Ortho Sport Sports Medicine Board Review | Dr Hutaif Sp -...

DISCUSSION: Lahti and associates reported that the most common dental injury in a study of 479 injured ice hockey players was a noncomplicated crown fracture, which accounted for 43.5% of all maxillofacial/ dental injuries. The most common cause of injury was a blow from an ice hockey stick. As a cause of injury, the stick was approximately three times as common in games as in training, and only 10% of injured players wore some sort of protective guard. A tooth avulsion is a partial or complete
displacement of the tooth from aleveolar support. A crown fracture is an incomplete loss or fracture of the tooth enamel without loss of the tooth. The other injuries (mandible fracture, lip laceration, tooth
avulsion, and temporomandibular contusion) occur but are not nearly as common.

Scientific References

: Lahti H, Sane J, Ylipaavalniemi P: Dental injuries in ice hockey games and training. Med Sci Sports Exerc 2002;34:400-402.
Minkoff J, Stecker S, Varlotta GP, et al: Ice hockey, in Fu FH, Stone DA (eds): Sports Injuries, ed 2.
Philadelphia, PA, 2001, pp 516-517.

Figure 2a Figure 2b Figure 2c

DISCUSSION: The MRI scans and ultrasound show an articular surface partial-thickness rotator cuff tear of the supraspinatus tendon. This condition most commonly involves the supraspinatus tendon and is

usually found on the articular surface where the blood supply is less robust. There are multiple intrinsic and extrinsic factors contributing to this condition which include age-related metabolic and vascular changes that lead to degenerative tearing, subacromial impingement, shoulder instability (typically anterior), internal impingement, and repetitive microtrauma. Acute trauma is less often the cause. The physical examination for this condition is often nonspecific and requires supplemental imaging studies for diagnosis.
REFERENCES: Matava MJ, Purcell DB, Rudzki JR: Partial-thickness rotator cuff tears. Am J Sports Med 2005;33:1405-1417.
Wright SA, Cofield RH: Management of partial-thickness rotator cuff tears. J Shoulder Elbow Surg
1996;5:458-466.
McConville OR, Iannotti JP: Partial-thickness tears of the rotator cuff: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43.

DISCUSSION: Dunaway and associates reported that the nerve was extrafascial in only 43% of their cadaveric specimens. Therefore, in medial meniscal repair, the nerve may be present during deep dissection. The sartorial branch of the saphenous nerve is posterior to the sartorius; dissection should remain anterior to the sartorius. The branch becomes extrafascial between the gracilis and the sartorius. The nerve is anterior to the semitendinosus with the knee in extension. The infrapatellar branch of the saphenous nerve exits the adductor canal and travels to the anteromedial aspect of the knee.
REFERENCES: Dunaway DJ, Steensen RN, Wiand W, et al: The sartorial branch of the saphenous nerve: Its anatomy at the joint line of the knee. Arthroscopy 2005;21:547-551.
Rodeo SA: Arthroscopic meniscal repair with use of the outside-in technique. Instr Course Lect 2000;49:195-206.

DISCUSSION: The late cocking phase of the overhand throw places a marked valgus moment across the medial elbow. This repetitive force reaches the tensile limits of the medial collateral ligament.
REFERENCES: Fleisig GS, Andrews JR, Dillman CJ, et al: Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med 1995;23:233-239.
Lynch JR, Waitayawinyu T, Hanel DP, et al: Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg 2008;33:430-437.

Figure 5a Figure 5b

DISCUSSION: The patient has an acute traumatic anteromedial dislocation of the knee with occlusion of the popliteal artery with a possible tear. Treatment should include reduction and reevaluation of the vascular status. At this time, if pulses are symmetric, observation may be appropriate without surgical

intervention of the artery, but documentation with studies would be appropriate. Delayed reconstruction of injured structures is appropriate.
REFERENCES: Fanelli GC, Orcutt DR, Edson CJ: The multiple- ligament injured knee: Evaluation, treatment, and results. Arthroscopy 2005;21:471 -486.
McDonough EB Jr, Wojtys EM: Multiligamentous injuries of the knee and associated vascular injuries.
Am J Sports Med 2009;37:156-159.
Wascher DC: High-velocity knee dislocation with vascular injury: Treatment principles. Clin Sports Med 2000;19:457-477.

DISCUSSION: Preparations of hyaluronic acid can be divided into low and high molecular weight compounds. Contraindications to intra-articular hyaluronic acid include joint or skin infection, overlying skin disease, and allergies to chicken or egg products if using a preparation derived from rooster comb.
REFERENCES: Gloyscen DN, Gillespie MJ, Schenek RC: The effects of medication in sports injuries, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopedic Sports Medicine: Principles and Practice, ed 2.
Philadelphia, PA, WB Saunders, 2003, vol 1, pp 121-124.
Schenck RC Jr: New approaches to the treatment of osteoarthritis: Oral glucosamine and chondroitin sulfate. Instr Course Lect 2000;49:491-494.

DISCUSSION: Schilders and associates reported their results of treating adductor-related groin pain in competitive athletes. They reported that a single corticosteroid injection into the pubic cleft can be expected to provide at least 1 year of relief of adductor-related groin pain in a competitive athlete with normal findings on MRI. In contrast, when there is evidence of enthesopathy on MRI in this competitive- athlete population, these injections are not therapeutic and are associated with a high likelihood of recurrence of symptoms. Hip arthroscopy is generally reserved for intra-articular problems. Percutaneous adductor tenotomy is not indicated for this condition. A bone scan is unlikely to provide any useful information for clinical decision-making. Rheumatology consultation is also not indicated in the absence of any evidence of inflammatory arthropathy.
REFERENCES: Schilders E, Bismil Q, Robinson P, et al: Adductor-related groin pain in competitive athletes: Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007;89:2173-2178.
Robinson P, Barron DA, Parsons W, et al: Adductor-related groin pain in athletes: Correlation of MR imaging with clinical findings. Skelet Radiol 2004;33:451-457.

DISCUSSION: Intersection syndrome is also known as “squeakers wrist,” “oarsmen wrist,” and crossover tendinitis. It occurs where the first and second dorsal wrist compartment structures pass over one another, resulting in fibrosis, muscular changes, and inflammation of the bursa in this area. The structures involved are the abductor pollicis longus and extensor pollicis brevis (first dorsal compartment) that pass across the second compartment structures (extensor carpi radialis brevis and extensor carpi radialis longus). An audible “squeak” is occasiona**l** y heard at the intersection point, which is approximately 4 to 5 cm proximal to the proximal dorsal wrist crease.

REFERENCES: Grundberg AB, Reagan DS: Pathologic anatomy of the forearm: Intersection syndrome. J Hand Surg Am 1985; 10:299-302.
Thorson E, Szabo RM: Common tendinitis problems in the hand and forearm. Orthop Clin North Am 1992;23:65-74.
Williams JG: Surgical management of traumatic non-infective tenosynovitis of the wrist extensors. J Bone Joint Surg Br 1977;59:408-410.
Wood MB, Dobyns JH: Sports-related extraarticular wrist syndromes. Clin Orthop Relat Res 1986;202:93-102.

DISCUSSION: Generally, partial articular side rotator cuff tears are treated by either debridement or repair. The decision to repair depends on the “thickness” of the tear and the retraction of the undersurface of the rotator cuff as well as the quality of the remaining tissue. More than 6 mm of footprint exposure suggests a 50% thicknes tear. If it is poor quality as in this case, the surgeon should complete the tear and repair the tendon as in a small full-thickness tear. Intrasubstance tears with an intact footprint can be treated with trans-tendon repair.
REFERENCES: Wolff AB, Sethi P, Sutton KM, et al: Partial thickness rotator cuff tears. J Am Acad Or- thop Surg 2006;14:715-725.
Mazzocca AD, Rincon LM, O’Connor RW, et al: Intra-articular partial-thickness rotator cuff tears:
Analysis of injured and repaired strain behavior. Am J Sports Med 2008:36:110-116.

DISCUSSION: Flattening of the femoral condyles indicates the onset of significant arthritis of the joint
and is a contraindication to meniscus allograft transplantation. Criteria to proceed with allograft transplantation includes prior total meniscectomy, age of 50 years or younger, BMI of less than 30, clinical symptoms of pain in the involved tibiofemoral compartment, 2 mm or more of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph, ligamentous stability, normal alignment, and no radiographic evidence of advanced arthrosis. Recurrent effusions are associated with chronic meniscus deficiency, and is one criteria for meniscal transplantation. High tibial osteotomy is often considered in conjunction with meniscal transplantation to correct tibiofemoral malalignment.
REFERENCES: Noyes FR, Barber-Westin SD: Meniscus transplantation: Indications, techniques, clinical outcomes. Instr Course Lect 2005;54:341-353.
Kang RW, Lattermann C, Cole BJ: Allograft meniscus transplantation: Background, indications, techniques, and outcomes. J Knee Surg 2006;19:220-230.

DISCUSSION: There is legal precedent for banning a scholarship athlete from participation in college

athletics if the physician feels that it presents a significant physical risk to the athlete. The courts have decided that the athlete has no constitutional right to participate in NCAA sports, and as a team physician you must advise your athlete and the school as to the best course of action. The athlete must be allowed to keep his or her college scholarship.
REFERENCES: Klossner D: NCAA Sports Medicine Handbook, ed 18. Indianapolis, IN, National Collegiate Athletic Association, 2007.
Pearsall AW IV, Kovaleski JE, Madanagopal SG: Medicolegal issues affecting sports medicine practitioners. Clin Orthop Relat Res 2005;433:50-57.

