
Heels plates, deseriptien nf, 1|]
Hnnit test, 36
a tests, 131, 3155
Hntnhlnwer sign, 35
Her tubs, felliculiris frnm, 531-533
Human papillemayirus {HEW}
sexually transmitted, 59E;
yerruca and, 535—539
Humeral ayulsien ef the glenehumera]
ligament jHAGLj, 115
Humeral head
defects, 1'
pesterusuperier fractures cf, 3
Humerus, axulsiens, 4f
Humerus, preximal, displaced, 1113f
Humphrey ligament, 119
Hurdle heps, 364
Hyaline cartilage, damaged, 751
Hyalurnnate iniectinns, 5-5, 141
Hyaltu'nnic acid injectinns, 111
Hydratiun, dietary requirements, 543
Hygiene, prnphylactic, 535
Hyperecheic, definitien nf, 155
Hypertensinn, heat illness and, E31
Hypertrepic cardiemynpathy
anammy cf, SESf
sudden death and, 566—515"?
Hypherna, £119
Hypnechnic, definitinn nf, 1'55
Hypnnatremia, 543, 1533.
Hypethermia
after SCI, 413-431]
therapeutic, 419—4311
®

Icnnix 1 anchnr,532f
lliac spine, imaging pf, 13
[liufemural ligamenti ‘19, llflf
[liupsuas intp' 1?, 23 9—241,
24flf
iliopsuas tenduu
anatmny of, 145,!“
snapping nf, 145
ultrasnund evaluatinn nf, T613, T6 If
Iliutibial band {1TB}
anatmny uf, 146
autngt‘afts, 656
release cf, 143—144
[liutibial band syndrnme, 354
Imiquhnnd, 539
Immediate Pnst—Cnncussinn Assessment
and Cugnitive Testing {Im FACT), 416
Immubilisatiun, fur shuulder instability,
5
Immune funcfiutt, exercise and, 555
Immunuglubulin A, 535
Impetigu, 535, 5136—532, 53??
Implants
binmechanics nf, 523-542., 525'
ever-view, 522—529l
Infectinus diseases
in the athlete, 535—6fl2
blend-heme, 593
Inferiur epigastric artery, 613
Inferinr glennhumeral ligament {IGI-l},
3
Influenza virus, 534—535
Infnrmed cnnsenr, 4'22
Infranrbital nerve, 6415
Infraspinatus muscle
atruphy cf, 5?
EMG activity, 315'
Infraspinatus tend-an
evaluatinn uf, 223
ulnasnund evaluatinn nf, 256
Injectinn therapies, fur lateral
epicundylitis, 95
Injury recnvery, spurt psychnlngy and,
553—5 59
InsalI-Salvati index, EDS, 263,1F
Insults, fer knee ustenarthritis, 241
Insulin-like grnwth faster, 5I15
Intercarpal spaces, lflflf
Interleukin, 455
Internal ublique fascia, 163—164
Internal nblique muscle, 163-164
Internal rntatiun exercises, 314
Internatiunal Cartilage Repair 5nciety
classifieatiun, 5?, 2513
Internatinnal Federatinn nf Spnrts
Medicine Cede nf Ethics, 4T2
Internatiunsl Hip {Jutcume Tue-l til-[DT—
33}, 355
Intematinnal Knee Dncurnentatiun
Cuntmittee {IKDCL 526
Internatiunal Ulympis: Cflfl‘u‘lfiflee, 26?
l
@ 16 American Academy nf flrthnpaedic Surgenns
Internssenus tibinfibular ligament, 231 GED of, 641-644
Intersectiun syndrome, wrist pain in, classificatinn, 642—643
166 imaging, 642
Interval thrmving prngrarn {ITP} fur presentati-nn, 642
baseball players, 3325-3 331-, 3351! treatment, 643—644
Intracranial bleeds, in adnlescents, nstenarthritis nf
635—636 M05 clinical practice guideline,
Intracranial hemurrhages, 636, 637? 235‘s
Intralesiunal drilling, 223 histnry, 23'?r
binantuscular enmparnnent pressure imaging, 232—23 E, 233:
[IMCP], ass-an} management nf, 2.32—2.49
Iun channel disurtlers, sudden death nunsurgical management, 233-243
and, 563 patient histnry, 232:?
Ipsilateral pallnaris ten-dun, T3 physical examinafien, 23?, 2.33!
Iscbial tubernsity, avulsinn injury, 1543‘; ustenchundral autugraft transfer, 223
156 esteechnndrnses, 625—626
Ischinfemnral impingement, imaging presentatinn nf, 625—626
uf, 235' treatment nf, 6T6
Isthmic spundylulisthesis, 45E particulated juvenile cartilage, 23IllI
platelet—rich plasma {PEP}, 23f]
pnsttraurnatic nstenarthrits, 355*
J research registries, 436
Jeffersnn fractures, 4331‘ ultrasnund evaluatiun uf, 262, 262f
Jerk tests, 3 Knee braces, 156
Jersey finger, 1135 recunstructinn, 15'1f
ae exercises, 315 Knee Injury and Dstenarthritis Dutcnme
Jube precedure, 342-344 Ecnre {RUDE}, 1‘39
jnint fluid Knee Snciety .5c measures, 155'
1l1 signal, s31 Knee-up exercises, 3513f
ultrasnund-guided aspiratien, 755 Knutless anchnrs, 531
juint hypermubility, hip, 352-353 KT-lflflfl test, 525
Juggerliinnt, 532 Kujala Anterinr Knee Pain Scale, 212
Kyphusis, cervical spine, 444
K
Kaner Pennanente REL Registry, 436 L
Kaplan-Meier analysis, 435 Labral instability, 224—226
Kehr sign, me labral—chnndral junctiun, 2423’
Kellgten-Lawrence classificatiun, 255 Lahrnligamentnus sulcus, T41
Keratnennj Linctivitis, epidemic, 55'2 Labruru
Kemig sign, 593 anarmnic variants, 44
Ketncunaaule, 53i} blend supply tn, 43
Kidneys. See else Renal injuries MRA, 2215a"r
imaging, 621-622 nennal variants, 2'25f
injuries tn, 621-622 shape cf, 43
sulitary, 622—623 signal intensity, 224
Kiesselbach plexus, 6:36 tears, 43f, .741f
King-Davie}: test, 416, 41?}: 633 tears, acetabular, 1121-115, 112?
Klippel-Feil anumalies, 441 hamstring allngraft, 119,;
Klippel—Feil syndrnrne, 424 physical examination, 1131‘
Knee treatment, 113
amniutic stem cell transplants, 23IE|I Lacerariuns, facial, 6134—606
arrhrnscupic debridement, 223 Lacbman test, 126—12?
articular carlilage nf, 221—236 Ladder drills, 363, 36 3f
caru'lage-resturing pmcetlures, 23!] Larssen technique, 199
card bleed stem cell transplants, 23D Latarjet precedure, 2, 3f
effusinn, reductinn nf, 360—361 Lateral cullateral ligament {LCL}
irnaging cf, 242-253 anaumny cf, 34, 135
micrufracture uutcnmes, 223 binmechanics, 135
micrufracture technique, 223f injuries, tt'ean'nent uf, 196r-192t, 193
next-generatinn chn-ndrney'te Lateral epicundylitis
implantatiun, 23||I|| elb-rnlr.r arthruscupy fur, Til-71
Drthupaedic Knnwlndge Update: Sparta Medicine 5

