4/7/2014

Sports Medicine:
Lower Extremity
& Team Physician

Miller MD, et al. RTP

Wolters Kluwer 2013 COLORADO 2014

Mark D. Miller, MD
S. Ward Casscells Professor
UVA Dept of Orthopaedic Surgery
Team Physician, JMU

Disclosures
• Elsevier/LWW
– Book Royalties
• JBJS
– Deputy Editor
• MRC
– Founder/Director

COLORADO 2014

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Sports Med LE in 2 hours is like…

Sports Knee Sources

• OITE 2004-2013
• AOSSM Self Assessment 1-6
• OSAE 2008/2010
• OKU 9&10
&
• OKU Sports 4
• Core Knowledge Sports
• Sports Medicine &
Arthroscopy Review Text &

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LE Sports Sources

Image sources in this presentation are Originals or are from

Elsevier, Wolters Kluwer, and JBJS; and used with permission
Note: Several images in this talk are from these 2 texts

Sports Medicine

Not Brain Surgery Not Rocket Science

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Sports Knee
Overview
• Anatomy & Biomechanics
• Hx/PE/Imaging
• Meniscus & Cartilage
• Ligaments
• Osteotomy
• Patellofemoral
• Pedi Knee
• Top 10 List

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Knee Anatomy
Neurovascular Supply
• Posterior articular
branch of Posterior
Tibial Nerve –Intra-
articular innervation
• Geniculates have a
rich anastamosis at
the knee
Miller, et al. OSA, Elsevier, 2008

Miller, et al. OSA, Elsevier, 2008

Knee
Anatomy
• ACL
• PCL
• MCL
• LCL
• Posteromedial
Corner
Miller, et al
• Posterolateral OSA, Elsevier, 2008

Corner

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Knee Biomechanics
• Diarthrodial Joint
• Simultaneous Rotation
and Translation
• Articular Cartilage
– Type II Collagen
– Mostly Water
– Increased Water and
Decreased
Proteoglycans with DJD Miller et al Review of Orthopaedics
6th Edition, Elsevier, 2012

ACL: Anatomy and Biomechanics

• Tibia => LFC
• 33 mm x 11 mm
• 2 Bundles:
– AM (tight in flexion)
– PL (tight in extension)
• Middle Geniculate A.

Miller MD, et al Chhabra A, et al JBJS 2006

Primer of Arthroscopy
AM
PL Elsevier, 2010

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PCL Anatomy
• MFC => Tibia sulcus ALB
PMB
• 38 mm x 13 mm
• 2 Bundles (PAL):
– AL (tight in flexion) Lower images from Anderson CJ

– PM (tight in extension) JBJS 2012

• Meniscofemoral Ligs:
– Humphry (anterior) aMFL
– Wrisberg (posterior) pMFL
• Middle Geniculate A.

Knee
Anatomy-MCL
• MFC => Tibia
• Superficial
• Deep VMO SM

MPFL
Origin

Superficial MCL Origin

ME

Superfical MCL
Insertions

LaPrade et al JBJS 2010

Warren LF et al JBJS 1982

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Knee
Anatomy and Biomechanics-LCL

• LFC => Fibula

• Cord-Like
• Tight in Extension
• Capsule’s most
distal extent is just
posterior to the
fibula Laprade et al JBJS 2008 Tria, et al Illustrated Guide to the Knee
Churchill-Livingstone 1992

Knee
Anatomy and Biomechanics
Ligament Properties:

ACL: 2200 N (Anterior)

PCL: 2500 N (Posterior)
MCL: 4000N (Valgus)
LCL: 750N (Varus)

Woo S L-Y, et al. JBJS 2009

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Knee-Anatomy
Posteromedial Corner:
(1) Sartorius
(2) Superficial MCL, POL, SM
(3) Deep MCL

Miller, et al
OSA, Elsevier, 2008

Warren LF et al JBJS 1982

Knee Anatomy
Posterolateral Corner:
Superficial: Biceps,
ITT
Deep: LCL, Popliteus*
(Int Rotates Tibia) Miller, et al

Popliteofibular lig. OSA, Elsevier, 2008

Seebacher JR et al.
JBJS 1979

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Knee
Anatomy and Biomechanics
Patellofemoral Joint:
• Patella increases
moment arm
(Quadriceps)
– Fully engaged @ 40o
• Forces = 3-5 x BW
• Cartilage 5 mm thick
• 2 Facets:
– Medial (Proper & Odd)
Tria, et al Illustrated Guide to the Knee
– Lateral (Longer/Wider) Churchill-Livingstone 1992

• MPFL Key restraint

Miller MD et al Operative Techniques: Sports Knee Surgery, Elsevier, 2008

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Knee
Anatomy and Biomechanics
Meniscus
• Crescent shaped
• 2/3 – ¾ Water
• 20-30% vascularized
– Medial and Lateral
Geniculates
• Medial = C-shaped
• Lateral = Semicircular
• Deepens tibial surface, 2o
stabilizer (PHMM),
nutrition, lubrication

Knee
Anatomy and Biomechanics
Meniscal Biomechanics:
• Longitudinal
(Circumferential) and
Radial fibers
– Type I collagen
• Lateral meniscus 2x
excursion of medial
Tria, et al Illustrated Guide to the Knee
• Attachment @ horns: Churchill-Livingstone 1992

– Lateral: Near ACL

– Medial: Far separated

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Knee
History & Physical Examination
Feature Significance

Pop/swelling ACL
Dashboard PCL
Fall PF Foot PCL
Fall DF Foot Patella
Locking Meniscus
Pain w/ stairs Patella

Knee
History & Physical Examination
Injury Exam
ACL Lachman, Pivot
PCL Post Drawer
Quad Active
MCL Valgus 30o Tria, et al Illustrated Guide to the Knee
Churchill-Livingstone 1992
LCL Varus 30o
PLC ER Asymmetry
Meniscus JLT, McMurray
Patella Apprehension

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ACL
Knee Exam: Lachman

20-30o Flexion:
Reduced => Subluxed

ACL
Knee Exam: Pivot Shift

Subluxed in extension =>

Reduced in flexion (ITB)

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PCL
Knee Exam: Posterior Drawer

70-90o Flexion: Posterior Disp

(*Assess normal Starting Point))

PCL
Knee Exam: Sag

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MCL
Knee Exam: Valgus

30o Flexion: Isolated

0o Flexion: Combined

MCL/PMC
Knee Exam: Slocum

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MCL/PMC
Knee Exam: Slocum (Continued)

LCL
Knee Exam: Varus

(30o Flexion: Isolated)

0o Flexion: Combined

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LCL/PLC
Knee Exam: ER Asymmetry
(Dial)

30o Flexion Only

Isolated PLC ) +/- ACL

LCL/PLC
Knee Exam: ER Asymmetry
(Dial)

90o Flexion: Combined (PCL)

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LCL/PLC & PCL

Knee Exam: Posterolateral
Drawer

LCL/PLC & PCL

Knee Exam: Recurvatum

Knee Hyperextension,
Vaurs and Tibial ER

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Knee--Imaging
Segond: “…lateral chip fracture Adjacent to
the lateral joint line—ACL injured.”

Miller MD, et al. Review of Orthopaedics Elsevier 2012

Finding Significance
Segond Lateral Capsule-ACL
MFC Ca Pellegrini Stieda-MCL
Patella Alta Patellar instability
Fairbanks Post meniscectomy
OCD Lat aspect MFC
Widen/cup Discoid Meniscus

Standing Flexion Weight Bearing PA

Rosenberg View

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Knee
Imaging
Stress Radiographs

• Varus/Valgus:
– MCL/LCL
– Physeal Fractures
• Posterior:
– PCL Measurement

* Knee
Imaging
Patellar Height:
• Blumensaat’s Line
• Insall-Salvati
– LT/LP = 0.8 - 1.2
• Blackburne-Peel
– a/b = 0.6 - 1.0
Miller MD, et al. Review of Orthopaedics Elsevier 2012

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Knee
Imaging
Tibial Tubercle-to-Trochlear
Groove (TT-TG) offset:
• Distance between TG apex
to ATT apex measured
along a line connecting the
posterior femoral condyles
on Axial CT or MRI images
• TT-TG > 20 => TT AMZ
(Fulkerson)

Miller MD et al Operative Techniques: Sports Knee Surgery, Elsevier, 2008

Knee
Imaging
MRI

• Meniscal &
Ligament Tears--
Excellent
• “Bone Bruise”
– Osteochondral
injury
– LFC (Mid 1/3) & LTP
(Post 1/3) with ACL

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MRI

Bucket Handle MMT Bucket Handle LMT ACL with Fx PCL

Knee
Arthroscopy

• Portals: Superior,
Inferior,
Accessory
• PHMM: AL & PM
= Best Miller, et al
OSA, Elsevier, 2008

visualization
• Patellar tracking:
Superior = Best
visualization

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Knee
Meniscal Pathology
Meniscal Tears:
• Most common injury
• Higher risk in ACL-deficient knee
• Medial > Lateral
• Young: Traumatic, peripheral, ACL
• Older: Degenerative tears (PHMM)
• Meniscal Root Tears can lead to
meniscal extrusion
Tria, et al Illustrated Guide to the Knee
Churchill-Livingstone 1992

ISAKOS Classification
Scheme for Meniscal Tears

Knee
Meniscal Pathology
Partial Meniscectomy:
• If Irreparable
• Minimal removal
– DJD Risk proportional to
amount removed
• Thermal => chondral
injury
Scott N, The Knee Mosby (Elsevier) 1994
• MRI False Positives:
– ISD
– AHMM

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Knee
Meniscal Pathology
Meniscal Repair:
• Peripheral vertical tears
– Red-Red/White 1-4cm
• Improved healing with
combined ACL recon
• Healing by inflammatory
cell infiltration
• Techniques: Open, Miller MD, et al. Op Tech Sports Knee Surgery
Outside-in, Inside-out*, All Elsevier 1008

inside
*Vertical Mattress Sutures strongest

Knee
Meniscal Pathology
Meniscal Repair Risks:
Medial: Saphenous N/V, Popliteal vessels
– Sartorial Branch of Saphenous Nerve lies between
the Anterior Border of the Sartorius and the ST-G
– Keep Dissection anterior to the Sartorius
Lateral: Peroneal N, Popliteal vessels
– Keep Dissection anterior to the Biceps

Tria, et al Illustrated Guide to the Knee

Churchill-Livingstone 1992

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Knee
Meniscal Pathology
Meniscal Repair Risks:
Newer Techniques: Breakage, Migration,
Synovitis, Chondral Injury, Dec. strength

Miller MD Op Tech Orthopaedics,

Atlas, Elsevier, 1997

Results of Meniscal Repair

All Inside Repair (New
120
Devices)
110
100
90 Double Vertical
80 Suture
70 Single Vertical Suture
60
50 BioStinger, Horizontal
40 Suture, T-Fix
30 Arrow, Clearfix
20 Screw, Mitek, Staples
10
0
Strength* *Barber & Herbert Arthroscopy 2000;16:613-618

Vertical Mattress stronger than

all rigid devices

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5th Generation ???

• Bioabsorbable
• Strong We’re
• Low Profile Still
• Low Iatrogenic Looking!
Potential
• Efficacious

In the meantime…
If you see this:

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Do This:

Miller MD, et al, RTP Wolters Kluwer 2014

Meniscus
Meniscus Transplantation
• Indications Controversial
– Pain, Swelling, Mechanical
Sx
– Avoid Grade IV Chondrosis
– Mechanical Alignment Key
• Technically Difficult
• Long-term Results Unclear
– Shrinkage/Degeneration
– Proteoglycans decreased and
Water content increased at 6
months

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Meniscus Transplantation
Miller MD, et al, RTP Wolters Kluwer 2014

• Technique
– Medial: Bone Plugs
– Lateral: Bone Bridge
– Peripheral Suture

Meniscus
Meniscus Transplantation

• Second Looks
– Good Healing of
Periphery
– But does it function
normally?