DISCUSSION: Injuries to the anterior and middle column in gymnasts occur but are far less common than posterior column injuries such as spondylolysis and spondylolisthesis. The data on injuries to the anterior and middle columns are more limited. Long-term gymnastics exercise is associated with disk degeneration and other anterior and middle column abnormalities as reported by Katz and Scerpella. They identified a series of anterior and middle column abnormalities, including vertebral compression fractures, Schmorl’s nodes, disk degeneration, and disk herniation in young competitive female gymnasts with back pain. Therefore, the differential diagnosis of back pain in these athletes should include abnormalities of the anterior and middle column. Although diagnostic imaging should begin with radiographs, MRI is the best way to diagnosis these abnormalities. A bone scan is more useful for imaging bony abnormalities of the posterior elements. Flexion-extension radiographs are not indicated in this patient. Treatment such as physical therapy or a lumbosacral corset should not be initiated prior to a complete work-up.
REFERENCES: Katz DA, Scerpella TA: Anterior and middle column thoracolumbar spine injuries in young female gymnasts: Report of seven cases and review of the literature. Am J Sports Med 2003;31:611-616.
Tertti M, Paajanen H, Kujala UM, et al: Disc degeneration in young gymnasts: A magnetic resonance imaging study. Am J Sports Med 1990;18:206-208.

DISCUSSION: Cervical spinal stenosis is a contraindication to participation in collision and contact sports. Previously, the risks of permanent quadriparesis from cervical spinal stenosis were thought to be unclear and athletes with cervical spinal stenosis were often allowed to play contact sports. In 1996, Torg and associates reported that developmental narrowing of the cervical canal in a stable patient does not appear to predispose an individual to permanent catastrophic neurologic injury and therefore should not preclude an athlete from participation in contact sports. However, the current understanding is that the actual risks of permanent neurologic injury from cervical stenosis are significant. The Torg ratio was previously used for diagnosis but is more recently thought to be of low predictive value as reported by Cantu. Current methods for diagnosis of cervical spinal stenosis rely on MRI and CT. Current diagnosis is based on comparisons of measurements with normal values. A cervical canal of less than 13 mm is considered stenotic whereas a diameter of less than 10 mm is considered absolute stenosis as reported by Crowl and Kong. This patient has symptomatic stenosis and should not be cleared for contact sports. A neck roll will not prevent neurologic injury in the presence of cervical spinal stenosis. Electrodiagnostic studies are not likely to add any additional significant findings with central canal stenosis. Cervical traction is not of value in the long-term. Epidural steroid injections or a methylprednisolone dose pack are not of value in this situation.

REFERENCES: Torg JS, Naranja RJ Jr, Pavlov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Cantu RC: The cervical spinal stenosis controversy. Clin Sports Med 1998;17:121-126. Crowl AC, Kong JF: Cervical Spine, in Johnson DL, Mair SD (eds): Clinical Sports Medicine. Philadelphia, PA, Mosby Elsevier, 2006, pp 143-149.

DISCUSSION: The patient has a sports hernia or athletic pubalgia. The exact nature of this pathology is not well understood. MRI scans are not very helpful in making a diagnosis. In high-performance athletes who have failed to respond to nonsurgical management, surgical intervention is needed to strengthen the anterior pelvic floor. Additional nonsurgical management at this point will not improve symptoms. Cortisone injection will not strengthen the pelvic floor. CT scan of the pelvis is valuable to rule out bony injuries such as osteitis pubis. Ultrasound of the scrotum will have no additional diagnostic use in management of this patient.
REFERENCES: Meyers WC, Foley DP, Garrett WE, et al: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.
Biedert RM, Wamke K, Meyer S: Symphysis syndrome in athletes: Surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes. Clin J Sport Med 2003;13:278-284.

DISCUSSION: Secondary amenorrhea is defined as the absence of menstrual bleeding for 6 months or the absence of three to six consecutive menstrual cycles after normal menses has begun. The prevalence of amenorrhea among female athletes is estimated at 10% to 20% in women who exercise vigorously and as high as 40% to 66% in elite runners and professional ballet dancers.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 345-346.
Feingold D, Hame SL: Female athlete triad and stress fractures. Orthop Clin North Am 2006;37:575-583.

DISCUSSION: Infectious mononucleosis (IMN) is a self-limiting viral (Epstein-Barr virus) infection that affects mostly adolescents. One of the clinical findings in IMN is splenomegaly. Unfortunately, the splenomegaly is palpable only 50% of the time. The risk for spontaneous splenic rupture is highest 3 weeks after the onset of symptoms. Thus, most clinicians recommend return to contact sports after 4 weeks from the onset of symptoms. This patient presented 1 week after the onset of symptoms, so he can return to play in 3-4 weeks from the time he was examined. The athlete should be afebrile, well hydrated, and asymptomatic. Airway obstruction is usually not of concern. Disease transmission to teammates is possible in the acute phases.
REFERENCES: Waninger KD, Harcke HT: Determination of safe return to play for athletes recovering from infectious mononucleosis: A review of the literature. Clin J Sport Med 2005; 15:410-416.
Auwaerter PG: Infectious mononucleosis: Return to play. Clin Sports Med 2004;23:485-497.

Figure 17

DISCUSSION: The arthroscopic photo shows a grasper removing a loose body from the posterolateral compartment through an accessory posterolateral portal. The blunt arthroscopic trocar is placed through the intercondylar notch in the direction of the posterior horn of the lateral meniscus. The trocar passes between the ACL and the posterior aspect of the lateral femoral condyle into the posterolateral compartment.
REFERENCES: Wu WH, Richmond JC: Arthroscopy of the knee: Basic setup and techniques, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott-Raven, 2003, pp 215-216. Kramer DE, Bahk MS, et al: Posterior knee arthroscopy: Anatomy, technique, application. J Bone Joint Surg Am 2006;88:110-121.

DISCUSSION: Proximal fifth metatarsal Jones fractures can be successfully treated by intramedullary screw fixation. This technique may stimulate an early healing response when compared to nonsurgical management. When studies were done to look at the failure rate in patients undergoing this procedure, elite athletes appeared to have the highest rate of failure. This most likely does not represent a failure in the surgical procedure as much as it is a failure in the treatment of the patient. If an athlete is allowed to return back to playing their sport before the fracture is healed, they are putting themselves at risk for hardware failure. Bone grafting has not been shown to necessarily accelerate the healing process in these patients.
REFERENCES: Larson CM, Almekinders LC, Taft TN, et al: Intramedullary screw fixation of Jones fractures: Analysis of failure. Am J Sports Med 2002;30:55-60.
Glasgow MT, Naranja RJ Jr, Glasgow SG: Analysis of failed surgical management of fractures of the base of

the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 1996;17:449-457.

Figure 19a Figure 19b Figure 19c

DISCUSSION: The MRI scans show a large superior labral cyst. Impingement of the cyst on the suprascapular nerve is implied by the visible atrophy of the infraspinatus muscle as seen in Figure 19c. Clinically, this is manifested by atrophy of the posterior aspect of the shoulder inferior to the scapular spine. The suprascapular nerve provides only motor function and does not provide any sensory function to the shoulder girdle; therefore, sensory deficits will not be present in this patient.
REFERENCES: Westerheide KJ, Dopirak RM, Karzel RP, et al: Suprascapular nerve palsy secondary to spinoglenoid cysts: Results of arthroscopic treatment. Arthroscopy 2006;22:721-727.
Schroder CP, Skare O, Stiris M, et al: Treatment of labral tears with associated spinoglenoid cysts without
cyst decompression. J Bone Joint Surg Am 2008;90:523-530.
Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002; 11:600-604.

DISCUSSION: The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient’s symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.
REFERENCES: Meister K: Injuries to the shoulder in the throwing athlete. Part two: evaluation/ treatment. Am J Sports Med 2000;28:587-601.
Liu SH, Boynton E: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000;28:668-673.

2010 Sports Medicine Examination Answer Book • 21

DISCUSSION: The patient has external-type snapping hip (coxa saltans). It is not uncommon for patients to have a very long duration of symptoms that limit running or other sporting activities, and commonly affects the downward leg (usually the left leg when running on the left side of the road). The snapping causes a profound bursitis at the greater trochanter, and occasionally corticosteroid injections may be helpful. Her physical examination does not suggest an intra-articular process, and is not consistent with an internal-type snapping hip, usually caused by the iliopsoas tendon as it moves over the iliopectineal eminence. Stretching is the mainstay of treatment, as testing with a positive Ober signifies a tight iliotibial band as the thigh has difficulty crossing the midline with adduction. Various iliotibial band lengthening procedures have been described, including a Z-plasty near the proximal origin of the iliotibial band. Release at Gerdy’s tubercle has not been described.
REFERENCES: Provencher MT, Hofmeister EP, Muldoon MP: The surgical treatment of external coxa saltans (the snapping hip) by Z-plasty of the iliotibial band. Am J Sports Med 2004;32:470-476.
Faraj A A, Moulton A, Sirivastava VM: Snapping iliotibial band: Report of ten cases and review of the literature. Acta Orthop Belg 2001;67:19-23.
Brignall CG, Stainsby GD: The snapping hip: Treatment by Z-plasty. J Bone Joint Surg Br 1991 ;73:253-
254.

DISCUSSION: The coracohumeral ligament has been shown to be the primary restraint to inferior translation of the shoulder. Although Bigliani and associates have demonstrated that the inferior capsule and inferior glenohumeral ligaments also play a role, none of the other choices provide primary inferior stability of the shoulder. The coracohumeral ligament is an important structure of the rotator interval of the shoulder (the rotator interval contains the long head of the biceps, the superior glenohumeral ligament, the coracohumeral ligament, and a thin layer of capsule). Harryman and associates demonstrated that an open rotator interval closure via imbrication of the coracohumeral ligament improves inferior stability of the glenohumeral joint.
REFERENCES: Harryman DTII, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53 -66.
Bigliani LU, Pollock RG, Soslowsky LJ, et al: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.
Boardman ND, Debski RE, Warner JJ, et al: Tensile properties of the superior glenohumeral and coracohumeral ligaments. J Shoulder Elbow Surg 1996;5:249-254.

DISCUSSION: The ACL is composed of two anatomic bundles: the anteromedial (AM) and the posterolateral (PL). They are both considered important to the stability of the knee. Although they work in concert, the AM bundle controls translation, especially in flexion, whereas the PL bundle prevents rotation.