evaluatinn of, 94
recalcitrant, 96—92
treatment uf, 94—92, 96f
Lateral epicundylitis tendinupathy,
91—99
Lateral femural cutaneuus nerve
{LFCN}, 11s
Lateral menisci stabilisatiun, 253
Lateral pivut shift test, 33
Lateral ulnar cnllateral ligament iLUCLj
attachment, 233
Latissimus dutsi muscle, 396
Lawtunuwer exercises, 315,!r
Le- Fc-rt classificatiuu, ISSUE-6|]?
Leash cf Henry, 235
[eddy classificatiun, 1ll|5
Left ventricular hyputtctphy, 566
Leg pain discrders, 2.6542.215. See disc
Specific disutdets
cummun causes uf, 263;r
ccmmn-n lncaticns cf, 2613f
Leg presses
after ACL injury, 361
shutde leg, 362f
Lhermittc sign, 43 E, 4363
Lidn-caine, 61115
Ligament nf Humphrey, 129, 2522'
Ligament cf Wrisherg, 1251I
Ligamentuus laxity, assessment cf, 4
Ligaments, elbew, 232—233. See else
Specific ligaments
Ligamentum flavum, wheel, 453
Ligamentnnt teres iLT], 115I
injury 11], 122
rnicrntrauma, 122
pain cf, 121
rule uf, 121—122
Lilcert scale, 414
Linear regressicn analysis, 435
Lineanlid, 5E6
Lisftanc fiacture-dislucatiuns, 233—296,
269,15, 2961‘
Little Leaguet’s elbnw, 342, 235, 2352'
little Leaguet's she-alder, 2132
Liver injuries, 62'0—621
healing times, 6211
management cf, 621::
ultrasnnugtaphy, 621t
Lcadrand-shift tests, 4, 9'
Lucitetl facet dislncatinn, cervical spine,
43E
Lnng head cf the biceps {LI-IE} tendnn
bluud supply re, 44
detachment injuries, 43
imaging, as, as
ncrmal attachment, 44f
origin cf, 43
passage cf, 44
tenudesis
indieafiuns fur, 5i)
pttI-cedures fut, 5|], 51,:
Lung QT syndrume, 566, 56E
lEl2il16 American Academy uf flrthupaedic Surgenns
Indcx
Lung-tell external tntatinn test, 126* Manipulatinn under anesthesia away,
[DDS-E budies, temuval cf, 20 56
aeramide, 595 l'vlamtal pruprinceplive neurnmuscular
Lew-lead, lung duraticrn {LLLD} facilitaticn, 334,1‘r
stretch, 332, 3322' Manual resistance external tntatiun,
Lumbar radiculupathy, 455—456 335f
Lumbar spine l'vlannal therapy, benefits cf, 33.3
disk hetniatinn, 453-456, 454,6. 455f Marfau syndrnme,562
imaging ef, 454 Masun classificatiun, 31—32
presentatiun uf, 454 Mast cells, in tendinupathy, 496
treatment at, 455-456 Matrix metallcpmtein-13, 495
gulf injuries, 355 Matrix metallnprcrteinases [MMFs], 514
physical examinatiun cf, 451—452, MaxFire meniscus repair device, 535,
4523 sssf
Lum lac-pelvic regiun, cute strengthening, Macrce, 523
394 Maxillary fractures, 6H6—6I12
Lunges, after MEL injury, 361 Maximal vuluntary isumeuic
Lyshulm Knee Questictmaite scare, 1'99, cunttacriuns {MVICs}, 323
255 Mayu Elbcw Perfutntance Index, 33, 5‘6
Lyshulm-l] Knee Questinnnaite, 151 McCarthy test, 122
McConnell taping, 211
McMuttay test, 254
M Means cumparisuns, 434-435
Magic angle artifacts, 224, 231 Medial antebrachial cutaneuus nerve,
Lingerie resonance ardirngraphy 23f
(tuna) Medial cullatetal ligament {MEL}
cuntraindicatiuns, 223 anatumy uf, 191i}
elbuw, 231—233 attachment, '2fl6f
empty hicipital gtncve, 43f basic science uf, 139-195
fat suppressed, 226-222, 2221’ binmechanics, '1 9E!
intta-articulat cunttast, 2'23 elb-Env stability and, 31
fc-r Ll-IB lesinns, 46 injuries
fur SLAP lesinns, 46 surgical treatment cf, 1321-3193:
Magnetic resnnance treatment cf, 1910—191
chulangiupancreatugtaphy, 625 reconstruclicn, 194—195, 194115 1935f
Magnetic resonance imaging {MRI} strength cf, 19C!
in adductnt strain, 162 tears, 2:16
in athletic pubalgia, 165, 1651‘ Medial epicundylar apuphyais edema,
cartilage ahncrmalities cm, 243 surf
cervical spine, 432r Medial epicundyle, displaced fractures,
disl-t hemiatiun, 454—455 2135:; 2fl5t
elbuw, 231—2313 Medial epiccndylitis, 91-99, 339-341
fat-suppressed, 24W descriptinn cf, 5'1
glenuhumetal juint, 223-230 evaluatien cf, 92
hamstring, 154 pathuphysiulugy pf, 91—92, 94
ltnee, 242 treatment uf, 92-93, 93f
ltnee 0CD, 642-643 Medial femeral cundyle, 205
lumbar dislt hemiatinn, 453-456 Medial gastrucnemius hyperttnphy, 2'20
magnet strength, '252 Medial mallenlus fractures, 294-
nsteilis pubis, 12'flf Medial menisci
patellufemural dysfuncn'un, 2fl9—2l 1 ctnssusectiun, 2531' ,
cf rutatut cuff tears, 35 red-red rune, 255, 2551‘ ,1
fur SLAP lesitxls, 46 met ears, r51;Ir
spine imaging, 422-423 stabilisatinn by, 253
in spundylulysis, 45.2 tears, 254;; may
Magnus muscles, 164 in slteletally immatln'e athletes, 655
Malleular cstectcmy, 642 Medial npening wedge cstentcmy, 24-4f
Mallet linger, 134, “34f Medial patellefemeral ligament
Mandatery repurting, death in athletes, {MPFL}, 662
563—564 anatcrmy cf, 1125-206
Mandibular dislctafiuns, 6132 distal realignment, 6619I
Mandibular fractures, 6|]? femural fixatiun nf, 621,1"