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Knee
Meniscal Pathology
Meniscal Cysts
• Associated with LM
horizontal tears
• Cyst fluid is gel-like
and similar in content
to synovial fluid
• Partial meniscectomy
and arthroscopic
decompression Tria, et al Illustrated Guide to the Knee
Churchill-Livingstone 1992

Knee
Meniscal Pathology
Discoid Meniscus
• Type I - Incomplete
• Type II - Complete
• Type III- Wrisberg
• Treatment:
– Saucerization of
tears
– Repair of
detachments
Miller MD, et al. Surgical Atlas of Sports Medicine
– Observation if ASx Elsevier, 2003

MRI Diagnosis requires 3 or more consecutive 5mm sagittal

images with meniscal continuity (often missed)

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Knee
Osteochondral Lesions
Osteochondritis Dissecans
• Juvenile form (open physes)-
Better prognosis
– Initial management
conservative (Non-weight
bearing 6-12 weeks)
• Most commonly affects
Lateral aspect of MFC
• Pathological changes begin
in subchondral bone
• Operative treatment of loose, Tria, et al Illustrated Guide to the Knee
Churchill-Livingstone 1992
symptomatic, and adult
forms
1. Arthroscopic Drilling
2. “Advanced Procedures”

Knee
Osteochondral Lesions
• Microfracture
• Remove Ca Cart Layer
• Autograft Transfer
• < 2.5 cm
• Autologous Chondrocytes
• 2 Stage/$$$
• Allograft Transfer
Miller MD et al. RTP Wolters Kluwer 2014

Indications: Focal defects without

mirror lesions

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Knee
Osteonecrosis
Atraumatic ON
• Related to Steroids
• Wedge shaped
• Core decompression
SONK
• Subchondral Insufficiency
Fracture
• Cresentric
• May follow scope in older
patients (>55 yo Females)
• Symptomatic treatment is Atraumatic ON SONK
usually successful

Knee
Synovial Lesions
Arthroscopic Synovectomy
• Results similar to open synovectomy
• Useful for RA, PVNS, Hemophilia,
etc.
• Must use Proximal and Posterior
Portals

Miller MD, et al, RTP Wolters Kluwer 2014

Miller MD, et al. Surgical Atlas of Sports Medicine

Elsevier, 2003

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Knee
Synovial Lesions
Plicae
• Medial Plicae most
common
• MFC abrasion
• Responds to resection
• Diagnoses overused
Cruciate Ganglia Miller MD, et al. Surgical Atlas of Sports Medicine
Elsevier, 2003
• Rarely symptomatic

Knee
Ligamentous Injuries
ACL*
• Non-contact pivoting inj
• “Pop”/effusion (70%+)
• Quad avoidance gait
• Exam:
– Lachman
– Pivot Shift (Extension
to flexion; Subluxes @ Miller MD, et al. Surgical Atlas of Sports Medicine
Elsevier, 2003
20-30o of flexion)

*ACL #1 Area of Sports Test ?’s

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Knee
Ligamentous Injuries
• ACL Injury not suitable
for primary repair
– Ruptured ends are
covered by
myofibroblast -like cells
with alpha-smooth
muscle actin
• ACL injuries
commonly associated
with lateral meniscal
tears
– Especially in skiers

Knee
Ligamentous Injuries
ACL Treatment:
• Nonoperative: Low-demand
patients with less laxity
• Operative: Higher demand,
active patients
– Reduces the incidence of
chondral and meniscal injury
• Graft choices:
– PT: Anterior knee pain Miller MD, et al, RTP
Wolters Kluwer 2014
– Hamstrings: Fixation
• Highest Strength &
Stiffness
– Quadriceps
• 1.8 x as thick at the PT
– Allograft
• HIV Risk 1:1 Million

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ACL Grafts
• Preconditioning of grafts can reduce stress
relaxation up to 50%

ACL Allografts
• Radiation of >3 Mrads required to kill HIV
– Affects structural and mechanical properties
• Freezing destroys cells
– Doesn’t adversely affect grafts
• Cryopreservation
– Chemicals used to remove cellular
water and freezing rate is controlled
to prevent ice crystal formation
• Delayed Incorporation in Animal Studies
– Loss of cellular DNA by 4 weeks
– Similar process, just delayed
• Infection
– Clostridium
– HIV (1 : 1.6 Million)

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ACL

• Late Arthritis related to

meniscal integrity
• ACL Post-op Rehab:
– ROM (extension)
• Beware with medial
sided surgery!
– Avoid isokinetic quad
strengthening (0-30o)
during early rehab
– Immediate weight-
bearing reduces
patellofemoral pain

Knee
Ligamentous Injuries
ACL Reconstruction Complications:
• Tunnel Placement*
• Arthrofibrosis (Acute)
– Patella Baja
• Hardware/Fixation
– Early cause of failure
• First 6 weeks
• Avoid IF Screw divergence >15o
• Recurrent Injury
• Missed concurrent injuries
*Most common cause of failure:
Technical Error

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ACL Complications—LOM
• Pre-op
– ROM, Effusion, Quad
tone, Gait
– MCL/MPFL Injury
• Intra-op
– (Ant) Tunnels & Tension
• Post-op
– Hemarthrosis (Ice) Miller MD, et al, RTP
Wolters Kluwer 2014
– Early LOM (Extension!) Towel under heel!
• LOA/MUA after 6-12
weeks if PT and
serial splinting fails
– RSD (CRPS)

ACL Complications--Fractures

• Most Fractures occur 8-

12 weeks post-op

• Reducing incidence:
– Smaller Saw Blade*
– Cutting Undersurface
– Drill holes at corners
– Less Rectangular graft
– Bone graft defects
Miller MD, et al Arthroscopy 1999 999

Viola et al, Arthroscopy 1999

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ACL Complications
Hamstring Harvest
• Graft Amputation
• Saphenous Nerve Injury
– Saphenous Nerve
passes superficial to
gracilis tendon (between
gracilis and Sartorius) at
the postero-medial joint
line
• ? Loss of Terminal
flexion strength

Knee
Ligamentous Injuries
ACL Reconstruction
Complications:
• Hemarthrosis
– Aspirate
• Tunnel Osteolysis
– Observe
• Cyclops Lesion
– Fibroproliferative tissue
blocks extension
– “Click” at terminal
extension

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*
Knee
ACL Tunnel Placement
• Tunnel Anterior =>
– Strain (Tight) in Flexion
• Tunnel Posterior =>
– Strain (Tight) in Extension

Miller MD, et al, Review of Orthopaedics 6

Elsevier, 2012

ACL Tunnel Placement

Roof Impingement

• Tibial tunnel must be

posterior to
Blumenstaat’s line on
hyperextension lateral
radiograph (Howell)
• “Roofplasty” not
necessary if tunnel
placement is correct

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ACL Tunnel Placement

Technical Considerations
• New Emphasis on
“Anatomic” Reconstruction
• Placement of twice as
much tendon in tunnels
results in >50% increases
in strength at six weeks
(Greis AJSM 2001)

ACL Femoral Tunnel

• ACL Outcome related to correction of

Pivot Shift
• 2 Tunnels?
– Good in Lab
– Clinically Unproven
• More Horizontal Placement
– 10 to 10:30 O’Clock
– Improved Clinical Results
– May result in shorter tunnels

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ACL Tunnels

• “Anatomic” (Fu)
– DB: In center of
Bundles
– SB: Between
Bundles

ACL “Shrinkage”

• RF “treatment” of 18
Canine ACL’s
resulted in 100%
ACL rupture @ 8
weeks post-tx!*

*Lopez and Markel Am J Sports

Med 2003, 31:164-167.

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ACL Injury Prevention

– Skier Training-Vermont
• Beneficial for Elite Skiers, not Novices
– Female Athlete
• Neuromuscular training/plyometrics beneficial
• Focuses on Improving Balance & Strengthening
Hamstrings
– ACL Bracing—only beneficial in skiers

Valgus
Hyper-
extension

Female Athlete ACL Injury

4.5 x more common than Men!

COLA5A1 gene protective.
Risk Factors:
• Femoral notch width
• Generalized ligament laxity
• Medial knee collapse
• Increased knee laxity

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Knee
Ligamentous Injuries

PCL Injury:
• MOI:
– Blow to tibia (PF foot)
– Hyperflexion/extension
• PE (Displaced in flexion)
– Posterior Drawer
– Quadriceps Active
– Reverse Pivot Shift

Knee
Ligamentous Injuries
PCL Injury Treatment:
• Bony Avulsion
– ORIF
• Isolated PCL
– Nonoperative
• Favored by some surgeons
if Posterior Drawer
improves with Internal
Rotation
• Quad Rehab
• Extension Brace for 2-4
wks for Grade III injuries
– Late Chondrosis (MFC and Miller MD, et al, RTP Wolters Kluwer 2014
Patella)
• Combined Injuries
– Reconstruction

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Knee
Ligamentous Injuries
PCL Reconstructions:
• Arthroscopic
(Transtibial)
• Tibial Inlay
• Two-bundle
– Anterolateral graft
tensioned in 90o and
posteromedial tensioned
in 30o of flexion
Post-op:
• Immobilize in extension,
protect vs gravity, Quad
rehabilitation

PCL Techniques
Biomechanics
Inlay Technique Results
In Less Graft Attrition and
Failure

Two-Bundle Technique
Results in Better Stability
In Extension and Flexion!
[Not proven in vivo]

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Knee
Ligamentous Injuries
MCL Injury:
• MOI: Valgus contact
• PE: Valgus opening
– 30o - Isolated
– 0o - Combined
• Tx: Hinged knee brace
6-8 weeks
• Delay ACL reconstruction in
combined ACL-MCL Injuries
• Proximal injuries (Femur) heal
Miller MD, et al, RTP Wolters Kluwer 2014
better than distal (Tibial)
injuries

Knee
Ligamentous Injuries
LCL Injury (Rare):
• MOI: Varus contact
• PE: Varus opening L
– 30o Isolated C
– 0o L
Combined/Severe
• Tx:
– Isolated - Brace
– Combined - Repair/
Reconstruction

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Knee
Ligamentous Injuries
Posterolateral Rotatory
Posterolateral Corner: Instability (PLRI)—Lateral Tibial
• MOI:Rotational injury plateau moves posterior to the
– Often combined (PCL > lateral femoral condyle
ACL)
– If missed, may be late
cause of failure of ACL/PCL
reconstruction
• PE:
– ER Asymmetry
• 30o Only = Isolated
• 30o & 90o = PCL/PLC
– ER Recurvatum
– Posterolateral Drawer

Knee
Ligamentous Injuries
Posterolateral Corner:
• Acute Treatment:
– Primary repair +/-
supplementation
– Best Results
• Chronic Treatment:
– Reconstruction
• Popliteofibular lig
Miller MD, et al, RTP Wolters Kluwer 2014

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Knee
Ligamentous Injuries
Multiple Lig Injury:
• Rule out N/V Injury
– Popliteal A/Peroneal N
– Non-Invasive
studies/Arteriogram
• Mandatory if absent/diminished
pulses or ABI < 0.9
– Incidence 30-50%
• Named by direction of tibial
displacement
– Ant>Post>Lateral
• Treatment: Miller MD et al.
Review of Orthopaedics
– Reduction (traction) 6th Edition Elsevier 2012

– Reconstruction

Classification
• KDI: ACL, MCL and/or LCL; PCL intact
PCL, MCL and/or LCL; ACL intact
• KDII: ACL, PCL; MCL, LCL intact
• KDIII-M: ACL, PCL, MCL; LCL intact
• KDIII-L: ACL, PCL, LCL; MCL intact
• KDIV: ACL, PCL, MCL, LCL
• KDV: Associated peri-articular fracture

• Modifiers: C – vascular injury, N – nerve injury

~Schenck ICL 1994

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Knee
Proximal Tib-Fib Dislocation

• MOI: Fall on flexed

adducted knee
• Anterolateral
common
• Closed reduction
– Flexion - Pressure
• Post-operative
– Immobilize in Ext
Miller MD, et al, RTP Wolters Kluwer 2014
• Chronic/Recurrent
– Fib Head Resection

Proximal Tib-Fib Cyst

• Can compress
Peroneal Nerve
• Treatement:
Decompression
• Consider Tib-Fib fusion
if it recurs because of
high rate of recurrence
with repeat excision

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Knee
Bioabsorbable Materials

• Polyglycolic Acid (PGA)

– Absorbs in weeks
• Polydioxadone (PDS)
– Absorbs in months
• Poly-L-Lactide (PLLA)
– Absorbs in years
• Hybrids

Knee Osteotomy

• Best Indication is for early

isolated arthritis
• Also indicated for
ligamentous instability
with a (varus) thrust
• Precise technique
required
• May be combined with
PLC reconstruction in
patients with increased
ER and varus

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Why Medial Opening?