REFERENCES: Zelle BA, Vidal AF, Brucker PU, et al: Double-bundle reconstruction of the anterior cruciate ligament: Anatomic and biomechanical rationale. J Am Acad Orthop Surg 2007;15:87-96.
Yasuda K, Ichiyama H, Kondo E, et al: An in vivo biomechanical study on the tension-versus-knee flexion
angle curves of 2 grafts in anatomic double-bundle anterior cruciate ligament reconstruction: Effects of initial tension and internal tibial rotation. Arthroscopy 2008;24:276-284.

DISCUSSION: The loss of hair or alopecia, is the only nonreversible effect of anabolic steroid use.
Once anabolic steroids are stopped, muscle hypertrophy and training gains are quickly lost and the HDL/ LDL ratios return to their preexisting levels. Fortunately, the personality effects and the acute acne are reversible.
REFERENCES: Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med 2004;34:513-554.
Evans NA: Current concepts in anabolic-androgenic steroids. Am J Sports Med 2004;32:534-542.

DISCUSSION: Internal impingement is characterized by articular-sided partial-thickness rotator cuff tears and superior glenoid labral tears. The capsule is characterized by laxity anteriorly and tightness posteriorly.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 82.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I:
Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.

Figure 27

DISCUSSION: The clinical picture reveals medial scapular winging, which involves the serratus anterior muscle, potentially due to an injury to the long thoracic nerve that innervates this muscle. Injury to the long thoracic nerve is usually due to closed trauma, direct compression, traction or stretching injury, a direct blow, or, very rarely, viral infection such as Parsonage-Tumer syndrome. The nerve is easily injured in surgical dissection of the axilla, and is predisposed to injury due to its relatively long course, it is small in diameter, and it has little surrounding connective tissue. If rehabilitation and time are unsuccessful, both nerve and muscle transfers have been described with mixed results.
REFERENCES: Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop Relat Res 1999;368:17 - 27.
Warner JJ, Navarro RA: Serratus anterior dysfunction: Recognition and treatment. Clin Orthop Relat Res 1998;349:139-148.

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DISCUSSION: The condition described in this case is known as a stinger or burner. It is caused by stretching the upper trunk of the brachial plexus in the C5 and C6 nerve roots. The symptoms are temporary and last 15 to 20 minutes. There are no residual deficits, unless the patient has had multiple repetitive injuries. Once motor and sensory examination findings and reflexes have normalized, the athlete can return to play. Acute spinal cord injury may cause temporary complete paralysis in the upper and lower extremities with resolution of symptoms within 24 hours. Central cord syndrome affects the upper more than lower extermities and affects mostly elderly patients. Nerve root avulsions lead to permanent deficits and have a poor prognosis for return of function. Guillain-BarDe syndrome is an autoimmune disease that presents as an ascending paralysis with weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes.
REFERENCES: Safran MR: Nerve injury about the shoulder in athletes. Part 2: Long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med 2004;32:1063-1076. Aval SM, Durand P Jr, Shankwiler JA: Neurovascular injuries to the athlete’s shoulder: Part I. J Am Acad Orthop Surg 2007;15:249-256.

DISCUSSION: Cadaveric studies have demonstrated the important role of the posterior horn of the medial meniscus in stabilizing the anterior cruciate ligament-deficient knee with significantly greater resultant force in the medial meniscus when subjected to anterior tibial loads. The posterior horn of the medial meniscus is thought to limit anterior tibial translation by acting as a buttress by wedging against the posterior aspect of the medial femoral condyle. The other soft tissues mentioned do not play any significant role in prevention of anterior tibial translation in the anterior cruciate ligament-deficient knee.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 200.
Allen CR, Wong EK, Livesay GA, et al: Importance of the medial meniscus in the anterior cruciate ligament-deficient knee. J Orthop Res 2000;18:109-115.
Levy IM, Torzilli PA, Warren RF: The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am 1982;64:883-888.

Figure 31

DISCUSSION: In the setting of significant anteroinferior glenoid bone deficiency (greater than 20% to 25%), both open and arthroscopic Bankart repairs have demonstrated higher rates of failure. Bony glenoid augmentation procedures such as the Bristow-Lataijet, which describe coracoid transfers to reconstruct the deficient glenoid, have led to decreased rates of recurrent shoulder instability. In this scenario, the patient has a significant loss of glenoid bone. There are also several clues in the history to suspect bone deficiency: multiple recurrences, a long history of recurrence, and instability in the midranges of motion.

A bony augmentation procedure such as the Lataijet has been well-described to provide a well functioning and stable shoulder joint. A hemiarthroplasty is not indicated in the absence of arthritis. Subscapularis
advancement will not address the bone loss.
REFERENCES: Hovelius L, Sandstrom B, Sundgren K, et al: One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study I— clinical results. J Shoulder Elbow Surg 2004;13:509-516.
Schroder DT, Provencher MT, Mologne TS, et al: The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. Am J Sports Med 2006;34:778-786.
Itoi E, Lee SB, Berglund LJ, et al: The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am 2000;82:35-46.

DISCUSSION: Recurrence of a ganglion cyst of the tibiofibular joint is most successfully treated by proximal tibiofibular joint fusion. A repeat excision will most likely result in recurrence of the cyst. Total or partial excision may lead to instability of the posterolateral structures of the knee. Interpositional arthroplasty has not been proven to be effective for the treatment of recurrent ganglion cysts of the proximal tibiofibular joint.
REFERENCES: Miskovsky S, Kaeding C, Weis L: Proximal tibiofibular joint ganglion cysts: Excision, recurrence, and joint arthrodesis. Am J Sports Med 2004;32:1022-1028.
Vatansever A, Bal E, Okcu G: Ganglion cysts of the proximal tibiofibular joint review of literature with three case reports. Arch Orthop Trauma Surg 2006;126:637-640.

DISCUSSION: The physical examination findings are consistent with an acute anterior cruciate ligament tear. In the acute setting, a lateral meniscus tear is a more common secondary injury than a medial meniscus tear. In one study of acute anterior cruciate ligament tears in alpine skiers, the incidence of lateral meniscus tears was over four times that of medial meniscus tears. Medial meniscus tears are more common in the chronic setting, most likely secondary to its role as a secondary restraint.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 201.
Greis PE, Bardana DD, Holmstrom MC, et al: Meniscal injury: I. Basic science and evaluation. J Am Acad Orthop Surg 2002;10:168-176.
Duncan JB, Hunter R, Purnell M, et al: Meniscal injuries associated with acute anterior cruciate ligament tears in alpine skiers. Am J Sports Med 1995;23:170-172.

DISCUSSION: Hewett and associates reported in a study of 205 female athletes that female athletes, with increased dynamic valgus and high abduction loads, were at increased risk of ACL injury. The same investigators in an earlier study of 81 high school basketball players reported that female athletes landed with greater total valgus knee motion and a greater maximum valgus knee angle than male athletes. Female athletes were also found to have significant differences between their dominant and nondominant side in maximum valgus knee angle. Lephart and associates reported that in single-leg landing and forward hop tasks that female athletes had significantly less knee flexion and lower leg internal rotation maximum angular displacement, and less knee flexion time to maximum angular displacement than males. Females with an adduction moment during landing should have a lower incidence of ACL tears. Males in general have a lower incidence of ACL tears.
REFERENCES: Hewett TE, Myer GD, Ford KR, et al: Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med 2005;33:492-501.
Ford KR, Meyer GD, Hewett TE: Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exerc 2003;35:1745-1750.
Lephart S, Ferris CM, Riemann BL, et al: Gender differences in strength and lower extremity kinematics during landing. Clin Orthop Relat Res 2002;401:162-169.

Fig ure 35

DISCUSSION: The MRI scan reveals a HAGL lesion. It more commonly affects older patients and is associated with more violent trauma.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 53-54.
Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the
glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96. Question 36
An 18-year-old woman injures her left knee playing soccer. At the time of anterior cruciate ligament (ACL) reconstruction, she was noted to have an irreparable posterior horn medial meniscus tear. Partial meniscectomy will have what primary effect?
1. #### Increase medial compartment peak loads
2. #### Increase medial compartment contact area
3. #### Decrease in situ forces in the ACL graft
4. #### Decrease anterior tibial translation
5. #### Increase posterior tibial translation PREFERRED RESPONSE: 1
DISCUSSION: The medial meniscus distributes force through the medial compartment. Peak loads in the affected compartment are increased by partial and complete meniscectomy. The posterior horn of the medial meniscus is also an important secondary restraint to anterior tibial translation in the ACL-deficient knee. In situ forces in the reconstructed ACL are increased with loss of the posterior horn of the medial meniscus.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 199-201.

Greis PE, Bardana DD, Holmstrom MC, et al: Meniscal injury: I. Basic science and evaluation. J Am Acad Orthop Surg 2002; 10:168-176.

DISCUSSION: The biceps is primarily responsible for supination of the forearm. The brachialis muscle is primarily repsonsible for elbow flexion strength. Failure to repair the distal biceps tendon will result in loss of 40% supination strength and 10% loss in flexion strength. Therefore, surgical repair of a complete distal biceps tendon rupture is most indicated to maximize supination strength. Improved cosmesis should not be the primary indication for surgical repair. Degenerative changes of the elbow have no bearing on whether the distal biceps is repaired or not. Loss of terminal extension is common in distal biceps tendon repairs.
REFERENCES: Altcheck DW, Altcheck AJ: The Athlete’s Elbow. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, p 288.
Morrey BF, Askew LJ, An KN, et al: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418^4-21.

DISCUSSION: The collateral ligaments of the MCP joint of the thumb can be isolated by flexing the joint to 30 degrees. Full extension is best to assess the accessory collaterals and the palmar plate. The ulnar collateral ligament nearly always separates from the base of first phalanx of the thumb; it frequently becomes lodged between adductor pollicis aponeurosis and its normal position (Stener lesion). The creation of a Stener lesion requires significant radial deviation of the phalanx along with combined tears of the proper and accessory collateral ligaments in order for the ligament to be displaced above the adductor aponeurosis.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgery, 2002, pp 339-358.
Stener B: Displacement of the ruptured ulnar collateral ligament of the MP joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1962;44:869-879.