Drtbupaedic Knuwledge Update: Spurts Medicine 5 a
1'
 insertitln, 5513f
recenstruerinn cf, 111—113
cnmplicalimls, 6'?”
trcchleuplasty, ass-era
t, anatnmy
Medial tibia] sum syndrnme {M55},
155-166
Medial tibinfemnral chundrnsis, 1'51
Median narve
ceutse nf, T36
entrapment, 7'35
ulrrasnund nf, Féflf
Median neurupathy, T36
. Medical infnrmatinn, ethical
cansideratic-ns, 4'15
Meningitis
in athletes, 593-595
bacterial, 593
sympmms cf, 593
Meniscal all-:Jgraft transplantafifln
in meniscal tear repair, 153-159
prucedure, 159,1r
Meniscal Cinch, 53.5
Meniscal injuries, 151—1154
Meniscal instability, 513-I514
Meniseal Tear in Daren-arthritis
Research {METEDRL 4E?
Meniscectetny, arthrnscnpic, 143
Menisci
anatnmy, 151—153, 151,1r
biumechanical smdies, 156
imaging cf, 749-?5fl
lead sharing and, 153
repair
binmechanics nf, 535
candidates far, 534
clinical ccnsitleralicns, 53E
defines, 53-4—5345
platelet-rich plasma in, 5[19-5 11'}
stem cells in, 511
rent tears, 15v, 1'51f
tears, 1.55, 15?, 749—751, Tfiflf
binlc-gic treatments, 151-153
descripdnn cf, 154—155
diagnnsis cf, 153-155
failure {If repairs, 155-15?
imaging cf, 154f
treatment nf, 154—159
unstable, 155
white-white sane, 155
Mcniscnfelncral ligaments, 151
Meniscutibial ligament tears, 191
Menstrual dysfunctinn, 516-511, 519
Mental fnramen, Efl5f
Mental health, spurt psychclcgy and,
553-555ll
Mental status
caneussinn and, 413—414
head injuries and, I536
Metacarpal bnnes
intraarticular fractures, 1fl1
16 American Academy nf flrrhnpaedic Surgenns
neclt fractures, 1il1-1 [l1
shaft fractures, 1fl1—1fl1
N
Naftiiine, 591
Metacarpal head fractures, 1fl1
Nasal fractures, E436
Metacarpnphalangeal {MCF} juint,
Natinnal lCenter fc-r Catastrnphic Spnrt
thumb, lfl3—1fl4
Injury Research, 413
Merhieillin-resisranr Staphyincnccas
Naticnal Ccllegiatc Athletic
caress {MESA}
Asschciatinn, 414
appearance sf, 5361f
Natiunal Fastball Head and Neck
in athletes, 586
Injury Registry, 414
tliHerential diagncses, 5315
Naficnal Fc-nthall League (NFL!
N-tnethyl-D-aspartate receptur 1
en certicc-sternids. 155
tblMDAfllj, 499 Sideline Cnncussinn Assessment Toni,
N—mediyl-D-aspartie acid, 419
414
Methylprednisnlnne, 413—419 Naticnal Generating Cummittef: nn
Meyers and McKeever classificatiun,
Standards fer Athletic Equipment,
EFIf 414
fvficrcfractures
Natinnal Pediatric Trauma Registry,
AEII versus, 119-1313
615—1515
arthrusccrpic view cf, 114f
Nariunal Spinal Curd Injury Statistical
bane matte-v.r stimdatinn by, 113
Center, 413
for chandral lesitms, 5T
Near classificafinn, 11, 23,:
ltnee, 113!’
Neisserr'a gancrrbusne, 596-59?
DAT Iesians, 1E4 Nee-Cart, 513
DAT arrays, 119
Nerve hicclts, fcrr facial injuries, EDS
nutcnmes, 113
Nerve tact ten sinn
talar nstenchnndral III-Inns, 1E4f signs cf, 454
Middle glennhumeral ligamem
tests far, 451
[MGHL], 44 Neurapraaia, 415—416
Midfont injuries, 139.!
Next-generatiun chnndrncyte
Mild traumatic brain injury {mTE-I}. See
implantatinn, 1313
Cnncussic-n
Hitachi lesicn, Tl]
Mind, Eddy mad Spurs (scam, 554 Nirschl npen tendinclsis resecticm, 5'6
Mnlluscum cuntagic-sum virus [MEVL
Nirschl pain sec-res, 91
539,539f Nansrernidal anti—inflanunatery drugs
Mnnnnucleasis {Iii-'1}, 5'94
{HSAIDsl
Mend diserders, 555, 555
after strains, 151
Meter vehicle accidents, E14
fer knee usrenarthfltis, 141
Mnuth guards, 611
Ncrnvirus, 595—5 9'6
MulficentEt AC1 Revisinn Study ae, fractures, EDIE
{MARS}, 436
Nucleus pulpnsus, herniated, 414
Multicenrer flrthnpaedic Dutcnmes
Null hypnthesis {Ho}, 43!}
Netwnrlt IIMDDN} Knee Grcup, 436
false acceptance cf, 433
Multicenter flrthupaedic |flutcutnes
Nutritinn, 545—551
Nenvc-tlt iM0014} Shuulder Grnup,
Nutritinnal supplements, 141
435—43?
Multiiidi muscles, spinal stability and,
393
MulIJ'ple regressinn analysis, 435
0
fiber rest, It]?
Mupirncin, 53'?
Dbeaity
Muscle cuntusinns, 153
heat illness and, I532
Muscle cramps
knee nstenarthritis and, 1311-135II
heat—related, 533
spcrts tsychnlngy and, 55E
preventian nf, 55D
O’Brien active cc-tnpressinn test, 46
Muscle strains, treatment nf, 151
Dbservatinnal studies, 43!}
Muscles, energy snurces far, 545
flbsessive campulsive disnrder, 55?
Musculnfascial ccrset, 394
Uccipital tnndyle fractures, 43'?
Musculetendinnus iunctinn {MTJ},
flccipitn-atlantal dissociatinn, 4'31r
154—155
III-ED. See flstec-chnndritis dissecans
Musculntendinnus strains, High, 1513‘
Mycnpfasma Wflhfl, 594-595 {GED}
leflctylcyancacrylate, EDS-I506
Myncarditis, 55?
antnid fractures, 431'
fldnntc-id hypnplasia, 414
Drthnpaedic Knowledge Update: Spnrts Medicine 5
 Index

