Orthopaedic Knowledge Update: Sports Medicine 5 [5 ed.] 1975123247, 9781975123246, 9781975123314

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Orthopaedic

Knowledge Update Sports Medicine *

erican Orthopaedic Society for Sports Me 1'

Mark D. Miller, lVlD: Editor

.'

hi“ Illifl Vll-Ii'iii"=‘ili

.

Acknowledgments Editarlal Beard, Drthnpaatlle Knawlatlga

Francis H. Shen, MD

Mk 13- Miller, hm

Divisien Head, Spine Surgery Department elf Grtimpaedic Surgery

3. 1Jli'ard Cassceiis Prefesser

Chafiflfigsyiflgr Virgiflm

Update: Sports Medicine 5

Hflfld: Difiiiiflfl flfSPWfl Mfldifiiflfi Department ef Drtirepaedic Surgery Universi 9f Virginia

Charigrrfipmg, Virginia

Stealin- F- Brockmier. MD

Warren G, Stamp Endamed Prafessar

University at 1it"irginia Health Systems

Stephen R. Thempstnl, MD, Med, FRESH

Assaciate Prefesser elf Sperts Medicine Eastern Maine Medicai Center

Tire University atMaine

Asseciate Prefesser

gflflgflfl Maine

University at It'irginia Cbariettesviiie, Virginia

Kfltifl 15- Wflks PT. DPT: EMA Ciinicei Directer

Cree M- 53$t MD Asseeilrte Prefesser, 1iiiee Chair; Associate Chief

Champion Sperts Medicine Birmingham, diabanra

Department at I[irttrepaedics .

Medicai Inferrnatien Ufficer

Department at Radieiegp and Medical Inmging,

Pirysicai Therapy

Drtnepaedic Surgery University at It'irginia Heaiti:I System Cbariettesviiie, Virginia

. ADSSM Board “f Directors, 1015 Annuntiate Ame-fiddle, MI}

E Wmsttm Gwathmay, hill]

Prmrdent—Eiect

Cirariettesviiie, 1Fiir,r_.1rinia

Rifik 13- WEE-“13911: DU

Assistant Prafesstrr [If Drtirtrpaedic Surgery Department of Drtfiepaedic Surgery Universi at Virginia Heaitir System

James]. Irrgang, PM}, PT, ATE, FAFI'A

(31131135 A“ Bush-Jnseph, hm Vice Pfggidgflf Secretary

Prafessar and Directer ef Clinicai Research Department c-f Drtircvpedic Surgerj.I

511d ]- {305231331 MD Treasurer

Pittsburg, Pennsyivama

Herbert A. firmer-a, MD Past President

David R, McMIistet, MD Prafessar and. Cbiefi Sparts Medicine Department ef Urtiropaedic Surgery

Jfl A" Hannafin, MD, PhD PM: President

Matthew D. Mflewslti, MD

C. Bfifliflfl'fifl Ma MD

Universi pf PittsirurgiiI

David Gefien Scbaai elf Medicine at UCLA Les Angeies, Caiifernia

Assistant Prefesser af Drtnepaedic Surgery and Sports Medicine

Eiite Sperts Medicine Cennecticut Ciriidren’s Medicai Center

reflfl‘mflfl”,Co ””3ne ' e Suntan K. Pnddat, MD

Asseciate Prefesser and Dire-star; Printer}! l{Jere

Sperts Medicine Department at Famiip Medicineiflrtirapedics University at Ceieradcr ver Ceieradcr

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.

Jeseph H, Guettler, MD Member at Large

Member at Large

Rick W, Wright, MD Member at Large

Christopher C. Kaeding, MD Ex-ficie _

Bruce Pfe'd‘f-FMD _ _ . Eflm Ed’m’i Medias! Punhsbmg 7 Heard flfTTHSWES

[w Bemberger

Executive Directtrr

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Preface

Jail

I have always been a fan of the American Academy of Orthopaedic Surgeons {MUS} Cirthopaedic Knowledge Update [UKU] series. As a resident when the first OKU was published, I literally read the cover off the edition in the department library and have referred to subsequent editions ever since. Two years ago, Jo Ann Hannafin, then President of the American Urthopaedic Society for Sports Medicine (AGSSM), asked me to edit UK U Sports Medicine 5. As is often the case with time- consuming requests from respected leaders, I agreed, knowing that time invested would lead to value for both authors and readers. As an academic project designed to be a useful resource for practitioners, the DKU series ultimately benefits our patients in clinics and operating rooms. So... 2 years and 5? chapters later, it is with great pride that I introduce the fifth

i

edition of Orthopaedic Knowledge Update—Sports Medicine.

The fifth edition is not a rehash of UK U Sports Medicine 4. Much of the credit goes to the 10 section editors, Drs. Brockmeier, Gwathmey, McAllisten Irrgang, Wilk, Shen, Thompson, Poddar, Milewski, and Gaskin. They played a key role in deciding on chapter topics, many of which are new, and selecting authors. They also did an outstanding job encouraging the contributors and editing their work. In addition, new figures were found or created specifically for this edition, adding a rich and informative contest to the written descriptions of medical processes and terminology. Video is also included for some of the chapters.

Finally, I want to give a shout-out to Lisa Claston Moore and the other members of the MOS publications department who worked on this project. As one of many invested in the future of sound practice in orthopaedic sports medicine,I am honored to be part of the team that put together this book. Thank you.

Mark D. Miiier; MD

Editor

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‘ Table of Contents Preface ........................ Iv 1Widen Abstracts .................. aJti

Section 1: Upper Extremity

Section Editor:

Chapter 3

Chroniefflveruse Elbow Disorders Champ L. Baker 1]], MD Champ L. Baker Jr, MD ........... 91 Chapter 9 Hand and 1't‘ilrist Injuries

Stephen F. Brockmeicr, DID

J. Taylor Jobe, MD

Chapter 1 Shoulder Instability

A. Bobby Chhabra, l'vID .......... lfll

Jeanne C. Patzkowski, MD

Brett D. Dweus, NED ........... . . . . 3

Section 2: Hip and Pelvis

Chapter 2

Section Editor: F. Wmston Gwathmey, MD

Brian R. 1Wolf, MD, MS

Chapter Ii] Athletic Hip Injuries

Disorders of the Acrotnioclavicular Joint, Sternoclavicular Joint, and Clavicle Yousscf El Bitar, LID .............. 1?

Chapter 3

Rotator Cuff Disease Evan J. Conte, MID

Stephen F. Brocloneier, MD ......... 33 Chapter 4

Superior Labrum and Biceps Pathology

Bryan G. Vopat, MD Jeffrey E. Wong, MD Petar Golijanin, BS Matthew T. Provenchcr, DID ........ 43 Chapter 5

Adhesive Capsulitis, Cartilage Lesions,

Richard Charles Mather 1]], MD, MBA MichaelS.Ferrell,MD ...........115

Chapter 1 1 Femoroacetabular Ilnpingement Ljiljaua Bogunovic, MD Shane J. Nho, MD, MS ........... 127

Chapter 12 Extra-articular Hip Disorders

J.W. Thomas Byrd, MD

Guillaume D. Dumont, MD........ 141 Chapter 13

Muscle Injuries of the Proximal Thigh

James T. Beckmann, MD, MS

Nerve Compression Disorders, and Snapping Scapula

Marc E. Safran, MD ............. 151

Joshua A. Greenspoon, BSc

Athletic PubalgiafCore Muscle Injury and

Chapter 14

Maximilian Petri, MD

Peter]. Milieu, MD,MSc . . . . . . . . . . 55

Chapter 6 Elbow Arthroscopy and the Thrower’s Elbow

Ekaterina Y. Urch, NED

Lucas S. McDonald, MD, Isl-PHSETM

Joshua S. Diues, MD

Groin Pathology Christopher M. Larson, MD David M. Rowley, MD .......... . 163 Section 3: Knee and Leg Section Editor: David R. MeAllister, MID

David W. Altchelt, MD . ........... (i? EIChapter 15 Cruciate Ligament Injuries Chapter 7' Lucas 5. McDonald, HID, WHBCTM AcutefTraumatic Elbow Injuries Nathan Coleman, MD John P. Haverstock, IvID, FBCSC Andrew D. Pearle, l'vID ........... HS George 5. Athwal, MD, FRCSC. ..... 31

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I Chapter 16

Collateral Ligament

luries

Eduard Aleutorn-Geli, MD, MSc, PhD,

Section 4: Rehabilitation

Section Editors:

FEBDT Joseph J. Stuart, MD

James J. lrrgang, PhD, PT, ATC, FAPTA Kevin Willi, PT, DPT, FAPTA

Claude T. Moorman I[l, MD ....... 189

Chapter 23

Chapter I? Patellofemora] Joint Disorders

Rotator Cuff Pathology: Nonsurgieal and Postoperative Considerations Todd 5. Ellenbecker, DPT, MS, SCS, (JCS, CSCS George J. Davies, DPT, MEd, PT, SCS, ATC, LAT, CSCS, PES, FAPTA ..... 311

J.H. James Choi, MD

Miho J. Tanalta, MD

John J. Elias, PhD Andrew J. Cosgarea, MD ......... 205 I Chapter 13 Articular Cartilage of the Knee Andreas H. Gomoll, l'vID

Brian J. Chilelli, l'viD . ............ 121 Chapter 19

Nonarthroplastv Management of Dsteoarthritis of the Knee Ljiliana Bogunovic, MD

Charles A. Bush-Joseph, lviD ....... 23? 1 Chapter 20

Meniscal Injuries

Stephanie W. Mayer, MD

Johnathan A. Bernard, Md}, MPH

Scott A. Rodeo, lvfl) . ............ 251

Chapter 21

Leg Pain Disorders

Justin Shu Yang, MD Thomas M. DeBerardino, MD ..... 165 1 Chapter 22 Ankle and Foot Ininries and Other Disorders Thomas D. Clanton, MID

Norman E. Waldrop III, MD Nicholas 5. Johnson, MD Scott R. 1|i'ii'hilzlow, MD ............ 1??

Current Concepts in Rehabilitation of

Chapter 24 Nonsurgical and Postoperative Rehabilitation for Ininries of the Dverhead Athlete’s Elbow Kevin E. Will-t, PT, DPT, FAPTA Todd R. Hooks, PT, ATC, (JCS, SCS, NREMT-lj BEES:- CMTFT:

FAADMPT .................... 319

El Chapter 25 Hip Rehabilitation

Keelan Enselti, MS, PT, DCS, 5C5, ATC, CSCS Dave Kohhieser, DPT, PT, DCS, 5C5, CSCS Ashley.r Young, PT, DPT, CSCS. ..... 351

El Chapter 26

Current Rehabilitation Concepts Following Anterior Crueiate Ligament Reconstruction Penny Goldberg, PT, DPT, ATC

Giorgio Zeppieri Jr, PT, SCS, CSCS Debi Jones, PT, DPT, SCS, {JCS Terese L. Chmielewski, PT,

PhD, SCS ...................... 359 Chapter 2? Patellofemoral Pain Syndrome: Current Concepts in Rehabilitation

Mark V. Paterno, PT, PhD, MBA, SCS, ATC

Jeffery A. TaylooHaas, PT, DPT,

DCS, CSCS .................... 3?] Chapter 23

Foot and Ankle Rehabilitation RobRov L. Martin, PhD, PT ....... 333

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Drthopaedie Knowledge Update: Sports Medicine .5

Chapter 2.9

Core Stabilization Rafael F. Escamilla, PhD, PT, CSCS, FACSM ....................... 393 Section 5: Head and Spine

Current Applications of Drthohiologic Agents Ryan M. Degen, MID, MSc, FRCSC

Scott A. Rodeo, MD ............. 503 Chapter 33

Section Editor: Francis H. Shen, .MD

The Biology and Biomechanics of Crafts and Implants

F. Alan Barber, MD, FACS ......... 523

Chapter 30

Concussion Siobhan M. Statuta, M.D, CAQSM John M. MacKnight, MLD, FACSM Jeremy B Kent, MD, CAQSM

Section ?: Medical Issues

Section Editor:

Jeremy L. Riehm, DD ......... . . . 411

Chapter 3 1

Traumatic Spine Injuries in the Athlete Sophia A. Strike, MD Hamid Hassanaadeh, MD ......... 423 El Chapter 32

Souray K. Foddar, MID Chapter 39 Sports Nutrition Jacqueline R. Berning, PhD, RD, CSSD

Kelly L. Nesdlle, MS ............. 545 Chapter 40

Sport Psychology

The Cervical Spine William R. Miele, hiD

Christopher M. Bader, PhD, LP;

CC-AASP . ................... . 553

Brain J. Neuman, MD

Asjay Khanna, M.D, hilBA......... 433 Chapter 33 Thoracolumhar Spine Anuj Singla, NID Christopher A. Burks, MD ........ 451 Section 5: Miscellaneous Topics Section Editor:

Stephen R. Thompson, MD, Med, FRCSC Chapter 34

The Team Physician and the Ethics of Sports Medicine

Andrew M. Watson, NED, MS

Warren R. Dunn, lyiD, MPH ....... 469 Chapter 35

Research Studies and Registries in Sports

Medicine Robert H. Brophy, MD Matthew V. Smith, hfl) ........... 4?"? Chapter 36 Current Concepts in Tendinopathy

Trevor Wilkes, MID

Chapter 3?

Chapter 41

Cardiac Issues in Athletes

Kimberly G. Harmon, hiD Jonathan A. Dreaner, MD ......... 561 Chapter 42

Female Athlete Triad Marissa M. Smith, MD

Marci A. Goolsby, MI} ........... 5 75

Chapter 43 Infectious Disease in the Athlete Matthew Leiszler, MED Kari Sears, MLD

DaridSiuith,DD ...............535 Chapter 44 Facial Injuries

Jeffrey a. Housner, MD, MBA

3}/

Laurie D. Donaldson, hvfl) ....... . fifl/ /

Chapter 45

Abdominal Injuries Stephen IL Paul, BID

Sagir Girish Bera, DD, MPH, MS

Brenden J. Balcik, MD ........... 615

W. Benjamin Kihler, MD . ......... 493

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Chapter 46 Heat Illness and Hydration Alexander B. Ehirlger, MD ....... . 631 Section B: The Young Athlete Section Editor:

Matthew D. Milewski, MD Chapter 4?

‘ Gsteochondritis Dissecans Kevin G. Shea. MD

Ted J. Genie}; I'dD ............. . 6-41

Chapter 43

Anterior Cruciate Ligament Tears in Skeletal]? Immature Athletes

Benton E. Heyworth, MD Melissa A. Christine, MD ......... 653

El Chapter 49'

Patellofemoral Instability,r and flther

Common Knee Issues in the Skeletall'f

Immmure Athlete

Chapter 52 Strength Training and Conditioning in

Young Athletes

Tracy.r I.. Zaslow. MD. FAAP,

CAQSM . ..................... 7'11 Section 9: Imaging

Section Editor:

Cree M. Gaskin, MD

Chapter 53 I'VIRI of the Glenohumeral Joint J. Derek Stenshg, MD . ........... 7’23 Chapter 54

NIRI of the Elho‘nr

Nicholas C. Naceg MD........... 731 Chapter 55

Imaging of the Hip Jennifer L. Pierce, MD. ........... 1739 Chapter 56

Aristides I. Cruz Jr. MD Matthew D. Milewslti, MD ........ 66?

Imaging of the Knee

Chapter 50 Special Considerations in Head Injuries in

Chapter 5? Diagnostic Ultrasound and Ultrasound-

Regina Kostyun, MSEd, ATC Carl W. Nissen, MID

Jemtifer L. Pierce, 1'l Nicholas C. Naceg hiD........... T55

Adolescent Athletes

Imran Hafeer, hfl) .............. 635 Chapter 51

Meredith C. Northam, MID. ....... '14?

Guided Procedures

Index ........................... 5'69

Shoulder and Elbow Injuries in the

Skeletally Immature Athlete EricW.Edmonds,MD ...........?fll

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@I Video Abstracts Chapter 15 cruciate Ligament Inju rles 1ifideo 15.] Kim S], Kim SG, Kim SH, Lee DY, Jo IK: Video Excerpt. Arthroscopic Double-Bundle

ACL Reconstruction Using Quadriceps Tendon Autograft. Rosemont, IL, American Academy of Orthopaedic Surgeons, lfllfl. {11'} min)

This video demonstrates an arthroscopic reconstruction of the ACL using a quadriceps tendon

autograft on a 30-year-old man. Examination reveals grade 2 instabilitv during the anterior drawer

test, a grade 3 Lachman test, and jumping during the pivot shift test. The graft is harvested with a rectangular bone plug and is split sagittallv at a 3:2 ratio with regard to the anteromedial and

posterolateral bundles. The graft is whip stitched at the ends. Portals include a high anterolateral,

a low anteromedial, and an accessory anteromedial. Tunnels are reamed, and the graft is passed.

The bundles are passed alternately,r to prevent jamming. Sutures are tensioned while the knee is cycled, and all ends are fixed with absorbable interference screws. All tests are negative and do not

indicate instability, and rehabilitation is discussed.

1"fideo 15.2 Bach Jr BR: 1|v"ideo Excerpt. Revision Single Bundle ACL Reconstruction Using BPTB Autograft pt 1. River Forest, IL, EDIE]. (21 min)

This video demonstrates the first part of a two-part video showing a revision single bundle ACL reconstruction using a transfibular endoscopic technique with a bone-tendon-bone autograft for a 19-year-old woman who is an athlete. An examination under anesthesia reveals a grade two pivot shift, and the importance of checking for medial- or lateral-side instabilityr is discussed. The graft is harvested through an incision along the medial edge of the patellar tendon. The tibial bone plug is cut first, and the soft tissue is left attached to the infrapatellar fat pad for stabilitv while cutting the patellar plug. Diagnostic arthroscopv is carried out through a standard infralateral portal through

the wound incision, which allows for better visualization. A medial portal is made adjacent to the patellar tendon at the level of the patella. The remnants of the REL are removed with arthroscopic scissors, and a posterior notchplast;-.r is performed with a spherical burr. An aecessoo.r inframedial

portal is made with a spinal needle, which aids in distaliaatiou of the insertion on the tibial

entrance site, as well as allowing for a more oblique orientation with the tibial tunnel. An aiming device is inserted through the transpatellar portal. Video 15.3 Each Jr BR: 1|Ii'itlean Excerpt. Revision Single Bundle ACL Reconstruction Using BPTB Autograft pt 2. River Forest, IL, lfllfl. {13 min) This video demonstrates the second part of a two—part video showing a revision single bundle ACL reconstruction using a transfibular endoscopic technique with a bone-tendon-bone autograft for a 19-year-old woman who is an athlete. The orientation of the guide pin is checked in flexion and extension. The femoral tunnel is drilled with a cannulatcd reamer, and the removed bone is saved for grafting, and the tibial tunnel is cleared with a shaver. The graft is delivered into the

femoral tunnel iotta-articularlv, and the knee is hyperflerted while placing the interference screw. Improvements in Lachman and pivot shift tests are demonstrated. The tibial plug is rotated 1 Eli“ and secured with an interference screw with the knee in extension. The screw is placed on the

conical edge of the anterior aspect of the bone plug. Pivot shift and translation are tested for,

bupivacaine is used intra—articularlv and in the surgical wound, and rehabilitation and physical therapy,r are discussed.