33 • American Academy of Orthopaedic Surgeons

DISCUSSION: Although anaerobic weight training in this age group does not lead to muscle hypertrophy, it can increase the efficiency of muscle action by increasing muscle memory. There is insufficient testosterone in this patient population to allow for muscle hypertrophy. Proper techniques of weight training have been shown to be safe and do not damage the growth plates or joints in these individuals.
REFERENCES: Blimkie CJ: Resistance training during preadolescence: Issues and controversies. Sports Med 1993;15:389-407.
American Academy of Pediatrics Council on Sports Medicine and Fitness, McCambridge TM, Strieker PR: Strength training by children and adolescents. Pediatrics 2008;121:835-840.

Figure 40a Figure 40b Figure 40c

DISCUSSION: The arthroscopic images show a microfracture procedure. Perforation of the subchondral bone results in so-called “marrow stimulation” that results in the formation of fibrocartilage. This reparative tissue is composed predominantly of type I collagen with a disorganized matrix lacking a true tidemark, as opposed to hyaline cartilage which is composed primarily of type II collagen. This operation is indicated for full-thickness chondral defects without associated degenerative arthrosis. Microfracture is most commonly performed in the knee, though it has also been applied to other joints. Type III collagen is not a predominant component of fibrocartilage. Type IX and X are minor collagenous components of cartilage.
REFERENCES: Magnussen RA, Dunn WR, Carey JL, et al: Treatment of focal articular cartilage defects in the knee: A systematic review. Clin Orthop Relat Res 2008;466:952-962.
Williams RJ III, Hamly HW: Microfracture: Indications, technique, and results. Instr Course Lect 2007;56:419-428.
Mithoefer K, Williams RJ III, Warren RF, et al: Chondral resurfacing of articular cartilage defects in the knee with the microfracture technique: Surgical technique. J Bone Joint Surg Am 2006;88:294-304.

DISCUSSION: Stress fractures can be seen in female athletes who develop the female athletic triad including amenorrhea, osteoporosis, and eating disorders. Any female athlete with a history of stress fractures should undergo a workup for this disorder. Workup should include obtaining a menstrual history, obtaining a nutritional consultation, and obtaining a bone density. When properly counseled, these athletes may return to high endurance sports activities. Although these athletes may require a change in training intensity or psychiatric consultation, it would not be the next step in management. Psychiatric consultation may not be necessary unless an eating disorder has been diagnosed. Serum calcium levels are normal in these patients.
Tension-sided stress fractures of the femoral neck require surgical stabilization with internal fixation as opposed to compression-sided stress fractures that can be treated with rest and nonsurgical management.
REFERENCES: Feingold D, Hame SL: Female athlete triad and stress fractures. Orthop Clin North Am 2006;37:575-583.
Joy EA, Campbell D: Stress fractures in the female athlete. Curr Sports Med Rep 2005;4:323-328.

DISCUSSION: In symptomatic throwing shoulders, loss of internal rotation in abduction resulting from posteroinferior capsular contraction exceeds adaptive gains in external rotation. Glenohumeral internal rotation deficit (GIRD) is defined as the loss in degrees of glenohumeral internal rotation of the throwing shoulder compared with the non-throwing shoulder. The pathologic cascade initially begins with decreased velocity and command, followed by posterior stiffness and trouble loosening up. Posterior shoulder pain without mechanical symptom occurs during late cocking and early acceleration phases due to the contracture of the posterior-inferior capsule. This results in a posterosuperior shift of the glenohumeral contact, resulting in internal impingement on the undersurface of the posterior superior rotator cuff and strain on the posterior superior glenoid labral interface. The “slap event” is when the posterior superior labrum and biceps anchor fail in tension. After the “slap event”, surgery is the likely solution. Prior to this event, however, posterior inferior capsular stretches may result in resolution of symptoms.
REFERENCES: Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology Part II: Evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531-539.
Morgan CD: The throwing shoulder, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott-Raven, 2003, pp 570-584.

Figure 43a Figure 43b

DISCUSSION: The patient has mixed cam and pincer-type femoroacetabular impingement. The radiograph shows an aspherical femoral head, and an acetabulum with increasd lateral coverage. The MRI arthrogram shows a degenerative labral tear and an aspherical femoral head. The triad of MRI- arthrographic findings consists of anterosuperior labral tears, anterosuperior cartilage lesions, and an increased alpha angle as reported by Kassarjian and associates. The pathoanatomy of cam-type impingement is characterized by a pistol-grip deformity of the femoral head-neck junction and a relative retroversion of the femoral head. As a result, there is convexity of this area that causes abutment against the normal hip acetabulum with range of motion. Surgical treatment involves recontouring of the femoral head-neck. It can be performed arthroscopically or as an open procedure. The early results of these procedures are promising. However, Gerdeman and associates have pointed out that available evidence is very limited and long-term studies will be needed as to whether treatment halts the natural history of hip arthritis. In contrast, pincer-type
impingement is characterized by retroversion of the acetabulum and abutment of the normal proximal part of the femur against the abnormal acetabulum. An abduction orthosis has no role in the treatment of femoroacetabular impingement. A DEXA scan is unlikely to provide any additional useful information. It is unlikely that a bone scan will add any additional information. A hip osteotomy is not indicated.
REFERENCES: Clohisy JC, McClure JT: Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression. Iowa Orthop J 2005:25:164-171. Gerdeman AC, Hogan MV, Miller MD: What’s new in sports medicine? J Bone Joint Surg Am 2009;91:241-256.
Kassaijian A, Yoon LS, Belzile E, et al: Triad of MR arthrographic findings in patients with cam-type femoroacetabular impingement. Radiology 2005;236:588-592.

DISCUSSION: Sudden death in athletes without structural cardiac damage is referred to as commotio cordis. This is an emergency. The immediate priorities are protection of the airway, starting CPR, and early cardioversion as this patient has an arrythmia. It is hypothesized to occur from apnea, vasovagal reflex, or ventricular arrhythmia as reported by Maron and associates from the direct impact of the baseball during a vulnerable part of the cardiac rhythm. Janda and associates reported that soft-core baseballs may not differ from standard baseballs with regard to the risk of fatal chest-impact injury while playing baseball. High survival rates are associated with rapid treatment.
REFERENCES: Maron BJ, Poliac LC, Kaplan JA, et al: Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med 1995;333:337-342.
Janda DH, Bir CA, Viano DC, et al: Blunt chest impacts: Assessing the relative risk of fatal cardiac injury from various baseballs. J Trauma 1998;44:298-303.

DISCUSSION: Cam impingement creates shearing forces that result in an outside-in directed detachment of the labrum in the anterosuperior quadrant. Retroversion of the acetabulum is associated with pincer
impingement. The impingement is exhibited with hip flexion. Cam impingement involves a morphologic abnormality of the femoral head. Pincer lesions result from stresses of a normal femoral neck against an abnormal acetabular rim. Cam impingement is not associated with osteonecrosis.
REFERENCES: Jaberi FM, Parvizi J: Hip pain in young adults: Femoroacetabular impingement. J Arthroplasty 2007:22;37-42.
Byrd JW: The role of hip arthroscopy in the athletic hip. Clin Sports Med 2006:25;255-278.
Beck M, Kalhor M, Leunig M, et al: Hip morphology influences the pattern of damage to the acetabular

cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005:87; 1012-1018.

§. immediate repositioning or replantation of the tooth.

DISCUSSION: Avulsed teeth must be replanted immediately to enhance viability of the periodontal ligament cells on the root. With the tooth in place, the athlete should bite down on a towel to maintain stability. The athlete should be taken emergently to a dentist’s office or emergency room. The avulsed tooth should not be handled by the root or scrubbed to remove debris. If immediate replantation is not possible, the tooth should be transported in saline solution, milk, or saliva on gauze.
REFERENCES: Flores MT, Andreasen JO, Bakland LK, et al: Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001; 17:97-102.
Ranalli DN, Demas PN: Orofacial injuries from sport preventive measures for sports medicine. Sports Med
2002;2:409-418.

DISCUSSION: Ball and associates reported that “horseback riding was more dangerous than motorcycle riding.” In a 10-year study of major traumatic injuries, they reported that 151 (2%) of 7,941 trauma patients had major equestrian injuries (injury severity score > or = 12). Injuries included the chest (54%), head (48%), abdomen (22%), and extremities (17%). Only 9% of riders wore helmets, and 64% believed the accident was preventable. The authors noted that “helmet and vest use will be targeted in future injury prevention strategies.” In another study, Frankel and associates noted that helmet use was only documented in 34% of riders. Although orthopaedic injuries are common, knee pads, wrist guards, boots, and quick release stirrups would most likely have less impact on injury prevention.
REFERENCES: Ball CG, Ball JE, Kirkpatrick AW, et al: Equestrian injuries: Incidence, injury patterns, and risks factors for 10 years of major traumatic injuries. Am J Surg 2007;193:636-640.
Frankel HL, Haskell R, Digiacomo JC, et al: Recidivism in equestrian trauma. Am Surg 1998;64:151-154.
A 38-year-old man is three quarters of the way through the Hawaiian Ironman events run in a temperature of 60°F. He is sweating profusely and suddenly collapses. Prior to this he had been drinking large amounts of bottled water at every water stop. What is the most likely diagnosis?
1. #### Hypernatremia
2. #### Hypothermia
3. #### Hyponatremia
4. #### Subendocardial myocardial infarction
5. #### Ruptured berry aneurysm
PREFERRED RESPONSE: 3