fldnntoideum, 4-24, 441 definition of, 641 mobility, 2i}?

Off-loading taping, 3545, SEPT elbow, 342, 644—645, 545;“ ultrasound evaluation of, P61
Clllecranctn imflsins: 5445f Patcllar tilt test, If]?
neteuphytes, Tfif elhuw arth roscopy fur, Tl] Patellofemsral dysfunction, ass-so?
stress fractures, TIE-PT, Ff ltnee, implants, 4544s Patellofemoral histability, 111-214
Olympic sports, 555 loeao‘on of, 641 anatomy of, 615 P—titifl
Uh'lHIrResistance Exercise Scale, 31?, talaa 645-643“, east biomedlanics, HIST-6153
313f imaging, ass-ass diagnosis of, 667-663
flmniSpan, 535, 53H presentation, 645—646 epidemiology, 56?
flpioids, for knee osteoarthritis, 141 treatment, 645—64? first dislocation, 21 1-111
Drbital blowout fracture, ED? Usteuchctntlruses, ETS-EWS, 5'34 medial patellofemoral reconstruction,
Drdirtal variables, 433 flsteophytes 112—213
Organ injury grading system, Ell] excision, 345—346 recurrent, 211
ornaaapt, 52s, sas ulecranon, Pfif skeletally immature aflsleees, ESP—634
Dfihubiulngic agents, applications of, flsteoplasty, hip arthroscopy and, 3.54 treatment, sss
5133—511 lflsteoporosis Patellofemoral joint [PFfl
flrtboflord, 534 in the female athlete ttiad, 5iii-.531 disorders, 105—219
firthureatia uervusa, .556 stress fractures and, 115? dynamic trunlt mechanics and, 3H-
Dsborne-Cuterill lesions, 34 Ifleitis externa, 592-5 9'3, 593f 31?
Dseltamivir, 595 Utitis media, 592 dysflmction, imaging in, film-211
Usgu-nd—Schlatter disease, STE—6T6 Iliiiuterhriclge classificatiun, 5T gait remaining, 3TH
Dssificati on centers, capitellar, T34 Dverhead athletes stabilizers, 212
flsteitis pubis elbosv injury rehabilitation, 319-349, Patellofemoml pain syndrome {PFPS}
complication, 1TB 33o: imaging, 21 1
imaging, 169 SLAP lesions in, 44 rislt Inf, 3T6
pathoanatomy, 163—169 Uveruse disorders rehabilitation
physical examination, 1459' Achilles tendon, 195—196 distal imervennons, svsf
presentalicm, 1155i elbow, 91-99, Til-4 gait retraining, 3T6
rehabilitation, 1TH shoulder, Till-Fill local interventions, 374-3T5
treatment, '1?!) skeletally immature athletes, Till-Till proximal interventions, 372-3734
Osteoarthritis lIii!triers-Ireight, sports psychology and, 555 renon-to-aetivity interventiu-rts,
ltnee ncudune, 55D svs, svsf
MUS Appropriate Use |Criteria, nmetasolhte, EDS Patellofemural pain syndrome [PPS]
144}, can: rehabilitation, Sid—331
RAGE clinical practice guideline, Patient auttrnomy, 4T1—4T1
139a 14m? P Peal-t height velocity, gender and, 653
imaging, 231%, 144;“ Pain Pectineus muscle, 164
management of, 13 P—149 elbow tendinopathy and, 91 Pedian'ic patients. See also Adolescents;
medicafiuns, 241—242 medial epicontlylitis and, 91 Skeletally immature athletes
nonsurgical management, 2.33—2.43 playing through, 4TB kidney injuries in, 621-522
patient history, EST-it Palmer classification, lfliit patellofemoral instability, 559
surgical treatment, 143 Panalolt, .531 rectus femuris, avnlsinn of, 11?—1 13
meniscal tears and, 254 Pancreatic injuries, 624—625, 614!- spleuic injuries, healing times, I519:
platelet—rich plasma in, 5D? classification of, 615 PEDro scale, 31.!
stem cells in, 511 resection, 515 Pelvic fractures, 513—614
flsteochundral allu-graft transfer Panic attacks, 55'? Pelvis, anatumy of, 163
AC1 versus, 23B Par-net disease, 644, fill—TH Pemphigus vulgaris, 53?
DAT lesions, 134 Parainfluenta virus, 594-595 Penicillin, 53?
Usteochurtdral allcsgraft transplantatitrn, Paralabral ganglion cysts, 49 Performance-enhancing drugs, 4T4-4TS j”
sagaasfi ass Parameniscal cysts, Pfiflf Peripheral nerve injuries, ST—Sfl, 763
microfracture Harms, 229 Paratenouitis, 196 Peripheral vascular disease, 53-2
Usteochondral aotograft transfer Parathyroid hormone, 26? Peritrochanteric ccmpattrncnt, 115
{oar}, ass—ass, aaaf Pars interarticularis Permacol, 523
dunor site, 224 fracture of, 456, 459' Perthes lesion, P26
outcomes, 123 repair, 453 Permrhation training, 353;“
steps in, llfif Particulated juvenile cartilage, 230 Phalanges, fractures, Hill—1'31
flsteuchnrldral grafting, 5'? Passive forearm prunafion test, 3E Pharyngitis, 593—594
Dsteochondral lesion of the talus (BLT), Patella Pharyngoconjunmival fever, epidemic,
233—185 fracture of, llflf 591
Usteochc-ndritis disseeaus {OED}, height of, 5:53 Phosphocreatine, 545
641-652. DIED, +541 Physes, function uf, 653
arthroscopy, 6?, T511” Patellar tendons Physical activity. See also Exercise

@1015 American Academy of flrthopaedic Surgeons Orthopaedic Knowledge Update: Sports Medicine 5 ®

1'
 fer ltnee estenarthritis, 1.33-
WHD guidelines, 311—1711
Physician—patient-tearn ttia , 4T1
Pilte exercises, 3333‘
Pilcin fractures, 133
Pin and rubberband tractien, 133,6