• Single cut—less demanding, more
precise
• Easier intraoperative correction
• Sagittal plane correction
• Does not violate anterior leg
compartment
• Reduced patellar baja
• Reduced LCL laxity
• Reduced Tib-Fib/
Peroneal Nerve injury

*
Measurements
• 45o PA Flexion-weight-bearing radiographs
– Extent of arthrosis
– Truly only one compartment affected?
• Lateral radiographs
– Sagittal alignment (normal 5-10o)
• Patellofemoral radiographs
– Significant Patellar arthrosis
• Double-Standing hip-ankle radiograph
– Mechanical axis—normally slightly Medial
– Anatomical axis—normally 5o to 7o
The Joint Line is normally oriented
3o varus relative to the Mechanical Axis

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Planned Correction

• 62% across the tibial

plateau
• Mechanical axis
transferred into the
unaffected
compartment

Planned Correction
Sagittal Plane
Increase Tibial Slope
• Increases Anterior Tibial Translation
• Good for PCL deficiency,
• Bad for ACL deficiency
• Put the plate more anteriorly
Decrease Tibial Slope
• Increases Posterior Tibial Translation
• Good for ACL deficiency
• Bad for PCL deficiency Miller MD, et al, RTP Wolters Kluwer 2014

• Put the plate more posterioly

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Maybe you should have paid more

attention in high school geometry…

Unicompartmental Arthroplasty

• Mobile –Bearing Uni (e.g.

The Oxford Knee) is
contra-indicated with ACL
deficiency.

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Knee
Overuse Injuries
• Patella tendinosis
– Degenerative not
inflammatory
– Pain @ inf border
– Eccentric Exercise for Rehab
• Quadriceps Tendintis
– Pain superior
– Symptomatic treatment
• Prepatellar bursitis
– Extra-articular
– Aspirate in Wrestlers to rule
out infection

Knee
ITB Syndrome
• ITB Syndrome
– Hx: Hill running
– Associated with pronated feet,
varus alignment and prominent
lateral femoral epicondyle
– PE: Ober Test
• Patient on side with
symptomatic leg up
• ABD-Ext-ADD
Treatment:
• Stretch/Strengthening
• Surgical Excision/Z-
lengthening for refractory
cases

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Knee
RSD/Complex Regional Pain
Syndrome
• Hx
– Disproportionate pain
• Dx
– Skin changes
– Osteopenia
• Tx
– Sympathetic Block
– Alpha Blocking
Agents
• Phenoxybenzamine

Patellofemoral
• Alignment Exam
– Q-angle (Supine, Sitting)
• Measures lateral displacement
of the tibial tubercle with
respect to the femoral sulcus
• Position
• Height
• Mobility
– Superior/Inferior
– Medial/Lateral
• Glide (Quadrants)
• Tilt
• Patellar Apprehension Test

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Patellofemoral Imaging

-8o

Miller MD et al Operative Techniques: Sports Knee Surgery, Elsevier, 2008

Knee
Extensor Injuries
• Quadriceps rupture
– Patients > 40 yo Miller, et al. Review 6

– Delayed reconstruction leads

to worse results
• Patella tendon rupture
– Patients < 40 yo
• Patella fracture
– ORIF if displaced
– Debride and PT repair for
comminuted distal pole
fractures Tria, et al Illustrated Guide to the Knee
Churchill-Livingstone 1992
• 1o Patella dislocation
– MPFL primary restraint
– Affects future stability
– Medial patellar facet articular
cartilage injury up to 95%!

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Knee Extensor Tendon

Ruptures

Miller MD, et al, RTP Wolters Kluwer 2014

Knee
• Exam:Recurrent Patellar Instability
– Apprehension
• Radiographs
– Sulcus, Congruence
– Patella Alta
– Trochlear Dysplasia
• Risk Factors: Prior Instability, ,
young, malalignment, MPFL injury
• Treatment
– Rehabilitation
– Proximal/Distal Realignment
• Superomedial arthrosis is a
contraindication for a Fulkerson
• Overshifting/Medial reefing can result
in Iatrogenic Medial Instability
• Medialization alone can lead to
increased PF contact forces

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Proximal: MPFL Reconstruction

Miller MD, et al, RTP

Wolters Kluwer 2014

Distal: Anteromedialization of the Tibial Tubercle

Knee
Lateral Patellar Compression
• Exam:
– Tight Lateral Retinaculum
• Radiographs
– Tilt, No Chondrosis
• Treatment
– Rehabilitation
– Lateral Release
• Rarely Indicated!
• Patellar tilt < 5o
• Excessive Superior
extension of lateral
release can result in
medial subluxation of the
patella

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Knee
Patellar Chondrosis
• Exam:
– Compression
• Radiographs
– Chondrosis
• Treatment
– Rehabilitation
– Tubercle Elevation Tria, et al Illustrated Guide to the Knee
• Contraindicated with Churchill-Livingstone 1992

proximal medial
arthrosis

Knee
Patellofemoral Syndrome
• Etiology:
– Muscle Imbalance
• History:
– Pain with stairs
– Theater sign
• Exam:
– Compression
• Treatment
– Rehabilitation Tria, et al Illustrated Guide to the Knee
• Closed chain short arc Churchill-Livingstone 1992
quadriceps exercises

“Miserable triad” = Femoral Anteversion,

Genu Valgum, External Tibal Torsion

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Knee
Pediatric Disorders
Traction Apophysitis
• Osgood-Schlatters
– Tibial Tubercle
• Sinding-Larsen-
Johansson
– Inferior patella
Treatment:
• Rest/activity mod Tria, et al Illustrated Guide to the Knee
Churchill-Livingstone 1992
• NSAIDs, Quad
Stretch

Knee
Pediatric Disorders
Physeal Injuries
• Salter Harris Class
– 1. SH II Distal
Femur
• Stress radiographs
(or MRI)
• ORIF displaced fxs Tria, et al Illustrated Guide to the Knee
Churchill-Livingstone 1992

• Late effects
– Growth problems

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Knee
Pediatric Disorders
Ligament Injuries
• Displaced avulsion fractures
(Medial Tibial Eminence
[spine])
– ORIF
– Lateral Meniscus/Inter-meniscal
ligament may block reduction
Tria, et al Illustrated Guide to the Knee
– May have interstitial injury Churchill-Livingstone 1992

• Midsubstance injury
– Physeal sparing (esp distal
femur); soft tissue graft for
Tanner 1/2 and pre-menarchal
females
– Avoid crossing Physes with bone
or hardware!

Patella Sleeve Fracture

• High index of
suspicion required
• May have no
associated fracture
• Obtain MRI if patient
is unable to perform
a straight leg raise

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Knee
Pediatric Disorders
Other “Problems”
• Popliteal cyst
– Spontaneously
resolves
• Bipartite Patella
– Male >> Female
– Bilaterality uncommon
– Observe
– Bone Scan if Acute
– Role for lateral
release?

Knee Pain
Pediatric Disorders

• Hip pain (SCFE) can

present as knee pain
• Other (missed)
pediatric hip conditions
can present as knee
pain well into
adulthood

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Top 10 Lists
…and you thought this was David
Letterman’s idea?

Knee TOP 10
1. ACL: MOI, Exam, Bundles, Imaging, Tunnels, Prevention
2. Meniscus: Exam, Repair, Discoid, Meniscal Cysts
3. PCL: MOI, Exam, Bundles, Imaging, Non Op Tx, Contact
Pressures
4. PLC/MCL/MLI: Exam, N-V Risk, Recon vs. Repair
5. OCD: Location, Open vs Closed Physis, MFx Type I Collagen
6. Patellar Instability: MPFL, Cartilage Injury Pattern
7. Pedi Knee: Tib Em Avulsion, Stress X-Rays, Popliteal Cyst
8. Rehab: Avoid Open Chain Short Arc, ROM early
9. Overuse Injuries: ITB (Ober)
10.Anatomy: Popliteus/LCL insertion

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Knee Questions

Oh NO!

Knee

• “Wrong” answers:
– Indiscriminate ordering of MRI’s
– Steroid injections
– “Diagnostic” arthroscopy
– ACL “repair”/Acute ACL reconstruction
– Initial operative treatment of PCL injuries
– Initial operative treatment of PF/overuse
problems

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Knee
• K1 Which of the following statements best describes the tension in the
different components of the posterior cruciate ligament when the knee
is taken from full extension to 90 degrees of flexion?

• 1- Both the AL and PM bands are isometric and do not change

• 2- AL band is lax and becomes tight; PM is tight and becomes lax
• 3- AL is tight and becomes lax; PM is lax and becomes tight
• 4- Both the AL and PM bands are lax and become tight
• 5- Both the AL and PM bands are tight and become lax

Knee
• K2 Which of the following ligaments provides the major static
restraint to lateral patellar displacement?

• 1- Medial patellotibial
• 2- Medial patellofemoral
• 3- Medial patellomeniscal
• 4- Lateral patellofemoral
• 5- Lateral patellotibial

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Knee
• K3 A college football player twists his knee when he attempts to tackle
an oncoming player. Examination reveals no medial lateral laxity or
jointline tenderness. The anterior and posterior drawer tests and pivot
shift results are negative; however, the Lachman test result is positive.
What is the most likely diagnosis?

• 1- Minor knee sprain

• 2- Medial collateral ligament injury
• 3- Lateral collateral ligament injury
• 4- Anterior cruciate ligament injury
• 5- Posterior cruciate ligament injury

Knee
• K4 The lateral fragment of bone (Segond fracture) associated with an
injury of the anterior cruciate ligament is the result of an avulsion of
the

• 1- oblique popliteal ligament

• 2- lateral capsule
• 3- popliteal tendon
• 4- fibular collateral ligament
• 5- posterior oblique ligament

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Knee
• K5 A 13-year-old quarterback feels a “pop” in his knee while being
tackled. Radiographs of the knee and results of a Lachman’s test are
normal. Examination reveals tenderness over the distal femoral physis.
To help confirm the diagnosis, management should first include

• 1- an MRI scan
• 2- arthroscopic examination
• 3- AP and frog-leg radiographs of the pelvis and hips
• 4- varus and valgus stress radiographs of the knee
• 5- physical examination of the knee under anesthesia

Knee
• K6 A patient sustains a tear of the ACL, and an MRI reveals a
bone contusion. Signal changes as the result of this injury would
most likely be located at the

• 1- posterior 1/3 of the LFC and middle 1/3 of the LTP

• 2- posterior 1/3 of the LFC and anterior 1/3 of the LTP
• 3- anterior 1/3 of the LFC and posterior 1/3 of the MTP
• 4- middle 1/3 of the MFC and posterior 1/3 of the MTP
• 5- middle 1/3 of the LFC and posterior 1/3 of the LTP

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Knee
• K7 What part of the meniscus has the highest incidence of
degenerative tears?

• 1- Anterior horn of the medial meniscus

• 2- Anterior horn of the lateral meniscus
• 3- Posterior horn of the lateral meniscus
• 4- Posterior horn of the medial meniscus
• 5- Middle and posterior horns of the lateral meniscus

Knee
• K8 Successful healing of a meniscal repair is most likely associated
with which of the following tear patterns?

• 1- Radial tear
• 2- Parrot-beak tear
• 3- Vertical tear in the “red-red” zone
• 4- Vertical tear in the “red-white” zone
• 5- Vertical tear in the “white-white” zone

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Knee
• K9 Palpable jointline cysts in the knee are most commonly associated
with

• 1- Baker’s cyst
• 2- medial meniscus tears
• 3- lateral meniscus tears
• 4- congenital discoid lateral meniscus
• 5- anterior cruciate ligament and meniscal tears

Knee
• K10 Osteochondritis dissecans of the knee most commonly involves
what structure?