DISCUSSION: Hyponatremia is often seen in endurance athletes such as triathloners, ultramarathoners, and marathoners after prolonged exertion. It is commonly attributed to excess free water intake that fails to replete massive sodium losses that result from sweating as reported by O’Connor. Exercise-induced hyponatremia is generally asymptomatic, particularly in patients in whom the sodium is only mildy reduced. Up to 10% of ultradistance athletes have a sodium level of 135 mEq/L or less, but those who are symptomatic usually have a sodium level of 125 mEq/L as reported by Noakes and O’Connor. The best way to prevent hyponatremia is to maintain the proper volume and types of fluid intake to ensure fluid balance during exercise. Beverages containing carbohydrates in concentrations of 4% to 8% (ie, “sports drinks”) are recommended for athletes participating in exercise lasting more than an hour (eg, marathon runners, etc.) To avert brainstem herniation and death, severe, acute hyponatremia requires rapid correction. Oral rehydration with salty solutions is safe and effective in patients with mild symptoms.
Too rapid correction has been reported to cause central pontine myelinolysis; therefore, correction ought to be performed slowly. Hypernatremia, hypothermia, subendocardial myocardial infarction, or ruptured berry aneurysm are unlikely in this scenario.
REFERENCES: O’Connor RE: Exercise-induced hyponatremia: Causes, risks, prevention, and management. Cleve Clin J Med 2006;73:S13-S18.
Noakes T: Hyponatremia in distance runners: Fluid and sodium balance during exercise. Curr Sports Med Rep
2002;1:197-207.
Laureno R, Karp BI: Myelinolysis after correction of hyponatremia. Ann Int Med 1997;126:57-62. Question 50
A 20-year-old male tennis player reports the acute onset of ulnar-sided wrist pain after hitting a forehand shot. Examination reveals dorsoulnar tenderness and minimal swelling. The pain is recreated with supination, wrist flexion, and ulnar deviation. Radiographs are normal. What structure is most likely involved?
1. #### Ulnar styloid
2. #### Flexor carpi radialis tendon
3. #### Extensor carpi ulnaris tendon
4. #### Scapholunate ligament
5. #### Transverse carpal ligament PREFERRED RESPONSE: 3
DISCUSSION: Extensor carpi ulnaris (ECU) lesions produce pain at the dorsoulnar aspect of the wrist, particularly during wrist supination, wrist flexion, and ulnar deviation. It has been frequently described in tennis players. Most ECU tenosynovitis can be successfully treated nonsurgically with immobilization techniques. Surgical treatment is generally indicated for ECU tenosynovitis or tendinopathy that does not respond to rest. Anatomically, the ECU retinaculum can rupture and the tendon can leave its sheath. With supination, the tendon can leave the sheath and then return to its position during pronation.
REFERENCES: Montalvan B, Parier J, Brasseur JL, et al: Extensor carpi ulnaris injuries in tennis players: A study of 28 cases. Br J Sports Med 2006;40:424-429.
Allende C, Le Viet D: Extensor carpi ulnaris problems at the wrist: Classification, surgical treatment and results. J Hand Surg Br 2005;30:265-272.

DISCUSSION: The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps are the “workhorse” portals of the posterior compartment and although relatively safe, risks exist. The radial nerve proximity averages 4.8 mm (3 to 8 mm) from the posterolateral portal. The central posterior portal close to 20 mm from the ulnar nerve.
REFERENCES: Steinmann SP: Elbow arthroscopy. J Am Society of the Hand 2003 ;3:199-207.
Dodson CC, Nho SJ, Williams RJ III, et al: Elbow Arthroscopy. J Am Acad Orthop Surg 2008:16:574- 585.

DISCUSSION: Biomechanical in vitro studies of double-row fixation of rotator cuff tears during cyclic loading and tensile loading to failure have demonstrated that double-row fixation results in a higher ultimate tensile load when compared to single-row fixation. Peak-to-peak elongation, stiffness, and conditioning
elongation for double-row fixation were all similar to single-row fixation. These initial findings, however, may or may not lead to improved clinical outcomes.
REFERENCES: Ma CB, Comerford L, Wilson J, et al: Biomechanical evaluation of arthroscopic rotator cuff repairs: Double-row compared with single-row fixation. J Bone Joint Surg Am 2006;88:403-410. Kim DH, El

Attrache NS, Tibone JE, et al: Biomechanical comparison of single-row versus double-row suture anchor technique for rotator cuff repair. Am J Sports Med 2006;34:407-414.

DISCUSSION: The anterior bundle of the ulnar collateral ligament of the elbow is the primary constraint to valgus force of the elbow. In pitchers and in overhead athletes, injury to this portion of the ligament results in valgus instability. Reconstruction of the anterior band of the ulnar collateral ligament is necessary in many elite athletic throwers to allow them to return to this competitive activity.
REFERENCES: Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.
Cain EL, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635.
Rettig AC, Sherrill C, Snead DS, et al: Nonoperative treatment of ulnar collateral ligament injuries in
throwing athletes. Am J Sports Med 2001 ;29:15-17.

/
Figure 55a Question 55
A 22-year-old male basketball player has had knee pain for the past 3 months. He denies any history of trauma. He has symptoms of catching but no locking. He has rested for 2 weeks but symptoms returned when he resumed sporting activities. Tr and T2-weighted MRI scans are shown in Figures 55a and 55b. What is the most likely diagnosis?
1. #### Locked lateral meniscus tear
2. #### Anterior cruciate ligament tear
3. #### Ganglion cyst of the anterior cruciate ligament
4. #### Synovial osteochondromatosis
5. #### Pigmented villonodular synovitis PREFERRED RESPONSE: 3
DISCUSSION: The MRI scans show a cystic structure within the anterior cruciate ligament. It is fluid filled as seen on the T2 sequence. Ganglion cysts of the cruciate ligaments are rare. The most common presentation is pain with occasional loss of motion. Instability is not a chief complaint and often there is no evidence of laxity on examination. If nonsurgical management fails, arthroscopic debridement of the cyst is the accepted method of treatment.
REFERENCES: Liu SH, Osti L, Mirzayan R: Ganglion cysts of the anterior cruciate ligament: A case report and review of the literature. Arthroscopy 1994; 10:110-112.
Parish EN, Dixon P, Cross MJ: Ganglion cysts of the anterior cruciate ligament: A series of 15 cases. Arthroscopy 2005;21:445-447.

Figure 56

DISCUSSION: It is important to recognize that rotator cuff tears are a common finding in the setting of a dislocated long head of the biceps tendon (LHB) from the intertubercular groove of the shoulder. If a LHB tendon dislocation is found on examination or radiographic work-up (ultrasound or MRI), it is imperative to rule out associated rotator cuff pathology, specifically of the subscapularis tendon. Although very rare, injury to the lesser tuberosity should also be ruled out. There are a variety of methods to treat the dislocated biceps (tenotomy versus tenodesis); however, the entire rotator cuff, especially the subscapularis, should be carefully inspected and treated if necessary. The corollary is also true - if you find a tear of the subscapularis tendon insertion, especially the superior half, the LHB should be carefully inspected to ensure that it is not unstable as it exits the shoulder. If the LHB is unstable, this is also addressed surgically with either tenotomy or tenodesis. The middle glenohumeral ligament and Bankart tears are not stabilizers of the biceps.
REFERENCES: Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654.
Edwards TB, Walch G, Sirveaux F, et al: Repair of tears of the subscapularis: Surgical technique. J Bone Joint Surg Am 2006;88:1-10.
Tung GA, Yoo DC, Levine SM, et al: Subscapularis tendon tear: Primary and associated signs on MRI. J Comput Assist Tomogr 2001;25:417-424.

46 • American Academy of Orthopaedic Surgeons

Figure 57

DISCUSSION: The MR arthrogram shows medial subluxation of the biceps tendon out of the bicipital groove and a subscapularis tendon tear. Biceps tendon subluxation is almost always associated with subscapularis tears. Whereas other diagnoses can be associated, none of them is directly related to this finding or seen on the MR arthrogram.
REFERENCES: Lafosse L, Jost B, Reiland Y, et al: Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 2007;89:1184-1193.
Tonino PM, Gerber C, Itoi E, et al: Complex shoulder disorders: Evaluation and treatment. J Am Acad Orthop Surg 2009:17:125-136.

DISCUSSION: One of the most difficult aspects of posterior cruciate ligament reconstruction is placement of the tibial tunnel and passing of the graft through this tunnel. The tibial inlay technique requires a posteromedial approach to the tibia whereby the graft is directly fixed to the posterior aspect of the tibia. This obviates the need for a tibial tunnel. This technique has never been shown to be less invasive, more cosmetic,

or require decreased surgical time. It has also never been shown in a published level I study to have superior clinical results. However, it does eliminate the need for the 90-degree critical “killer” turn and passing of the tibial graft through the tibial tunnel which may lead to graft failure.
REFERENCES: McAllister DR, Petrigliano FA: Diagnosis and treatment of posterior cruciate ligament injuries. Curr Sports Med Rep 2007;6:293-299.
Cosgarea AJ, Jay PR: Posterior cruciate ligament injuries: Evaluation and management. J Am Acad Orthop Surg 2001;9:297-307.

DISCUSSION: The figure is a stress-strain diagram representing specific metal subjected to increasing tensile stress. The portion of the curve from A to B is a straight line demonstrating a proportional increase in strain for each increase in tensile stress. If the stress is removed at any point between A and C, the material will return to its original shape, returning back along the original curve without permanent deformation. This is termed elastic behavior. If the applied stress causes strain beyond point C, then permanent deformation occurs and returns along a different path to a different zero stress point. This is termed plastic behavior. The point C at which the material stops behaving in an elastic manner and begins behaving in a plastic manner is the elastic limit or yield point. Point D represents a point on the curve of plastic deformation. Point E is the fracture point when the stress on the material creates enough strain that the material fractures.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 45-46.
El-Ghannam A, Ducheyne P: Biomaterials, in Mow VC, Huiskes R (eds): Basic Orthopaedic Biomechanics and Mechano-Biology, ed 3. Philadelphia, PA, Lippincott-Raven, 2005, pp 501-503.