Pineer impingement, 113.. 134
Pirifermisi'hamstting celnplex, T61
Pitifermis muscle, injectinns, P61
Pirif-nrmis syncltnme, 144—145
characteristics. bf, 144
diagnnsis, 144
imaging at, 144
treatment algc-ritllnt for, 144—135
Piril'brmis tendcin release, 145
Fitted keratcilysis, 533
Piynt shift test, 655
Planks, after ACL injury, 363
Plantar fascia, evaluatien cd', T63
Plantar fasciitis, 13H
esidence-hased practice, 33.53
exercise fer, 335-336
manual therapy far, 334
presentatinn nf, 334
taping, 334-335
Plantar gap, 192-193
Plantar plate tear, 191;!“
Platelet ct-granules, 53.5, 5351‘.
Platelet-derived grewth factnr [PDGF],
535
isnfnrms DE, 513
Platelet-rich plasma {PRP}, 533-513
for adductnr strain, 16.7'
in ehnndral resurfacing, 539
cnmmerc'ial separatinn systems, 5341‘
cnmpnsitien nf, 533-336
certicnsternids with, 155
healing augmented by, '31—'33
knee, 133
fer knee estenartbritis, 241-243
in meniscal repair, 253—253, 539—3 13
in nstenartbritis, 539
preparatinn bf, 333-536
in retatnr cuff repair, 336—533, 533t
in tendinnpadiy, 536, 5373
fer UCL sprains, 343
PLLA anchnrs, 533-532
Plyntnettic exercises, 364
Pneumnnia, in athletes, 595
Pnlydiuxannne {P133}, 333-534
Pnlyglycnlic acid {PGAL 533
Pnlyglycnnate sutures, 5.3.3
Pnlylactide-cc-glycnlide, 513
Pnly-L-lactic acid, 513
Pnpeye sign, interpretatinn cf, 46
Pnpliteal artery entrapment synclrnme
{FEES}, 2'33
Pnplitenlibnlar ligament jPFLj, 193
PnPLnlt, 533
Positive impingement test, 123
Pnst-Cencnssinn Symptntu Scale,
633—633
16 American Academy cf flrthnpaedic Surgeries
Pestcnncnssinn syndrnme, 413-419 Prnteea, G1 infectinns, 596
Pcrsteriur apprehensinn sign, 9, 133 Prereimal fibular squeeze test, 232
Pneterint bnny anlele impingement, 136 Prnrcimal interphalangeal {PIP} jnints
Pnsterinr cruciate ligament {PCL} disincatiens, 132-133
anatnmy cf, 179-131, 1331'" retatnry subluxatien, 133.!F
hintnechanics ui, 139—131 rntatnry subluxatinn-dislncatinns, 133
imaging nf, 743—349, T49f 1insular, 133
injuries tn, 139-131 Prnxitnal tibial plateau, 252,1“
diagnosis cf, 131 Pseudnaneurysm, radial artery, 339f
nutcnmes, 131 Paeadnmnnes infecticins, 533-533
treatment cf, 131 Psychiatric cliscllrders.I 56‘?
Pesterier humeral circumflex artery, 43 Psychelegic injuries, 556
Pustericir intertnallecilar ligament, 136 Psychcisncial health, strength training
Pctstericir nhlique ligament jPflLl, 1513, ancl, 3'13
191f Pubic apnneuresis, 164
tear bf, 191 Pubic symphysis
Pnsterinr nlecranen, nstenphyte ligamentnus camplex nf, 164
excisien, 345-346 palpatinrl 3f, 164
Pesteric-t talnlibular ligament jPTFL}, Pubis tubercle, 164
1?3 Pubefemnral ligament jPFLj, 119
Pctsterninferinr tihinfihular ligaIttent, Pulley ruptures, 13.5
231 Pulmenary in fectinn, 534—595
Pesternlateral cnrner [PLCJI Pupil sites, eye injuries and, 633-639
anatcimy, 193—139 Pust-clt, 533
bin-machines, 193 Push-up exercises, 313, 334f
diagnnstic studies, 199 Push-up with fnrearm in supinatinn, 33
injuries, surgical treatment, 199 Pylnrnetric exercises
Pnsternlateral drawer test, 33 elbnw, 335—336, .336f
Pnsternlateral rntatnry instability iPLEJ} fer retatnr cuff pathology, 313
chronic, 33
diagnnsis bf, 33
persistent, 33 Q
Pesternmedial cnrner {P3113}, 191, 194!" Q alleles, 135'
Pcisterntnedial impingement, 35—36 Qaadriceps muscle
P-nsternmedial rntatnry instability acijyaticn exercises, 111—112
jPMRI}, s4, s5 anatnmy, 156
Pestherpetic neuralgia, 593 inhibitinn, 363
Pnstnaumatic stress disc-rder, 33? injuries
Pntasaium hyclrnxide, 5139 antlsinns, 156—153
Fewer analysis, 433 patient evaluatinn, 156-15“?
Pewer Wheel, 393—433, 431t, 4331‘ strains, 156-163
Practice Management Guidelines, 613' prendmal thigh injuries, 151—161
Preparticipatinn exaniinatinns, 561-563 strength testing, 362.
Press-dawn exercises, 313, 313]“ strengthening, 361
Prefessienal spnrts, 555 weakness, 23?
Pr-ngesternne, 536—5 '3'? Quadriceps tendnn
Pregressire myelepathy, 432-453 graft, 5.14f
Prenatnr quadratus attephy, 3'36}r ultrasnund eraluatinn 61', 762
Pmnatnr teres, 91 Quadriparesis, transient, 42.5, 413; 435
Prnne ball drnp and catch, 336]Ir Quadrnped nppnisite armvantl-leg lift,
Prene hangs, 361 395
Prene herinnntal abducticin exercises,
stsf
Prune planlt exercises, 334,6 396, 3333' R
cemparisnns, 3931' Racefethnicity, [HID rates and, 641
Prnprinceptinn, neestablishment bf, 36] Radial artery, pseudeaneurysm, 3591’
Prnteins, dietary requirements, 54?, Radial enllateral ligament (REL), T33
543-353 Radial head
Prerenglycan-glycnsaminnglycan elbow stability and, 31
(133.13}, 343 fractures nf, 31—32
Pretnn densinr-weighted sequences with ass-ticiatecl injuries, 31
fat suppressitm, 316-32? treatment bf, 32
Drthnpaedic Knowledge Update: Sparta Medicine 5