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Videe 15 .4 Jelmsen DH: ee Excerpt. Pitfalls in ACL Recenstructien. Resement, IL, American Academy ef lI'L'Irthepaeelic Surgeens, 201B. {12 min} This videe demenstrates varieus pitfalls that can eccur with AEL receustructien. lE'J‘ne is that a tenden stripper may get caught en a band branching eff the tenden, which kinks the main tenden

and causes it te be cut shert. The next pitfall is patellar fracture resulting frem an “everrun” herizental cut when harvesting a benete—bene graft. flvereealeus use ef an esteeteme en the

pat . la is alse demenstrated and discussed. Impreperly pesitiened tunnels and selutiens fer fixing

. m are discussed extensively. Insufficieutly large er brelcen bene plugs are alse discussed.

1ividee 15.5 Miller MD. Hart J. Kurkis G: Anatemic AEL Receustructiennflll Cemers. Charlettesville, VA, 2fl13. {ll} min}

In this videe. techniques are presented fer achieving anatemic anterier cruciate ligament MEL}

recenstructiens in a variety ef clinical scenaries. The intreductien demenstrates a primary single-

bundle anatemic ACL recenstructien using a hamstring autegraft. Subsequent sectiens fecus en adaptatiens te this technique fer primary single—bundle anatemic ACL recenstructien with a benepatellar tenden graft, revisien REL recenstructien, and femeral physeal recenstructien. All ef the techniques that are shewn fecus en restering the native ACL in its anateruic feetprint. Videe 15 .6 Shine K: 1Fv’idee Excerpt. Anatemical Rectangular Tunnel ASL Recenstructien Using ETB Graft. Usalta, Japan, 1010. {16 min}

Three benefits ef this precedure are eutlined: that it uses the deuble bundle cencept with a single bene-te-bene graft, that it maximises the graft-tunnel centact area, and that neteh anatemy is preserved. Fiber arrangement is demenstrated with a diagram. and the rectangular prefile ef the graft is everlaid. The graft is harvested and bene plugs shaped. Pertals are made: anteremedial,

auterelateral, and the far anteremedial. The ACL stump is excised, and attachment peints are made. The tibial and femeral tunnel rectangular prefiles are demenstrated. The femeral

interference screw is intreduced with an eutside-in technique, then the graft is passed threugh the

tibial and then femeral tunnels. Beth ends are fixed, and netch er PCL impingement is net present. Rehabilitatien is discussed. 1|viidee 15 .7" Fulkersen JP: 1videe Excerpt. ACL Recenstructien Using a Free-Tenden Quadriceps Autegraft. Farmingten, CI". 201i]. {20 min}

This videe demenstrates ACL recensn'uctien using a free-tenden quadriceps autegraft. Videe 15 .3 Hewell 5M: Vidflfl Excerpt. Technique fer Harvesting Hamstring Tendens fer REL Recenstructien. Sacramente. CA, 2fl1fl. {3 min)

This videe demenstrates a technique fer harvesting hamstring tendens fer ACL recenstructien fer a 23-year-eld man whe plays seccer. The incisien is made and a right angle clamp is placed

ever the graeilis, and its tenden and that ef the semitendinnsus are identified. Beth are retracted with a Peurese drain. stripped with a blunt epen—ended tenden stripper. and remaining muscle is

remeved. The tendens are cembined, deubled ever, and the ends have sutures placed. The cheice

ef allegraft versus autegraft is discussed. The graft is sized and submerged in a saline bath while still inside an B—ntm sizing sleeve te prevent drying eut ef the graft.

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Drthepaedic Knewledge Update: Sperts Medicine 5

Videe 15.9 Shelbeurne ED: 1F«fitlee Excerpt. Tips fer Harvesting BTE Antegraft. Indianapelis, IN, 2611'}. {13 min] This yidee demenstrates tips fer the centralateral harvesting ef a bene-te-bene autegraft fer ACL recenstrnctien. The patella and patellar tenden are marked, and an incisien is made aleng the

medial berder ef this tenden. An incisien is made inte the paratenen te expose the tenden, and flaps are maintained fer clesure. A Ill-mm graft is taken frem the central third ef the tenden frem preximal te distal. lILIentimeter-deep bene plugs are cut first medially, then laterally fer each end.

Heles are drilled in beue plug ends and sutures passed, and a sizing guide is used In ensure the graft passes threugh an ill—mm hele. The seft tissues ef the graft are injected with bnpiyacaine and epinephrine. Bene graft is packed late the patellar and tibial defects, and the paratenen is clesed

eyer beth. Rehabilitatien is discussed and includes high-repetitien lew-weight exercises; then

flexien and extensien are checked, a subcutaneeus drain is placed, and clesure is perfermed.

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

discussed.

1li'idee 15.11 Hewell 5M, Andres ID: Videe Excerpt. Anatemic Single Bundle ACL Recenstructien withent Reef and PCL impingement - Tibialis Allegraft. Sacramente, CA, lfllfl. {2111' min} This 1sidee demenstrates a single-bundle ACL recenstrnctien with a tibialis allegraft and the

impertant steps te ayeid reef and PCL impingement. Pertals are made at the jeint line at the

medial edge ef the patellar tenden and at the appreximate midline ef the patellar tenden. A 6.5"

guide is used te gauge the space between the lateral femeral cendyle and the PCL; this space is tee narrew, se a wallplasty is perfermed. The femeral tunnel drill peint sheuld be halfway between the apex and the bettem ef the intercendylar netch. The sagittal trajectery is aimed te ayeid reef impingement, and the cerenal trajectery is aimed te ayeid PEL impingement. The tunnels are

reamed and the graft passed.The knee is cycled 15 tn 1'] times, and the tibial end is fixed in full extensien. The desirable triangular space between the I’CL and the graft is demenstrated. Chapter 15 Cellateral na ment Injurles

1ll'idee 16.1 Gerden D, Pincaewski L: Medial Cellateml ligament - MEL - Acute Meniseetibial Repair. Sydney, Australia, Hill. {9 min}

I’

Grade 3 medial cellateral ligament {MEL} injuries inyelye tearing ef beth the superficial and deep

cempenents ef the MCL. These structures may he tern frem either the femur er the tibia. Tibialsided [meniscetibiall injuries require surgery te clese the knee capsule and step syneyial fluid extrusien, which prevents adequate healing ef the MCL. In this yidee, the surgical technique fer repair ef acute meniscetibial MCL injuries, including diagnesis, eperating theater set-up, surgical steps, and rehabilitatien, is shewn and described.

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Video “16.2 Miller MD. W

er EC. Higgins 5: Posternlateral Corner Primary Repair and

Reconstruction. lEase Based. 'o'Zharlottesville,r VA, 2014 {13 min}

This video uses three case examples to demonstrate surgical techniques for repair and reconstruction of the posterolateral corner of the knee. The first case presented is a primary repair

backed up by a free soft-tissue graft. The second case is a reconstruction of the posterolateral corner. The final case is a reconstruction of an isolated lateral collateral ligament {LCL} injury

usigg a strip of biceps tendon. The posterolateral corner of the knee is often misunderstand, and

I 's video simplifies repair and reconstruction techniques.

Chapter 13 Artieular Cartllage of the Knee Video 18.1 Chalmers P, Yanke A. Sherman S, Karas V, Cole B]: Combined Cartilage Restoration and Distal Realignment for Patellar and Trochlear Chondral Lesions. Chicago. IL. EDDIE. {24- min}

Chondral lesions of the patellofemoral ioint are relatively common and pose a treatment challenge to the orthopaedic surgeon because of the complex three-dimensional topography and highcontact stresses. Anterior knee pain. either at or surrounding the patella. is the most common

symptom in patients with patellnfemoral cartilage defects; however, posterior knee pain may also suggest a trochlear defect. Given the wide differential diagnosis for anterior knee pain. the

patient history and physical examination should focus on osseous. cartilaginous, and tendinous

structures from the hip to the ankle. MRI and CT should be considered to better visualize the state of the underlying cartilage and to quantify the patellar alignment and tilt. Treatment options for patellofemoral cartilage defects include realignment procedures such as anteromedialiaation of the

tibial tubercle, or cartilage restoration procedures such as autnlcgous chondrocyte implantation,

microfracture, and osteochondral allografi: transplantation. Although reasonable results have been reported with distal realignment and cartilage restoration used in isolation, better outcomes are seen when these types of procedures are combined. Chapter 20 Meniseal Injuries

Video Elli Shelton WE: Video Excerpt. All-Inside Meniscus Rwair - FAST-FIE. Jackson, MS,

2&1 1. [12 min]

This video demonstrates meniscal repair using the FAST-FIE system. FAST-FIX is introduced with

its blue sheath and the first grommet is deployed automatically, and sutures are made from the periphery to the middle. A slip knot is tied and tightened with a ringed tightener, and excess suture is trimmed with an arthroscopic scissors. The most difficult suture to make is above the tear, and this is demonstrated. The importance of vertically oriented sutures is emphasized. A bucket-handle tear repair is demonstrated. Video 10.2 Lawhorn KW: Video Excerpt. All-Inside Meniscus Repair - MaxFire Maeeu. Fairfax, VA, 2'01 1. {3 min} This video demonstrates meniscal repair with the MaxFire Marflmen system. Setup includes a

leg holder. and the lateral and medial portal placements are demonstrated. A tourniquet is not

used, and bupivacaine or lidncaine with epinephrine is injected into the portal sites. A. posterior horn tear of the medial meniscus is repaired with a horizontal mattress suture. Suture tensioning is demonstrated with the inner and outer loops. Anchors are spaced 1 cm apart to ensure a soft-tissue

bridge to enhance fixation. Vertical mattress repair of a posterior horn tear of the medial meniscus

is also demonstrated. and again suture tensioning is demonstrated. A probe is used to assess repair, and suture ends are trimmed.

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Orthopaedic Knowledge Update: Sports Medicine 5

1ii'ideu 20.3 Vyas D, Harrier CD: Videu Excerpt. Pusteriur Hurn Medial Meniscus Rent Repair. Blawnex, PA, 21311. {14 min} This viden demunstrates a pusterinr burn medial meniscus runt repair fur a 45-year—nld man. The tear is demunstrated an MRI, and the difficulty uf making this diagnnsis is discussed. Patient pcsin'nning and pcrtals are demcnstrated. A diagncstic artbrnsccpy is perfarmed, alnng with a reverse nutchplasty tn imprnve visualisatiun. The first suture, a mnnnfilament, is pierced inter the rent with a suture shuttle; and then a braided suture is leaped thruugh the munufilament and

passed. The tear is reduced. A tibial tunnel is drilled. The braided ends are passed thruugh the tunnel, and the ends are fixed on the tibia with a 6.5—mm cancellnus screw with a washer. Suture

ends are trimmed.

1ii'iden 20.4 Egagliune NA, Chm E: Videu Excerpt. All-Ardiruscupic Meniscus Repair With

Eiulngical Augmentatic-n. Rusemunt, IL, American Academy uf flrthupaedic Surgenns, Zfll 1. {23

min]

This viden is a cadaver demunstratiun (if an all-arthrnscupic repair uf bath a pusterinr and an anterinr hnrn tear cf the medial meniscus. The impnrtance cf evaluating a tear fur stability and vasculariry is discussed, as are spacing and number ef sutures. A pertal skid is used tn intruduce needles and sutures, and is alsu used as a retractnr. The index vertical mattress suture is placed

with a curved, pruprietary device, and then platelet-rich fibrin matrix is inserted in the tear. Twc mere sutures are made in the pusteriur hurn cf the medial meniscus, and a final suture is placed in the anteric-r junctinn. Repair uf an anteriur burn cf the medial meniscus is demunstrated an a

different cadaver specimen. Twc sumres are placed with a clet nf platelet-rich fibrin matrix, and an uutside—in technique is demnnstrated. The suture ends are retrieved thruugh a cut—dawn incisiun, and the sutures are tied duwn against the capsule. Stability is checked with a prnb-e, and clusure plurfnrmed. Videu 20.5 Shaffer ES: Videu Excerpt. Lateral Meniscus Transplantatinn. Rusemunt, IL, American Academy nf Drthupaedic Surgenns, 2011. [6 min]

This viden demnnstrates a lateral meniscus transplantatic-n in a 31—year-uld wuman wbu plays snccer with a 2-year histnry uf lateral right knee pain. The patient has nurmal gait and alignment,

but the primary pusitive findings are juint line tenderness and mild valgus defermity. Graft size is

determined frum measuring an AP radingraph and MRI. A diagnustic arthrnscupy is perfurmed, and the meniscus is resected. Then, the tcurniquet is inflated and an anterclateral incisiun is made in line with the lateral artbrnscupic purtal. A pusterulateral incisiun is alsu made in preparatinn fur the meniscal repair. The graft is prepared and the bane black checked in a truugh gauge. Culinear

placement is discussed, as is the need tn pussibly make an incisicn in the patellar tendcn tn achieve this. A shall-aw guuge is used tn create a preliminary truugh, and then a deep guuge the size uf the bane black is used. This is checked with a template. The graft is inserted thruugb the pusterinr

cnrner, and its sutures are retrieved thruugh the pusternlateral incisiun. The graft is seated and then secured with an inside—nut technique using vertical mattress sutures.

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Viden 111.6 Cale ll]: Vida

cerpt. Lateral Meniscus Transplantatinn - Bridge-in-Slnt. Rnscrnnnt,

1L, American Academyr nf IIIthnpaedic Surgenns, 2131 1. {15 min}

This viden demonstrates a lateral meniscus transplantatinn using the bridge—in—slnt technique fur a 14-vear-nld girl. The graft is prepared with nnlv twn cuts needed tn shape the bane blnclt, and snft tissue pnstetinr tn the pnsterinr hnrn is cut awav tn imprnve visibility during placement. The graft width is cnnfirmed in an S-mm slnt gauge, and the meniscus is marked pnsterinr tn the expected site nf the pnpliteal hiatus. A diagnnstic flflhfflfiflflpf is perfnrmed with a standard twn-pnrtal

setup, and a standard rneniscectnrn}r is perfnrnlnd. A trans-patellar tendnn apprnach is used fur the arthrntnmv tn establish anterinr—pnsterinr directinn. A reference slnt is made, checked with a depth gauge, cnnverted tn a rectangular channel with a three-sided base cutter, and rasped. A lateral-side

incisinn is made while taking care tn avnicl the cnmrnnn pernneal nerve. A nitinnl pin pulls the

graft in thrnugh the arthrntnnivr frnm the lateral—side incisinn, and the graft is seated. The bone bridge is fixed anterinrl}.r with a screw, and the meniscus is fixed with vertical mattress sutures. The meniscus is assessed fnr balance, and the sutures tied dnwn with the knee in extensinn. Viden 21].? Carter TR: 1|iupl'iden Excerpt. Medial Meniscus Transplantatinn - Dnuble Enne Plug. Phennix, AZ, 21311. {1 1 min]

This viden is a demnnstratinn nf a medial meniscus transplantatinn with a dnuble bone plug graft. The difference between medial and lateral meniscal repair is illustrated. A diagnnstic arthrnscnpv ensures that the patient is a candidate fnr transplant befnre the allngraft packaging is npened. Tissue is remnved at the medial nntch tn imprnve visualisatinn, and the meniscus remnant is

dehrided until bleeding tn ensure healing. The graft is shnwn and the dimensinns nf the hnne plugs are marked, cut, and their size checked. Hnles are drilled thrnugh the plugs and sutures passed. A F-mm siner is hrnught thrnugh the nntch tn ensure that the drill guide and guide pin will fit.

Drilling is similar tn that used in PCL repair, and the tibial tunnel is drilled nver a guide pin. A lnnped wire is brnught up thrnugh the tunnel and will be used tn pass the pnsterinr plug sutures. The needles fer the anterinr reductinn sutures are passed using an inside-nut technique. The graft

is pulled intn the jnint with all reductinn sutures engaged. The graft pnps intn place pnsterinrlsr

as with a bucket-handle tear repair. Bnne plug sutures are secured anterinrlv, and a pnlvethvlene buttnn is used in this case. The meniscus is repaired as it is with a bucket-handle tear repair. The anterinr burn and plug are secured last, as these are mere amenable tn adjustment. Tvpicallv, eight sutures are needed. The anterinr bnne plug has a guide pin placed and then a sncket drilled fnr press-fit fixatinn. The repair is shnwn again at 5 mnnths. Viden 10.3 Richmnnd JC: 1|Ivi'iden Excerpt. Medial Meniscus Transplantatinn During ACL Repair. atnn, MA, 2011.{11min} This viden demnnstrates a medial meniscal transplant in an active vuung adult wuman print tn ACL recnnstructinn. Piecrusting is perfnrmed tn stretch the tight medial cnllateral ligament tn

irnprnve visualizatinn nf the medial meniscal remnant. Residual rneniscal tissue is débridecl, and a mini nntchplastv is perfnrmed cm the medial femnral cnndvle tn allnw passage cf the graft. The allngraft is prepared and bane plugs are harvested frnm the heme black with a caring reamer.

Sutures are passed thrnugh the heme and the snft tissue. If an ACL is being recnnstructed with the

transplantatinn, the ACL tunnels wnuld be fashinned at this time. A cnunterincisinn is made at the pnsternmedial cnmer tn retrieve the graft sutures. The tibial tunnel is reamed, and suture retrievers are passed. The meniscus graft is passed up thrnugh the tibial tunnel, and the sutures retrieved. The bnne blnck and meniscus are seated, and the meniscus is captured with classic insidewnut technique. The ACL graft is passed intn place and fixed. This is cnnsidered a salvage prncedure, and the

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Drrhnpaedic Knnwledge Update: Spnrts Medicine 5

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

Chapter 22 Ankle and Foot Injuries and Other Disorders 1"fidee 22.1 Ferkel RD, Stuart KI): Video Excerpt. Autelegeus ||.'.".hrendrec3rte Implantation. 1‘vi'an Nnvs, CA. , 2fl'11. {13 min}

The program begins with a review of published studies on ACI. Patient indications are reviewed, and a two-stage procedure is summarised. Cultivation of biopsy tissue is discussed and one patient

case is demonstrated beginning with imaging studies {a—rav, CT, and MRI}. Preoperative planning is discussed using :c-rav imaging. The initial incision is made at the medial malleelns and the surgical site is dissected for complete visualization of the talar dome. The esteetemj.r is completed using an oscillating saw and esteetome. The esteechondral lesion is identified and removed.