• 1- Medial tibial plateau

• 2- Lateral tibial plateau
• 3- Patella
• 4- Medial femoral condyle
• 5- Lateral femoral condyle

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Knee
• K11 A 13-year-old boy complains of knee pain and swelling
following training lessons for ski racing for the past six months. MRI
demonstrates an OCD lesion with open physes. The only abnormal
finding on physical examination is an effusion. Management should
consist of

• 1- cast immobilization for 6 weeks

• 2- activity modification and re-evaluation in 2 months
• 3- internal fixation with or without bone grafting
• 4- retrograde drilling of the defect without articular cartilage
penetration
• 5- drilling of the defect directly through the articular cartilage

Knee
• K12 A 20-year-old football player reports hearing a “pop” in his knee
as a result of a noncontact deceleration injury. Examination 24 hours
later reveals a large effusion. The incidence of a rupture of the anterior
cruciate ligament in this situation is closest to

• 1-15%
• 2-30%
• 3-70%
• 4-90%
• 5-95%

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Knee
• K13 What type of gait pattern characterizes the patient with an anterior
cruciate ligament-deficient knee?

• 1- Normal biphasic flexion-extension moment

• 2- Quadriceps avoidance gait
• 3- Hamstring avoidance gait
• 4- Prolonged stance phase on the involved leg
• 5- Prolonged swing phase on the involved leg

Knee
• K14 An 18-year-old high school football player injures his knee while
decelerating and pivoting to throw a ball. Hemarthrosis develops
immediately after the injury. Examination shows a large effusion, a
15- to 90-degree range of motion, a 2+ Lachman test result, and no
jointline tenderness. Treatment should consist of

• 1- acute ACL repair

• 2- acute ACL reconstruction using autogenous graft
• 3- acute ACL reconstruction using autogenous graft and a LAD
• 4- ACL repair when ROM has returned to normal
• 5- ACL reconstruction with autogenous graft when ROM
has returned to normal

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Knee
• K15 Physical examination of a high school soccer player who sustains
a knee ligament injury reveals grade III tears of the anterior cruciate
and medial collateral ligaments. In addition, a MRI scan reveals a
lateral meniscal injury. Delaying anterior cruciate ligament surgery
until the patient has full, pain-free range of motion will decrease the
risk of:

• 1- patellar chondromalacia
• 2-failure of meniscus repair
• 3-arthrofibrosis
• 4-varus-valgus instability
• 5-anteroposterior instability

Knee
• K16 Which of the following mechanisms is most likely to result in
graft failure 4 weeks after anterior cruciate ligament reconstruction
with a patellar tendon graft?

• 1- Loss of fixation
• 2- Midsubstance graft rupture
• 3- Notch impingement
• 4- Stretching of the graft
• 5- Tear at the bone-tendon interface

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Knee
• K17 A 23-year-old football player sustains a hyperflexion injury to the
knee, reports feeling a “pop,” and is then unable to bear weight. A
hemarthrosis develops within 1 hour. Which of the following
ligaments has most likely been damaged?

• 1- Medial collateral
• 2- Posterolateral complex
• 3- Posterior cruciate
• 4- Anterior cruciate
• 5- Anterior and posterior cruciate

Knee
• K18 Posterior cruciate insufficiency diagnosed using the quadriceps
active test is confirmed with tibial translation

• 1- anteriorly at 20 to 30 degrees of flexion

• 2- anteriorly at 70 to 90 degrees of flexion
• 3- posteriorly at 20 to 30 degrees of flexion
• 4- posteriorly at 70 to 90 degrees of flexion
• 5- anteriorly with the knee in full extension

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Knee
• K19 Which of the following best describes the relationship of the tibia
to the femur during a positive reverse pivot shift?

• 1- Tibia reduced with flexion and subluxates posteriorly in extension

• 2- Tibia reduced with flexion and subluxates anteriorly in extension
• 3- Tibia reduced with flexion and fibula subluxates posteriorly in knee
extension
• 4- Tibia subluxated posteriorly with flexion and reduces in extension
• 5- Tibia subluxated anteriorly with flexion and reduces in extension

Knee
• K20 Examination of a 25-year-old man who has knee pain after a
motorcycle accident reveals an effusion, normal stability to varus/
valgus stress, a negative Lachman test, and a grade III posterior
drawer. Radiographs demonstrate a bony piece off the posterior
aspect of the tibia. Treatment should consist of

• 1- Repair of the injured structures

• 2- Posterior cruciate reconstruction with patellar tendon graft
• 3- Immobilization for 4 weeks
• 4- Physical therapy focused on quadriceps strengthening and ROM
• 5- Diagnostic arthroscopy followed by rehabilitation

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Knee
• K21 A 32-year-old man has swelling of the knee as a result of falling
with the knee flexed and his foot in plantar flexion. A Lachman’s test
reveals an apparent increase in anterior translation. Passive external
tibial rotation at 30 degrees and 90 degrees is equal to the contralateral
side, and the quadriceps active test is positive on the affected side. The
neurovascular exam is normal. Treatment should consist of

• 1- an anterior cruciate functional knee brace

• 2- a physical therapy program
• 3- reconstruction of the PCL and posterolateral corner
• 4- reconstruction of the PCL
• 5- reconstruction of the ACL

Knee
• K22 Examination of a 27-year-old man who injured his knee playing
soccer shows full range of motion, no jointline tenderness, negative
Lachman and anterior drawer tests, but a positive grade I posterior
drawer test result. Radiographs and signs of posterolateral instability
are negative. Initial management should consist of

• 1- primary posterior cruciate ligament repair

• 2- rehabilitation, with emphasis on quadriceps strengthening
• 3- rehabilitation, with emphasis on hamstring strengthening
• 4- reconstruction of the PCL using an autogenous patellar tendon
• 5- reconstruction of the PCL using an autogenous
hamstring tendon

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Knee
• K23 Cadaver studies show that alteration in joint kinematics following
posterior cruciate ligament sectioning leads to

• 1- increased contact pressures in all three compartments of the knee

• 2- increased contact pressures in the medial and patellofemoral
compartments
• 3- increased contact pressures in the lateral and patellofemoral
compartments
• 4- decreased contact pressure in the patellofemoral compartment, but
increased contact pressures in the medial compartment
• 5- decreased contact pressure in the patellofemoral compartment,
but increased contact pressure in the lateral compartment

Knee
• K24 Treatment to minimize posterior sag following posterior cruciate
ligament reconstruction consists of immobilization at which of the
following flexion angles?

• 1- 0 degrees
• 2- 30 degrees
• 3- 45 degrees
• 4- 70 degrees
• 5- 90 degrees

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Knee
• K25 Which of the following findings on physical examination best
indicates isolated posterolateral instability of the knee?

• 1- Reverse pivot shift

• 2- Positive Lachman test result
• 3- Positive quadriceps active test result
• 4- Increased external rotation of the foot relative to the contralateral
side at 30 degrees of knee flexion only
• 5- Increased external rotation of the foot relative to the contralateral
side at both 30 and 90 degrees of knee flexion

Knee
• K26 A 25-year-old woman who sustains a direct blow to the
anteromedial aspect of her leg while playing basketball has immediate
pain and cannot walk. Examination of the knee reveals an increase in
posterior translation and external rotation at 90 degrees of flexion. At
30 degrees of flexion, posterior translation and external rotation
decrease. Radiographs are normal.Which of the following structures
are injured?

• 1- Posterolateral complex
• 2- Posterior cruciate ligament
• 3- Lateral collateral ligament
• 4- Posterior cruciate ligament and posterolateral complex
• 5- Posterior cruciate ligament and medial collateral ligament

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Knee
• K27 A 25-year-old man is struck by a motor vehicle and sustains an
injury to the right lower extremity. Radiographs show a posterior
dislocation of the knee; however, examination reveals that the limb is
neurologically intact. Initial management of the limb should include

• 1- application of an above-knee splint

• 2- application of an external fixator
• 3- an arteriogram
• 4- closed reduction of the knee dislocation
• 5- open reduction of the knee dislocation

Knee
• K28 The incidence of vascular injury after an anterior knee dislocation
is

• 1- less than 5%
• 2- 10 to 25%
• 3- 30 to 50%
• 4- 60 to 80%
• 5- greater than 95%

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Knee
• K29 A 26-year-old marathon runner reports lateral knee pain after hill
training. Examination reveals no effusion; and results of Ober’s test
are positive. What is the most likely diagnosis?

• 1- Lateral meniscal tear

• 2- Popliteus tenosynovitis
• 3- Iliotibial band friction syndrome
• 4- Peroneal nerve entrapment
• 5- Biceps tendinitis

Knee
• K30 A middle-aged woman who runs about 30 miles weekly on hilly
terrain is evaluated for a several months’ history of lateral knee pain
that has progressively worsened. She has pain with weightbearing on
her flexed knee and complains of deep lateral knee pain with tibial
rotation. Exam confirms diffuse lateral pain and no ligamentous
instability. Radiographs are normal. The physician should recommend

• 1- a lateral heel wedge

• 2- arthroscopy
• 3- neutral mold running orthotics
• 4- injection of steroid into the iliotibial band
• 5- a stretching and strengthening program

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Knee
• K31 What is the most common clinical indicator of reflex sympathetic
dystrophy of the knee?

• 1- Effusion
• 2- Muscle atrophy
• 3- Atrophic hair changes
• 4- Disproportionate pain
• 5- Decreased range of motion

Knee
• K32 A 38-year-old woman was treated surgically for a traverse
patellar fracture 4 months ago. The fracture is healed and the hardware
is intact; however, she now reports severe diffuse pain. Although she
has gained 60o of flexion soon after surgery, and her pain was initially
tolerable, she now has continuous and severe searing pain. Exam
reveals that the knee is cool to touch with a small effusion.
Radiographs show osteopenia. Management should consist of

• 1- arthroscopic lysis of adhesions

• 2- arthroscopic irrigation and debridement
• 3- ionophoresis
• 4- a sympathetic block
• 5- neuroma resection

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Knee
• K33 What is the most appropriate indication for lateral retinacular
release in the knee?

• 1- Diffuse knee pain following arthroscopy

• 2- Anterior knee pain following physiotherapy
• 3- Acute patellar dislocation associated with an increased Q angle
• 4- Lateral patellar compression syndrome following physiotherapy and
associated lateral patellar subluxation
• 5- Lateral patellar compression syndrome following physiotherapy and
associated lateral patellar tilt

Knee
• K34 A 21-year-old woman has had anterior knee pain for the past 4
weeks that worsens when she descends stairs and squats. Examination
shows patellar apprehension and medial facet tenderness; however,
there is minimal effusion, full range of motion, no jointline tenderness,
and stable ligaments. Treatment should include

• 1- lateral retinacular release

• 2- patellar tendon realignment
• 3- arthroscopic debridement of chondromalacia
• 4- short arc open chain quadriceps exercises
• 5- short arc closed chain quadriceps exercises

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Knee
• K35 A 6-year-old girl has an area of painless swelling in the medial
popliteal fossa that is 4 cm in diameter. Aspiration reveals the
swelling to be consistent with a popliteal Baker’s cyst, and the cyst
disappears following aspiration. Three months later the cyst recurs but
is still painless. What is the appropriate treatment at this time?