Radial nerve
abnnrmal, 7315f
causes at neurupathy, TJS—FSE
centre at, Eli-336
Radiatiun, heat dissipatinn, 6321'
Radiatien expel-sure, eye injuries, 61!}
Radinrcapitellar cnrnparttnent, 9'34f
Radincapitellar jnint nverlnad, 7’4—5'5
Randetniaatien, clinical studies, 431-
433
Range cf mutiun {RUM} excremes
after REL injuries, 361
circumducljnn, 353, 354.!r
early eerstes delayed
in retatnr cuff rehabilitatinn,
333—313
RE fillegraft, 513, 519
Realignment usteuturny, 243, 1431f
Rectal sheath hematurna, SIS
Rectus ahduminis muscle
ahdnminal wall, 163—164
activity ul, 3915
Rectus femutis muscle
acn'vity cf, 396
anaturny, 156, 1531‘
hulls-eye lesiens, 15?!
injuries
classificatinn, 15?
treatment, 157-153, 1533“
Registries
research based en, 453—43?
spurts medicine, 419-491
Rehabilitatic-n
beinre ACL recenstructien, 3513
after REL recenslructinn, 359-333]
early
after MIL recenstruetinn, 3Sfl-361
elbnw injuries
nyerhead athletes, 329—349
phase I, 330-333
phase I], 333—334
phase 1]], 334—336
phase 1'95, 3315-333
pastnperative, 3311*
late, after ACL recnnscructinn, 361—
366
patellnfetnntal pain syndrome, 33'1-
332
rcrtatur cuff, 311—313, 310s
in slteletally immature athletes, 1559
Relative tisle {RRL 4S}!
Relecau'en test, 4
Remplissage, [-Iill-Sachs lesiuns, 3
Renal injuries
adult, 623
management crf, 613!
pediatric, till-632
Research studies
hyputheses, 413i]
lcnee registries, ass
prutemls, 43 1t
in spurts medicine, 499-491
@1015 American Academy ef flrthnpaedie Surgenns
statistics, 433-435
study design, 439—430
study types, 4SD—433
Resistance exercises, 312
Resistance training, Tl 1—313
Reeisted clam shell exercises, 352f
Resisted sidestep exercise, 3551f
Rest, ice, campressinn and elevatien
(RICE), 151
Resting metabolic rate {RMR} testing,
5??
Restnre firthuhiulngic suit-tissue
implant, 513
Retinal injuries, Elli]
Retrnhulhat hemerrhage, ED945113
Return te activity, elhmv injuries,
336—333
Return tn learn, after head injury,
SS9—S9i}
Return tn spurt
adulescents after head injury, E90
after ACL injury, 3645::
after Ail recnnstructinn, 359—3311
after ACLrepaie, 199
after cencuseinns, 41 S, 4191!
after spinal injury, 423
atidetes with hip injuries, 353
graduated prntnccil, 4T4t
ptntucnls, 151-152
ptnximal thigh injuries, 151-152
team physicians and, 4711, 491
Reverse tntal shnulder arthrnplasty, SS
Reva ltnuts, 534
Rheumatulugic inflanunatinn,
ultrasound elf, T59
Rhinnrrhea, clear, SIDS
Rhinnvirus, 594-395
Ringwnrrn, S91
Rnbhery exercise, SISf
Rnhinsnn classificatinn, 24f
Reman numeral 14 recenstructinn, 19f
Rclmherg sign, 4315, 436s
ahetg test, pnsitive, 4S3
Rutatinnal usteetulny, 3
Rctatur cuff, 33—41
anatumy, 33-34
bietnechanics, 33-34
ctielugy uf disease, 34
genetics, 33—34
glenuhurnetal MRI, 733-730
imaging cf, 35, 379'
interval, FIE—7'13, 913;“
muscle degeneratiun, 341'
natural histnty ef disease, 33
pathulngy nf
ncmsurgical treatment, 35-36
surgical cansidetatinns, 36-3?
physical examinatien of, 34-35
pnsteperative cuneerns, 3?
rehabilitatiun, 311-323, sans-sate
' Sesanieid disorders, 391
implants in, SIT—519
firthepaedic Knnwledge Update: Sperts Medicine 3
1'
Indcx
platelet-rich plasma in, SUE-SEE,
SIDS!
stern cells in, 511
RUM, early see-sac delayed, 322—313
secietal effect ef disease, 33
tears, 34, 35f, 3'34f
man, ass
MRI, 7'33
prevalence by age, 341’
tendnn Hansfers, 3T—33
ultrasnund evaluatinn c-i, T56, FEET
Rntavirus, 595—596
RutnrlcE, S31
Reuse-Geldthwait precedure, 6-59
Rmving tnutien exercises, 313-314
Rayal Lenden Hnspital Test, 336
Rurming athletes, reha hilitatinn, 354
Ruptured glnhe, 609
5
areas pretein, 416
Sacrc-iliac jnint laxity, 394
Saddle—nese determines, EDS
Sagittal hand injury, “34
Salicylic acid, fnr yettuca, SSS
Salmeneiia
elicilcgy, 59H
GI infectiuns, 59E
Salter-Harris physeal fractures, 655
San Dirge knuts, S34
Scaffnlds, tissue therapies, 5 11—5 13
Scaphnlunate interval, lflilf
Scaphelunate ligament injuries, 1i}?
Scapular plane elcyaticin
early stahiliaafiun exercises, 33!]
musculature, 333s
fur rutater cui-f pathelugy, 311—3 13,
313f
Scapular retractien exercises, 313-314
Scapuletheracic dysltinesia, 4?
Sciatic nerve
anatnmy cf, 1441‘
ultrasuund evaluatien ef, 7'61
Sciau'c nutch, ultrasuund at, lf
Seller-axis gene, 499
Sclerutherapy, in tendinnpathy, 49S
Sculiusis Research Suciety questiennaite,
415i}
Scranten-McDermntt classificatiun, 335
Seated knee extensinn, 3151
Seattle Criteria, 561, 3531'
Secund—impact syndrome
in adelescents, 1591-691
cancnssinns, 419—410
Selective sernmnin reuptalte hihihitnrs
isSRlsj, 41‘}?I
Sensery flrganisatinn Test {SGT}, 415
Sequent device, 535
Sertaccnaacile, S913
Sexually transmitted infectiuns, S96, 59'?
@
 Shigelfu Skeletal maturity, definitinn nf, 653 imaging nf, 459
etinlngy, ssn Skeletally immature athletes. See presentatinn, 459
GI infectinns, .596 clan Adnlescents; Athletes, ynung; treatment, 459—466
Shin splints. See Me STI'ESS Pediatric patients Wiltse classificatinn pf, 45S, 459t
syndrnrne MIL tears in, 653-664 Spendylnlysis
Shingles, 5913 injuries in, 1111—1119 epideminlngy nf, 456
She-rt QT .e,566 patellnfemnral instabilitjg 661-6154 imaging, 459r
Shnulder Skier’s thum h, 1133-1114 presentatinn, 456—451, 456,!“
anatnmy, 60f Skin treatment, 451—453, 4513f
benign hypermnhility, 11.13 fungal infentinns, 5 96—591 Spnrt Cnncussic-n Assessment Tnnl 3"
thundral lesinns, 51' human dermal grafts, 5.11f ctlitictn [SETS], 414, 631-633
fractures, 161—1113 viral infectinns, 533—590 Spnrt psychnlngy, 553—559
injuries, 161—103 Snapping hip, 14!]. See alsn Cnxa Spnrtl'viesh graft, 519, 5151f
instability, 3—16, ms saltans externa; Eflxi‘l saltal'la interns Spurs drinks, 54s, 54s:
with hnnelnss,1—S Snapping scapula syndrnme, 59-61 Spnrts medicine
multidirectinnal, 9, 111-11 causes of, 59 Ethics ctf, 469—411
nutenmes, 11 imaging nf, 59 research studies in, 419-491
patlinphysinlngy cf, I'll IIealmcnt cf, 59-61, 61: Spurts nutritiurn.JI 545-551
treatment at, 16-11 Snellen chart, 61216 Spurts psychnlngists, 554
instability, anterinr Snyder criteria, 43 Sparta-related enncussinn {SEC}, 411—
imagine UL 4—5 SDcDer 411
natural histnry sf, 5 rectus femnris injuries, 15S Spurling sign, 436, 436::
pathnphysinlngy nf, 3-5 rehabilitatinn cnncerns, 354-355 Squats, 361
presentatinn nf, 4—5 Snft—tissue impingement nf the ankle, Squinting patellae, .1111, 1131f
recurrence cf, 6-? 136-13? Standardized Assessment nf Cnncussinn
risk factnrs for, 4 Snft-tissue injuries, facial, 6114—6116 {SAC}, 414
treannent nf, 5—6 Snfr—tissue mnhiliaatinn, 3S3 Stepbylneneeus err-treats
instability, pnsterinr Spear tackler spine, 444, 4-4-4f cnniunclivitis and, 591
with bane less, 16' “Spearing,” 424 fnlliculitis and, 531-533
epidemiulnggjr nf, 3-9 Special pnpulatinns, strength training GI infectinns, 596
imaging, 9 and, 1'13 impetign and, SS?
pathnphysinlngy cf, 9 Speed test, 46 Staphylncnccus pastimes-rise, 595
ptesentatinn, 9 Spins hilida ncculta, 45S Star excursinn balance test, 355
mania 10f Spinal curd injury {SCI}, 435 Stafisfies, research studies, 433—435
treannent, 9—111 cnmpreasinn, 443,:- Stern cells
research registries, 435—431r hy'pothennia and, 419-439 in chnndral resurfacing, 511-511
skeletally immature athletes, 1111-1113 imaging, 411-413 in meniscal repair, 511
ulnasnund nf, 156—15? incidence nf, 413 in meniscal tear repair, 1.51—1.53
Shuttle leg presses, 3631f ligamentnns, 43 9—441] in nstcnarthritis, 511
Side plank exercises, 314,6 396, 3913‘; management nf in rntatnt cuff rep-ah; 511
393f advanced trauma life supper-t, 416 in tendinnpathy, 511
Sign tests, 465 hnarcling patients, 416—41? Stener lesinns, 1133
Silver nitrate, in epistasis, 696 fidl-hn-dy irnmnhiliaatinn, 411" Stennsin-g tennsynnvitis, 1S6
Simple Shnuldet Test {SST}, 6 patient transfers, 416—411, 4113’ Stennsis, cervical spine, 444
Sinding—Latsen—jnhanssnn {SL1} disease, sternid prntncnl, 416—419 Step-up exercises, 361
ass, ass—err pathnphysinlngy ctf, 41.4-41.5 Sternnclavicular inint
presentatinn, 616 Spinal injury, return-tn-play after, 413 classificatinn cf, 16
radingraph, 6111' Spinal stennsis, 440 cnmplicatinns, 16
treannent, 616—611 Spine. See mists Cervical spine; Lumbar injuries, 16—13
Single phntnn emissinn CT {SPECI'}, spine; Theracnlumhar spine management cf, 16
451r cnre muscles and, 393 mechanisms nf injury, 16
Single—leg bridging, 314f' naumatic injuries, 413—431 rehabilitatinn, 13
Single-leg deadliffing exercises, 3951f- Spinnns prncess apnphysitis, 43 3—439' Sternid injectinns, 455. See site
Single-leg eccentric exercise, 496 Spleen Injury Scale, 613 Cntticnsternids
Single—leg eccentric squat exercise, 491':r Splenectnmy, 61 9 Stingers, 415—416
Single—leg lifts, 36.1 Splenic injuries, 613—61fl hrachial plexus injuries and, 434
Single-leg lumbar hyperextensifln test, Cl" grades,619s Stnmach ruh exercise, 3,3,,
451r healing times, 619:? Straight leg raise test, 451
Single-leg squat exercises, 355, 3141‘, management nf, 61m Straight-plane running, 363
31515 rupture, rnnnnnnclettsis and, .594 Sit-E'ngtl‘l training
Sit-up exercises, cnmpatisnns, 3931f Spnndylnlisthesis, 45 3—469 guidelines, 113—115
Skeletal age, estimates nf, 653-654 dysplastic, 4s exercises, 11 3—1'14