Figure 60

DISCUSSION: It is important to recognize the injury pattern sustained by this motocross rider by inspection of his traumatic scars present anteriorly over the proximal tibia and the dorsum of the ankle and dorsum of the forefoot, indicating that his foot was in a plantar flexed position with a concomitant blow to the anterior tibia. This is a classic mechanism for a posterior cruciate ligament injury, and external clues (the scars) should not be overlooked when examining the knee. Occasionally, a posterior cruciate ligament injury is overlooked; however, putting together the patient’s history, the examination (especially the posterior drawer and quadriceps active tests) provide a reliable diagnosis. Additional pathology should also be ruled out, such as a posterolateral corner injury and intra-articular pathology. Patella fracture, tibial tubercle avulsion, and patella tendon tears are unlikely because the patient can actively extend the knee.
An anterior cruciate ligament tear is unlikely with a negative Lachman examination.
REFERENCES: Janousek AT, Jones DG, Clatworthy M, et al: Posterior cruciate ligament injuries of the knee joint. Sports Med 1999;28:429-441.
McAllister DR, Petrigliano FA: Diagnosis and treatment of posterior cruciate ligament injuries. Curr Sports
Med Rep 2007;6:293-299.

DISCUSSION: The anterior bundle originates on the anteroinferior medial humeral epicondyle and inserts on the medial portion of the coronoid, known as the sublime tubercle.
REFERENCES: O’Driscoll SW, Jaloszynski R, Morrey BF, et al: Origin of the medial ulnar collateral ligament. J Hand Surg Am 1992; 17:164-168.
Grace SP, Field LD: Chronic medial elbow instability. Orthop Clin North Am 2008;39:213-219.

DISCUSSION: Biomechanical analysis has demonstrated that local dynamic stability of the elbow is provided by the flexor digitorum superficialis and the flexor carpi ulnaris, especially during the cocking and acceleration phases of the overhand throw. This provides dynamic joint compression across the elbow joint and may be protective to the static restraints such as the ulnar collateral ligament. It also emphasizes the need to strengthen distant muscles in the forearm to assist with elbow biomechanics and potentially prevent injury.

REFERENCES: Davidson PA, Pink M, Perry J, et al: Functional anatomy of the flexor pronator muscle group in relation to the medial collateral ligament of the elbow. Am J Sports Med 1995;23:245-250. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.

Figure 63a Figure 63b

DISCUSSION: The patient’s history, examination, and imaging studies are consistent with the os trigonum syndrome. The os trigonum is an accessory ossification center of the posterior process of the talus. It can become painful in some athletes after ankle dorsiflexion or jumping, and is most common in ballet dancers and basketball players. Traumatic disruption of the synchondrosis between the os trigonum and the talus can lead to pain. MRI imaging of these injuries typically shows fluid surrounding the os with associated marrow
edema. There is usually no marrow edema in the talus to suggest an acute fracture of the posterior process. These injuries are definitively managed with excision (either open or arthroscopic) of the inflamed os trigonum with return to sports expected within 2 to 3 months. Physical therapy may provide short-term relief but is unlikely to provide permanent relief. Corticosteroid injection is not recommended in this location.
Surgical fixation is not indicated for this entity.

REFERENCES: Chao W: Os trigonum. Foot Ankle Clin 2004;9:787-796.
Kadel N: Excision of os trigonum. Operative Techniques in Orthopaedics 2004; 14:1-5. Davies M: The os trigonum syndrome. Foot 2004; 14:119-123.

DISCUSSION: Approximately 5% of female recruits incur a stress fracture during the 13 weeks of Marine Corps basic training. Approximately 40% of these were femoral or pelvic stress fractures that were more severe than in civilian athletes or male military recruits. Only women who reported no menses during the previous year had a greater likelihood of femoral or pelvic stress fractures than did women who reported 10 to
12 menses. The referenced study did not find a statistically significant increase in risk of stress fracture in those recruits who had lesser menstrual irregularities in the year prior to recruit training, but there was a trend toward increased risk of stress fracture.
REFERENCES: Shaffer RA, Rauh MJ, Brodine SK, et al: Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med 2006;34:108-115.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2004, pp 273-283.

DISCUSSION: Herpes simplex virus (HSV) can cause serious outbreaks on athletic teams, especially wrestling. HSV is highly contagious; it is secreted from active blisters, saliva, and mucous membranes. For wrestlers, the NCAA states that the athlete must be free from systemic symptoms and any new blisters for 72

hours before being allowed to participate. Also, all lesions must be dry and crusted and at least 120 hours of antiviral therapy should have been instituted.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 301-309.
Johnson R: Herpes Gladiatorium and other skin diseases. Clin Sports Med 2004;23:473-484.

DISCUSSION: Eccentric strengthening for tendinopathies has proved most helpful in the later stages of rehabilitation. Although the exact mechanism of the effect on eccentric exercises is not known, the most widely accepted theory is that the absence of concentric stretching disrupts the normal lengthing/shorten- ing cycle which may cause shearing in the tendon and injury to the collagen. Isokinetic exercise maintains a constant angular velocity of joint motion. Isotonic exercise maintains a constant force of contraction while isometric contraction develops force without changing the length of the musculotendinous unit.
All three types of these exercises have not been shown to benefit Achilles tendinitis as much as eccentric exercise.
REFERENCES: Jonsson P, Alfredson H, Sunding K, et al: New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: Results of a pilot study. Br J Sports Med
2008;42:746-749.
Maffulli N, Walley G, Say ana MK, et al: Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Disabil Rehabil 2008;30:1677-1684.

Figure 67

DISCUSSION: The supplement is creatine. Approximately 17% of high school athletes and about 30% of high school football players use creatine. Creatine is a protein synthesized in the liver and the kidney, circulates in the bloodstream, and is incorporated into muscle. Its use is associated with increased muscle mass, short-term improvement in sprinting, and may allow for increased anaerobic resistance performance. Caffeine and ephedrine are taken orally but do not increase muscle mass. Testosterone and human growth hormone are both associated with increased body mass but must be injected.

PREFERRED RESPONSE: 1

REFERENCES: McGuine TA, Sullivan JC, Bernhardt DT: Creatine supplementation in high school football players. Clin J Sports Med 2001 ;11:247-253.
Rawson ES, Gunn B, Clarkson PM: The effects of creatine supplementation on exercise-induced muscle damage. J Strength Cond Res 2001; 15:178-184.
Branch JD: Effect of creatine supplementation on body composition and performance: A meta-analysis.
Int J Sport Nutr Exerc Metab 2003;13:198-226.

DISCUSSION: The patient has an olecranon stress fracture due to overuse injury from pitching. The repetitive forceful contraction of the triceps coupled with varus and valgus torques about the elbow are felt to cause the olecranon epiphysis to separate from the adjacent epiphyseal plate as reported by Torg and Moyer. This may persist into late adolescence; Charlton and Chandler described five throwing athletes between the ages of 16 to 20 years with delayed closure of the olecranon epiphysis and inability to throw. The ulnar collateral ligament was intact in all. The patients in their study underwent open reduction and internal fixation with tension band wire, screw fixation, and autogenous bone graft in some of the cases.
At 32 months, all were asymptomatic despite a prolonged preoperative course (> 30 months) of limiting pain. It is important to recognize stress fractures about the elbow in a young pitching population and treat accordingly first with rest and cessation of throwing activities. If prolonged, surgical fixation provides reliable results.
REFERENCES: Charlton WP, Chandler RW: Persistence of the olecranon physis in baseball players: Results following operative management. J Shoulder Elbow Surg 2003;12:59-62.
Torg JS, Moyer RA: Non-union of a stress fracture through the olecranon epiphyseal plate observed in an
adolescent baseball pitcher. J Bone Joint Surg Am 1977;59:264-265.
Rettig AC, Wurth TR, Mieling P: Nonunion of olecranon stress fractures in adolescent baseball pitchers: A case series of 5 athletes. Am J Sports Med 2006;34:653-656.

DISCUSSION: A loss of flexion and internal rotation are hallmarks of FAI. With the hip flexed 90 degrees, maximal internal rotation testing is also known as the anterior impingement test, causing deep groin pain and

reproduction of symptoms. Occasionally, a posterior impingement test will be positive with extension and external rotation. There are a variety of causes of FAI; however, the pathology limits motion as the femur (cam) and acetabulum (pincer) contact one another. Also, only one location needs to be present, such as cam- type or pincer-type versus both cam-pincer lesions to cause symptoms.
REFERENCES: Philippon MJ, Stubbs AJ, Schenker ML, et al: Arthroscopic management of femoroac- etabular impingement: Osteoplasty technique and literature review. Am J Sports Med 2007;35:1571 -1580, Siebenrock KA, Schoeniger R, Ganz R: Anterior femoroacetabular impingement due to acetabular retro- version: Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85:278 -286. Kubiak-Langer M, Tannast M, Murphy SB, et al: Range of motion in anterior femoroacetabular impingement. Clin Orthop Relat Res 2007;458:117-124.

DISCUSSION: The only reported cases of HIV transmission with tissue transplantation occurred more than 20 years ago. The only reported cases of tuberculosis and hepatitis B occurred more than 50 years ago. The donor-associated clostridium infection occurred in 2001. The facility was not AATB-accredited (American Association of Tissue Banks) and the local A ATB facility refused the graft. It is necessary for the surgeon using the allograft tissue to be aware of the current status of tissue regulation, and procurement and processing procedures.
REFERENCES: McAllister DR, Joyce MJ, Mann BJ, et al: Allograft update: The current status of tissue regulation, procurement, processing, and sterilization. Am J Sports Med 2007;35:2148-2158.
Safety of tissue transplants. American Association of Tissue Banks, 2006. Question 74
Which of the following types of intra-articular pathology is associated with lateral meniscal cysts?
1. #### Discoid meniscus
2. #### Posterolateral comer injury
3. #### Vertical meniscal tears
4. #### Middle third lateral meniscal tears
5. #### Popliteus tendon tears

PREFERRED RESPONSE: 4
DISCUSSION: Lateral meniscal cysts often arise from myxoid degeneration that progresses from the meniscal center and then outside the meniscus. Horizontal cleavage tears are commonly associated with the condition.
Cysts of the lateral meniscus are most commonly the consequence of a tear located in the medial third. If the
tear communicates with the joint, arthroscopic partial meniscectomy and cyst decompression are indicated. If the tear does not open into the joint, arthroscopy should be followed by an open cystectomy.
REFERENCES: Hulet C, Souquet D, Alexandre P, et al: Arthroscopic treatment of 105 lateral meniscal cysts with 5-year average follow-up. Arthroscopy 2004;20:831-836.
Ferrer-Roca O, Vilalta C: Lesions of the meniscus: Part I. Macroscopic and histologic findings. Clin Orthop
Relat Res 1980;146:289-300.
Ferrer-Roca O, Vilalta C: Lesions of the meniscus: Part II. Horizontal cleavages and lateral cysts. Clin Orthop Relat Res 1980:146:301-307.