1if'idee 22.2 Glasehroek M: 1|Infidee Excerpt. Conventional Treatment - DEhridement Abrasion Micrefracmre Drilling. Halifax, Neva Ecetia, 201 1. [4 min}

Anatomical structures are outlined on the patient’s skin, and the ankle joint is infused with

saline. Portals are made and tissue déhridement to improve visualisation of the ankle joint space is completed. Loose hedies are identified using a probe and then remeved. Cartilage defects are

identified. Using a Kirschner wire, suhchendral hene penetration commences. Alternative methods

for bone penetration and gaining access to more difficult lesions are discussed. After the surgeon

makes the necessary,r holes in the bone, blood and fat can be seen extruding from the holes. This sets the stage for fihrecartilangeens scar formation. Postoperative protocols are discussed.

1iiidec 22.3 Hangedv L: Videe Excerpt. GATE Procedure. Budapest, Hungary, 2G11. [lfl min} Radiographic imaging demonstrates osteoarthritis dissecans in the ankle joint. Patient positioning, application of tourniquet, and anatomic landmarks are discussed. A longitudinal incision is made for access to the surgical site, and anatomical structures are protected. A medial malleelar esteetem'g,r begins 121E procedure. The defect is visualized. The affected tissue at the site is removed and graft sizing is discussed. Twe grafts, 3.5 mm and 6.5 mm, are harvested at the knee using an arthrescepic approach. Tips and pearls regarding graft harvesting are discussed.

Optimal posifiening for graft placement is determined, and the two grafts are tapped into the defect. Tips, including the need for congruencv, are discussed. The larger graft is placed first.

Discussion on managing larger defects with more than two grafts is discussed. 1When the grafts

are in place, screws are used to place the medial malleolus into correct posin'en and the site is

closed. Postoperative management and rehabilitation are discussed, and a follow—up radiegraph demonstrates the repair. Video 22.4 Cuetzee JC: 1Widen: Excerpt. Anterior Ankle Impingement. Edina, MN, 201 1. [2 min} , / This video demenstrates arthrescepic debridement of soft tissue and bone spurs to relieve impingement cf the ankle jeint. Surface anatomic landmarks and arthroscopic portals are demonstrated, along with patient positioning to distract the ankle. Seft—tissue and bone spur removal on the distal tibia causing impingement are demonsnated. Use of fluerescepv to determine

the amount of déhridement and cerrect contour of the ankle is shown. Identification of additional pathelegjvr is discussed.

@2015 American Academy of Urthepaedie Surgeons

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Urthopaedic Knowledge Update: Sports Medicine 5

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Viden 12.5 Wie

'

Arthrnscnpy - [m '

{s min}

A uw PA], van Dijk EN: 1riiivzlen Excerpt. Posterior Ankle

ent Us Trignnum FI-IL Tennsynnvitis. Amsterdam, Netherlands, lflll.

The program begins with a demnnstratinn nf patient positioning and portal placement. The nick and spread method is used to create pnsternlateral and pnsternmedial portals. Soft-tissue shaving is demnnstrated to improve visualisatinn and to create nperating space in the joint capsule. Removal of the ns trignnum is demnnstrated in the first of three cases. A lnnse bndy forceps nr rnngeur is used to remove the ns trignnum when déhridement is completed. The second case involves management for chronic flesnr hallucis 1nngus {FHL} tennsynnvitis. Nnnsurgical treatments failed in this patient. The FHL is viewed and wear is seen. The FHL is decnmpressed using a basket

fnrceps. After cnmplete release there is unimpaired mutinn of the FHL. The final case invnlves

pnsternmedial ankle pain. A cyst on the talus is seen nn MR]. Edema is also present. Anatomic landmarks are seen and then a shaver is use to improve visualisation of the joint space. A curette

is used tn unrnnf the cyst and then cnmplete débridement is accomplished. Decompression nf the

lesion is seen. Pnstnperative care is discussed.

1Widen 12.6 Wiegerinck JI, de Leeuw PA], van Diilc EN: Video Excerpt. Haglund Deformity,

Achilles Prnblems. Amsterdam, Netherlands, Hill. {3 min}

This video demonstrates an endoscopic technique for a calcanenplasty. The patient is in a prone pnsitinn with a bnlster, and pnsternmedial and pnsternlateral portals are made adjacent tn the

Achilles tendnn and superior tn the palpable superinr border of the calcaneus. The large pnsterinr

calcaneal prnminence is demonstrated radiographically, and arthroscopy begins with the scope in the lateral pnrtal. A burr is intrnduced thrnugh the medial portal, and bone is removed gradually without compromising the Achilles insertion. The arthroscnpe is then changed tn the medial

portal, and the butt tn the lateral portal tn complete the prncedure. Postoperative radiographs and arthrnscnpic views are shown. Rehabilitation prntncnl is discussed, as are the benefits of an arthroscopic versus an open procedure.

Chapter 15 Hip Rehabilitation Video 25 .1 Enselci K: 1'Ini'iden. Manual Perturbation, Prnne and Quadruped. Pittsburgh. PA, 2015. [[1:23 min} This activity emphasises dynamic hip and pelvic control in a nnn—weight-bearing position. The

patient assumes the prone position. The clinician applies randnmly directed forces tn the free end nf the lower extremity fnrcing the patient tn utilise varinus hip muscles tn maintain stability of the limb. This activity emphasises dynamic hip and pelvic cnntrnl in a partial weight-bearing position.

The patient assumes the quadruped position. The clinician applies randnmly directed forces tn the pelvis, forcing the patient tn utilise varinus muscles tn maintain stability.

Chapter ss Current Rehabilitation Concepts Following Anterior Cruciate Ligament

Reconstruction

Viden 26.1 Goldberg P: Video. Perturbation Training for Neurnmuscular |IZ'Jnntrnl and Dynamic Stability. Gainesville, FL, 21315. [0:13 min}

Rollerbnards nr wobble boards create an unstable support surface in perturbation training to

challenge knee stability and enhance prnprinceptinn and neurnmuscular cnntrnl.

It? American Academy of flrthnpacdic Surgeons

Orthopaedic Knowledge Update: Sports Medicine 5

Videu 26.2 Guldberg P: Video. Anticipatcry Strategies tn Enhance Neurumuscular Central and Prcpriccepticn. lGaincsville, FL, 21315. {0:16 min} Anticipatcry balance strategies can be trained by placing an c-bject, such as a cnne, c-utside cf the patient’s base ef supp-err fer reaching tasks. The uninvnlved lcwer extremity may else be used tn reach nutsicle ef the base ef suppnrt. Videu 26.3 Guldb-erg P: Vidflfl. Reactive Strategies tn Enhance Neurumuscular Central and Prcpriecepticn. Gainesville, FL, 2015. [0:]? min}

Pestural perturbaticns can alsc be applied with a ball thruwn tn the patient by annther individual at a device such as a “Rebnundet.” The patient maintains a balanced pesitinn en a stable er unstable surface while catching the bail. Chapter 32 The Cervical Splne 1ii'idee 31.1 Faldini C, Gasbarrini A, IChehrassan M, lvliscinne MT, Acri F, D’nmatn M, Bnriani L1 Enriani 5, Giannini 5: 1|li'idec. Anteriur Interbudy Fusic-n in Cervical Disc Herniatiun. Belugna, Italy, Hill. {13 min}

Cumbined antericrr intetbcdy fusinn and cervical dishectumy is a surgical technique tu treat a

variety c-f cervical spine discrders, such as nerve tent er spinal curd cempressicn. This technique

pErmits the surgenn tn decntnpress the spinal card and nerve rec-ts and perfnrm interbn-cly fusinn tn previtle segmental alignment in letdnsis and sulid arthrodesis with minimal surgical risk. The aim nf this videe is tn shew the anterier cervical diskectnmy and interbndy fusinn ef a 55-year-

ulcl patient whu was suffering frnm cervical pain assc-ciatecl with intractable radiculnpathy cf the left E6 tcet far 6 mnnths. We rank an antericr apprcach tn the cervical spine and made a

lengimdinal skin incisinn en the medial berder cf the sternncleidemastnideus {SUM} muscle. We

gently incised the platisma muscle and isnlated the medial burder cf the SCM muscle. Then we isclated and partially retracted the hemeyeid muscle and separated the lnngus culli te expense the C5-C6 space. The diskectemy was performed; the pnsterinr esteephyte was remeved, aleng with the pnsterinr lengitudinal ligament tn eitpnse the dural sac. 1With the arthrcscnpe, it was pussible

te visualize and remeve the pnsterinr lengitudinal ligament and expese the dura. A E'mm anatcmic

cage was placed into the intervertebral space tn achieve the cerrect height at the intervenebral space and cnrrect the physiclngic letdcsis. Finally, the incised fascia and muscles were reattached.

Pnsteperative care censisted nf having the patient wear a scft cellar fer 4 weeks and then undergn

physinthcrapy. Twin-year clinical and radingraphic fnllnw-up detnnnstrated scllid anterinr intetbcdy fusinn cf the C5—C6 space.

Chapter 49 Patelletemeral Instability and Other Enmmen Itnee Issues in the Skeletelly Immature Athlete 1il'idee 4.9.] Ellis HE, Jr, Wilsnn PL: Viden. A Surgical Technique fer Medial Patellnfemeral

Ligament Recnnstructinn in the Skeletally Immflure. Dallas, TX, 2014. {14 min}

A surgical technique tc- treat skeletally immature patients with patellar instabilityr and c-pen physes is described. With recent evidence suppcrting anatcmic erigin cf the medial patellefetncral ligament {MPFL} distal tn the physis, a safe surgical technique tn recnnstruct the MPFL with a physeai-sparing technique is presented. Thirty-five censecutive patients with npen physes have undergune MPFL recnnstructiun with feur revisicns and nu physeai injury.

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Chapter 1

Shoulder Instability

Ieanne C. Patskowski. MD

Brett D. Dwens, MD

abstract

Athletic Association athletes.1 Given this high incidence,

Glenohumeral instability is common in young ath-

instability should be actively ruled out in a young athlete with shoulder problems. Although solely epidemiologic

subluxation events result in Bankart lesions in young

that most instability events are anterior, and only 1i]% are posterior events:1 Posterior instability is an area of

letes. Most instability events are traumatic anterior subluxations. Both traumatic anterior dislocation and

studies of instability are rare, one study has confirmed

athletes. Early surgical repair is recommended to optiu mice outcome and minimize risk of bone and soft-tissue

increased awareness and study. Approximately 35% of

damage. lvlany in-season athletes can return to play

traumatic anterior events are subluxation or incomplete instability events not requiring manual reduction. This is

will experience recurrent events. Attention to glenoid and humeral bone loss is increasing along with renewed

a variable history and examination and can be difficult to diagnose.

[depending on their sport and position} but two—thirds

important because these injuries sometimes present with

interest in bone augmentation procedures. Posterior

instability comprises approximately was of events

and usually is a subluxation. Posterior labral tears are often seen, as well as loose posterior capsules, and

Anterior Instability Pathophysiology

arthroscopic repair is the mainstay of treatment with excellent results. Multidirectional instability continues

Acute anterior or anteroinferior instability is the most common injury pattern in shoulder instability. The gle-

comes with physical therapy and surgical stabilisation , in select patients.

but translation of the humeral head on the glenoid is limited by multiple static and dynamic restraints. Static

to he a common area of study, with good reported out-

Keywords: shoulder: instability: repair Introduction

lGlenohumeral instability is endemic in young athletes.

Instability comprises 13% of all shoulder injuries {includ-

ing contusions and strains} among National Collegiate Dr: flwens or an immediate family member senses as a paid consultant to Miteit and the Muscuioslreietai Transplant Foundation, and serves as a board member; owner; officer; or committee member of the American Drthopaedlc So-

ciety for Sports Medicine. Neither Dr. Fatzlro arslri nor any

immediate family member has received anything of value from or has stock or stock options held in a commercial

company or institution related directly or indirectly to the

subject of this chapter:

@ lfllfi American Academy of Drthopaedic Surgeons

nohumeral joint moves through a large range of motion, restraints include the glenoid labrum, which deepens the

otherwise shallow glenoid, joint capsule, and glenohumetal ligaments. The anterior band of the inferior glenohumeral ligament {IGHL} is the primary restraint to

anterior translation with the arm in abduction and exter— nal rotation jABER}. The middle glenohumeral ligament

prevents anterior translation in mid AEER, whereas the

superior glenohumeral ligament and rotator interval resist anterior and inferior translation with the arm at the side. The Bankart lesion, a separation of the anteroinfetior

labrum and IGHL from the glenoid, is found in up to 9D% of anterior shoulder dislocations. Humeral avulsion of the glenohumeral ligament {Figure I} is identified in

up to 10% of shoulder instability cases.3 In the setting of a bony Bankart lesion, variations such as glenolabral articular disruptions and anterior labroliga mentous peri-

osteal sleeve avulsion lesions as well as acute glenoid rim fractures can be present. Hill-Sachs lesions, or impression fractures of the posterosuperior humeral head, are

common following acute dislocations. In severe cases, the labrum can be injured at multiple locations. Careful

Orthopaedic Knowledge Update: Sports Medicine 5

E "fl 1]

a; F”

E's E.

fill

a!

Section 1: Upper Extremity

lesion can be associated with a positive prognosis for future shoulder stability."r

Presentation

For the patient who presents with an acute dislocation,

the joint should be reduced as soon as possible. This can he performed on the field or sidelines by a physician or

certified athletic trainer or in the emergency department.

With a delayed reduction, muscle spasm can prevent successful reduction and may require the use of intravenous sedation or intra—articular local anesthesia. Postreduction radiographs, including axillary lateral views, should be

obtained to confirm concentric reduction and evaluate for

1: Upper Extremity

bony injury. Standard radiographs can be supplemented

with a 1|West Point or Stryker notch view to evaluate for glenoid bone loss or Hill-Sachs lesions, respectively.

a thorough physical examination, to include neuro-

vascular status and rotator cuff testing, is essential. Assessment of seapulnthoracic kinetics can elicit weakness Figure 1

Coronal Tit-weighted MRI shows humeral avulsinn of the glenohumeral ligament.

patterns amenable to physical therapy. Ligamentous laxity

should also be assessed {typically with Beighton criteria] because this can have a substantial effect on surgical treatment outcome. Physical examination findings in

inspection of postinjury imaging studies and recognition

of all intra—articular pathology at the time of surgery is

important to ensure that all instability components are

the patient with anterior shoulder instability can include positive results for the apprehension and relocation tests

in the ABER position. The load—and—shift test helps as—

addressed.

sess laxity in all directions, and the results should be compared with the contralateral side. The Gagey sign,

events is similar to acute dislocations. A prospective study of high-risk individuals identified 1? patients who sus-

can indicate injury to the IGHL if more than IDS“ of abduction is noted or if substantial asymmetry to the

The pathoanatomy of firstdtime traumatic subluxation

tained a primary traumatic subluxation event.“l MRI

or passive abduction with the arm in a neutral position,

uninjured extremity is seen. The |l'Eragey test can also be

identified Bankart lesions in 16 patients and Hill-Sachs lesions in 15. Fourteen patients underwent surgery, 13 of

used to delineate the presence of inferior capsular laxity most commonly associated with hyperlaxityr‘multidirec-

a wide spectrum of injury from microinstability to the spontaneous reduction of a dislocation event.

Advanced imaging is often obtained following shoulder reduction or in cases of recurrent instability. Magnetic

whom had Bankart lesions. Subluxation events represent Known risk factors for anterior instability include a

tional instability.

resonance arthrography {MRA} is performed with in-

history of shoulder instability and participation in con— tact or collision sports. In high-risk athletic and military

tra—articular gadolinium to delineate soft—tissue detail. The diagnostic accuracy of MRA has recently been

have a fivefold increase in the risk for the development of subsequent instability? Identifying modifiable risk factors

traumatic anterior instability undergoing arthroscopic surgery, MBA had only moderate agreement {x = (1.4?)

populations, those with prior instability in any direction

can help mitigate these troublesome outcomes. A recent

prospective study of T14 young athletes without prior instability found that only positive apprehension and re-

location signs nn physical examination, increased glenoid index {a tall, thin glenoidj, and increased coracohumeral

questioned. In a prospective study of 13 patients with

with arthroscopic findings for Bankart lesions and did

not identify two labral lesions that required fixation at the time of surgery.fl MRA had poor results for identifying superior labrum anterior to posterior tears and glenohu-

distance were predictive of future shoulder instabilityf

meral ligament lesions. Given the additional time and cost associated with MRA, the authors recommended against

and signs of hyperlaxity were not. Increased age at the time of dislocation and the presence of a bony Eankart

improved visualization of the inferior labrtun {Figure 2}, but this is anecdotal. Including the ABER sequence has

modifiable risk factors such as strength, range of motion,

flrrhopaedie Knowledge Update: Sports Medicine 5

routine use of Milo. The ABER view has been used for

El 1016 American AcadMy of Urrhopaedic Surgeons

Chapter 1: Shoulder Instability

not been shown to improve accuracy; instead, the expe-

rience level of the radiologist and consensus agreement

were found to he more important. The ABER view has a high rate of motion artifact, and 12% of patients with instability could not tolerate the AEER position for ima g—

ing.’ MRI has known limitations regarding bony detail. and CT is indicated in cases of suspected boneless. In a prospective, blinded study comparing MRA and CT ar-

thrography with arthroscopic findings, CT arthrography had superior results overall, with excellent identification

of labral and bony pathology.” MRA outperformed CT

in identifying glenohumeral ligament tears, but the studies were equivalent in identifying humeral avulsion of the

glenohumeral ligament lesions. CT can be an acceptable

E

alternative to MBA for instability evaluation in the shoul— der, but its lower cost and decreased time are balanced

"fl 1]

e,

by the risks of exposure to ionizing radiation.

F”

El E.

fill

Natural History

Multiple studies have demonstrated a high rate of recur-

rent dislocation in young, active patients, particularly in contact and collision athletes. Recurrent instability rates can be as high as 94%. Recurrence rates decrease sub—

stantially with each decade after age It] years, and older patients are more likely to sustain a concomitant rotator

cuff tear or greater tuberosity fracture after shoulder dislocation.“

a? MRI abduction and external rotation {ABEH} view shows anteroinferior labral tear in a

patient experiencing recurrent su blusations who did not demonstrate pathology in other imaging seq uentes. This correlated with arthroscopic findings at time of repair.