l,
® 16 American Academy nf flrthnpaedic Surgenns Drthnpaedic Ennwledge Update: Spnrts Medicine 5

intensity, T14—F’15
vnlume, 1'14—T15
health benefits nf, TIE-T13
medical cnnsideratinns, 1"14t
prngram prngressinn, 1'15
repetitinn velncity, 7'15
rest intervals, T15
training frequency, 115
ynung athletes, T1 1—919
Strengthening exercises, 361
Streptncnccas, cnnjunctiyitis and, 592
Stress fractures
caleaneal, 13'?
nnnuninn rates, 3163
nlecrannn, TS-‘F'Tr', TFf
Student t test, 434—4 S5
Suhacrnmial decnmpressinn, 5T
Subscrnmial impingement syndrnme,
311-511
Subacrnmial space, arrhrnscnpic view
nf, 59f
Subacrnmial-subdeltnid bursa, T56, T51"
Subarachnnid hemarnmas, 631T
Subdural hemnrrhage, 636
Subgluteus maximus bursa, 142
Subgluteus medius bursa, 761
Sublabral sulci
anatnmy, T41—T41
nnrrnal variants, 1’42)“
Sublime tubercle. See T sign
Suhscapular artery, 43
Subscapular entrapment, ST-59
Subscapular tendnn, 723
Subscapularis rendnn, 9'56—‘1’51r
Suhspine impingement test, 132,1;
15?—15S
Substance P, 499
Sudden cardiac death {SUD}
in athletes, 561
causes nf, 566-569
incidence nf, 563—565, 564t—565t
Sulcus sign, 9
Super Abdominal Machine, 396,6 39?,
46W
Superinr labrum anterinr tn p-nsterinr
{SLAP} lesinns
artbrnscnpic 1triens, 45,IF
ciassiiitarinn cf, 45, 46!; 49f
description nf, 43
imaging, 46, 4S
nnnsurgical treannent, 41-43
pad‘tnphysinlngy nf, 44—45
physical examinatinn nf, 45—46
with pnsterinr eatensinn, 49f
surgical treatment nf, 43—56, 51f
Supernmedial scapular harder, 6flf
Supine impingement test, 129
Supplements, 556—5 5 1
Supranrbital nerve, 665
Supranrbital nntch, 6fl‘Sf
Suprapatellar recess, 1'62
Suprascapular nerve stimulatinn, 56, 59f
l@1616 American Academy nf flrdinpaedic Surgenns
Indcsr
Supraspinatus tendnn Tendinnpathy
EMG activin', 519 current cnncepts in, 4195—5112
evaluatinn nf, T13 earrcise prntncnls, 496—49?
tensile leading nf, 519 NSAIDS fnr, 499-493
ultrasnund evaluatinn nf, T56, 1'51"}r platelet-rich plasma in, 56?:
Surface electrnmwgraphy, 364 recent research in, 499
Suryiyal analysis, 455 stem cells in, 51 1
Suture anchnrs, 529-534 surgical management fnr, 493-499
bindegradable, 5303‘ therapeutic interventinns, 496-49?
binmechanics, 53 1—531 ulnasnund fnr, 499-493
failure nf, 533 Tendinnsis
materials fnr, 536-531 cellular changes, 495t
SutureFia, 53,1 mnrphnlngic changes, 495—496, 495t
Sutures ultrasntmd evaluatinn nf, T56
Innp failure, 534 Tendnn allngrafts, 523
materials fnr, 533-534 Tendnns
use cf, 533—534 elbow, 9'3 1—1’31
Sweat, heat dissipatinn, 631 injuries
Swimming pnnls, infectinns related tn, acute, 494
5S? cellular respnnses tn, 494—495
Swiss Hall, 399—4611, 399,15. 4611:, 4113 chrnnic, 494
Swiss Ball decline push-up, 596-391Ir structure nf, 493-494
Syndesmnsis Tennis players, medial epicnndylitis and,
injuries, 131—133, 23215. 133;“ 91—91
ligaments nf, 132,6 Tennsyunvitis, ultrasnund evaluatinn
Synnvia] fringe, 7’35 nf, T56
Synnvitis, ultrasound nf, F59 Tensinn—band plating, 263
Systematic reviews, 433 Tensnr fascia latae, 141
Systemic factnrs, 513-515 Terbinaline
fnr tinea cnrpnris, 591
fnr tinea cruris, 591
T Teres minnr teudnn, T56
T sign, TEE-f Terrible triad, S4—S5
Tackling, headfirst, 414 diagnnsis, S4
Talar dnme, nstenchnndral lesinn, 133,6, treannent, 34
ESSf Terry Thnmas sign, 1|]?
Talar glides, anterinr tn pnsterinr, 3351'“ Thessaly test, 254
Talus Thigh, medial cnmparnnent, 164
GED nf, 645—647', Iii-416,1r Thigh, prnximal aspect, 151-161
nstenchnndral lesinn, 153—1135 Thirst, in athletes, 543
Tampa Scale fnr Kiuesinphnbia, 36D 3013-11136 pnsitinn, 314
Tandem gait test, 415f' Thnracic spine
Tangent sign, 36]Ir dislr herniafinn
Taping imaging nf, 453
fnnt and anlde, SSS—SS4 treannent pl, 453
fnr ltnee nsrenarthrids, 141 herniated disks
Tarsal navicular fractures, 293-294, epideminlngy, 451
294;" presenrarinn, 452—455
Tarsal nmnel, 9643‘ Thnracnlumbar spine, 451-465
Tarsal tunnel syndrnme, 23?, T63 Thrnwer’s Ten Prngram, 333
Tarsnmetatarsal {TMT} jnint, fracture- Thrnwing athletes
dislncarinns, ESE—196 biumechanics nf, 1'1
Tflpsulmnmy, 1211, 136f eibnw injuries, T31
Team Physician |Iiinnsensus Statement, mntinn nf, T1f
554 thrnwers elbnw, 6?—Sl]
Team physicians UCL injuries, THE—TS}
decisinn making by, 471} Tibia, distal aspect, nstenchnndral
ethics nf spurts medicine and, 469-411r lesinn, 233-235
financial cnnsideratinns, 4T1 Tibial eminence fracture, 6TH
psychnsncial pressures cm, 496 Tibial nerve, evaluatinn nf, T63
Team spurts.I demands nf, 469 Tibial plateau, 0CD, 641
Tegner Activity Scale, 131 Tibial spine, avulsinn fractures, 61'0-673
Drtbnpaedic Knnwledge Update: Spnrrs Medicine 5 ®
1'
 Tibial stress fractures, .i:'.66—.'.l.63‘iII Ttnchlear grnnve, measurement nf, llflf Ultrasnund-guided prncedures
Tibial stress reactinn, 266, 26 Trnchlenplasty, 213—114, 669-6TEI injectinn in hand and wrist, T53
Tibial tubercle-undies: grn Tubcrnsity nstentcuny tTTU}, 213 Uncunscinus patients, treatment Inf, 434