Figure 75

DISCUSSION: The MRI scan findings and patient history demonstrate a compression-sided femoral neck stress fracture. The stress fracture on the coronal MRI scan involves about one third of the width of the femoral neck. Surgical treatment would be recommended for tension-sided fractures of the femoral neck. The most appropriate initial treatment is protected weight bearing, with close examination and imaging follow-up. Skeletal traction is not currently used for nondisplaced femoral neck stress fractures, and there is no indication

for open reduction and internal fixation. There is no documented role for pulsed ultrasound or calcium supplements in the acute treatment of stress fractures.
REFERENCES: Shin AY, Morin WD, Gorman JD, et al: The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med 1996;24:168-176.
Pihlajamaki HK, Ruohola JP, Weckstrom M, et al: Long-term outcome of undisplaced fatigue fractures of the
femoral neck in young male adults. J Bone Joint Surg Br 2006;88:1574-1579.
Valimaki VV, Alfthan H, Lehmuskallio E, et al: Risk factors for clinical stress fractures in male military recruits: A prospective cohort study. Bone 2005;37:267-273.

DISCUSSION: Anabolic steroids increase procoagulant factors VII and IX and thromboxane, all of which lead to hypercoagulability which would decrease bleeding time. Liver function is usually upregulated as oral steroids induce hepatic enzymes and patients are therefore less sensitive to anesthetic agents. Anabolic steroids have a mineralocorticoid effect and users frequently use diuretics to mask this effect. Both can lead to fluid and electrolyte imbalances. Cardiovascular effects include hypertension, left ventricular hypertrophy, impaired diastolic filling, and thrombosis. Large muscle mass and high calorie intake lead to high ventilatory requirements caused by increased oxygen consumption and carbon dioxide production. Anabolic steroids have no effect on the spleen.
REFERENCES: Kam PC, Yarrow M: Anabolic steroid abuse: Physiological and anesthetic considerations. Anaesthesia 2005;60:685-692.
Ansell JE, Tiarks C, Fairchild VK: Coagulation abnormalities associated with the use of anabolic steroids. Am Heart J 1993;125:367-371.

Figure 77

DISCUSSION: The most serious, acute complication of severe maxillofacial trauma is airway obstruction that can result in early death. It is most likely to be associated with multiple mandibular fractures or combined maxillary, mandibular, and nasal fractures as reported by Seyfer and Hansen and Rohrich and Shewmaker.
The mandible suspends the tongue anteriorly. When the mandible is fractured and the patient is supine, the tongue falls posteriorly and obstructs the airway. Soft-tissue swelling around the injured oronasal structures can also result in a loss of airway patency. Endotracheal or nasotracheal intubation is often impossible and a surgical airway may often have to be created to prevent death by asphyxiation. Other injuries that may require immediate attention include head or cervical spine injury and hemorrhage. A cerebrovascular accident is also less common but is associated with injury to the common carotid artery or its branches. Periodontal disease is generally a long-term complication from dental injuries. Hearing loss is not a common complication of dental and facial trauma.
REFERENCES: Seyfer AE, Hansen JE: Facial trauma, in Moore EF, Feliciano DV, Maddox KL (eds): Trauma, ed 5. New York, NY, McGraw-Hill, 2004, pp 423-444.
Rohrich RJ, Shewmake KB: Evolving concepts of craniomaxillofacial fracture management. Clin Plast
Surg 1992;19:1-10.

DISCUSSION: Most imaging studies in mild traumatic brain injury will be normal. Neuropsychologic testing is the most sensitive test in assessing mild deficits after traumatic brain injury. Sideline assessment is important but less sensitive in assessing deficits. The precise role of neuropsychologic testing in determining return to play has not been fully defined.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 37-38.

62 • American Academy of Orthopaedic Surgeons

Maroon JC, Lovell MR, Norwig J, et al: Cerebral concussion in athletics: Evaluation and neuropsychological testing. Neurosurgery 2000;47:659-672.

Figure 79

images with tibial stress fractures.
5. #### After activity, pain persists longer with tibial stress fractures.
PREFERRED RESPONSE: 1
DISCUSSION: Anterior tibial pain can often be difficult to diagnose. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture. Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but are also seem in otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient’s history of increased physical activity and on imaging findings.
The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis. If the diagnosis is made early, most bone stress injuries heal well without complications.
REFERENCES: Mubarak SJ, Gould RN, Lee YF, et al: The medial tibial stress syndrome: A cause of shin splints. Am J Sports Med 1982;10:201-205.
Knobloch K, Yoon U, Vogt PM: Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int 2008:29:671-676.
Kiuru MJ, Pihlajamaki HK, Ahovuo JA: Bone stress injuries. Acta Radiol 2004;45:317-326.

DISCUSSION: The extensor carpi radialis brevis is most often cited as the anatomic location of pathology in lateral epicondylitis. Histologic examination demonstrates noninflammatory tissue, primarily
angiofibroblastic tendinosis though normal tendon histology is also present. There is usually no evidence of acute inflammation or chondroblastic tissue, or significant calcium deposition.
REFERENCES: Nirschl RP, Ashman ES: Tennis elbow tendinosis (epicondylitis). Instr Course Lect 2004;53:587-598.
Lo MY, Safran MR: Surgical treatment of lateral epicondylitis: A systematic review. Clin Orthop Relat Res 2007;463:98-106.
Calfee RP, Patel A, DaSilva MF, et al: Management of lateral epicondylitis: Current concepts. J Am Acad Orthop Surg 2008;16:19-29.

DISCUSSION: Appropriate management of osteitis pubis includes rest, nonsteroidal anti-inflammatory drugs, directed rehabilitation, and gradual return to sports. Lack of fever or chills excludes osteomyelitis as a source of pain. Examination with tenderness over the symphysis pubis and pain with resisted rectus abdominus testing is consistent with osteitis pubis as opposed to a sports hernia, where a patient would be tender in the abdomen, not the pubis. There is no symphyseal instability that would require symphyseal plating.
REFERENCES: Fricker PA, Taunton JE, Ammann W: Osteitis pubis in athletes. Sports Med 1991 ;12:266-

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279.
Williams PR, Thomas DP, Downes EM: Osteitis pubis and instability of the pubic symphysis: When nonoperative measures fail. Am J Sports Med 2000;28:350-355.

DISCUSSION: Closed chain kinetic exercises confer a margin of safety and are protective of healing or repaired tissues by the compressive nature of the applied forces. Closed chain kinetic exercise is associated with decreased shear, translation, and distraction of the joints within the chain. Because of patterns of motion with closed chain kinetic exercises, individual muscles may not be maximally strengthened or all joint motion returned to normal. Closed chain kinetic exercises may be used earlier in the rehabilitation process.
REFERENCES: Kibler WB, Livingston B: Closed-chain rehabilitation for upper and lower extremities. J Am Acad Orthop Surg 2001;9:412-421.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2004, pp 131-132.

DISCUSSION: Endurance training causes selective hypertrophy of type I muscle fibers. It stimulates an increase in the enzymes of the Krebs cycle which increases the capacity for aerobic ATP resynthesis during exercise. There is a decrease in the rate of glycogen depletion. Depletion of glycogen has been linked to

fatigue during endurance exercise. Endurance training blunts the catecholamine response and may contribute to the reduction in heart rate observed for the same exercise intensity following training. The greater use of lipid reduces the contribution of carbohydrate to ATP resynthesis and preserves muscle glycogen.
REFERENCES: Jones AM, Carter H: The effect of endurance training on parameters of aerobic fitness. Sports Med 2000:29:373-386.
Spina RJ, Chi MM, Hopkins MG, et al: Mitochondrial enzymes increase in muscle in response to 7-10 days of cycle exercise. J Appl Physiol 1996;80:2250-2254.
Kiens B, Essen-Gustavsson B, Christensen NJ, et al: Skeletal muscle substrate utilization during submaximal exercise in man: Effect of endurance training. J Physiol 1993;469:459-478.

DISCUSSION: Dynamic patellofemoral joint contact measurements on cadaveric knees with simulated increased Q angle demonstrated that forces shifted to the lateral facet. The lateral shift in the patella was most pronounced from 40 to 90 degrees of flexion. At lower degrees of flexion, the lateral shift was significantly less. At higher degrees of flexion, the continued shift of the patella was not as pronounced.
REFERENCES: Ramappa AJ, Apreleva M, Harrold FR, et al: The effects of medialization and anteromedialization of the tibial tubercle on patellofemoral mechanics and kinematics. Am J Sports Med 2006;34:749-756.
Huberti HH, Hayes WC: Patellofemoral contact pressure: The influence of q-angle and tendofemoral contact. J Bone Joint Surg Am 1984;66:715-724.

DISCUSSION: The incidence of preimplantation positive cultures of musculoskeletal allografts used for anterior cruciate ligament reconstruction has varied between 4.8% and 13.3%. Interestingly, in none of the studies evaluating this issue did any of the patients implanted with a “contaminated” graft develop a clinical infection. The results of the current literature suggest that the treatment of low- virulence organisms is unnecessary if no evidence of clinical infection exists. Preimplantation cultures do not appear to correlate with clinical infection. Therefore, the routine culture of allograft tissue is not recommended.
REFERENCES: Diaz-de-Rada P, Barriga A, Barroso JL, et al: Positive culture in allograft ACL- reconstruction: What to do? Knee Surg Sports Traumatol Arthrosc 2003; 11:219-222.
Guelich DR, Lowe WR, Wilson B: The routine culture of allograft tissue in anterior cruciate ligament reconstruction. Am J Sports Med 2007;35:1495-1499.
Centeno JM, Woolf S, Reid JB III, et al: Do anterior cruciate ligament allograft culture results correlate with clinical infections? Arthroscopy 2007;23:1100-1103.