• 1- Excision
• 2- Observation
• 3- Repeat aspiration
• 4- Aspiration and steroid injection
• 5- Aspiration and phenol injection

Knee-Answers
K1 2 K7 4 K13 2 K19 4 K25 4 K31 4
K2 2 K8 3 K14 5 K20 1 K26 4 K32 4
K3 4 K9 3 K15 3 K21 2 K27 4 K33 5
K4 2 K10 4 K16 1 K22 2 K28 3 K34 5
K5 4 K11 2 K17 3 K23 2 K29 3 K35 2
K6 5 K12 3 K18 2 K24 1 K30 5

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OK, Hang in there…

There’s more to follow

Lower Extremity

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Lower Extremity
Athletic Pubalgia
• Lower Abdominal/ Inguinal
pain at extremes of exertion
– Abdominal Hyperextention
– Thigh Hyperabduction
• Males >> Females
• PE
– Adductor Longus
– Pain with Adduction
– Pain with Valsalva/situps
• Tx
– Conservative
– Pelvic Floor Repair
– Adductor/Rectus Recession

• Sports Hernia Groin Groans

– Groin pain with heavy weight training
• Localized pain with “crunches”
– Adductor tightness MOI for “Athletic Pubalgia”
– Fascial Defect Is Extension-Abduction
– Imaging not helpful
– Hernia “Repair”
– Role for Endoscopy?
• Rectus Femoris tightness
– Modified Thomas Test
• Adductor Strain
– Common in Hockey
– Adduction/Abduction < 80%
• Osteitis Pubis
– Adductor Longus Inflammation
– Gait Disturbance
– Self Limited

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Sports Hernia Repair

Bulge produces pressure on nerve
Nerve resected in 20%

Lower Extremity
Snapping Hip (Coxa Saltans)
• External
– ITT over GT
– Dx: Snapping with Hip
adduction and Knee extension
– Tx: Conservative; Z-Plasty
• Internal
– Commonly occurs in ballet
dancers
– Extend hip from FABER
– Iliopsoas (Bursogram or
Ultrasound)
– Tx: Conservative; Lengthening
• Intra-articular
– Labrum, Loose body

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Lower Extremity
Other Hip Disorders
• Hip Dislocation/ Subluxation
– 90% Posterior
– Look for posterior acetabular
fracture on obturator oblique
– 10-20% Incidence of Osteonecrosis
• Greater Trochanteric Bursitis
– 60% long-term relief with steroid
injection
• Hip Osteoarthritis
– Common in Runners
– Loss of Int Rotation
• Hip Pointer
– Iliac Wing Contusion—Sx Treatment

Lower Extremity
• Indications
Hip Arthroscopy
Biggest complications related to traction
– Loose bodies
– Labral tears
• Inc with acetabular dysplasia
• “Catching” sensation
• Sx relieved with I-A injection
• Arthro-MRI helpful
– Synovitis
• Positioning
– Lat Decub or Supine
• Portals
– Ant and Post to GT
• Anterolateral—SGN Risk
• Posterolateral—Sciatic N Risk
– Increased risk with hip Ext Rot
– Anterior (LFC N > Femoral N)

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Hip Arthroscopy
Compartments:
• Central
– Intra-articular
• Peripheral
– Femoral Neck
• Lateral
– Peritrochanteric

Femoral Acetabular Impingement (FAI)

Earliest Exam Finding is loss of FIR

• Pincer Type
– Anterior Acetabular impingment
– Anterior Acetabular buildup or
acetabular retroversion
– Cross-over/Posterior wall signs
– Excise overhanging bone
• Cam Type
– Anterior femoral head/neck
– Bony buildup or posterior offset
– Soft tissue debridement/careful
bony resculpting of head/neck of
femur
• Combined (Most Common)

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FAI Imaging
• AP
– Pistol Grip
– Acetabular Shape/X-Over

• Lateral/Axial
– Types of Impingment

• False Profile View

– Assess Anterior Femoral
Head Coverage

FAI Treatment
• Cam:
– Femoral “Osteoplasty”

Open Arthroscopic

• Pincer:
– “Acetabuloplasty” &
Labral Repair

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Lower Extremity
Stress Fractures
• Overuse/Insidious
– “Crack Propogation”
• Bone Scan/MRI
• Cross-Training
• Problem fractures (Tension):
– Femoral Neck (MRI)
– Femur
• Fulcrum Test
– Anterior Tibia
• MRI Correlates with Sx
• Dreaded Black Line=>IM Nail
– Tarsal Navicular
• CT; NWB
• ORIF Linear Fractures Tibia #1, Metatarsals #2

Stress Fracture Treatment

• Standard Answer (unless problem fracture):
– Restricted weight bearing until the pain
resolves (4-6 weeks), followed by a slow
return to play

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Lower Extremity
“Shin Splints”

Medial Tibial Stress Syndrome (MTSS):

• 10-15% of Running Injuries
• Distal/Posteromedial
• Pain decreases with running
• Foot Pronation
• Diffuse Longitudinal Uptake in Blood
Pool Phase on Bone Scan
Anterior Tibial Stress Syndrome
• Runners w/ decreased shock
absorption

Lower Extremity
Exertional Compartment Syndrome
• Onset with exercise
• Pressure Measurement
– Resting > 15 mm Hg
– >30 mm Hg 1 minute after exercise
– >20 mm Hg 5 minutes after exercise
• Treatment
– Conservative
– Fasciotomy
• Anterior compartment most often
affected—best results
• Watch for SPN (10-12 cm prox to LM)!
• May be associated with muscle
hernia
• Deep posterior compartment (FDL)
release is less successful

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Fasciotomy Continued
L
a
t
e
r
a
l
M
e
d
i
a
l

Lower Extremity
Popliteal Artery Entrapment Syndrome
• Medial Head of Gastrocnemius
Aberation leads to constriction of
Artery
• Intermittent Claudication (calf pain
and paresthesias) and Decreased
Pulses (Knee hyperextended Foot
Dorsiflexed)
• Symptoms increase with
walking and relieved with
running!
• Surgical Release

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Lower Extremity
External Iliac Artery Endofibrosis
• Recurrent exercise-
related pain of lower
limb
• More common in
cyclists
• Diminished pulses only
after activity (not at rest)
– Post-exercise ABI < 0.5
• Imaging
– Ultrasound 80% sensitive
– Arteriogram is diagnostic

*
Lower Extremity
Nerve Entrapment Syndromes
• LFCN (L2, L3)
– Entrapment @ Inguinal Ligament
– Meralgia Paresthetica
• Saphenous Neuritis
– Surfer’s Neuropathy
• Superficial Peroneal N
– 12cm proximal to LM
– Fascial defect
• Lateral Plantar N
– Add Digiti Quinti N
– ABD Hallicus fascia
• Medial Plantar N
– Jogger’s foot
– Arch support aggravates symptoms

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Lower Extremity
Muscle Injuries
• MOI:
– Fatigue reduces the ability of the
muscle to absorb energy
• Hamstring
– Variable location
• Proximal biceps at
musculoskeletal junction most
common
– Role for Muscle Strength Testing
• Normal Ham/Quad = 65%
• Quadriceps Contusion
– Immobilize in flexion
• Gastroc-Soleus
– “Tennis Leg”
– Treatment: Calf Sleeve/Heel Lift

Lower Extremity
Muscle Injuries

• Proximal Hamstring Avulsion

– Water Skiing Injury (Hip & Knee
hyperextension)
– Early Repair Advocated
• Adolescent Avulsion Fractures
– ASIS—Sartorius
– AIIS—Rectus
– IT—Hamstrings
– Fix only in higher level athlete with
significant (>3cm) displacement
– Minimally displaced fractures are
treated with NWB x 4 weeks then
PT

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Lower Extremity
Myositis Ossificans
• MOI: Intramuscular
Hematoma and Repeated
Injury
• Soft tissue mass with
Restriction of Motion
• Pain and Size decreases
with time
• Mature bone @ periphery
• Tx: Rest; Active (Not
Passive) ROM

Lower Extremity
Tendon Injuries

• Peroneal Tendons
• Post Tibialis Tendon
• FHL Tendon
• Achilles Tendon

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Lower Extremity
Peroneal Tendon Injuries
Subluxation/Dislocation
• Common in Soccer &
Skiing
• MOI: DF/Eversion
• PE: Eversion vs
resistance, Rim fracture
• Tx: Repair/Deepen
Groove/Reconstruction
Longitudinal Tears
• Usually involves Brevis at
the Fibular Groove
• Tx: Debride/Repair

Lower Extremity
Medial Tendon Injuries

Posterior Tibialis

• Older athletes

• Debride/FDL or FHL
transfer

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Lower Extremity
Medial Tendon Injuries
FHL
• “Push off” Athletes—
Dancers
• Dx:
FHL
– Posteromedial Pain
– Pain with resisted toe PF
– No Pain with Passive
Ankle Plantar Flexion
– Decreased Great toe passive
extension in neutral (normal in
PF)
• Tx: Ice, NSAIDs, Arch
Supports

Lower Extremity
Achilles Tendon Injuries
Achilles Tendinosis
• Overuse injury
– “Failed adaptive response”
• Rest and therapy
– Eccentric training later phases
Achilles Tendon Rupture
• MOI: Maximum PF
• Dx: Thompson Test
• Dx: Resting Prone: foot more DF
• Tx:
– Closed (Rerupture)
– Open (Skin Healing)
• Medial Incision—Avoid Sural N
– Late: FHL transfer if defect > 5cm

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Balanzia Grading

• Grade I
– Pain only after activity
• Grade II
– Pain with activity
– Not limiting
• Grade III
– Pain with activity
– Affects performance

Lower Extremity
Os Noviculare Os
Adolsecents, Prominence
Os Trigonum
• PF Impingement
• Posterolateral Pain with
Passive Ankle Plantar
Flexion
• Ballet (En Pointe)
• Surgical Excision (Lateral)
Os Subfibulare
• Avulsion fracture ATFL
• May be associated with
chronic ankle instability
Os Peroneum
• In Peroneus Longus tendon
near 5th MT Base
– Proximal location = PL Rupture

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Lower Extremity
Ankle Sprains
• ATFL
– Most common
– MOI: Plantar flexion
• CFL
– MOI: Dorsiflexion
• Syndesmosis
– Squeeze Test
– ER Stress Test
– “High” Ankle Sprain
Delay Return to Play

Lower Extremity
Ankle Sprains
Ottawa Ankle Rules

• Obtain Radiographs if:

– Distal/Post
tenderness
– 5MT base tenderness
– Navicular tenderness
– Inability to bear
weight
– >55yo with ankle pain

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Radiographic Exam
• Plain Radiographs
– AP, Lat, Mortise
• Stress radiography
• Standardized testing
apparatus to
measure talar tilt and
anterior talar
translation
• Contralateral ankle
used as control

Stress Radiographs
Syndesmotic Injuries

• External
Rotation Stress
Radiograph
• Look for
Asymmetric
Mortise
Widening

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Radiographic Exam

• MRI
• Peroneal tendon
pathology
• Osteochondral injury

Lower Extremity
Ankle Sprains
Treatment:
• RICE
• Strength/Proprioception
Training
• Surgery (Brostrom)
reserved for recurrent/
refractory cases
• Arthroscopy (“meniscoid
lesion”) Anterolateral
synovial impingement

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Syndesmotic (High) Ankle Sprain

Mechanism of Injury
• Foot External Primarily injures:
Rotation Anterior inferior tibiofibular ligament
Provocative tests
• Squeeze test
• Abd / ER stress test
• Single Leg Hop
Management
• Immobilization vs.
screw fixation (for
mortise incongruity)

Associated Injuries

• Osteochondral
Defects
• Peroneal Tendon
Injuries
• Fractures
• Chronic Ankle
Instability
• Subtalar stiffness
– Inadequate Rehab

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Operative Management

• >80 surgical procedures

-“Anatomic”
Reconstruction
Modified Brostrom
- Tenodesis
Watson-Jones
Chrisman-Snook
• Ankle arthroscopy

Modified Brostrom
• Torn ends of ATFL /
CFL shortened and
repaired directly by
midsubstance
suturing
• Lateral aspect of
extensor
retinaculum
advanced to fibula
over ligament repair

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Associated Conditions
“Impingement Lesions”

• Anteroinferior tibiofibular
ligament impingement
• Posteromedial
impingement lesion of
ankle
• Synovial impingement
“meniscoid” lesion

Prevention
• Semirigid orthosis1
• Semirigid orthosis
and disc
training program2
• Evertor muscle
strengthening3
• Season-long
prevention program4
1Sitler
M et al: AJSM 22:454-461, 1994
2Tropp H et al: AJSM 13:259-262, 1985
3Ashton-Miller JA et al: AJSM 24:800-809,