Treatment Treatment of the patient with a first—time dislocation re mains controversial. For patients who choose nonsurgical

In a double-blind, randomized clinical trial evaluating arthroscopic Bankart repair versus sham surgery, patients with a first—time dislocation had decreased recurrence of instability and improved outcome scores after repair.H Surgery resulted in lower costs and higher patient sat-

and early motion is initiated. Physical therapy focuses on regaining motion, strengthening the rotator cuff and

stability, not necessarily the surgery itself. Patients in the repair group also had a higher rate of return to contact

treatment, the shoulder is immobilized until pain resolves

periscapulat muscles, and proprioceptive training. Iniu

tial immobilization in external versus internal rotation may better reduce the torn lahrum to the anteroinferior

glenoid. Although initial clinical results were promis-

ing, follow—up studies could not reproduce the original results and meta-analysis showed no benefit in rates of recurrence or validated outcomes with external rotation bracing. Compliance was reported as problematic with the external rotation brace.” The goal of surgical management is to restore sta-

bility by repairing the injured lahrum or glenohumeral ligaments, and if needed, plication of the redundant

isfaction, but overall outcomes were related to shoulder sports. Similarly, a systematic review of only level I and II

studies demonstrated decreased recurrence of instability following arthroscopic Bankart repair when compared

with physical therapy and sham surgery, both together

and in isolation.” The patients in the repair group were noted to have one-fifth the rate of recurrent instability

and improved 1Et'lli’estern flute tio Shoulder Instability Index (WUSI) scores. The patients were 22 to 25 years old and

primarily male, representing the highest risk cohort of shoulder instability patients.

Technologic advances have increased the orthopaedic surgeon’s ability to manage shoulder instability ar-

capsule. Arthroscopic Bankart repair [Figure 3} has be-

throscopically. High rates of patient satisfaction and

treatment of choice among new surgeons in the United

and disability.'5 Radiographic evidence of dislocation

come common because it allows excellent visualisation of the entire joint and is minimally invasive; it is now the States.” Determining which patients need surgery after a first-time dislocation and how soon remains in question.

El Illlti American Academy of Urtltopaedic Surgeons

improved outcome scores have been reported in the short term and mid term, with low rates of recurrent instability

arthropathy can present with longer term follow-up and was reported in 41% of patients ll years after arthroscopic

Eirthopaedic Knowledge Update: Sports Medicine 5

Sectinn 1: Upper Extremity

50% nf patients had nn nrnre than twn suture anthers

placed during the repair in bnth grnups. A systematic

review nf mnre recent meta-analyses demnnstrated nn difference in recurrence between the twn techniques, but

nnted that the analyses perfnrtned befnre EDD? favnred

1: Upper Eatrem tty

npen surgery in recurrence rates, whereas thnse published after 10!}? shnwed nn difference.“ Similarly, the latest Cnchrane database review stated that evidence was insufficient tn claim superinrity nf nne technique nver annther in recurrence, need fnr subsequent surgery, and shnulder fu nctinn.21 Many athletes want tn return tn spnrt fnllnwing a traurnaric anterinr shnulder instability event during his nr her athletic seasnn. In a prnspective study bf 45 intercnllegiate

cnntact athletes, 73% returned tn spnrt after accelerated rehabilitatinn.” Sixty-seven percent finished the seasnn, Figure 3

Arthrnsrnpir image at the right shnulder at a 19-year-nld wnman vvhn plays rugby shnws a Bankart repair.

Bankart repair.” The presence nf radingraphic arthritis

did nnt cnrrelate with nutcnme scnres.

lIflpen Bankart repair has histnrically prnvided gnnd

results fnr shnulder stability. The prncedure requires tran~ seetinn, nr splitting, nf the subscapularis tendnn, and mild lnsses in fnrward elevatinn and external rntatinn can nccur, typically between 3“ and 1D“. In a series nf 49 patients, including 31 elite rugby players, 16% had recurrence nf instability during the 16 —year fnllnw—up pe—

rind after npen Bankart repair.” Of these patients, 65%

but 54% had recurrent instability during the seasnn. Ne

difference in recurrence was repnrted between thnse whn sustained an initial dislncatinn versus sublurratinn event,

but these with sublurratinns had a higher nverall rate nf

return tn spnrt and did sn mnre quickly. WDSI and Simple Shnulder Test {SST} scnres at the time nf injury were predictive nf ability tn return tn play, and WflSI, EST, and American Shnnlder and Elhnw Surgenns {ASESJ scnres

cnuld predict the time needed tn return tn play. Nnne at

the nutcnme scnres were predictive nf recurrence.

Recurrent shnulder instability increases the risk that existing intra-articular pathnlngy will wnrsen, including bnny attritinn nf the anternin ferinr glennid, enlargement

had radingraphic evidence nf arthritis at final fellow-up,

nr engagement nf a Hill—Sachs lesinn, and snft—tissue cnruprnntise. {liver the lnng terrn, nstenarthritis nf the

being pain free. Ninetyvfnur percent nf patients resumed athletic activity, 15% nf thnse at their nriginal level nf

excellent nutcnmes repnrted after surgical management nf instability, it must be questinned whether cnntinuing

mnst nf which was cnnsidered mild, and 311% repnrted cnmpetitinn.

The treatment nf cnntact nr cnIIisinn athletes remains cnntrnversial, and snme repnrts suggested higher rates

glennhumera] jnint can develnp in these patients. With

spnrts pa rticipatinn er rehabilitatinn nnly in the setting nf

recurrent instability is wise fnr future shnulder functinn.

nf recurrent instability in these patients fnllnwing ar-

A systematic review cnntpared arthrnscnpic management nf instability perfnrmed after the initial instability event

repair, an increased rate nf recurrence was nnted after

currence, range nf mntinn, nr cnmplicatinns.“ |Ei'l'utcnme

thrnscnpic management. In a recent randnmiaed clini— cal trial cnrnparing npen versus arthrnscnpic Bankart

er in a delayed fashinn after multiple recurrences and repnrted nn substantial differences in pnstnperative re-

arthrnscnpic repair {23% versus 11% in npen repair].” The highest rate nf recurrence was nnted in males ynunger

measures varied acrnss studies, precluding in-depth analysis. The lnvvest rates nf recurrence were nnted with suture

grnup cnmprised mnre cnntact athletes and hnne Inss

delaying surgical management did nnt appear tn have adverse effects.

than 25 years with Hill-Sachs lesinns. The arthrnscnpic was nnt evaluated; hnth facrnrs have been shnwn tn in-

fluence recurrence. In a trial nf isnlated Bankart lesinns randnmised tn arthrnscnpic versus npen repair, imprnved

Disability nf the Ann, Shnulder and Hand {DASH} scnres were nnted in the arthrnscnpic grnup, with an substan-

tial difference itt recurrence nnted?“ A differential lnss tn fnllnw-up between grnups was nnted, and mnre than

flrrItnpae-die Knnwledge Update: Spnrts Medicine 5

anchnr fixatinn nver elder implants. In the shnrt term,

Recurrence

Recurrent instability after surgical repair is a challeng-

ing prnblem. Snme studies demnnstrated recurrence

rates ranging between 4% and 19% fnr arthrnscnpic repair, mnst nf which nccurred during the first year after

El 1016 American Aesdenty nf Drrhnpaedie Surge-ens

Chapter 1: Shoulder Instability

surgery.” Independent risk factors included age at time of

surgery, glenoid bone loss greater than 25%, an engaging

Hill-Sachs lesion, male sex, competitive sports partic— ipation, fewer than three suture anchors, ligamentous

laxity, and the presence of an anterior labroligamentous

periosteal sleeve avulsion lesion.”-15

Revision open Bankart repair has demonstrated re-

liable results after failed arthroscopic repair. Improved outcome scores, pain, and return to almost prcinjury

activity levels have been shown with low rates of recurrence. Patients with substantial bone loss are still at risk for recurrent instability following open Bankart repair.” In appropriately selected patients, revision arthroscopic

stabilization can be a reasonable option. Recurrence rates

E

ranging from 6% to 10% have been demonstrated with revision arthroscopic Bankart repair in patients without

"fl 1]

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substantial glenoid or humeral head bone loss, without

F”

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hyperlaxity, and in those willing to comply with postoperative restrictions and therapy.ma Revision arthroscopic surgery including bony augmentation can be considered

after an open index procedure, but patient selection is critical. Low recurrence rates and high patient satisfaction can be achieved with meticulous attention to detail and surgical technique. Patients should be cautioned that pain may persist and osteoarthritis can still progress.” Studies of revision arthroscopic Bankart repair demonstrated

the importance of good surgical technique. In a study of 56 patients with recurrent postoperative instability, more than one—half had suture anchors placed above the

equator during the index procedure.” Instability With Bone Loss

Bone loss should be suspected in patients with unsuccessr ful instability repair, multiple subluxations andlor dislocations, or instability with minimal provocation {such as

activities of daily living or during sleep}. Attritional bone loss can be noted on the anteroinferior glenoid, resulting in an inverted pear glenoid or as a large Hill-Sachs

lesion. Glenoid and humeral head bone loss typically do

not occur in isolation, and the interaction of the two is important in determining the risk of continued instability.

The humeral head defect can fall into, or engage with, the area of the glenoid bone defect. In the glenoid track concept, glenoid bone loss narrows the track available for the

humeral head to articulate. If a concomitant Hill—Sachs lesion is wide or occurs in a medial enough location, the

humeral head can slip off track, resulting in an anterior dislocation“ [Figure 4].

Suspicion of bone loss warrants advanced imaging to quantify the defect for preoperative planning. Glenoid bone loss of greater than 2fl% to 25% is the general— ly accepted threshold for choosing a bony restoration

4D Illlii American Academy of Urthopaedic Surgeons

fill

a! Figured

lviFil abduction and external rotation {ABEH} view shows the glenoid traclc concept in a patient with a large Hill-Sachs lesion but no

glenoid bone loss. The lesion remains on track in this arm position.

procedure because this is an independent risk factor for

postoperative recurrence.”-15 Multiple techniques have

been described to measure glenoid bone loss, but no gold standard currently exists. CT, particularly three—dimena

sional {3D} CT, appears to be the most reliable means of calculating glenoid bone loss when compared with plain radiography and MRI. All imaging modalities underesti-

mated the degrec of bone loss to some extent, but 3D CT demonstrated the least inconsistency.31 3D CT has also

demonstrated high specificity and positive predictive values for the detection of Hill—Sachs lesions, with an overall

accuracy of Sfl‘i’h. Shallower lesions and lesions without subchondral bone damage are not as easily appreciated.“

Glenoicl augmentation procedures include open or arthroscopic coracoid transfer, iliac crest autograft, distal

clavicle autograft, and various allograft techniques. The open coracoid transfer, or Latarjet procedure {Figure 5},

has demonstrated excellent long-term results with low rates of recurrence and high patient satisfaction.” The

procedure is technically challenging, and a recent systematic review of level IV case series found a 3ll‘i’is complication rate with an average follow-up of 6.3 years.“

Recurrent instability was found in 3.?% of patients, most within the first year after surgery, and was associated with suboptimal graft placement. Most complications were

related to coracoid fracture, nonunion, or lysis. Low rates of neurovascular injury were reported. External rotation

Drrhopaedic Knowledge Update: Sports Medicine 5

Sectien 1: Upper Extremity

in University ef Califernia Les Angeles {UCLA}, Rewe, and Censtant sceres. Similar results were reperted in a

series ef 4? patients whe underwent remplissage with Bankart repair.3L9 flnly ene patient experienced recurrence

ef instability, and 63% returned te sperts participatien at

their previens level. External retatien was reduced by an average ef 3" and abductien by an average ef 9".

Either precedures can be used te treat a Hill—Sachs

lesien, including esteechendral allegraft, retatienal

{Weber} esteetemy, and arthreplasty. Allegraft recen-

structien may be indicated in yeung patients with very

1: Upper Extremity

large defects, whereas arthreplasty is reserved fer large defects in elderly patients. Currently, ne abselute guide-

lines exist te indicate these precedures. A recent systemat‘

ic review demenstrated high rates ef serieus cemplicatiens with Weber esteetemy, allegraft recenstructien, and ar-

?1'-"2"‘*-”r‘= ' 1'"

-

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-

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.

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threplasty.” The lewest rate ef recurrent instability was _

r - .,

Figure 5

AP radiegraph at a Lataerjet ceraceid transfer in a patient with unsuccessful arthreseepic Bankart repair and sex gleneid bene less.

feund with allegraft recenstructien, but cemplicatiens

such as esteenecresis and cellapse were seen in up re 74% ef patients. Arthrescepic remplissage remains a vi-

able eptien, with lew rates ef recurrence and the highest

safety prefile. was reduced by an average ef 13“. An all—arthreseepic technique has been described with rates ef recurrence

appreaching these ef the epen precedure, but is asseci—

ated with a steep learning curve.” Iliac crest and allegraft gleneid augmentatien have alse demenstrated reliable

Pesterier Instability Epidemielegy

Pesterier sheulder dislecatien is much less cem men than anterier dislecatien, cemprising appreximately 5 “if: ef all

leng—tcrm results,“ and the must recent systematic review

sheulder dislecatiens, with a prevalence ef LUIUGflDfl

Management ef a large Hill-Sachs lesien may else

with seizure activity and electrecutien than are anterier

available feund an evidence te suppert ene technique ever anetherfi?

per year.“1 A slight male predeminance exists, and frank pesterier dislecatiens are mere cemmenly asseciated

be necessary te restere sheulder stability. In cases ef substantial gleneid bene less and a large Hill-Sachs le-

dislecatiens. Almest twe-thirds ef pesterier dislecatiens are the result ef trauma such as meter vehicle cellisiens

needed te stabilize a jeint. In cases with minimal gleneid bene less, the Hill-Sachs lesien can be addressed using

5{1% ef pesterier dislecatiens can be missed in the emergency department setting; ehtaining an axillary lateral

sien, treatment ef the gleneid bene less may be all that is

multiple techniques. Remplissage invelves suturing the

infraspinatus tenden inte the hmneral head defect using either an arthreseepie er epen appreach. In a study ef

er falls, and 31% are related te seizure activity.“1 Up tn radiegraph is critical fer cerrect diagnesis. In athletes,

pesterier instability can be mere subtle, with primari~ ly subluxatien events in the at-risk pesitien ef ferward

recurrent anterier sheulder in stability with gleneid bene

flexien, adductien, and internal retatien.l Feetball

ic remplissage and Eankart repair were cempared with

particularly during the bench press, push-ups, er ether upper extremity weight—bearing activities. Recent reperts

less less than 25% and an engaging Hill-Sachs lesien, patients whe underwent cembined primary arthreseep-

centre] patients undergeing Bankart repair duly.” All patients demenstrated healing ef the tenden te bene at the remplissage site at 2 years en MRI; ne recurrent in-

stability was reperted in patients undergeing the cem— bined precedure. In these undergeing Bankart repair

enly, instability recurrence was 20%. Eighty percent ef

patients treated using remplissage returned te spert at their previens level and shewed substantial imprevements

flrrhepaedic Knewledge Update: Sperm Medicine 5

linebackers are at particularly increased risk. Pesterier instability in athletes can primarily manifest as pain,

suggest that cembined instability pathelegy may be mere cemmen than previeusly theught in certain pepulatiens.

0f 231 censecutive military patients undergeing surgery fer sheulder instability, enly 5?% had iselated anterier pathelegic changes.”ll Twenty-fen: percent had iselated

pesterier pathelegy, and 19% ef patients had cembined anterier and pesterier findings. MRI was enly 58%

El 1016 American Academ~y ef Unhepaedic Surge-ens

Chapter 1: Shoulder Instability

accurate for predicting intra-articular lesions. Pathophysiology Multiple lesions are associated with posterior instability.

determine humeral head bone loss, glenoid bone loss, and

glenoid retroversion.

Kim et al‘” described multiple lesions on the posterior

Treatment Nonsurgical management is the first—line treatment of

labrum without displacement. A prospective cohort of

larly of the infraspinatus. In a prospective series of 112

labrum in the setting of posterior instability, most commonly, an incomplete stripping of the posteroinferior EDD shoulders with isolated posterior instability found a patulous posterior capsule in 69% and posterior labral tears in 54%.“ Of note, patients with labral tears had

lower preoperative ASES scores, with no differences noted postoperatively. Other lesions include damage to the re-

tator interval, reverse Hill—Sachs lesions, bony deficiency

of the posterior glenoid, injury to the posterior capsule or posterior band of the IGHL, and glenoid retroversion. In a prospective series of military cadets, increased

glenoid retroversion at baseline was predictive for the

development of posterior shoulder instability, with every

1“ increase in retroversion increasing the risk of posterior

instability by 1T%.“5

Presentation Patients presenting with an acute posterior dislocation typically hold the arm in an adducted, internally rotat-

posterior shoulder instability. Physical therapy focuses on periscapular and rotator cuff strengthening, particu-

patients with posterior dislocations, recurrent instability did not develop after a formalized physical therapy regimen in 32% of shoulders. Persistent deficits in shoulder motion and function were seen in all patients at 2-year follow-up, irrespective of recurrence. Recurrent instability was independently predicted by age younger than

4i} years, dislocation resulting from seizure, and a large reverse Hill-Sachs lesion. Hyperlaxity was not predictive of dislocation recurrence.“ Surgery is indicated for patients with recurrent instability, pain, or functional limitations following appropriate therapy. Although both arthroscopic and open techniques

are described to treat the various lesions that can contribute to posterior instability, most surgeons currently prefer arthroscopic management {Figure Er}. In a prospective

cohort of if“) patients undergoing surgical stabilization for isolated posterior instability, Bradley et al‘”I reported

ed position. Full radiographic work—up that includes an

good results with arthroscopic capsular plication andfor

be maintained in patients presenting to the emergency

sports {64% at their previous level of competition}. Sim-

axillary lateral view is critical to determine the presence of an acute dislocation. A high index of suspicion should

department after sustaining a seizure or electrocution event. These patients are also at higher risk for bilateral

dislocations. Patients presenting with chronic posterior

dislocations can have profound lack of external rotation with a mechanical block. Radiographic evaluation can demonstrate large reverse HillHSachs lesions or humeral

labral repair; 94% of patients were satisfied with the result and would undergo surgery again, and 90% returned to ilar results were noted in contactr'collision athletes. Six percent of patients had failing ASE-S scores in pain and function, and Til: were noted to have continued instabil-

ity. All failures were identified within the first 7" months after surgery. (if those patients in whom treatment failed, 62.5%- had signs of multidirectional instability {MEI} at

head erosion. Chronic dislocations typically require an open reduction. Arthroplasty may be required in chronic cases with excessive bone loss. Patients with posterior shoulder subluxation may pres— ent primarily with pain. Symptoms are typically noted in

the time of revision. In the remaining patients in whom treatment failed, poor tissue quality was noted, typically a

rotation, and may be exacerbated by push—ups, bench press, and other activities that place a posteriorly directed

A retrospective series of 44 patients with posterior instability undergoing open capsulorrhaphy reported 34%

result of prior thermal capsulorrhaphy or ea rly aggressive

rehabilitation outside the established protocol. Gpen procedures to address posterior instability in-

the position of forward flexion, adduction, and internal

clude open capsular shift and bone block augmentation.

load on the shoulder. Physical examination should include a posterior load—and—shift test, ierk test, and posterior

overall satisfaction with a T4% rate of return to sport.“'5

apprehension sign, along with testing for anterior and

inferior instability because these conditions frequently

coexist. A sulcus sign that persists in external rotation can indicate rotator interval incompetence. MRI with or without intra-articular contrast can be used to evaluate the status of the posterior labrum, capsule, and other intra-articular structures, whereas CT scanning can help

Eb Ifllli American Academy of Urthopaedie Surgeons

Recurrent instability developed in 19% of patients, but in patients without signs of MD] at the time of surgery, the

recurrence rate was only 13%. Anterior instability devel-

oped subsequently in an additional 13% of patients, highlighting the risk of overaggressive posterior constraint.

lChondral injury and age older than 33 years at the time

of surgery were associated with worse outcomes.