72 • American Academy of Orthopaedic Surgeons

Figure 87a Figure 87b

DISCUSSION: The MRI scans reveal increased signal in the medial facet of the patella and the anterior aspect of the lateral femoral condyle. This pattern is typically seen in patients with acute patellar dislocations. In patients with ACL tears, the bone bruise of the lateral femoral condyle is usually seen in the central portion at the sulcus terminalis and the posterior half of the lateral tibial plateau and is not usually seen in the patella. This pattern of bone bruising is not seen with patellar tendon ruptures, LCL tears, and PCL tears.
REFERENCES: Elias DA, White LM, Fithian DA: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-743.
Virolainen H, Visuri T, Kuusela T: Acute dislocation of the patella: MR findings. Radiology 1993;189:243-246.

DISCUSSION: The goal in the initial phase of shoulder rehabilitation is to improve flexibility, reestablish baseline dynamic stability, normalize muscle balance, and restore proprioception. In the advanced strengthening and final phase, the goals are to initiate aggressive strengthening drills, enhance power and endurance, perform functional drills, and to gradually initiate throwing activities.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Wilk KE, Arrigo C: Current concepts in the rehabilitation of the athletic shoulder. J Orthop Sports Phys Ther 1993;18:365-378.

DISCUSSION: This is a typical presentation for an osteochondral lesion of the capitellum. This patient is young and has, by definition, a stable lesion and has excellent potential to heal this lesion with nonsurgical management. However, the patient should stop her activities (gymnastics) to prevent further damage and the possible development of an unstable lesion that might then necessitate surgery. Surgical procedures are generally not necessary for the treatment of these lesions.
REFERENCES: Byrd JW, Jones KS: Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: Minimum three-year follow-up. Am J Sports Med 2002;30:474-478.
Cain EL Jr, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J
Sports Med 2003;31:621-635.

DISCUSSION: Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability.
The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability.
REFERENCES: Beck M, Kalhor M, Leunig M, et al: Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005;87:1012-1018.
Ito K, Leunig M, Ganz R: Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res 2004;429:262-271.
Crawford MJ, Dy CJ, Alexander JW, et al: The 2007 Frank Stinchfield Award. The biomechanics of the hip labrum and the stability of the hip. Clin Orthop Relat Res 2007;465:16-22.

6,000,000

DISCUSSION: The calculated risk of a musculoskeletal allograft containing HIV despite adequate screening has been estimated to be approximately 1 in 1.6 million. This estimate is based on the risk of HIV in the population, projected population estimates, and current methods of donor screening.

REFERENCES: McAllister D, Joyce M, Mann B, et al: Allograft update: The current status of tissue regulation, procurement, processing, and sterilization. Am J Sports Med 2007;2148-2158.
Buck B, Malinin T: Human bone and tissue allografts: Preparation and safety. Clin Orthop Relat Res 1994;303:8 -
17.
Buck B, Malinin T, Brown M: Bone transplantation and human immunodeficiency virus: An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop Relat Res 1989;240:129-136.

_A i;___
Figure 92

DISCUSSION: The T2-weighted sagittal MRI scan shows the classic “bone bruise” pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T2-weighted images and diminished signal intensity on Trweighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus- extemal rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.

REFERENCES: Vellet AP, Marks PH, Fowler PJ, et al: Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology 1991;178:271-276.
Cone R: Imaging sports-related injuries of the knee, in DeLee J, Drez D, Miller M (eds): DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 2, pp 1595-1652.

DISCUSSION: A subpectoral biceps tenodesis requires an additional incision at the insertion of the pectoralis major tendon on the humerus. This can be difficult to do in the lateral decubitus position and certainly this technique does not decrease surgical time when compared to arthroscopic soft-tissue techniques. There have been no level I studies comparing the two techniques; however, the theoretical advantage of the open biceps subpectoral tenodesis is that the biceps tendon is removed from the bicipital groove, which may eliminate a source of pain in the biceps tendon.
REFERENCES: Mazzocca AD, Rios CG, Romeo AA, et al: Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 2005;21:896.
Osbahr DC, Diamond AB, Speer KP: The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy 2002;18:483-487.

Figure 94

DISCUSSION: The probe is on the middle glenohumeral ligament (MGHL), which, in this case, is a cordlike and robust structure, commonly known as a Buford complex. The space between the bony glenoid and the MGHL (in this case, a cord-like Buford complex) is a normal variant and should not be repaired or tightened to the bony glenoid with a soft-tissue anchor or other repair. If this structure is inadvertently repaired, the most common scenario is loss of external rotation with the arm at the side, as the MGHL/ Buford complex becomes tight with the arm in this position. The loss of external rotation is more pronounced with the arm at the side than abducted at 90 degrees as the MGHL/Buford complex becomes tighter with the arm at the side than abducted.
REFERENCES: Williams MM, Snyder SJ, Buford D Jr: The Buford complex: The “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex: A normal anatomic capsulolabral variant. Arthroscopy 1994;10:241-247.
Ide J, Maeda S, Takagi K: Normal variations of the glenohumeral ligament complex: An anatomic study for arthroscopic Bankart repair. Arthroscopy 2004;20:164-168.
Gerber C, Werner CM, Macy JC, et al: Effect of selective capsulorrhaphy on the passive range of motion of
the glenohumeral joint. J Bone Joint Surg Am 2003;85:48-55. Question 95
What allograft has the highest antigenicity when used for ligament reconstruction about the knee?
1. #### Tibialis anterior used for anterior cruciate ligament (ACL) reconstruction
2. #### Tibialis anterior used for posterolateral reconstruction
3. #### Bone-patellar tendon-bone used for ACL reconstruction
4. #### Semitendinosus used for posterior cruciate ligament reconstruction
5. #### Semitendinosus used for medial collateral ligament reconstruction PREFERRED RESPONSE: 3
DISCUSSION: Although theoretically the intra-articular environment is slightly more immune privileged, the role of immunogenicity is related more to bone than soft tissue. Therefore, the bone-patellar tendon- bone used for ACL reconstruction would have the highest risk of immunogenicity if storage techniques and harvest techniques were similar. This also is true for bone plugs associated with meniscal allografts.
REFERENCES: Rodeo SA, Seneviratne A, Suzuki K, et al: Histological analysis of human meniscal allografts: Apreliminary report. J Bone Joint Surg Am 2000;82:1071-1082.
West RV, Hamer CD: Graft selection in anterior cruciate ligament reconstruction. J Am Acad Orthop Surg

2005;13:197-207.

DISCUSSION: Common treatments for patellar tendinopathy include rest, ice, electrotherapy, massage, taping and injection. None has been demonstrated to be effective. Eccentric training has proven to be as effective as surgical treatment. Achilles insertional tendinopathy has also proven to respond to eccentric training.
REFERENCES: Bahr R, Fossan B, Loken S, et al: Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper’s Knee): A randomized, controlled trial. J Bone Joint Surg Am 2006;88:1689- 1698.
Coleman BD, Khan KM, Maffulli N, et al: Studies of surgical outcome after patellar tendinopathy: Clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 2000;10:2-11.

DISCUSSION: Chronic exertional compartment syndrome of the leg is characterized by pain (often burning in nature) of the involved compartment(s) (typically anterior) that worsens with activity and completely subsides within 15 minutes of activity cessation. A high index of suspicion is warranted for this condition. Intracompartmental pressure thresholds considered diagnostic are a 1-minute postexercise pressure of 30 mm Hg and a 5-minute post-exercise pressure of 20 mm Hg. This condition is not associated with the classic findings of an acute compartment syndrome. In this particular example, anterior leg pain with passive dorsiflexion of the toes and sensory loss of the plantar aspect of the foot would not be expected with an exertional compartment syndrome of the anterior compartment.
REFERENCES: Pedowitz RA, Hargens AR, Mubarek SJ, et al: Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990;18:35-40.
Rorabeck CH, Fowler PJ, Nott L: The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med 1988;16:224-227.

DISCUSSION: Idiopathic hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in athletes. The diagnosis is made with an echocardiogram; however, echocardiograms have not been shown to be a cost-effective screening tool for this condition. The most cost-effective method of screening for this condition includes obtaining a history of chest pain or syncope in the athlete, or a family history of early cardiac death. It has been estimated that it would cost over $500,000 to diagnose one case of hypertrophic cardiomyopathy if screening echocardiograms were used. Auscultation of the heart and heart sounds can be normal in an athlete at rest with this condition, and a stress test will not help diagnose idiopathic hypertrophic cardiomyopathy.
REFERENCES: Bader RS, Goldberg L, Sahn DJ: Risk of sudden death in young athletes: Which screening strategies are appropriate? Pediatr Clin North Am 2004;51:1421 -1441.
Maron BJ, Thompson PD, Ackerman MJ, et al: Recommendations and considerations related to prepar- ticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation. Circulation 2007;115:1643-1655.

DISCUSSION: The well-conditioned heart of an athlete leads to increased ventricular wall thickness which in turn increases the amount of blood ejected from the heart per given stroke (stroke volume). The increased parasympathetic (vagal) tone also leads to a lower (decreased) resting heart rate. Cardiac output is equal to stroke volume x heart rate and is increased during exercise in a well-conditioned athlete.
REFERENCES: Basilico FC: Cardiovascular disease in athletes. Am J Sports Med 1999;27:108-121. Huston TP, Puffer JC, Rodney WM: The athletic heart syndrome. N Engl J Med 1985;313:24-32.
An 18-year-old boxer sustained a blow to his right eye in a boxing match. Examination on the sideline reveals hyphema, reduced visual acuity and color vision, and a visual field cut. What is the next step in management?
1. #### Eye patch and ophthalmology evaluation in 2 days
2. #### Fluorescein eye stain
3. #### Emergent CT
4. #### High-dose systemic steroids
5. #### Observation PREFERRED RESPONSE: 3
DISCUSSION: With the examination demonstrating reduced visual acuity and visual field changes,
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