{TTvTG} distance, 663 Tuft fractures. 131 Unilateral bridge exercise, 351,1F
Tibial tubernsity, llflf Tumnr necrnsis factnr, 499 United States Military Academy, 36T
Tibial tnbernsity and trnchleat grnnvc Tunnel-graft mismatch, 534 Unstable surface training, 363,6
{TT-TG} distance, 213—21 1, Elflf Turf tee, 293—191, 291: Upper respiratnry infectinns iURIsj, 591
'Iibial tubernsity nstentnmy {TTD}, 336, Tympanic membrane, bulging, 55'2, Ureters, injury tn, 614
213, 2141’ 593T Uric acid crystals, T5 93"
Tmea enrpnris, lesinn, 591, 591f Type I errnr, 433 U.5. Olympic Cnmmittee {USES}, 555
Tmea tern ris, 5‘31 Type II errnr, 433
Tmea pedis, 533—591
Tmel sign, l3T V
Tissue adhesives, 635—6316 U Vaccines
Tissue inhibitnr nf matrix Ulnar artery thrnmbnsis, 133 disease preventinn and, 535
metallnprnteases fIIMs, 4?? Ulnar unilateral ligament {UCLj hepatitis B, 593
Tissue therapies, scatfnlds, 511—513 injuries, T31—T33 Valacyclnvir, 539', 533
'lissuelylend, 513.. 533' insufficiency, testing for, 69 Valg'us extensicm crverlnad {VECI'},
Tnbratnycin, 55'2 management at injuries, T3-T3 TE-T3
Tnes, Ei-th metatarsal fractures, 1913‘" MRI, T33f management nf, T1
Toggle ancbnrs, 531—532. pnstnperative guidelines, 342—344, pathnphysinlngy cf, T1
Tnmmy an surgery, T3 343s—34—41 UCL injuries, TE-T3
Tnnnis angle, imaging at, l33f recnnstructinn, T4f Valgus stress test, arthrnscnpic, 65', 651‘
Tnnsillar hypertrnphy, mnnnnuclensis rehabilitatinn guidelines, 333—33? Vancnmycin, 536
and,594 sprains, 3433 Variables, statistical, 433-434
Tn-nth avulsinn, 61!] T sign, TEE-f Varicella anster, 5 9i]
Teeth displacement, 613 tear, rssf Vastus intermedius tendnns, 156, 135
Tncttb fractures, 613 Ulnar nerve Vastus lateralis, 156
ag classificatinn, 393 cnurse nf, T35 Vastns medialis, 156
ag ratins, 443', 443]“ entrapment nl', T35, T35f Vastus medialis nbliquus [WU]
ag—Pavlnv ratins, 426 injury, 341—341 functinn nf, 135—136
asn Track, 396A SST-432, 403i} neuraprasria, T4 PPS develnprnent and, 3T1
Tntal disk replacement [THE], 456 transpnstinn, 344—345, 345:: rcspnnse times, 3T4
Training, eating during, 543—543I Ulnar neuritis, 91 Vegetarianism
Trarnadnl, 142 Ulnar neutnparhy, 341—342, T35 in athletes, 54T
Transfnrming grnwtb factnr-[31 , 535 Ulnar tunnel syndr-nme, pain in, 133 prutein requirements and, 54'T
Transfnrming grnwth iactnt—flii, 51 I] Ulnar wrist pain, lflT—l [I3 Ventricular fibrillatinn, 563—565ll
Transthnracic echncardingraphy, 56T Ulnnhumeral jnint Vetrucae, 53 3—533l
Transversalis fascia, abdntninal, 163— drnp sign, 33f Versiean, 493
164 enw stability and, 31 Vertebral disks
Transvetsus ahdnminis muscle Ultra-highsmnlecular-weight hematnma, 41T—423
abdnminal wall, 163—164 pnlyethylene [UHMWPE], 53 1—534 rupnired, 41T—413
reemitrnent nf, 395 Ultrasnnngraphy Vestibular-neular system, 416
spinal stability and, 393-394 Achilles tendnn, TEE-T63 Viral infectinns, skin, 533-55'3
Trauma, elbnw, 31—33 advantages nf, T55 Viscnsnpplementatinn, 3.11, 242
Trendelenberg gait, 141 ankle, TEE-T64 Visual analng scale [VASL 9'1
Triangular fibrncartilage cnmples diagnnstic, T55—T6'T Visual field, in eye injuries, 6133
{TFCEJ font, T62-T64 Vitamin D deficiency, 513-514
artbrnscnpic vievtg lfl‘ii'f hand, T53—T6i] Vitamin D hnmenstasis, 26T
injuries, 139 hip, ran—res, Tfilf aar wrist ganglinn, 1|]?r
tears, 133, 133': knee, T62
Triceps tendnn in medial epicnndylitis, Fl
esnrcise ed, 335 prnbes, T56f W
insertinn, 35f prneedures guided by, T55-T6T Weddell signs, 451
Trichlnrnacetic acid, 596 nf rntatnt cufl' tears, 35 Watanabe classificatinn, 6T4f'
Trichnphsnn mentagrnpbyteg 5913—591 Eur SLAP lesinns, 46 Weaver-Dunn procedure, 23
Tricnpbytnrt militias, ssn-s st transducers, T55—T5IE- Weber nstentnmy, 3
Ti'icnpbyrnu films, 5SID-591 wrist, T53-T6IIIl| Weight Ines, fnr knee nstcnarthritis, 333
Tricyclic antidepressants, 419 UltraSntb RC, 533 Weighted rntatinn tests, 233
Trnchanteric bursa, 1431f Uln'asnund Western {intarin and McMaster
Trnchlear dysplasia, 233, 3131‘; 213- artifacts nu, T56 Universities flstenarthritis Index, 43'Tr
214, 663 sbnuldet, T56-T5T Western flntarin Shnulder Instability

"x 16 American Academy at flrthnpaedic Surgenns Drthnpaetlic Ennwledgc Update: Spnrts Medicine 5
 Indss

Index [W951] scams, 5, fi, 2?

Was-stun Itttnts, 534
Wtst bulb glnh: tampcmturcs (WEST),
s33,s34:
Wiles-3:011 signed-tank test, 435
”Wilts: clsssificstipn, 453, 4.55%
Wulff-PsrkinsumWhitE {WW}
syndmme, 566, 5153
Wand classificatiutt, 155t
Wand lamps
cursl [Ed flmnesnence under, 533
disgnnstic use HE, 591
Wrcstl'utg, MESA infsctipns and, SEE
Wrist
differential disgnnsis pf pain, 11215-109
ulttssnutttl pf, TEE-76!]
Wrist sxtsnsipn splints, 95

It
Ksnttgtsfts, 513—529
K-recnnstt'uminn, l
IKE-repair, 515

1!
Tergsstttt Izlltst,I 4E
Y-Knttt, 532
Yputh spurts, spurts psyshnlngists, 554

i!
Eansmin'r, 595
Zune urbisulsris, 11.5I
nflmfltic fractures, El]?

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