Drthopaedic Knowledge Update: Sports Medicine 5

E "fl 1]

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E's 3.

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1: Upper Extremity

Section 1: Upper Extremity

a.‘=_‘

Figure 5

Arthroscopic image of the right shoulder of a 20—year-old man who is a football player shows a complete posterior labral repair.

-——_F-.—-'—_—-'I—-.—-—

Figure I

Instability 1lili‘ith Bone Loss Bone loss is a rare but challenging problem in the set-

Postoperative CT scan axial image from a patient with glenoid dysplasia shows healing of posterior gle noicl augmentation with osteoarticular autograft from the ipsilateral clistal clavicle.

ting of posterior shoulder instability. Although posterior

glenoid bone loss has been studied less than its anterior counterpart, both arthroscopic and open posterior bone

block augmentation techniques have been described for this rare condition {Figure 7’]. A biomechanical cadaver

Multidirectional Instability

Pathophysiology

study demonstrated that the bone block can overconstrain

MDI is poorly defined, but most authors agree that it encompasses a shoulder joint with excessive translation

tion in the setting of an incompetent posterior band of the IGHL.“ Precise positioning of the bone block is critical

a structural lesion such as a labral tear. Although many cases are atraumatic, traumatic onset does not rule out the

An all-arthroscopic technique using autograft iliac crest for recurrent posttraumatic posterior shoulder insta-

needs to incorporate an understanding of the physiologic

posterior translation while not treating inferior transla* to achieve the preferred mechanical effect.

bility has been described in 13 patients.“3 Graft union was

reported in all cases, however, complete lysis of the graft requiring revision proceeded to develop in one patient. Sixteen patients reported satisfaction with the procedure,

but a complication rate of 36%, steep learning curve, and worse outcomes in patients with glenoid dysplasia were noted. Long—term follow—up after open bone block procedures may not be as promising. [if 11 patients followed for 13 years, 3 had residual instability, 2 of whom eventually

required arthrc.tdesis.‘l'ir All patients had evidence of radio— graphic osteoarthritis at long-term follow-up, and clinical outcomes diminished over time. The worst outcomes were found in patients with hyperlaxity or MDI, and this pro— cedure should be avoided in these populations.

flrrhopaedic Knowledge Update: Sports Medicine 5

in two or more directions. Patients may or may not have

diagnosis. Patients with multidirectional laxity {asymptomaticj can sustain a traumatic injury, and the treatment laxity for a particular patient, with the need for capsular

tightening to augment a labral repair or capsulorrhapby. Multiple underlying etiologies exist with the common

theme of a patulous infBrior capsule, increased glenohumeral joint volume, and IGHL laxity.

Treatment The natural history of MD] is poorly documented, and various definitions of the disease have made interpretation of the literature difficult. Classically, MD] was

considered a self—limited condition that partially resolves

with increasing age, resulting in its universal treatment with physical therapy alone. Multiple protocols exist but

share a common theme of rotator cuff and periscapular muscle strengthening as well as proprioceptive training.

El ll] 16 American AcadMy of Cirrhopaedic Surgeons

Chapter 1: Sbeulder Instability

Hewever, athletic patients may net be willing te medify their activities and symptems may centinue even with

aggressive rehabilitatien.

In the largest lengitudinal study te date, 64 patients with MDI were fellewed fer a minimum cf 3 years.jfl All

patients underwent fermal physical therapy with a heme exercise pregram. At 2 years, 20 patients had undergene

surgery, and ef these whe had net, enly ene-half repert—

ed geed er excellent eutcemes fer pain and stability. Df these whe impreved with therapy, substantial gains were neted by 3 menths. At 3-year fellew—up, ene additienal

patient had undergene surgery, seven had given up sperts

cempletely, and an additienal nine admitted te substan-

tial lifestyle and eccupatienal changes te accemmedate

their sheulders. The need fer surgery was asseciated with unilateral invelvement, mere severe laxity, and difficulty

ef athletic activity. In the studies that stratified results by spert played, everhead athletes, elite athletes, and

swimmers had the lewest rates ef returning te spert at their previeus level. Dverall, both epen and arthrescepic techniques can be censidered safe, effective eptiens fer

the management ef MDI unrespensive te nensurgical measures. 5 u m m a ry

Sheulder instability is a cemmen preblem in a yeung,

athletic pepnlatien. Traumatic anterier instability cemprises mest instability events and can be treated using arthrescepic er epen techniques. Preeperative evaluatien

therapy fer at least 6 menths. At lung-term fellew-up,

fer bene less is impertant because unrecegnixed bene less is a substantial risk facter fer recurrence and peer eutcemes. Further research is needed te determine the mest accurate, reliable way te quantify bene less, determine which patients are at highest risk ef recurrence, and

sceres. This pepnlatien was yennger and mere active than these ef previeus reperts, but the diminishing subjective

shenlder instability may be mere cemmen in athletes and excellent eutcemes can be achieved with arthrescepic

perferming activities ef daily living. All patients whe

underwent surgery had persisted with fermal physical

enly 3U% ef all patients reperted geed er excellent Rewe eutcemes and need te medify lifestyles evident at lengcr

term fellew~up were cencerning. A recent prespective cehert cempared patients with MDI whe underwent physical therapy en ly, physical ther—

apy after epen capsular shift, and nermal centrel subjects witheut histery er physical findings ef instability.“ Sub-

jects underwent kinematic and electremyegraphic testing

during humeral elevatien. In the physical therapy—enly greup, the strengthening pregram did net restere the muscular activity er duratien parameters ef the nermal

shenlder, and at the 2- and 4-year peints, the values tested were similar te these ebtained befere therapy began. In centrast, the subjects whe underwent capsular shift and

pesteperative therapy had values similar te these ef the centrel greup that persisted threugheut fellew-up. Sur-

identify the best precedure te restere stability. Pesterier

repair. MDI is treated with fermal physical therapy, but

seme patients have persistent muscular deficits and unsatisfactery eutcemes. Selected patients will benefit frem arthrescepic er epen repair ef the capsule and injured

structures.

Key Study Peints

*- Traumatic anterier instability cemprises the majer—

ity ef shenlder instability cases, with sublnxatien events mere cemmen than dislecatiens. I Must traumatic anterier subluxatiens and dislecatiens in yeung athletes result in a Bankart lesien, but physicians sheuld be cautieus ef the HAGL,

which eccurs in up te lfl‘l‘r'i. ef patients.

gery cembined with therapy ceuld restere the stability

1‘ Preeperative risk stratificatien — including advanced

Beth epen capsular shift and arthrescepic capsular

xatien appreach in patients with anterier instability.

and muscular centrel ef the shenlder, whereas therapy alene was less reliable.

imaging fer bene less assessment—is critical tn a successful eutceme when selecting a surgical stabili-

plicatien have been described fer the treatment ef MDI, with the main geals ef decreasing capsular velnme and

I Pesterier instability may present with pain alene, and must cases have gee-d eutcemes with arthre-

tightening the IGHLs.fl In a systematic review ef avail-

scepic repairfplicatien.

able level IV studies, similar eutcemes were reperted fer recurrent instability, return te spert, less ef external retatien, and cemplicatiens between the ewe techniques.

The arthrescepic technique demenstrated a small increase in rate ef recurrence and impreved rate ef return te spert,

but these results did net reach significance. The system-

atic review was limited by variability in the definitien ef MDI used in the literature and incensistent reperting

Eb Ifllti American Academy ef Urthepaedic Surgeens

Annetatetl References 1. Dwens ED, Age] ], Meuntcastle 5E, |Cameren KL, Nel-

sen B]: Incidence ef glenehumeral instability in cellegiate

Drrhepaedic Knewledge Update: Sperts Medicine .5

E "fl 1]

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E's E.

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Sectien 1:1}pperExtremity

athletics. Am I Spell-1‘s Med lflflfififlfiirl'fifl-I'fid.

Medline

DUI

This retrespective analysis ef the Natienal Cellegiate Athletic Asseciatien injury database ever a 15—year pe— ried reperted the incidence ef sheulder instability events was ELIE per 1,001] athlete expesures. Males and feetball players sustained the mest injuries, with mere instability events neted during cempetitiens than practices.

Uwens ED, Duffey ML, Nelsen B], DeEerardine TM, I Tayler DC, Meuntcastle SE: The incidence and characteristics ef sheulder instability at the United States Military Academy. Am I Sperts Med lflfl?;35{?}:1163-11T3.

1: Upper Extrem fty

Medline DUI

Hui-Mansfield LT, Banks KP, Tayler DC: Humeral avul-

sien ef the gleeehumeral ligaments: The HAUL lesien.

Am I Sperts Med 200?;35f11]:196fl-1966. Medline DUI Uwens ED, Nelsen E], Duffey ML, et al: Patheanatemy ef first-time, traumatic, anterier glenehumeral subluxatien events. I Bette jefnt Strrg Arr-r Elli fl;91{?}:16fl5 4611.

Medline

DUI

This prespective cehert reperted ee 27" patients whe sustained a primary, traumatic anterier subluxatien event. MRI and surgical findings demenstrated high rates ef Bankart and Hill-Sachs lesiens. Feur ef thirteen had recur-

rence ef instability with uensurgical management. Level ef evidence: II.

IZlameren KL, Meuntcastle SE, Nelsen E], et al: Histery ef sheulder instability and subsequent injury during feur years ef fellew-up: A survival analysis. _,I BDHE jeirrt Surg Am 2fl13;95{5}:439~445. Medline DUI This prespective cehert studied 'FI-‘I- high-risk subjects. Subsequent instability was 5.6 times mere likely te develep in patients with print instability in any directien than these witheut a histery ef instability. Level ef evidence: I. |Uwens ED, Campbell 5E, Cameren KL: Risk facters fer anterier glenehumeral instability. Am I Sperts Med lfl]4:42{11j:1591-1596.Medline DUI

3. van der 1Eileen HE, |Cellies jP, Rijk PC: Value ef magnetic resenauce arthregraphy in pest—traumatic auterier sheulder instability prier te arthrescepy: A prespective evalu— atien ef MRA versus arthrescepy. Arc}: Gil-thee Trname 3mg 2U12:132{3]:3T1-3?5. Medline DUI This prespective, blinded evaluatieu ef 13 patients with pesttraumatic anterier instability cempared MRA findings with arthrescepy. Mederate agreement was seen fer Bankart lesiens: etherwise, peer agreement was seen fer ether intra-articular pathelegy. van lIGrinsven 5, Hagenmaier F, van Leen C], van Gerp M], van Hints M], van Kampee A: De-es the experience level ef the radielegist, assessment in censensus, er the

additien ef the abductien and external retatien view

impreve the diageestic repreducibilityr and accuracy ef MRA ef the sheulder? Effie Recife! 2fl14;69{11,1:115?1164. Medline DUI

In this blinded prespective evaluatien ef 53 patients with sheulder instability undergeing arthrescepy, radielegists evaluated MEAs and ABER views. The ABER view did net impreve accuracy er repreducibility, but the experience level ef the radielegist and censen sus agreements did. Many patients were unable te telerate the AEER pesitien. If}. Acid 5, Le Cerrellet T, Aswad R, Pauly V, Champsaur P: Preeperative imaging ef anterier sheulder instability: Diagnestic effectiveness ef MDC'I' arthregraphy and cem-

parisen with MR arthregraphy and arthrescepy. AJR Am

I Reenrgeeef lfl12:193{3}:eEI—EEI Medline

DUI

This prespective evaluatien ef 4!} patients cempared multidetecter rew CT and MBA with arthrescepy. Multideteeter rew CT identified labral and beny pathelegy and was recemmended as the preeperative imaging study ef cheice. MRA had superier results fer identifying lesiens ef the glenehumeral ligaments. 11. Rebinsen CM, Sher N, Sharpe T, Ray A, Murray IR: Injuries asseciated with traumatic anterier gleeehumeral dislecatiens. ,7 Bette jeint Surg Aer 2fl12:94{1}:13-16. Medline DUI

This prespective cehert studied "F14 high—risk yeung ath-

This prespective analysis reperted en 3,633.- censecutive patients with a traumatic anterier sheulder dislecatien at an average age ef 415 years. Neurelegic deficits were

humeral distance. Medifiable risk facters and hyperlaxity

ther a retater cuff tear er greater tuberesity fracture. The likeliheed ef neurelegic deficit was increased in patients with a retater cuff tear er greater tuberesity fracture. Level ef evidence: II.

letes. The risk ef sheulder instability was asseciated with pesitive apprehensiee and relecatien signs en physical examinatien, increased gleneid index, and increased ceracewere net predictive ef instability. Level ef evidence: II.

Salemenssen E, ven Heine A, Dahlbern M, et al: Eeny Bankart is a pesitive predictive facter after primary sheulder dislecatien. Knee 3mg Sperts Trenmrrfef Artfaresc

lfl]fl;13[lfl}:1425-1431.Medline eel

In 39 patients treated nensurgically after a first-time anterier dislecatien, the enly pregnestic facters fer a stable sheulder at 3 years after injury were age elder than 312} years at time ef injury and the presence ef a bony Bankart lesien en MRI.

feued in 13.5% fellewing reductien, and 33.4% had ei—

12. Liu A, Rue X, Chen T, Bi F, Tan 5: The external retatien immebilisatien dees net reduce recurrence rates er impreve quality ef life after primary anterier sheulder dislecatien: A systematic review and meta-analysis. Injury

2014:45i111flfi42-1341Medline eel

This meta—analysis ef seven retater cuff tears cempared external and internal bracing after acute glenehumetal dislecatien. Ne difference was funnd in rates ef recurrence er eutceme sceres. Werse cempliance was reperted iu the

external retatien greup.

Urrhepaedic Knewledge Update: Sperts Medicine 5

El 1016 American AcadMy ef Urrhepaedic Surgeens

Chapter 1: Shnulder Instability 13. Dwens ED, Harrast J], Hurwit: 5R, Thnmpsnn TL, Wnlf JM: Surgical trends in Hankart repair: An analysis nf data frnm the American Enard nf Urthnpaedic Surgery certificatinn esaminatinn. Am ,F Spa-rte Med 1011;39i9}:13651355'. Medline

DUI

This retrnspective analysis cf the American Beard nf flr— thnpaedic Surgenns database frnm Zflflfi tn lflflfl repnrted

that prinr tn lflilS, ?1% nf Bankart repairs were perfnrmnd arthrnscnpically, versus 33% after EDDIE.

14. Rnbinsnn CM, Jenkins P], White TD, Ker A, Will E: Primary arthrnscnpic stabilisatinn fer a first-time anterinr dislncatinn cf the shnulder. A randnmised, dnu— ble-blind trial. ] Bnrrefnint Surg Am Elli] 3.390(41903-1'21. Medline DUI 15. Chahal J, Marks PH, Macdnnald PB, et al: Anatnmic Ban-

kart repair cnmpared with nunuperative treatment andfnr

arthrnscnpic lavage fnr firstwtime traumatic shnulder dislncatinn. Arifrrnscnpy 2012;23l4lfii55 -.5 F5. Medline DUI This systematic review nf level I and II studies cnmpared arthrnscnpic Eankart repair with physical therapy nr sham surgery. Patients whu underwent Bankart repair had substantially decreased recurrence and imprnved WDSI scnres. Level nf evidence: II.

16. Ahmed I, Ashtnn F, Rnbinsnn CM: Arthrnscnpic Bankart repair and capsular shift fnr recurrent anterinr shnulder instability: Functinnal nutcnmes and identificatinn nf risk factnrs fnr recurrence. ,l' finite lei-1st Surg Am Zfl12:94(14}:1303-1315.Medline DUI In this study, 3fl2 patients were treated with arthrnscnpic Bankart repair. Recurrent instability was nnted in 13.1%.

Imprnved 1|i‘vii'lliiill and DASH scnres were nnted at 1 years,

but senres were decreased in patients with recurrence. Three independent risk factnrs fnr recurrence were age, gleunid bnne lnss greater than 15%, and an engaging Hill-Sachs lesinn. Level nf evidence: I.

1?. Elmlund AD, Ejerhed L, Sernert N, Rnstgdrd LC, Kartus J: Dislncatinn arthrnpathy and drill hnlc appearance in a mid- tn lnng-term fnllnw-np study after arthrnscnpic Bankart repair. Knee Sung Spurrs Traumdtni Artbrnsc lflllglflllllfiljfi—llfil.Medline DUI

19. Mnhtadi NG, Chan D5, Hnllinshead RM, et al: A ran-

dnmised clinical trial cnmparing npen and arthrnscnpic stabiliaatinn fnr recurrent traumatic anterinr shnulder

instability: Twp-year fnllnw—up with disease—specific quali-

ty-nf-life nutcnmes. I Hesse faint Sui-g Am 2fl14;95{51:35336:}. Medline DUI

Higher recurrence nf instability was nnted in patients in the arthrnscnpic Eankart grnup, particularly in ynung males with Hill—Sachs lesinns. The arthrnscnpic grnup had more cnntact athletes, and nn qua ntificatinn nf bnne lnss was performed. Level nf evidence: I. 20. Archerti Hetm H, Tamanlti M], Lensa M, et al: Treatment nf Bankart lesinns in traumatic anterinr insta-

bility cf the shnulder: A randnmised cuntrnlled trial

cnmparing arthrnscnpyr and npen techniques. Arthrnscnpy 2fl12:23{?}:9flfl-9fl3.Medline DUI Imprnved DASH scnres were nnted in tbe arthrnscnpy grnup, but nn substantial differences were nntnd in Rnse

nr UCLA scares, range nf mntinn, nr recurrent instability. Lewl cf evidence: II. 2.1. Chalmers PH, Mascarenhas lit, Leruus: T, et al: Du arthrn— scnpic and npen stabilisatinn techniques restnre equivalent stability tn the shnulder in the setting nf anterinr glennhumeral instability? A systematic review nf nverlapping meta-analyses. Arthrnscnpy 2015:31{2]:335-363.

Medline DflI

Dverall, no difference was nnted in recurrence rates nnted. Studies published befnre It'll]? favnred npen surgery

in recurrence rates, whereas thnse published after 101]?

demnnstrated nn difference. Level nf evidence: IV.

21. Pulavarti R5, Symes TH, Rangan A: Surgical interventinns fnr anterinr shnulder instability in adults. Enchrarte Database Syst REF Eflflflfiflflflififl TIT. Medliue

Insufficient evidence exists frnm available randnmiaed

clinical trials tn favnr nne technique nver annther.