1996
4Ekstand J et al: AJSM 11:116-120, 1983

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Tibiotalar Impingement

• Pain with forced

Dorsiflexion
• Spur on Lateral
Radiograph
• Surgical
(Arthroscopic)
Excision

Lower Extremity
Fractures
• Proximal Femur Fractures
– Skier’s Hip
• Tibial Plateau Fractures
– Late Arthrosis common
• Ankle Fractures
– 60% have associated tibiotalar
articular lesions
• Proximal Fibula Fractures
• Lateral Process of Talus
Fracture
– Snowboarder’s Ankle
– May need CT scan to Dx

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Subtalar Dislocation
Basketball Foot
• Medial > Lateral
• Medial is caused by forced
inversion
• Lateral is caused by forced
eversion
• Reduce with the knee in
flexion
• Foot is usually stable
following reduction
• Late subtalar LOM common

Lower Extremity
Osteochondral Injuries
Medial Talar Dome
• More common
• More posterior/Deeper
Lateral Talar Dome
• More superficial/ shallower and displaced
• Lower incidence of spontaneous healing
Treatment
• Arthroscopy: Symptomatic, displaced lesions
• ORIF > 1/3 of dome
• Osteochondral Autograft

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*
Superfical Peroneal N Branches

Lower Extremity
Ankle Arthroscopy
• Indications
– OC Lesions, synovitis,
impingement
• Portals
– AL: PT - SPN
– AM: TA - SV
– PL: AT - SSV/SN
• Risks
– Synovial-Cut Fistula
– NV Risk (SPN, SV)
• Nerve injury
represents almost 50%
of all complications

Ankle Arthroscopy

Visualized:
• Anterior Tib Fib,
Deep Deltoid, Deep
Posterior Tib Fib
Ligs
Not Visualized:
• ATFL

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Plantar Fasciitis
• Activity-related pain at origin of plantar
fascia near medial tuberostiy of heel
• Common in Runners
• Symptoms may occur when getting
up after sitting or sleeping
• Pain at medial calcaneal tuberosity
• Tight heel cords
• Treatment:
– Acute: Splint, crutches, stretching
– Shock wave treatment
• Painful
• Efficacious @ 6 month follow-up
– Surgical release
• ? Endoscopic
• Complications common

Lis Franc Injuries

• Presents with a swollen,
painful foot
• Weight-bearing radiographs
– Widening of the 1-2 MT space
– Insure that the medial border
of the 2MT aligns with the
medial border of the middle
cuneiform
• Treatment
– Non-displaced: SLC
– Displaced: ORIF

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Lower Extremity
Metatarsal Fractures
2nd Metatarsal
• Shaft: Stress fracture in
Recruits (March Fx)
• Base: Ballet Dancers
5th Metatarsal Base
• MOI = Forefoot Adduction
• Metaphysis/Diaphysis
• NWB in rec athlete
• ORIF (IM) in comp athlete 4.5 mm +
– Earlier return to training
– Higher failure rate in elite athletes Beware of
Cavovarus foot
– No RTP until after radiographic union
Increased risk of refracture with RTP prior to radiographic union

Lower Extremity
• MOI: Turf Toe
– 1MTP Hyperext injury
• Pathophysiology:
– Incompetent plantar
sesamoid complex
• Fracture or proximal
displacement of
sesamoid may be
seen
• Tx:
– Rest, Ice, Taping
– Orthotic (Morton Extension)
– Repair
• Late Sequela:
– Hallux rigidus
• Tx: Cheilectomy

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Forefoot Pain
Differential Diagnosis

• Freiberg’s infraction
– 2 MT Head AVN
• Flattening of MT head(s)
• MP synovitis
• Morton’s neuroma
– 3/4 webspace
• Stress fractures

Lead in to Questions

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*
LE Top Ten
1. Hip Arthroscopy: Portal Risks (LFCN), Art Cart Injury
2. Ankle Arthroscopy: Portal Risks (SPN, SV), ATFL non viz
3. Stress Fractures: Non-op mgt, At Risk Fractures (Tension)
4. Exertional Compartment Syndrome: 30-20-15
5. Pelvic Muscle Avulsions: ASIS (S) , AIIS (R), IT (Hams)
6. Foot Fractures/Dislocations: Jones Fx, Lis Franc Disloc.
7. Nerve Entrapment: Med Plantar N, Lat Plantar N (AbH)
8. Ankle Sprains: Syndesmotic Injuries, Non-op mgt, Brostrom
9. Tendon Injuries: Quad Flexion, ITB-Ober Test, Peroneal-Ev.
10. Turf Toe: Plantar Sesamoid Complex, Late Hallux Rigidis

Lower Extremity Questions

What is this Bull___?

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Lower Extremity

• “Wrong” Answers:
– Steroid injections
– Initial operative treatment of sprains/strains
– Aggressive management of “recreational”
athletes

Lower Extremity

• LE1 A 17-year-old boy who runs cross country has a 6-week history
of bilateral deep anterior medial leg pain that persists for 2 to 3 hours
after running. Examination shows no pain with palpation, and
radiographs are normal. Which of the following tests will best confirm
a diagnosis?

• 1- CT scan
• 2- MRI scan
• 3- Gallium bone scan
• 4- Stereoroentgenography
• 5- Preexercise and postexercise compartment measurements

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Lower Extremity
• LE2 A high school long distance runner reports a 3-week history of
heel pain while running. Examination elicits no pain with dorsiflexion
or with palpation of the plantar fascia; however, pain is evident with
palpation over the muscular origin of the abductor hallicus. What is
the most likely etiology of the pain?

• 1- Heel spur
• 2- Plantar fasciitis
• 3- Dysfunction of the tibialis posterior tendon
• 4- Compression of the first branch of the lateral plantar nerve
• 5- Compression of the calcaneal nerve

Lower Extremity

• LE3 A 25-year-old competitive runner who has progressive pain in the

medial arch of the foot with radiation of pain to the medial three toes
reports that the pain is worse with the use of a medial arch-supporting
orthosis. Examination reveals tenderness along the medial plantar
arch, and both active and passive eversion of the heel increase the
medial arch pain. What is the most likely diagnosis?

• 1- Rupture of the medial band of the plantar fascia

• 2- Compression of the medial plantar nerve
• 3- Tendinitis of the posterior tibial tendon
• 4- Early arthritis of the naviculocuneiform joint
• 5- Avulsion of the peroneus longus tendon

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Lower Extremity
• LE4 What role does fatigue play in the production of a muscle strain
injury?

• 1- Reduces the ability to absorb energy

• 2- Causes failure at shorter muscle lengths
• 3- Decreases the ability to elongate
• 4- Decreases stiffness
• 5- Decreases the force to failure

Lower Extremity

• LE5 Which of the following rehabilitation methods should be used for

the first 24 hours following a blunt injury to the quadriceps
musculature to avoid short-term stiffness?

• 1- Heat
• 2- Gentle active flexion-extension exercises
• 3- Isokinetic strengthening
• 4- Electrical muscle stimulation
• 5- Immobilization of the limb with the knee in full flexion

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Lower Extremity
• LE6 A 21-year-old patient reports chronic lateral ankle discomfort that
worsens with activity. Examination reveals tenderness along the
course of the peroneal tendon, posterior to the distal fibula. Resisted
eversion testing confirms gross subluxation of the peroneal tendon.
Standing hindfoot alignment approximates 5o of valgus. In addition to
repair of the superior peroneal retinaculum, management should
include

• 1- repair of any associated longitudinal tears of the peroneus brevis

• 2- repair of the inferior extensor retinaculum
• 3- a Dwyer osteotomy of the calcaneus
• 4- tenodesis of the peroneus longus and brevis tendons to the fibula
• 5- decompression and rerouting of the superficial peroneal nerve

Lower Extremity
• LE7 For 3 months, a 35-year-old man has had pain in the
posteromedial ankle when running, walking, or climbing stairs.
Physical examination reveals tenderness and swelling behind the
medial malleolus. Passive extension of the great toe is greater when
the foot is plantar flexed. The most likely diagnosis is

• 1- tarsal tunnel syndrome

• 2- posterior tibial tendinitis
• 3- flexor digitorum longus tendinitis
• 4- flexor hallucis longus tendinitis
• 5- sustenaculum talus impingement

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Lower Extremity

• LE 8 The most common complication associated with the use of

closed treatment of complete Achilles tendon ruptures is

• 1- higher rerupture rate

• 2- excessive lengthening of the musculotendinous unit
• 3- atrophy of the gastrocnemius-soleus muscle
• 4- lack of push-off power in running
• 5- loss of ankle motion

Lower Extremity

• LE9 A 31-year-old woman has had instability of the right ankle for the
past 10 years. Stress radiographs show asymmetrical anterior drawer
translation, excess lateral opening, and a unilateral os subfibulare on
the affected side. In this patient, the os subfibulare represents

• 1- a supernumerary bone
• 2- an unfused accessory ossification center
• 3- a nonunion of an avulsion fracture of the talus
• 4- a nonunion of an avulsion fracture of the fibula
• 5- a nonunion of an avulsion fracture of the os calcis

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Lower Extremity
• LE10 What ligament acts as the primary restraint to inversion and
anterior talar translation at 15 degrees of ankle plantar flexion?

• 1- Anterior talofibular
• 2- Posterior talofibular
• 3- Calcaneofibular
• 4- Deltoid
• 5- Anterior syndesmosis

Lower Extremity

• LE11 A 17-year-old boy steps into a hole, forcing his ankle into
dorsiflexion and inversion. Examination will most likely reveal
damage to which of the following ligaments?

• 1- Anterior talofibular
• 2- Posterior talofibular
• 3- Posterior tibiofibular
• 4- Calcaneofibular
• 5- Deltoid

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Lower Extremity

• LE12 A 20-year-old woman sustains a complete tear of the talofibular

ligaments of her ankle. Radiographs of the ankle show no other
abnormalities. Treatment should consist of

• 1- acute surgical repair

• 2- short leg cast for 6 weeks
• 3- nonweightbearing with a hinged ankle orthosis for 4 weeks
• 4- bandage and tape support; early weightbearing as tolerated
• 5- delayed reconstruction of the talofibular ligament

Lower Extremity
• LE13 Radiographs of a 20-year-old college athlete who sustained an
injury to the ankle reveal no fractures of widening of the ankle mortise.
Examination shows swelling at the ankle region and pain with medial
lateral compression of the distal tibiofibular joint. Which of the
following studies would best help in confirming a diagnosis?

• 1- Inversion stress radiographs

• 2- MRI scan
• 3- CT scan
• 4- Nuclear bone scan
• 5- External rotation stress radiograph

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Lower Extremity

• LE14 What is the standard interval for placement of an anterolateral

portal in ankle arthroscopy?

• 1- Peroneus brevis to peroneus longus

• 2- Peroneus tertius to extensor hallucis longus
• 3- Peroneus tertius to superficial peroneal nerve
• 4- Extensor hallucis longus to deep peroneal nerve
• 5- Extensor hallucis longus to extensor digitorum longus

Lower Extremity
• LE15 Which of the following nerves is most commonly injured during
arthroscopy of the ankle?

• 1- Sural
• 2- Saphenous and its branches
• 3- Posterior tibial and its branches
• 4- Deep peroneal and its branches
• 5- Superficial peroneal and its branches

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Lower Extremity
• LE16 Midfoot pain in a professional ballet dancer who has been
amenorrheic for more than 6 months is most likely to be a

• 1- stress fracture of the proximal fifth metatarsal

• 2- stress fracture of the base of the second metatarsal
• 3- stress fracture of the neck of the second metatarsal
• 4- Morton’s neuroma
• 5- Lisfranc’s joint subluxation

Lower Extremity
• LE17 An 18-year-old recreational soccer player has had pain in the
lateral foot for the past 4 weeks. Radiographs demonstrate a fracture at
the base of the fifth metatarsal metaphyseal-diaphyseal junction. He
reports no specific injury and has not undergone any treatment. Initial
management should consist of

• 1- an orthosis
• 2- observation
• 3- electrical stimulation
• 4- open reduction and internal fixation
• 5- application of a nonweightbearing short leg cast

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Lower Extremity
• LE18 A college basketball player has had foot pain for the past 3
months that is worse at the conclusion of a game or practice.
Radiographs show an incomplete fracture of the fifth metatarsal at the
proximal metaphyseal-diaphyseal junction. Treatment should consist
of

• 1- external bone stimulation and immobilization in a short leg cast

• 2- immobilization in a short leg cast with no weightbearing for 6weeks
• 3- open reduction and internal fixation and an immediate bone graft
• 4- open reduction and internal fixation with an A-O compression plate
• 5- open reduction and internal fixation with an intramedullary
cancellous screw

Lower Extremity
• LE19 Competitive athletes with proximal shaft fractures of the fifth
metatarsal are often treated with internal fixation to facilitate what
outcome?