23. Dickens JF, |['iwens ED, Camernn KL, et al: Return tn play and recurrent instability after in—seasnn anterinr shnulder instability: A prnspective multiceutcr study. Am 1 Sports Med 2014:42I121:2 342-2350. Medline DUI Ferty-five inrercnllegiate athletes with in-sea snn shnulder instability were fnllnwed after accelerated rehabilitatinn

In this study, 41% nf patients demnnstrated radingraphic signs cf nstcnarth ritis 3 years after arth rnscnpic Bankart repair fnr shnulder dislncatinn. |Eli'ntcnme scnres did nnt cnrrelate with radingraphic findings. Level nf evidence: III.

and return tn play, ?3% returned tn cnntact spnr'ts, but

13. Fabre T, Abi- Chahla l'vIL, Billaud A, llilieueste M, Durandeau A: Lnng-term results with Eankart prncedure: A

24. Grumet RC, Each BR Jr, Prevencher MT: Arthrnscnpic

16-year fnllnw—up study nf 5D cases. } Sbnaider Elbow Surg lfllfl;19(2l:313-323. Medline DUI

This Edeyear fnllnw-up reviewed 50 shnulders that underwent np-en Eaukart repair after shnulder dislncatinn. Mnst

patients were elite rugby players. At final fnllnw—up, 15%

had recurrent instability, 65% shnwed signed nf arthritis, 94% returned tn spnrts, and Edit. were pain free. Level nf evidence: IV.

64% had recurrent instability during the seasnn. Level

nf evidence: I].

stabilisatinn fnr first-time versus recurrent shnulder insta-

bility. Arthrnscnpy 2G1fl;26{2}:239-243. Medline DUI

This systematic review cnmpared arthrnscnpic Eankart repair immediately after first dislncatinn versus after mul— tiple recurrences. Hun difference was nnted in pnstnperative recurrence nf instability, range nf mntinn, nr cnmplicatinns. Level nf evidence: II. 15. Randelli P, Ragnne V, Carminati 5, Cabitsa P: Risk factnrs

fnr recurrence after Bankart repair a systematic review.

Eb Ifllii American Academy bf Urtlmpaedic Surgenns

Drrhnpaedic Knnwledge Update: Spnrrs Medicine 5

E "fl 1]

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:1:

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Sectien1:UpperExtremity

Knee Strrg Sperts Traumatel Arthresc lfl11;20{11l:11292133. Medline DUI Facters associated with recurrent instability after artl1re-

scepic Bankart repair included age yeunger than ED years,

male sex, cempetitive spurts pa rticipatien, fewer than three suture anchers, gleneid bene less, large Hill-Sachs lesiens, ligamenteus laxity, and anterier labreligamenteus periesteal sleeve avulsien lesiens. Level ef evidence: 11.

26'. Che NS, YiJW, Lee BG, Rhee 't'G: Revisien epen Bankart

31. Rerlte MA, Pan I, Denaldsen C, Jenes GL, Eishep IT: Cemparisen ef varieus imaging techniques te quantify gleneid bene less in sheulder instability. _l Shealder Elbert: Sttrg ED13:22{4]:523-S34. Medline DUI This cadaver study reviewed three sizes ef gleneid bene defects created and then imaged using 3D CT, CT, MRI,

and plain radiegraphy. Altheugh 3D CT was the must ac—

surgery after arthrescepic repair fer traumatic anterier sbeulder instability. Am I Sperts Med 20 09:3T{11}:21532164. Medline DUI

curate and reliable, all imaging medalities underestimated bene less te same extent. Level ef evidence: III.

Uf 26 sheulders that underwent revisien upen Bankart

32. Usalti R, Nakagawa S, lvlitune H, Mae T, Yeneda lvl: Hill-sachs lesiens in sheulders with traumatic anterier instability: Evaluatien using cemputed temegraphy

repair after failed arthrescepic precedures, 33% had 1: Upper Extremity

Resteratien ef the gleneid track sheuld be a primary geal ef instability surgery.

geed er excellent results, with impreved pain and stability sceres. Three additienal dislecatiens eccurred in patients

with engaging Hill—Sachs lesiens and hyperlaxity. Level ef evidence: IV.

2?. Eartl C, Schumann K, Paul J, Vegt S, Imheff AB: Arthrescepic capsulelabral revisien repair fer recurrent anterier sheulder instability. Am I Sperts Med 2fl11;39{3l:511-513.Medline

DUI

Fifty-six patients underwent revisien arthrescnpic surgery

fellewing unsuccessful epen er arthrescepic anterier sta—

bilisatien. Rese, Censtant, and SST sceres substantially impreved with 36% geed er excellent results, with 11% recurrence. Level ef evidence: IV. 23. Arce G, Arcuri F, Ferre D, Pereira E: Is selective arthroscepic revisien beneficial fer treating recurrent anterier sheulder instability? {filer Urthep Refer Res 2fl12:4?fl{4l:965-9?1.Medline DUI In this retrespective analysis, 16 patients underwent revisien arthrescepic Eanltart repair. Strict exclusion criteria included substantial gleneid er humeral head bane less, hyperlaxity, and participatien in centact spurts. UELA, |Censtant, and Rewe sceres impreved substantially, and three recurrences were reperted at mean 31-menth fel-

lew—up. Level ef evidence: I‘v’.

29. Eeileau P, Richeu J, Lisai A, Chuinard C, Eiclcnell RT: The

rele ef arthrescepy in revisien ef failed epen anterier sta-

bilisatien ef the sheulder. Artbrescepy lflfl9;25[1 Dial}???-

103 4. Medline DUI

Twenty-twp patients with unsuccessful epen anterier stabilitatien precedures underwent arthrescepic revisien.

with 3-dimensienal recenstructien. Am J Sperts Med 2fl14t42111}:259?-EEDS.Medline

DUI

3D CT perfermed in 135 patients with traumatic anterier sheulder instability undergeing arthrescepic Bani-tart re-

pair identified Sil‘lb ef Hill— Sachs lesiens with a sensitivity

ef 35%, a specificity ef IRE-'36, a pesitive predictive value ef mess, and a negative predictive value cf 46%. 3D CT was less accurate in shallevvr lesiens and these witheut sub-chendral bene damage. Level ef evidence: II. 33. Hevelius L, Sandstrtim l3, Ulefssen A, Svenssen U, Rahme

H: The effect ef capsular repair, bene bleclt healing, and

pesitien en the results ef the Bristew-Latariet precedure {study III}: Lung-term fellew-up in 319 sheulders. ] Sher-tider Elbert: 3mg 2111 2;11{.S 1:64.?- 650. Medline DUI In three series ef patients undergeing epen Latarjet pre-

ccdure with between .5 and 23 years ef fellew—up, 1% ef patients required revisien surgery fer recurrence and 96% reperted satisfactien with the precedure. Recurrence was asseciated with graft placement that was tee medial.

34. |[Siriesser M], Harris JD, l'vIcCey BW, et al: Cemplicatieus and re-eperatiens after Bristew—Latarjet sheulder stabilisatien: A systematic review. I Shealder Elbert: Sarg 2fl13;22{l}:236-292.Medline DUI This systematic review ef epen and arthrescepic Latarjet precedures reperted an everall cnmplicatinn rate c-f

311%, must ef which related te healing er fracture ef the

ceraceid. Recurrent instability was neted in 3.??6, rsss ef these within the first year fellewing surgery. The mean less ef external retatien was 13". Level of evidence: IV.

Geed er excellent results ebtained in 35%, and ene case

ef recu rrent dislecatien was reperted. Usteearthritis pregressed by ene stage in three patients. Level ef evidence: IV.

3S. Dument GD, Fegerty S, Hesse C, Lafesse L: The arthrescepic latarjet precedure fer anterier sheulder instability: 5—year minimum fellew—up. Am j Sperts Med 2014:42i11}:256fl-2566.Medline DUI

3-3. Trivedi 5, Pemerants ML, Gress D, Gelijanan P, Prevencher l'vIT: Sheulder instability in the setting ef bipelar {glennid and humeral head} bane less: The glean-id track cencept. Cfffi- Urrhep Relat Res Eli 14:4?213}:2 3522362.. Medline DUI

This retmspective case series reperted en 62 patients whe underwent an arthrescepic Latarjet precedure with a minimurn 5-year fellew—up. Recurrent instability was seen in 1.6%, and high WUSI sceres were reperted in all demains. Level ef evidence: IV.

This systematic review reperts en the biemechanical

and cadaver data related In the glennid traclt cencept.

Urthepaedic Knewledge Update: Sperts Medicine 5

. Sayegh ET, Mascarenhas R, Chalmers PN, Cele B], Venus NH, Remee AA: Allegraft recenstructien fer glennid

El 1016 American AcadMy ef Urthepaedic Surge-ens

Chapter 1: Shnulder Instability bane lnss in glennhumeral instability: A systematic review.

Hill-Sachs lesinns, and seizure as an etinlngy nf dislncatic-n. Level nf evidence: II.

Artlrrnscnpjr 2014:30i12}:1642-1649. Medline DUI

This systematic review evaluated multiple allngraft techniques fnr anterinr glennid recnnstructinn. At an aver-

age 44—mnnth inllnw—up, 93% nf patients were satisfied

with the nutcnme, despite lfl‘iis with residual pain. High Rnwe scnres and recurrent instability in 11% were repnrted; lflfl‘fl: graft incnrpnratiqn was nnted. Level [if

42. Snug DJ, Cnnk JE, Krul KP, et al: High frequency nf pnsterinr and cnmbined shnulder instability in ynung active patients. I Sbnuider Elbnw 3mg 1015;24{2}:13i5519fl. Medline DUI

In this retrnspective analysis, 231 patients underwent sur— gical stabilizatinn fnr shnulder instability. Isnlated anterinr labral tears were fnund in 57"?4: {if patients, with isnlated

evidence: IV.

pnsterinr tears in 24% and cnmbined labral injuries in

3?. Beran l'vlC, Dnnaldsnn CT, Bishnpj'f: Treatment pf chron-

ic glennid defects in the setting ni recurrent anterinr shnul-

der instability: A systematic review. I Sbnuider Elbnw Burg lfllflflSiSh'FSB-‘F'Sii.Medline DUI

19%. Level cit evidence: III.

43. Kim SH, Ha KI, Park JH, et al: Arthrnscnpic pnsterinr labral repair and capsular shift fnr traumatic unidirectinnal recurrent pnsterinr subluxatinn nf the shnulder. I Hnue

A systematic review cf the current evidence demunstrated

nn data tn suppnrt nne glennid bnne restnratinn technique nver annther. Level nf evidence: IV.

33. Franceschi F, Papalia R, Riaaelln G, et al: Remplissage

repair—new frnntiers in the preventinn nf recurrent shnulder instability: A 2-year fnllnw-up cnmparative study. Am

I Spurts Mad 2fl12;4fl{11}:1461«2459. Medline DUI

This retrnspective cnhnrt nf patients with Bankart and engaging Hill— Sachs lesinns was treated with remplissage and Bankart repair nr Bankart repair alnne. Patients in the remplissage grnup had substantially decreased recurrence. All had imprnved nutcnrne sen-res, returned tn spurts, and had minimal mntinn lnss. All remplissage tendnns were fully healed at 2 years an MRI. Lewl nf evidence: III. 39. Enileau P, {J‘Shea K, Vargas P, Pinedn l'vI, Ifllld J, Zumstein ivi: Anatnmical and functinnal results after arthrnscnpic Hill-Sachs remplissage. I Brine Inint Surg Am 2012;94{?}I:SIS-Sld.Medline DUI

A retrnspective analysis evaluated 4? patients undergoing

arthrnscnpic remplissage with Bankart repair fnr recurrent instability. Recurrence was repnrted in DIIE patient; 63% returned tn previnus level pf spnrt. The average mntinn

less in REEF. was 3" tn 9". Level nf evidence: IV.

4G. Lnngn UG, apini l'vl, Riaselln G, et al: Remplissage, humeral nstenchnndral grafts, weber nstentnmy, and shnulder arthrnplasty fur the management nf humeral bnne defects in shnulder instability: Systematic review and quantitative synthesis nf the literature. Arihrnsenpy su14,suus}:1ssn-isss. Medline DUI This systematic review evaluated all fnur techniques tn treat humeral head defects. |Eilverall, remplissage was an effective, safe technique. High rates {if substantial enm-

plicatinns were repnrted with nther techniques. Level nf evidence: IV.

41. Rubinsnn CM, Seah M, Akhtar MA: The epideminlngy, risk nf recurrence, and functinnal nutcnme after an acute

traumatic pnsterinr dislncatinn cf the shnulder. I Buns faint Surg Am 2fl11;93{1?}:15i}5 4613. Medline DDI This prnspective cnhnrt nf 110 patients with isnlated pnsterinr dislncatinns reviewed epideminlngy, assnciated injuries, and functinnal nutcnmes. The risk nf recurrence was independently predicted by ynung age, large reverse

Eb Ifllii American Academy nf Urthnpaedic Surgenns

juint SHTE am anus,ss-ais}:14vs-14sv. Medline 44.

Bradley JP, McClincy MP, flruer JW, Tejwani 5G: Arthrnscnpic capsulnlabral recnnstructinn fur pnsterinr

instability nf the shnulder: A prnspective study nf lflfl

shnulders. Am: J Sprints Med 2G13:41{9}:2flfl$-2fl14. Medliue DUI This prnspective case series evaluated 2nu shnulders with unidirectinnal pnsterinr shnulder instability treated with arthrnscnpic capsulnlabral recnnstructinn. At 36-mnnth fnllnw-up, patients demnnstrated imprnved nutcnmes related tn stability, pain, and functinn. Level nf evidence: II. 45. flwens ED, Campbell SE, Camernn KL: Risk factnrs fur pnsterinr shnulder instability in ynung athletes. Am I Spain‘s Med1013;41:11}:1645-1549. Medline DUI

This prnspective cnhnrt study nf high—risk, ynung athletes

in whnm pnsterinr shnulder instability develnps repnrted that the must substantial risk factnr fur subsequent pnsterinr instability was increased glennid retrnversinn. A

was increase in risk at acute pnsterinr instability with

every 1" increase in retrnversinn was demnnstrated. Level pf evidence: I].

46. Wait ER, Strickland S, 1Williams R], Allen AA, Altehek DW, 1|ilil'arren RF: |Iii-“rpen pnsterinr stabilizatinn fur recurrent pnsterinr glennhumeral instability. ] Sbnuider Eihnw Surg lflfl5;14{2]:15T—IE4.Mcdline DUI 4?. Wellmann lid, prnwitsch E, Khan N, et al: Binmnchanical effectiveness nf an arth rnscnpic pnsterinr bankart repair versus an npen bane blnck prncedure fur pnsterinr shnulder instability. Ann I Spurts Med 2D11:39{4]:T96-Sll3. Medline 130]

This cadaver binmechanical study evaluated eight matched

pairs nf shnulders with a simulated pnsterinr Bankart lesiun and laceratinn of the pnsterinr band cf the IGHL. Pathnlngic translatinn in all directicrns was returned tn the intact state using an arthrnscnpic pnsterinr Eankart repair, whereas the jnint was nvercnnstrained tn pnsterinr translatinn and inferipr instability was nnt addressed with the brine blnck prncedure.

43. Schwartz DIG, |IGnebel 5, Piper K, Knrdasiewicz E,

Bnyle S, Lafnsse L: Arthrnscnpic pnsterinr hnne blnck

Drrhnpaedic Knnwledge Update: Spurts Medicine 5

E "fl 1]

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fit

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Sectien 1:1}ppcrExtrcmity

augmentatinn in pestericrr shnulder instability. I Sbnflider Eibnw 3mg 2013;22i3}:1i}91—11{H. Medline DUI This retrnspective case series reviewed 19 arthrnscnpic pesterinr bane black precedures fur patients with recurrent pnsteric-r instability and heme less. Level nf evidence: W. 45.

Meuffels DE, Schuit H, van Eieacn FC, Reijman M, 1Inferhaar JA: The pesrerier bnne blnck precedure in pnsterinr shcrulder instability: A lung-term fnllnw-up study. I Brine Joint Surg Br 1010;3l}:551— 655. Medline D01

In this pruspective case series of 11 patients when under-

went pesterier bcme bleclr. precedure with 13-year felr lbw-up, patients with traumatic etinlngy nf instability had the best results versus hyperlaitity nr MDI. Mare than

1: Upper Entrem ity

cue—half nf patients had residual instability, and diminish— ing nutcentes were mated ever time. Level nf evidence: W.

5f}. Misan-mre GW, Sallay PI, Didelnt W: a luugitudinal study

nf patients with multidirectinna] instability ef the she-alder with seven- tn ten-year fellow-up. I Sbnufder Efbpm 5mg EDDS ,14-{5 }:4EE-4?fl. Medline DUI

flrfltnpaedic Knnwledge Update: Sparta Medicine 5

51. Nyiri P, Illyés A, Kiss Iii, Kiss J: Intermediate biume-

chanical analysis flf the effect nf physiotherapy nnly

campared with capsular shift and phys-intherapy in multidirecticmal shcmlder instability. I Sheafder Elbe-w Snrg 2010;19l5}:3{}1-313.Mcdlinc

DUI

A ccrhnrt of patients with MDI when underwent physical therapy alnne was compared with these whc: underwent physintherapy after an epen capsular shift. At 1 and 4 years after therapy, the cembined surgicalftherapy grnnp had kinematic and electrcniyngraphic values similar

tn these cf centre] patients. Therapy alcme was unable tc:

restere nc-rmal jeint kinematics and prevent instability. Level nf evidence: II.

52. Jacebsen ME, Riggenbach M, 1iiii'b:::luilridge AN, Bishep JY: Dpen capsular shift and arthrnscnpic capsular plicatinn fur treatment nf multidirectinnal instability. Artfarnscnpy

ac:s,2srv:;:s1s—1mv. Medline no:

This systematic review campared npcn and arthrnscnpic surgical management of MDI. bin substantial differences were repc-rted; bnth app-ear tn be safe, effective techniques. Overhead athletes and swimmers were least likely tn return tn price level nf spurt. Level cf evidence: IV.

El 1016 American Acadenw crf Drrhnpaedic Surge-ans

Chapter 2

Disorders of the Acromioclavicular

Joint, Sternoclavicular Joint, and Clavicle Youssef El Bitar, MD

Abstract

Acromioclavicular (AC) joint injuries are common in

young athletes, ranging from a simple sprain to frank

fractures are common injuries involving the shoulder

dislocation. Managing the AC joint separation is usually nonsurgical in type I and ”I injuries, and type IV to VI

common. Ma nagement of AC joint separations depends on the injury type; management of type III is the most

for both non

on the fracture location along the clavicle shaft. Near

who are ho,

Acromioclavicular {AC} joint separations and clavicle girdle; injuries to the sternoclavicular {SC} joint are less

controversial. Clavicle fracture management depends

type II lateral third fractures and complex unstable

him-aura Action :1

Brian R. Wolf, MD, MS

injuries are treated surg@Thc management of type

III AC joint scparan fractures are

,. ,

u

r

,'

,rovcrsial, with proponents

“- “.1 surgical treatment Clavicle

juries in adults, affecting patients

'

middle shaft fractures require surgical intervention. SC

joint injuries are mostly treated nonsurgically, except in cases of instability and pain. An understanding oi?

the mechanism of 1njury for these shoulder Injuries

is important, along with knowledge about the commonly used classification systems for each'111] management options based on classification,

arive rehabilitation, outcomes reported in th *'

and possible complications.

Keywords: acrornioclavicular joint separation: clavicle fracture; sternociavicular joint dislocation Introduction

Shoulder injuries can result in various pathologies in— cluding suhlusations, dislocations, and fractures.

' noclav1cular (SC) joint is injured less often than the

"i; *1: AC joint or the clavicle because the surrounding ligaments

are strong. The most common type of management of 5C

joint injury is nonsurgical. Closed reduction is required in type 3 SC joint dislocation whether anterior or posterior. Occasionally, open reduction and internal stabilization is required for unstable, symptomatic dislocations. AC Joint Injuries

Injuries to the AC joint comprise 9% of shoulder injuries and are often caused by direct trauma to the shoulder or

a fall on an outstretched hand.1 Younger, physically ac= rive athletes are at particularly increased risk} especially

Dr. Woif or an immediate famiiy member serves as a paid consultant to CONMED Linvatec; has received research or institutionai support from the Orthopaedic Research and Education Foundation; has received nonincome support {such as equipment or services), commerciaiiy derived honoraria, or other non-research-reiated funding (such as paid

trove!) from Arthres; and serves as a board member, owner; offices or committee member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Society for Sports Medicine, and the Mid-America Orthopaedic

Association. Neither Dr. E! Eitar nor any immediate famiiy member has received anything of vaiue from or has stock or stock options heid in a commerciai company or institution reiated directiy or indirectiy to the subject of this chapter.

Q 2016 American Academy of Orthopaedic Surgeons

Orthopaedic Knowledge Update: Sports Medicine 5

l,i j l

i' l‘.

l

.

a i ,

Sectinn 1:1}pperExtremity

thnse invnlved in cnntact and extreme spnrts, as well as

high-risk activities such as skiing and cycling. The extent nf injury tn the AC and cnracnclavicular {CC} ligaments

as well as the amnunt and directinn nf clavicle displacement nften determine the severity nf AC jnint separatinn.

Debate cnutinues regarding the best management nf such injuries, especially type III AC jnint separatinn. Several

factnrs play a rnle in decisinn making nn the management

nf these cnmmnu injuries including age nf patient, type nf injury, time frnm injury, activity level, and re snme

extent, aesthetic appearance. Treatment invnlves nnnsur—

1: Upper Extremity

gical and surgical measures, including acute repairs with nr withnut augmentatinn nr late recnnstructinn. Overall, the nutcnmes are favnrable with mnst treatrnent nptinns.

Mechanism of Injury

Injuries tn the AC jnint are usually the result nf a direct

blnw tn the superinr and lateral aspects nf the shnulder

Management Type I and Type II N: Jnint Injuries

Nnnsurgical management has been the first-line treatment nf type I and type II AC. jnint separatinns, using an arm sling fnr immnbilieatinn and pain cnntrnl. Additinnally,

several nther therapeutic modalities are used including rest, nral analgesics, NSAIDs, icing, and activity mndi-

ficatinn. Snme studies advncate the use nf intra-articular lnng-acriug anesthetic injectinns intn the AC jnint in highly cnmpetitiye athletes tn allnw faster return tn play in the

acute setting. The arm sling is usually used fnr apprnxi‘

mately 1 week in type I injuries, and fnr 2 tn 3 weeks in

type II AC jnint separatinns. When the pain subsides, the

arm sling is discnntinued and physical therapy is initiated

with active and passive shnulder range-nf-mntinn {REM} exercises. Strengthening exercises are started after full

ROM is nbtained. Patients shnuld refrain frnm returning

with the arm in an adducted pnsitinn, resulting in the

tn cnntact spnrts nr heavy lifting for apprnximately Z tn 3 mnnths, until restnratinn nf full, painless shnulder ROM.

relative tn the clavicle. The first ligament injured is the AC ligament. 1|With increasing severity nf injury, the CC

patients are at risk fnr recurrent nr persistent shnulder

displacement nf the acrnrninn inferinrly and medially

Currently, nn evidence suppnrts early surgical manage‘ ment fnr type I nr type II AC jnint separatinns. Hnwever,

ligaments are injured next, fnllnwed by the deltntrapeeial

symptnms after type I and type II injuries. Injury can

humerus being pushed intn the acrnminn with a superinrly

injury. Retrnspective studies have repnrted persistent

fascia.5| Annther less cnmmnn mechanism nf injury is a fall nn an nutstretched hand, resulting in the prnximal directed fnrcex” Classification

nccur tn the AC jnint articular cartilage nr articular disk that can result in shnulder cnmplaints subsequent tn the symptnms in up tn “1% tn 5fl% nf patients at 1, E, and 1|} years after injuryf'"it Despite the relatively high percentage nf persistent symptnmatic patients, nnnsurgical

intn types I, II, and III.“i The classificatinn was later ex-

treatment is still the standard nf care in type I and type II AC jnint injuries. In nne study, 3% nf patients under-

and VI,5 relying nn cnmparative films nf the cnntralateral shnulder rn determine each type {Figure 1}. A type I

injury."r Distal clavicle resectinn, either arthrnscnpic nr npen, cnuld prnvide a pntential snlutinn in patients whnse

In 1963, AC jnint injuries were initially classified in 1953

panded by Rnckwnnd in 1934 tn include types W, V,

injury invnlves AC ligament sprain withnut injury tn the

CC ligaments, and nn AC jnint widening nr clavicular displacement. Type II injuries cnnsist nf cnmplete rupture

went surgical interventinn at a mean nf 26 mnnths after nnnsurgical treatment failed secnndary tn the develnpmenr nf nstenarthritis in the AC jnint.El

nf the AC ligament, CC ligament sprain, widening nf

Type III AC Jnint Injuries

shnulder. In type III injuries, the AC and CC ligaments are disrupted, the AC jnint is widened, and the CC distance

Several studies have advncated nnnsurgical treatment

the AC jnint, and increase nf the CC distance by mnre than stern tn less than 25% cnmpared tn the cnntralateral

The initial management nf type III AC jnint separatinns is still cnntrnversial in the literature and in clinical practice.

is increased 15% tn 1i] [1% cnmpared tn the cnntralateral

with gnnd tn excellent nutcnmes at final fnllnw—upg‘jI nther studies have repnrted persistent pain and symptnms}1

the distal clavicle is displaced pnsterinrly intn the trape— zius muscle. Type V injury is similar tn type III, except the

in the acute setting.11 Therefnre, nn cnnsensus has been

shnulder. A type IV AC jnint separatinn is diagnnsed when

CC distance is increased by mere than lflfl% cnmpared

tn the cnntralateral shnulder because nf disruptinn nf the deltntrapeaial fascia and renting nf the nverlying skin can result. Type VI injury is rare and invnlves inferinr

displacement nf the clavicle intn the subcnracnid space [Table 1}.

flrrhnpaedic Knnwledge Update: Spurts Medicine 5

A 2011 study recnmmended surgical management for type III AC jnint separatinn in ynung, active patients reached regarding the best treatment nptinn fur type III AC jnint injuries. These injuries shnuld be treated nn a

case-by-case basis, depending cm the age and activity

level nf the patient. A 200? study repnrted the results nf

a survey nf 664 members and residency directnrs from the American Drthnpaedic Snciery fnr Spnrts Medicine:

El ll] 16 American AcadMy nf Cirrhnpaedie Surgenns

IShapter 2: Disprclers at the Accumicclavicular Jeint, Seemedavicular Joint, and Claeicle

E "fl 1]

11: H1

E's E.

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WW

TI'PEV

Til-“3W

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

Classification of AC Joint Separation

Ligaments

Ugaments

EC

Deltatrapezial

I

Sprained

Intact

Intact

H

Disrupted

Sprained

III

Disrupted

W

We

A:

Fascla

Increase in Radiegra phic Ci:

Distance

At: Hadieg ra phic

A: Joint

Appearance

Heducihle

Narmal {1.1 'lD 1.3 cm]

Normal

NA

Intact

c25%

Widened

‘r'es

Disrupted

Disrupted

25% 111 100%”

Widened

‘r'es

Disrupted

Disrupted

Disrupted

Increased

Pesterinr clavicle displacement

ND

V

Disrupted

Disrupted

Disrupted

mate to 3012119

HA

He

VI

Disrupted

Intact

Disrupted

Decreased

HA

He

AI: = acremlnclaulcular. CE = curacecla'lrlcular. NA = net applicable.

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

4D Ifllii American Academy nf flrdinpaedjc Surgeries

Dnhnpaedie Knnwledge Update: Spur-ts Medicine .5

e

Section 1:1}pperExtremity

36.3% preferred nonsurgical treatment of uncomplicated

for successful outcomes. Repairing andfor reconstructing

Several studies have compared results of nonsurgical and surgical management to treat type III AC joint sep-

reduction. Supplementing the CC ligament repair andfor reconstruction with synthetic material or plate fixation

type III AC joint injuries.”

arations using randomised trials, cohort studies, and

retrospective designs. Support for both initial nonsurgical treatment”!15 and early surgery15 was found. A 1011

can provide adequate stability for CC ligament healing.

nonsurgical and surgical management of type III AC joint injuries in 330 patients.” No difference was found

Repairing or imbricating the damaged deltotrapeaial fascia are integral parts of surgical management to optimize outcomes. Numerous surgical techniques are described in the literature for the surgical management of AC joint in-

surgical group had substantially greater duration of sick

without reconstruction are available. The objective is to

If surgery is preferred or deemed necessary, early surgical repair of type III AC joint injuries with or without

or allow them to scar or heal together. Reduction of the AC joint promotes healing of the damaged CC ligament

tion and clinical outcomes compared with delayed reconstructionJ“ A 1014 systematic review compared early

ious techniques. A book plate is a clavicular plate that includes a lateral extension that goes under the acromion,

dislocation involving mostly type III injuries.” Dverall, superior functional outcomes were found in the early

ation between the clavicle and the coracoid and include a screw through the clavicle into the coracoid, heavy sutures

gery. Partial dislocations or redislocations were found in 26% of cases in the early treatment group compared with

suture constructs aroundfthrough the coracoid and clav— icle (Figure 2). A 2fl14 study compared arthroscopically

meta-analysis of six nonrandomiaed studies compared

between the groups in pain, strength, throwing ability, or incidence of AC joint osteoarthritis. Patients in the 1: Upper Extremity

the CC ligaments are important for maintaining anatomic

leave with better cosmetic appearance.”

augmentation seems to result in better patient satisfac—

and delayed surgical intervention in complete AC joint surgical group (P c 0.115} compared with delayed sur33.1% of cases in the delayed group {P e DJJS].

Type IV, V, and VI AC Joint Injuries and Surgical

juries. No consensus exists on technique or timing of surgery. For type III injuries, options for primary fixation reduce the AC joint and directly repair the CC ligaments

tissue. AC joint reduction can be maintained using var—

reducing the AC joint. Other methods focus on direct fixi

around or through the coracoid and clavicle, or button

assisted reduction of acute AC joint separation using the

double~button suture technique compared with the hook plate technique.“ Both techniques had good to excel-

Management

lent results, with comparable outcome scores and com-

der pain and dysfunction and substantial deformity of

reduction using two doubleubutton sutures {one for each

Surgical management is usually indicated for type IV and V AC joint separations given the high likelihood of shoul-

plication rates. A 2013 study followed 23 patients who underwent arthroscopically assisted acute CC ligament

the shoulder. Type VI injuries are extremely rare and are treated surgically. Surgery for type IV and type V injuries

CC ligament).22 There were 3 type III, 3 type IV, and 1‘? type V AC joint injuries, and patients were followed

but can be performed on a delayed basis if nonsurgical treatment fails or if the patient presents for treatment late.

satisfied or satisfied at final follow-up, with a significant improvement in the visual analog scale and Constant

is usually recommended in the acute or subacute setting,

A recent retrospective study looked at conservative treatment of type V AC joint separations in active—duty service members.lEI After exclusions, 21 underwent conservative treatment initially, whereas 3 underwent acute repair. In

for an average of 53 months; 96% of patients were very

scores, even with eight radiographic failures.

Ligament reconstruction is another method for surgical management and is commonly used for acute surgical

management of grade IV and V injuries, as well as for

the conservative group, 11 patients (61%) returned to full duty without surgery at an average of 9'13 days, whereas

delayed treatment {longer than 5 weeks] after type III

to full duty at an average of 169.3 days. Type IV and type V injuries are relatively less common, with most

string autograft or allograft, tibialis anterior allograft, or coracoacromial ligament transfer {the 1‘il'llieaver-lll nnn pro-

or as part of larger series involving type III injuries. Sev— eral key elements of surgical intervention are critical for

options for managing both acute and chronic AC joint

in the acute surgical group, I5 patients 95%] returned published data involving small case series, case reports, successful outcomes in treating those high-grade injuries.

Anatomic reduction of the dislocated clavicle to correct

posterior, superior, or anterior translation is important

flrtltopaedie Knowledge Update: Sports Medicine 5

injury. Reconstruction is performed to reconstruct or replace soft-tissue stabilizers of the AC joint using ham-

cedure}. The ligament reconstruction techniques provide

injuries. In lfllfl, free tendon anatomic reconstruction of the CC ligaments became widely accepted for surgical

management of AC joint.” Anatomic reconstruction uses a free tendon graft and nonahsorbable sutures that wrap

El ll] 16 American AcadMy of Urthopaedic Surgeons

IEhapter 1: Disorders of the Acromiociavieular Joint, Sternociavicular Joint, and Ciavicle

E

L1“

Figure 2

A, Preoperative AP radiog ra ph of the left shoulder of a 25-year-old woman who is an athlete demonstrates a

type V acromiotlavicular {AC} joint separation. B, AP radiograph obtained 2 weeks following acute repair using a double-endobutton suture ted'lnique, demonstrates adequate reduction of the AC joint separation.

"fl 1]

s; F”

El a.

fill

a!

"Ill.

II‘II._

Figure 3

r'_

l' *3.-

A, Illustration demonstrates the den hie-loop coracoclavicular ligament reconstruction technique for chronic

unsta b-le acrornioclavicular [AC] joint separation. I. Postoperative AP radiogra ph of the left shoulder of a 49-year-

old man wlth type III A: joint separation whose nonsurgical treatment was unsuccessful shows adequate reduction of the AI: joint.

around the base of the coracoid and are passed through

using a doubled loop of tendon graft with zero failures at

clavicle resection is occasionally.r performed with AC joint

Postoperative Rehabilitation

the clavicle using small bone tunnels. Several variations of this technique have been reported.“45 A small distal

shortrterm foliowwup24 [Figure 3}.

reconstruction if the distal clavicle has become deformed and cannot be reduced. The decision to routinely,F perform a distal clavicle resection with reconstruction is controversial. A Zfllfl stud}.r reported on 1? cases managed using anatomic ligament reconstruction, 14 of which were suc-

wrist, and hand exercises are encouraged as long as the

and Elbow Surgeon and Constant scores.13 A 21314 study rcported on seven patients who underwent reconstruction

However, motion can also be delayed until 6 to 3 weeks with minimal risk of stiffness. Gradual progression of

cessful with excellent improvement in American Shoulder

El Ifllli American Academy of flrdiopaedic Surgeons

Following snrgerv, the shoulder is usually,F immobilized in a sling or supportive brace for 6 to 3 weeks. Elbow,

shoulder is kept stable. Passive supine shoulder flexion and abduction up to 90” in the plane of the scapula

can be considered safe early in the rehabilitation phase.

Drrbopaedie Knowledge Update: Sports Medicine .5

Section 1:11pperExtrecnity

shoulder RUM exercises are usually started 6 to 3 weeks after surgery and slowly progressed until 12 to 14 weeks.

Strengthening exercises for the shoulder muscles can be started when the patient achieves painless shoulder ROM at approximately 12 weeks postoperatively, taking care to avoid downward force on the arm and shoulder. Return

to work without restrictions usually occurs at 16 to 14

weeks following surgery, with full—contact athletic activ—

ities resumed at approximately 6 months postoperatively,

after the patient has achieved similar shoulder strength and RUM compared with the unaffected shoulder. Full

1: Upper Extrem fty

recovery can take 9 to 11 months.~"'n~15 Complications

Both nonsurgical and surgical management of AC joint separations can result in complications. Complications associated with nonsurgical management include persistent pain, crepitus, and swelling at the AC joint; late arthrosis;

and persistent instability. Usteolysis of the distal clavi-

cle also has been reported. Postoperative complications

depend on the type of surgical technique used. Implant failure and migration, resulting in vascular injuries, have

3%.“‘13 Nousurgical management has been the preferred

initial mode of treatment for most clavicle fractures. However, according to more recent literature, nonunion can be

a substantial cause of morbidity, with some publications reporting unfavorable patient—based outcomes. Therefore, treatment of clavicle fractures should be tailored to each

patient and the type of fracture, amount of displacement

and comminution, age and level of activity of the patient,

and to some extent, the esthetic appearance of the shoulder, should be considered. Mechanism of Injury and Classification The most common mechanism of injury in clavicle frac-

tures is a direct blow to the shoulder, whether following a

fall or because of direct trauma. Less commonly, a fall on

an outstretched hand can result in clavicle fracture; this mechanism was initially thought to be the most common

cause of these fractures. These injuries are rarely open,

despite being caused by high-energy trauma?”