• 1- Anatomic alignment of the lateral column of the foot

• 2- Early return to training
• 3- Early relief from pain
• 4- Decreased incidence of refracture
• 5- Return of bone density

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Lower Extremity

• LE20 A 19-year-old college football player who sustained a turf toe

injury returned to activity after 8 weeks of rest. After 2 days of
running activity, he now reports pain directed to the hallux metatarso-
phalangeal (MTP) joint. Examination reveals generalized swelling and
dorsal tenderness at the MTP joint. What is the most likely diagnosis?

• 1- Occult fracture of the metatarsal head

• 2- Collateral ligament tear
• 3- Incompetent plantar sesamoid complex
• 4- Overuse with reactive synovitis
• 5- Acute hallux rigidus

Lower Extremity

• LE21 What is the most common sequela of turf toe (hyperextension of

the first metatarsophalangeal joint)?

• 1- Hallux rigidus
• 2- Hallux valgus
• 3- Neuroma of the first web space
• 4- Fracture of the sesamoid
• 5- Rupture of the flexor hallucis longus

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Lower Extremity Answers

LE1 5 LE8 1 LE15 5
LE2 4 LE9 4 LE16 2
LE3 2 LE10 1 LE17 5
LE4 1 LE11 4 LE18 5
LE5 5 LE12 4 LE19 2
LE6 1 LE13 5 LE20 3
LE7 4 LE14 3 LE21 1

Time to Refocus!

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…What does that spell

without any r’s?

Team
Physician

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Training Room Issues

• Privacy—HIPAA
• Trainer Issues
– Dispensing Prescription
Drugs can not be
delegated to a Trainer
• Team Physician—Although
the majority of injury
problems are
musculoskeletal, they
constitute only a fraction of
the athlete’s health care
needs.

Pre-Participation Physical
• Identify conditions that
may predispose an athlete
to injury or illness
• Orthopaedic History and
Questionnaire most useful
tool for identifying
musculoskeletal problems
• Systolic Cardiac Murmur
that increases with
valsalva consistent with
HCM
– Participation
contraindicated with
outflow obstruction

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Significant Eye Injury

• Vision loss (complete
or partial)
• Decreased acuity
• Bright flash of light
• Sudden increase in
floaters
• Pain
• Tearing
• Foreign Body
Sensation
• Photophobia
• Double Vision

Eye Injuries
• Corneal Abrasion
– Common; Follows finger-eye
– Pain, photophobia, FB Sensation
– Diagnosed with fluerescein stain and UV light
– Treated with antibiotics and eye patch
• Traumatic Mydriasis
– Contusion of Iris sphincter with temporarily
dilated pupil

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Team Physician
Eye Injuries
• Baseball 5-14yo
• Basketball 15-24 yo
• Racketball, Boxing, Martial
Arts
• PREVEN TION!
• Hyphema
– Blood in the anterior
chamber
– May represent vitreous or
retinal injury
– Treatment: Bed Rest

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Ear Injuries

• Auricular Hematoma
– Common in Wrestlers
(Cauliflower ear)
– Treatment includes
aspiration and
wrapping
– Start antibiotics if
Symptoms persist >24
hrs

EAR

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Nasal Injuries
• Epistaxis (Bleeding) &
Fractured Nasal Septum
– Most Common
– Rx: Ice, Compression, Reduction
– Watch for clear fluid (CSF)
• Ring Sign
• Immediate ENT Referral

Active Bleeding
• Athlete may return to play only after
bleeding is stopped
• Wound should be covered with a sturdy
occlusive dressing

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Nasal
Pathology

Dental Injuries
• Avulsed tooth should
be replaced
immediately
– Replacement within 30
minutes gives best
chance of survival
• Wash with saline and
place in milk
• May place temporarily
in buccal fold
Crown Fractures common in Ice Hockey Players

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Mouth
Pathology

Team Physician
Sudden Cardiac Death
1. Hypertrophic Cardiomyopathy
– Asymmetric Thickening of ventricular
myocardial walls restrict blood outflow
during systole
– Occurs in Young patients
– Genetic component (AD)
– Contraindication--vigorous exercise!
– Controversy re. screening-Echo
required
• ECG—Q waves and inverted T’s (inconsistent)
• Echo—LV thickness > 16mm;
• VS to Free Wall thickness ratio > 1.3
• No Vent cavity dilation

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Sudden Cardiac Death

2. Commotio Cordis
• Direct blow to chest
– Impact directly over LV
just before T-wave peak
• Fatal (V Fib)
• Mean Age—13
• Chest protectors for high risk sports
• Immediate CPR/Defib!
• AED’s encouraged at Sporting Events

Sudden Cardiac Death

3. Coronary Artery Disease

– Older patients
+ Family history and hyper-
tension increase risk

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Sudden Cardiac Death

Wolf-Parkinson-White
• Accessory Conduction Pathways
• ASx, or Syncopal episodes and/or
palpatations
• Delta Waves on ECG
• SCD if HR exceeds 240 bpm
• RF ablation may be required

Cardiac

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Myocarditis

• Infectious Etiology
– Usually Coxsackie virus
– Also Adeno- or paro-virus
• Responsible for 10-13%
of Sudden Cardiac Death
• < 50% have anti-mortem
symptoms!

Other Heart Problems in

Athletes
• Arrhythmogenic RV Cardiomyopathy
– Rare fibro-fatty infiltration of myocardium
• Long QT Syndrome
• Athlete’s Heart
– Increased Vagal Tone leads to:
• Sinus Arrhythmia
• PAC’s, PVC’s
• Junctional Rhythm
• Bradycardia
• AV Block

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Exercise Induced
Bronchospasm/Asthma
• Very Common (10-50%)!
• Symptoms (Triad)—Occurs after exercise:
– Coughing
– Shortness of Breath
– Wheezing
• Drying and Cooling of Mucosa => Edema
• Decreased FEV1 of >10-15%
• Chest Pain and other symptoms
improve with warm-up
• Treatment:
1. Beta2-Agonist Inhaler (albuterol)
2. Steroid Inhaler

Other Pulmonary Problems

in Athletes
• Pneumothorax
– Occurs from Blunt Trauma
– Rx: Chest Tube
• Tension Pneumothorax
– Emergency!
– Rx: Large bore Needle 2nd IC Space
• Negative Pressure Pulmonary Edema (NPPE)
– Caused by large negative intra-thoracic pressure against an obstructed
upper airway (e.g. following anesthesia)
• Exercise-Induced Anaphylaxis
– Occurs after food ingestion prior to event
– Warmth, Pruitus, Urticaria
– Rx: Epi-Pen, O2, bronchodilators
• (use beta-agonist inhaler as first line treatment),
antihistamines

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Vocal Cord Dysfunction

• May be associated with EIB/EIA
• May be seen in EIB refractory to
standard therapy
• Inspiratory Stridor
• Dx may require view of vocal
cords during exercise
• Treatment: Relaxation
techniques, Speech Therapy,
Counseling

Exertional
Dyspnea

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Marfan Syndrome
• AD Defect in fibrillin 1 gene
• Get Pre participation echocardiogram
• Risk of Aortic Dissection

Marfan’s

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Team Physician
Blunt injuries
• Kidney
– Most common
– Boxers, Football
• Spleen
– Football
– Presents with
abdominal pain,
nausea and vomiting
after blow
• Diaphragm

Repeat Exams are important

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Kidney Injury
• Blow to flank
• Hematuria
• If significant, CT/IVP required
• Extensive bleeding with renal fracture or
vascular pedicle injury Requires urgent
surgery

Team Physician
Testicular injuries
• Usually a result of a kick
– Scrotal Pain/Swelling
– Inability to Void
• Rupture of Tunica Albuginea
(outer covering) causes a
Hematocoele (Painful, firm
scrotal mass that doesn’t
transilluminate
• Testicular Torsion--
Emergency
• Ultrasound/Doppler

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Paired Organs

• Athletes missing an
eye, kidney, or
testicle cannot be
excluded from
sports solely on the
basis of their organ
loss (ADA 1990)

GI
Injuries

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Nutrition
• Proper Nutrition important
– Decreased caloric intake is the
most common cause of
amenorrhea in the female athlete
• Hydration
– Important prior to event
– Too much => Hyponatremeia
• Carb loading
– Decreaed training and increased
carb intake a week prior to an
endurance event

Team Physician
Female Athlete Triad
• Menstrual dysfunction*
No regular
– BCP’s helpful Physical
– Increase Ca/Vit D in Diet Activity
• Disordered eating Should be
Allowed
– Education, counseling
With triad
• Decreased bone And <85%
mineral density Ideal Body
– Proper training Weight

*Secondary Amenorrhea = 6 months

of no cycles after menses
At least one normal cycle

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Female
Athlete
Triad

Team Physician
• Title IX Female Athlete Issues
• Pregnancy causes Increased Estradiol =>
Ligament Laxity
– Pregnancy also increases 02 consumption
16-32% because of increased body weight
• Iron deficiency anemia
– Low Ferratin
– Poor dietary intake
• Bone loss—2-3%/yr p menapause
• ACL Injury Risk (4.5 x men!)
– Strength, alignment, training, notch size,
generalized ligamentous laxity, medial
collapse
– Incidence can be reduced with
Neuromuscular training

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Sickle Cell

• Sickle Cell Trait

– Inherited
– Not contagious
– May predispose to sickling with heavy
exertion at high altitude in
unacclimated athlete.
– Fluid and electrolyte balance
important

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Heat Illness
• Hydration key
10-14 days acclimatization
– Low Osmolality (<10%) Required for Adolescents
Solution
– Carbs and Glucose
stimulate GI fluid
absorption
• Monitor Weight
– 5% Loss—keep out
– 7% Loss—See MD
• Table Salt for Heat
Cramps
• Rapid cooling for Heat
Exhaustion (no Neuro Sx)
• Heat Stroke—Emergency!

Pre-Participation Examination
Red Flags

• Exertional Dizziness
• Systolic Murmurs
• History of Transient
Quadraplegia
• JRA

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Heat stroke

• Dx: Hypothermia, Decreased CNS function,

loss of thermoregulatory function
• Management:
– Activate EMS
– Lower temp. below 39o C (102o F)
– Active cooling: ice immersion, ice
packs, cooling blanket, fanning
– Internal cooling measures if necessary
– IV hydration
– Heat sensitivity may last 1 year

Heat
Illness

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Cold Injury

• Frostbite
– Rewarm extremity
in water bath 110o
to 112o F (40o C)

Cold
Injury

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Environmental Illness
• Acute Mountain Illness
– Prophylactic Treatment with Acetazolamide
helpful

Skin Infections
• Herpes Simplex
• Herpes gladatorum—face
and body wrestler and
rugby (scrumpox)
• Incubation 2-14 days
• Antiviral Rx
– Acyclovir
– Valaciclovir
– Famciclovir

No wrestling until lesions have scabbed

over and no new lesions within the preceding
72 hours

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Impetigo
• Bacterial skin infection
• Honey-colored crusted
fascial lesions with an
erythematous base
• Treated with
Erythromycin and topical
Bactroban
• No wrestling until all
lesions are clear of
crusting

Tinea
• Fungal Infection
• Ring Worm
• Topical Creams
– Antifungal BID for 2 weeks
• Oral Medication if wide-spread
– Diflucan 150 mg Q Week x 4
weeks
– Sporanox 200 mg QD x 1-2
weeks
– Lamlell 250 mg QD x 2 weeks

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MRSA

• Training Room Disaster

• Occurs in areas of skin trauma
– Abrasions
• Pustule with erythematous base
• Cellulitis/Abscess
• Spread by physical contact &
sharing of equipment
• Treatment with ABx (Sulfa/Trimethoprim and
Rifampin), I&D, Chlorhexadine soap, close
monitoring for systemic infections

Molluscum Contagiosum
• Viral Warts
• Smooth and Dome-shaped
• White or flesh colored
papule with an umbillicated
center
• Minimal erythema
• Rx: Scrape, Liquid N2,
Curretage

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Derm

Physically Challenged
Athletes

• Spinal Cord injured at

increased risk for heat
illness
– Thermoregulatory
function impaired

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Down Syndrome

• Cervical instability
– Lateral C-Spine required
before participation
• 20% A-A Instabiltiy
• < 5 mm ADI on F-E—OK
• >9 mm ADI on FE—Fusion
• Congenital Heart Disease

Team Physician-Exercise
• Isometric
– No change in length
• Isotonic
– Constant resistance
– Concentric (shortens)
– Eccentric (lengthens)
• Isokinetic
– Constant velocity (speed)

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Team Physician
Weight Training
• Increase Mitochondria
• Increase capillary density
• Thickening of connective tissue
• Increased cross-sectional area
• Increased strength
• Pre-Adolsescent:
– Neurogenic Adaptations
• Motor Learning (Change in Motor Unit)
• Increases efficiency of muscle action

Team Physician
Exercise

Anaerobic Aerobic
• ATP-CP • Oxidative
– High Intensity Phosphorolation
– Short Duration (Krebs Cycle)
(10 seconds) – Requires O2
– Type II Muscles – High ATP yield
• Glycolytic • Endurance
– 2-3 Minutes
– Low ATP yield • Type I Muscles
– Lactic Acidosis
(Threshold)

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Team Physician
Exercise
• Contraindicated in athletes with fever
• Plyometrics
– Good for sports requiring explosive power
– Jumping to different heights
– Enhances myotactic (muscle stretch) reflex
• Proprioceptive Neuromuscular
Facilitation (PNF)—Increased stretching
– Best to increase ROM and flexibility
– 3 Step Stretching—
• Passive & isometric

Sports Periodization
• Planned variation in exercise intensity and/or
volume
– Avoids overtraining
• Comes from Selye’s General Adaptation Syndrome
(GAS) model
– 3 stages: Alarm, Resistance, Exhaustion (try to avoid!)
– Encourage “eustress” and discourage “distress”
– Microcycle (7 days), Mesocycle (2 weeks-3 months),
Macrocycle (1-2 years)

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Muscle Physiology
• Force of muscle
contraction is
proportional to its
cross-sectional area
• Progressive
overloading leads to
muscle hypertrophy

Endurance Training can increase storage and

Utilization of intramuscular lipids

Delayed-Onset
Muscle Soreness
• Follows intense exercise
– Especially
unaccustomed
eccentric exercise
– 24-48 hour peak
– Varies with intensity and
duration of exercise
• Caused by edema and
inflammation in
connective tissue
• Increased CK Levels

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Muscle Atrophy

• From disuse, nerve

injury, or decreased
tension
• Fatty infiltration
• Muscles crossing a
single joint atrophy
faster

Rehabilitation
• Acute Phase
– Cryotherapy
useful
• Decreases Pain
and
Inflammation
• Recovery Phase
• Functional Phase
– Proprioception
– Return to Sport
Closed chain = Co-contraction of
quads and hams.
Axial Loading results in better joint stability

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Modalities
• Superficial Heat
• Deep Heat (Diathermy)
– Ultrasound (sound waves)
– Phonophoresis = Ultrasound delivered
medication
– Short wave Diathermy (SWD): EM
energy
• Cold (Cryotherapy)
• Electotherapy
– TENS
– Iontophoresis: Electrical current
used to deliver medication
• Low Power Laser
• Magnetic Devices
• Acupuncture

Team Physician
Prophylactic Knee Bracing
• ACL/PCL: No proven efficacy except
for ACL-deficient skiers
• MCL: May reduce MCL injury
Lineman and Linebackers

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Anesthesia in Athletes

• High Association of
Bradycardia
• Increased risk of aspiration
• Regional Anesthesia Risk
– Sensory Neuropathy
– Diaphragm Palsy

Antibiotics
• Must be ordered by MD
• Consider Septrum/Bactrim
in Training Room (MRSA
potential)
• Fluoroquinilones may have
tendon toxicity effect.
• Indiscriminate use may
increase resistance

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Pudendal Nerve Neuropraxia

• Common in
bicyclists
• Causes penile shaft
numbness
• Modify seat

Team Physician
Viral Infections

• Viral Gastroenteritis
• Upper Respiratory – Fever and
Tract Infections Diarrhea—Rx
(URI) Bactrim DS
• Influenza (Flu) • Skin Infections
• Pharyngitis • Myocarditis
• Meningitis • Postviral Fatigue
• Mononucleosis Syn
• CMV • HIV
• Hepatitis

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Meningitis
• Outbreaks common in
team sports
• Fecal-oral
transmission
• Enteroviruses
• Sx: Fever, HA, Neck
stiffness
• CSF evaluation
essential to rule out
bacterial meningitis

Mononucleosis
• EBV (a Herpesvirus)
• Incubation 30-50 days
• 3-5 day prodromal
period (malaise,
myalgia, nausea, HA)
• Organomegaly,
pharangytis
• Heterophile Ab test
• No contact sports
for 4 weeks and no
splenomegaly
– Splenic rupture most
likely in first 3 weeks

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Team Physician
Human Immunodeficiency Virus
• HIV infection alone is insufficient grounds to
prohibit an athlete from competition
– HIV status is confidential information
• Athlete education
– Regular, Moderate Exercise is beneficial
• Affects CD-4
T-Helper cells
• Wound care
– Universal Precautions
– No return until bleeding
stopped and occlusive dressing applied
• OSHA

Team Physician
Ergogenic Drugs
• Anabolic Steroids
– Enhances muscle
– Side Effects: Cardiac (LV Hypertrophy,
decreases HDL) Premature Physeal
closure, Hypercoagulability (may lead to
fluid and electrolyte imbalance)
Increased aggression, Testicular
Atrophy, Alopecia*

*Irreversible

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Human Growth Hormone

(hGH)

• 1st documented use in early 1980’s

• Not accurately detected with
current labs!
• No testing protocol (not in urine)
• Blood tests require further
validation
• Androgenic
• Side effects: Hypertension,
Gigantism

Creatine
• Muscle and power-building supplement,
widely used in conjunction with off-season
weight-lifting programs
• Enhances ADP => ATP anerobic threshold
– No advantage for endurance athletes
• Pulls water from the blood vessels
into cells, creating a theoretical risk
of dehydration
• Reports of cramps, increased muscle injury,
and, rarely, renal insufficiency
Best administered dose: 20 g/day 5 days prior to anticipated
Short bursts of maximal exercise with short recovery periods

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Supplement Use
• Use pattern continues to rise sharply
across athlete groups
• Quality, purity, and extent of contents
remain major issues for safety
• Every attempt should be made to know
what supplements, if any, your athletes
are using
• “See the bottle” and utilize your sports
medicine staff for guidance

CNS Stimulants
• Ephedra, Ephedrine, “Ma Huang”,
Phenylpropanolamine
• A common, often “hidden,” component
of muscle or energy-building
supplements
• High risk for dehydration and impaired
heat management, high blood pressure,
and nervous system impairment
• Prescription drugs- Ritalin, etc.
• See the bottle!

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Caffeine

• Improves Performance/Endurance
• Marked variation in metabolism
• >9 mg/kg IOC limit
– This is the only “threshold” ban!
– About 5 cups of coffee/day
• May not be on label

Supplements
Glucosamine/
Chondroitin Sulfate
• Endogenous
molocules found in
articular cartilage
• Cartilage Synthesis?
• Some efficacy in
placebo controlled
studies with minimal
side effects1,2

1MazieresB. J Rheumatol 2001;

28:173-181
2McAlindonTE. JAMA 2000;
284:1241

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Lube Job
Hyalagan/Synvisc
• Hyaluronic acid—
normal component
of articular cartilage
• Increase viscosity
• Transient + effect1,2
• Costs about $1G
• No better than
Steroid

1Altman RD J Rheumatol 1998;

25:2203-2212
2Brant KD Clin Orthop 2001;

385:130-143

Team Physician
Steroid Injections
• Not recommended into tendons
– May actually weaken tendons
• Can cause skin changes
• Elevates Glucose levels in Diabetics
Intra-articular knee injections are
Best given laterally adjacent to
Upper portion of patella with the
Knee extended

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Team Physician
Stress Fractures
• Rowers - Rib
• Recruits/Dancers - 2nd Metatarsal
• Basketball - 5th Metatarsal
• Bowling - Ulna
• Runners – Hip
High Risk stress fractures:
Tension side Hip, Femur,
Navicular, Tibia, 5MT

MRI is the most sensitive and

Specific test for diagnosis

Top 10 Training Room

1. Sudden Cardiac Death: HCM Anatomy, CC MOI, CAD
2. Female Athlete: Triad, ACL Risk, Bone Loss, Iron deficiency
3. EIA: Cold Weather, Dx: FEV1, Tx: Beta2 Agonist
4. Rehab Principles/Types of Exercise: Chain, -Tonic
5. Blunt Abdominal Injuries: Kidney, Spleen, Eye, Bleeding
6. Skin Lesions in Wrestlers: Herpes, Impetigo, MRSA
7. Viral Infections: Meningitis, Mono, GI Illness, HIV
8. Thermoregulation: Heat Illness, Dehydration, Frostbite
9. Performance Enhancement:Anabolic Steroids, GH, Creatine
10. Perioperative Problems: Cardiac, DVT, Regional Blocks

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Team Physician Questions

I’m trying to get in touch with

my sensitive side.

Team Physician

• “Wrong” answers:

– Isometric Exercise
– Delayed Dx/Tx of on-the-field injury

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Team Physician
• TP1 An eccentric, isotonic muscle contraction occurs when a
contracting muscle undergoes which of the following processes?

• 1- Shortens against constant resistance

• 2- Shortens against variable resistance
• 3- Lengthens with constant velocity
• 4- Lengthens against constant resistance
• 5- Remains at constant length against variable resistance

Team Physician
• TP2 Joint motion is maintained at a constant velocity under changing
resistance in which of the following exercises?

• 1- Isotonic
• 2- Isometric
• 3- Isokinetic
• 4- Eccentric
• 5- Co-contraction

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Team Physician
• TP3 Which of the following terms describes a rehabilitative exercise
in which the foot is mobile and motion of the knee is independent of
hip and ankle motion?

• 1- Isotonic
• 2- Isokinetic
• 3- Isometric
• 4- Open kinetic chain
• 5- Dynamic variable resistance

Team Physician
• TP4 What organ is most commonly injured as a result of blunt
abdominal trauma during participation in sports?

• 1- Kidney
• 2- Diaphragm
• 3- Liver
• 4- Spleen
• 5- Bladder

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Team Physician
• TP5 As the physician covering a football game, you examine a player
on the field who has labored respirations, distended neck veins, and
cyanosis. You suspect a tension pneumothorax. What is the preferred
management?

• 1- Chest radiographs
• 2- Immediate intubation
• 3- Intrathoracic large-bore needle insertion
• 4- Insertion of a chest tube
• 5- Administration of nasal oxygen

Team Physician
• TP6 The female athlete triad consists of

• 1- menstrual dysfunction, stress fractures, and anemia

• 2- menstrual dysfunction, disordered eating, and decreased bone
mineral density
• 3- menstrual dysfunction, muscle cramping, and anemia
• 4- anemia, weight loss, and muscle cramping
• 5- amenorrhea, bulimia, and anemia

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Team Physician Answers

TP1 4 TP4 1

TP2 3 TP5 3

TP3 4 TP6 2

My back is
hurting,
I can’t carry you
any farther!

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GOOD
LUCK!

Thank You

168