Clavicle fractures were initially described in 196?

based on their anatomic location and in descending order of incidence."Mil Type I fractures involve the middle third

been reported. Hence, Kirschner wires and pins are not

of the clavicle; type II and type III fractures involve the

of synthetic suture loops. Early or late fractures of the

classification)” and 1996 {Craig classification},m type II {lateral third} clavicle fractures were subclassified into

advised. Aseptic foreign body reaction and erosion of the coracoid or clavicle have been reported with the use

lateral and medial thirds, respectively. In 1953 [Neer

clavicle or coracoid process have been reported as well, especially with surgical techniques that involve tunnels

three types, depending on the integrity of the CC ligaments and the relationship of the fracture line with the

related to the hook plate or CE screw usually requires a second procedure for implant removal. Loss of AC joint

occur lateral to the CC ligaments and are usually stable. Type II lateral third fractures are medial to the CC lig-

through the coracoid andl'or clavicle. Painful hardware reduction, persistent pain, and instability can potentially complicate surgical outcomes. Neurologic injuries are

CC ligaments and AC joint. Type I lateral third fractures aments, are usually unstable, and require surgical man-

rare, but can involve nerve root injuries secondary to

agement. Type II was further subclassil'ied into type 11.91, in which the fracture is medial to the intact conoid and

ular nerve resulting from aggressive dissection during reconstruction, or injury to the brachial plexus with tech-

is lateral to the torn conoid ligament but medial to the intact trapezoid ligament. Type III lateral third fractures

traction during surgery, direct injury to the suprascapu

niques that pass grafts or suture loops under the coracoid

processf‘

{lavicle Fractures

Fractures of the clavicle comprise 2% to 5 “xi. of all fractures in adults and 35% to 44% of all fractures in the shoulder, with an incidence of 50 to 64 per 10!],iIDiI persons annuallyFfi'lf The risk for clavicle fracture is increased in

trapezoid ligaments, and type IIB, in which the fracture

are intra-articular fractures through the AC joint with

intact CC ligaments. These fractures are usually stable, but can result in the development of AC joint arthritis.

Type IV fractures are rare and involve disruption of the

clavicular periosteal sleeve in pediatric patients, in whom the epiphysis and physis remain with the AC joint and the

displacement occurs at the junction of the metaphysis and

physis. In type V fractures, a small, inferior cortical bone fragment remains attached to the CC ligaments, with the

men age 30 years or younger and all patients older than

proximal and distal fragments of the clavicle fracture not

of all clavicle fractures. Lateral third fractures account

for reduction and stabilization.

Tl} years. Middle third fractures are the most common types of injuries, comprising approximately 69% to 31%

for approximately IT'if: to 23% of all clavicle fractures, and medial third fractures comprise the remaining 2% to

flrrhopaedie Knowledge Update: Sports Medicine 5

connected to the coracoid process {Figure 4). These fractures are rare and generally require surgical intervention The Edinburgh classification was proposed in 19193, with clavicular fractures divided by anatomic location

El 1016 American AcadMy of Cirrhopaedic Surgeons

IIShapter 2: Disorders of the Acromioclavicular Joint, Seernoclavicnlar Joint, and Clavicle

E "fl 1]

a, F”

E's E.

m

a!

Fig u re 4

Illustration demonstrates the Heer classification for distal clavicle fractures. AC = acromioclavicular. [Reproduced from Banerjee H, Watennan B, Padalecki J, Robertson W: Management of dlstal davlde fractures. J' Am Acad

firthop 5mg 2H11:15Ii‘l:392-dfl1.l

into type I {medial third}, type II {middle third}, and

type III {lateral third}?1 Further subclassification of each

type was based on fracture magnitude and displacement. Subgroup A indicates displacement less than 100% and subgroup B indicates displacement more than Iflfl%. Ar-

ticular involvement determined further subdivision of types I and III. Subgroup 1 indicates no articular involve-

best predicted nonunion or delayed union of lateral third

clavicle fractures, and the Robinson classification had

the best prognostic potential for middle third clavicle fractures.31 Management and Complications Medial Third Clavicle Fractures

of the fracture. Type II fractures are also subdivided: subgroup 1 indicates simple or wedge-type fractures and

The treatment of media] third clavicle fractures is usually nonsurgical, with satisfactory outcomes and low nonunion rates of 4% to 8%.“ These fractures are un-

{Figure 5]. A 2011 study compared the previous classifi— cation systems and reported that the Craig classification

rarely involved in such injuries. Treatment consists of an arm sling for comfort, with shoulder immobilization for

ment and subgroup 2. indicates intra-articular extension

subgroup 2 indicates comminuted or segmented fractures

Eb Ifllii American Academy of Urthopaedic Surgeons

common and are usually nondisplaced. The SC joint is

Drthopaedic Knowledge Update: Sports Medicine 5

Sectien 1:1}pperExtremity

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

Extra-articular {type 3A1}

Inna-articular {type 3A2}

1: Upper Extremity

Displaced fractures [type 3A)

Extra-articular (type 331) Figure 5

Intra-articular (type 332}

Illustratien demenstrates the Hebinsen classificatien fer distal clavicle fractures. {Repreduced frcIm Ba nerjee It. Waterman B. Padaledti l, Hebertsen W: Management cf distal clavlcle fractures. Lem Arad Orthep Sury

act 1;1s[?]:392-4s1.l

2 ta 5 weeks. Sheulder RUM is started as seen as the

Middle Third IElavirle Fractures

pain subsides er becemes telerable. Ice can help decrease

Middle third clavicle fractures cemprise mast clavicle

cmmending them because ef the pessibility ef delayed

perred successful eutcemes. A nenunien rate less than 1% has been reperted fer nensurgical management, less

the swelling, with eral medicatiens fer pain centre]. Use cf NSAIDs is centreversial, with some studies net rec—

fractures and have been treated nensurgically with re-

fracture healing. Centact sperts sheuld be aveided fer

than rates reperted fer surgical management.” High pa-

and sheulder rehabilitatien.” Surgical management ef medial third clavicle fractures is usually reserved fer fractures asseciated with injury te

has previded mere infcrmatien abeut clavicle fracture

at least 2 re 3 menths te allcw cemplete fracture healing

the mediastinal structures secendar},r te fracture displace-

ment. These fractures sheuld be reduced fairly emergent-

ly, with an attempt at clesed reductien. Open reductien

and internal fiaatien {GRIP} is semetimes necessary te

maintain reducticn cf an unstable fracture. Several techniques have been used fer DRIP cf displaced medial third clavicle fractures including wire fiaaticn, plate-and-screw

ccnstructs, cr intercssecus sutures. Because this type cf

clavicle fracture is rare, few case reperts er small series exist en this subject, with faverable eutcemes.”

flrrhcpaedic Knewledge Update: Sparta Medicine 5

tient satisfactien has alse been reperted fellewing nen— surgical treatment. Hewever, the mere recent literature management, with many studies reperting less faverable eutcemes fellewing nensurgical management with high

nenunien t*ates.3""'3T A 2i] [)5 meta-analysis cempared sur-

gical and nensurgical treatment ef middle third clavicle fractures in 1,144 cases with a mean fellew-up ef £1

menths.“ Hensurgical management was perfcrmed in 1,145 {53.4%} cases, with a nenunien rate ef 5.9%, as

eppesed te a nenunien rate c-f 1.2% in 999 surgically

treated cases. 1|iii'hen examining displaced fractures sep-

arately, 159 cases were treated nensurgically, resulting in a nenunien rate cf 15.1%, as eppesed te 2.1% fer 612

El 1016 American Acadenw cf Cirrhepaedic Surgeries

IIShapter 2: Disorders of the Acromioclavicular Joint, Sternoclavicular Joint, and Clavicle

surgically treated cases. A lflil meta-analysis compared

Surgical management of distal clavicle fractures de-

surgical and nonsurgical management of middle third

pends on several factors including fracture stability [which

ing comparable Constant shoulder and Disabilities of the

in bleer type II or Edinburgh type 313: fractures, with

clavicle fractures.345 The nonunion rate was substantially higher in the nonsurgical group, with both groups achiev-

relies on the status of the CC ligaments}, fracture displacement, and patient age. Displacement of the clavicle occurs

agement of displaced middle third clavicle fractures-“*3? The |Constant and Disability of the Arm, Shoulder and

nonunion rates up to 23% for nonsurgical treatmentdifig fllder age has also been associated with an increased risk of nonunion.39 Intra—articular extension of the fracture can increase the risk of AC joint arthrosis, requiring distal clavicle resection when symptomatic.

tially superior in patients in the surgical group.35~~"i The risk of nonunion and malunion was significantly higher

more technically challenging than middle third fractures.

Arm, Shoulder and Hand scores at final follow-up. Two multicenter randomized clinical trials compared the clinical outcomes of surgical and nonsurgical man— Hand scores as well as patient satisfaction were substanin patients in the nonsurgical group, and patients in the

surgical group had higher risk of wound infection and implant irritation requiring removalfif-JT The mean time

to union in a 2430? study was substantially shorter in the

Several surgical techniques have been described in the treatment of lateral third clavicle fractures, which are

1'i'lliire fixation has been abandoned because of reported

cases of pin migration. CC screw fixation has resulted in mostly favorable outcomes, with only small cohorts reported.” Hook plate, standard plating, and locking plate

surgical group [16.4 weeks} compared with the nonsurgical group (23.4 weeks, P = Oflflllfii Surgical treatment

fixation have also been successful despite the reported rare incidence of complications such as nonunion, stiffness,

patients between age 16 and El} years, with no infection or skin compromise at the surgical site, and who are med-

tures can be repaired using reconstruction techniques also

cations for surgical management of middle third clavicle fractures include fracture displacement with shortening of

ligament reconstruction and suture augmentation. Hybrid plating of the clavicle and CC ligament reconstruction is

of middle third clavicle fractures is usually reserved for ically fit and have an active lifestyle. In general, the indi-

more than 2 cm, skin tenting with an impending or open fracture, neurovascular compromise, floating shoulder,

and obvious clinical deformity.~""I

fracture around the plate, and progression of AC joint arthritis.“ Last, some unstable lateral third clavicle fracused for high-grade AC joint separations and include CC also an option for unstable lateral fractures. Hook plates

and CE screws require removal at a later stage secondary

to decreased RUM and discomfort and are associated

GRIP of middle third clavicle fractures is usually

with a risk of screw breakage and hook plate damage to

nique provides rigid fixation, allowing early mobilisation.

when the distal fragment is small, although the number

performed with a plate—and—scrcw construct or with ins tramedullary pinning. The plate-aud-screw fixation techHowever, implant prominence and irritation usually rev suits in a second surgical procedure for implant removal. |Either complications such as infection, implant failure

the AC joint. In addition, use of CC screws or traditional plate-aud-screw constructs is occasionally not possible

of plates designed for the lateral clavicle has increased. CC ligament suture or ligament reconstruction techniques have resulted in generally acceptable functional results

with nonunion, subsequent fracture following implant removal, hypertrophic scarring, and adhesive capsulitis

with high union rates.“I

fixation has become more common because of better

Postoperative rehabilitation for lateral third clavicle fractures generally follows that used following surgical man-

of the shoulder have been reported. Intramedullary pin

Postoperative Rehabilitation

cosmetic appearance following surgery. However, some intramedullary pins lack a locking mechanism, resulting

agement of grade III through VI AC joint dislocations,

in no rotational control at the fracture site. Those pins require routine removal, with complications such as implant

with shoulder immobilization for 6 weeks. Generally, rehabilitation is slower and more conservative for lateral

and temporary brachial plexus palsy reported.”

fractures. Following surgical management of medial or middle third clavicle fractures, an arm sling is used for

migration or breakage, skin breakdown and infection,

Lateral Third Clavicle Fractures Most lateral third clavicle fractures are nondisplaced or minimally displaced extra-articular fractures; therefore, treatment has been typically nonsurgical. The nonsurgi-

cal management modalities are similar to those used for middle third and medial third clavicle fractures.31

Eb Ifllii American Academy of Urthopaedic Surgeons

third fractures compared with medial or middle third pain control and comfort, with shoulder RUM started

as soon as postoperative day 1. lEllverhead lifting is withheld until approximately ti weeks after surgery. Resolution of pain is successful enough following DRIP using plate—and-screw constructs that patients sometimes need to be prevented from overdoing shoulder exercises and

Drthopaedic Knowledge Update: Sports Medicine 5

E "E "U

s, F”

ii E.

fill

a!

Sectien 1:1}pperExtremity

activities te prutect the cunstruct. When intramedullary

pinning is perfermed in middle third clavicle fractures

the directien ef clavicle sublunatienfdislecatien {anteriur

ef the fixatiun, furward flexiun and abductiun exercises fer the sheuldcr sheuld be restricted te 90" fer the first

jury severity (sprain, subluaatiun, ur dislucatiun), and the unset ef injury {acute er chrenic]. 5C jeint injuries have

and sums cencern exists regarding retatienal stability 4 weeks. Shuulder muscle strengthening can be started as seen as 1 weeks pesteperatively as lung as fracture

reductien is maintained and cenfirmed en sheuldcr ra—

diegraphs. Seme athletes return te nuncuntact athletic activities as seen as 1 tu 3 weeks and tu centact spurts in 6 te 3 weeks fellewing surgical management ef middle third clavicle fractures. ‘I: Upper Eatrem ity

Classifieatiun uf SC juint instability can be based en

5C Jeint Injuries

er pusteriur}, cause ef injury {traumatic er atraumatic}, in-

been classified intu three types based en the extent ef 5C jeint ligament injuries.If Type 1 invelves SC ligament and capsule sprain, with ac sublunatien er dislucatiun. Type 2

invelves disruptien ef the 5C ligaments and capsule, with subluaatiun ef the medial clavicle anteriurly ur pusteriurly.

Type 3 invelves rupture ef all supperting ligaments tn the

SC jeint, with cemplete anteriur er pusteriur dislucatien ef the medial clavicle.M Management and Cemplicafiens

SC jeiut injuries cumprise 3% uf all injuries invelving the sheuldcr girdle and are uncemmen because ef the high

Type 1 and Type 2 5E Jeint Injuries The management ef type 1 5C jeint injury is typically

structures such as the trachea, esephagus, lungs, and great

and eral HSAIDs can help decrease pain and centrel

5C jeiut strain er sublunatien in any directien is usually

ed and the patient can resume nermal daily activities,

energy required te disrupt the SC ligaments. Altheugh rare, these injuries semetimes result in damage te adjacent vessels. The management ef such injuries depends en the directien uf sublustatien er dislucatiun. Acute anteriur treated nensnrgically as lung as the jeiut is reduced. Acute anteriur ur pusteriur dislucatiens are treated in the acute setting with clesed reductien, especially when mediastinal structures are at risk, with DRIF reserved fur certain

unstable cases. Chrunic pain and instability uf the SC jeint can be managed by ligament recenstructien as well

as medial clavicle resectien, either upen er arthrescepic. The risk uf majur cumplicatiuns is asseeiated with upen

nensnrgical. The sheuldcr is immebiliscd in an arm sling fur apprunimately 1 week fur pain centrel. Ice applicatiun

inflammatien. After the pain subsides, generally a few days fulluwing the injury, the arm sling can be discard-

with gradual integratien intu cempetitive sperts."'3'-“ 1EIiith type 2 injuries, the medial clavicle is typically sublurrated

anterierly. The sublunatien can be reduced in a clesed

manner by pushing the sheuldcr pesterierly and medially. Generally, a lunger peried is spent in an arm sling with

er witheut a figure-ef—B clavicle brace, typically 4 te 6 weeks, until the EC ligaments are healed. At 4 re 6 weeks,

surgical interventien because ef the preximity ef majer

the sheuldcr is mubilized, with RUM and strengthening exercises started fer rehabilitatienfi‘“

Mechanism uf Injury and Classificatiun

Type 3 5C Jeint Injuries The management ef type 3 SC jeiut dislecatiens depends

vital structures re the SE jeint."3'1‘H

SC jeint dislucatien usually requires a large ferce be— cause ef the strung suppurt previded by the surruunding ligaments. Athletic injuries and meter vehicle accidents cemprise mere than 30% cf injuries re the SC jeint. An—

terier dislucatien, the must cummen furm uf SC juint

dislucatien, usually results frem an indirect ferce te the

en the directien ef clavicle dislucatiun. Anterier dislucatiens are mere cummen than pusteriur dislucatiuns.

Acute anteriur dislucatiens are usually treated with clesed

reductien under anesthesia er sedatien. The patient is placed supine en the table, with a pad between buth scapulae. Direct pusteriur pressure is applied te the medial

sheuldcr, with ferces transmitted threugh the clavicle re the SC jeint. Pesteriur SC juint dislucatien can result

clavicle until reductien is ebtained. 1|When reductien is successful and stable, figure-uf—B sling immehilizatien is

medial ferce usually resulting in the clavicle being pushed pesteriurly intu the mediastinum. The media] clavicle

are usually unstable because uf the less ef the stabilizing

frem beth indirect and direct ferces, with direct antereepiphysis dues nut fuse with the shaft until age 23 re 25 years.” Therefere, the injury re the 5C jeiut can, in

applied fer ti weeks te allew seft tissues te heal. Hewever, unlike pusteriur dislucatiens, anteriur dislucatiens effect uf the turn SC ligaments, and cuuld require acute

seme instances, result in a fracture thruugh the medial

er delayed upen surgical reductien with stabilisatien.‘3*‘“ Acute pusteriur dislucatiun can be asseeiated with

anterierly er pesterierly, leaving the epiphysis attached re the sternum.“

that cuuld require urgent management by a cardietheracic surgeun. In stable patients, clesed reductien under

physis, with the clavicle shaft subluaating er dislucating

flrrhupaedie Knuwledge Update: Spurrs Medicine 5

cencemitant injuries te vital surreunding structures

El 1016 American AcadMy uf Drrhupaerlie Surge-ens

IIShapter 2: Disnrders cf the Acrnminclavicular Jnint, Sternnclavicular Jnint, and Clavide

E

A A. lllustratinn demnnstrates the 'l'tnman numeral I" recnnstructinn technique fnr 5C jnint separatinn. B. Intranperative phntngraph demnnstrates the finished recnnstru ctinn.

"fl 1]

g F”

ii E.

m

anesthesia is the first-line treatment, preferably with a

cardinthnracic surgenn available in case nf mediastinal injury. The patient is placed supine nn the table, with a

Currently, ligament recnnstructinn is the rnnst widely

used technique fnr 5C jnint stabilizatinn.‘“-‘H

In ann4, a binmechanical study cnmpared three dif-

pad between bnth scapulae and the affected shnulder

ferent types nf ligament recnnstructinn techniques nf the

intn pnsitinn. Shnulder and arm extensinn can assist in the

and pnsterinr directinns cnmpated with the subclavian

pnsitinned at the edge nf the table. In a slender patient, the clavicle can be manually grasp-ed and pulled anterinrly

SC jnint ligaments.“ The figure~nf~3 technique had substantially higher mechanical strength in bnth the anterinr

reductinn. Alternatively, tractinn is applied tn the affected extremity, with cnuntertractinn applied tn the chest using

nique. Hnwever, all three techniques were fnund tn be

extremity mnved intn extensinn. This can help lever a pnsterinrly dislncated clavicle intn a reduced pnsitinn.

Mnst clinical studies published nn ligament recnnstruc— tinn nf the SC jnint are case repnrts nr case series with

a large sheet. Tractinn is then increased with the upper

tendnn technique and the intramedullary tendnn tech-

binmechanically inferint tn the native SC jnint ligaments.

Last, tractinn can be applied tn a fully adducted arm, in

generally favnrable nutcnmes. A 2fl14 study repnrted cm

a clamp can be used under sterile cnnditinns tn hnld the

dnni." Twentyuseven patients were fnllnwed fnr a median nf 54 mnnths (minimum, 2 years}, with significant im-

additinn tn pnsterinrly directed pressure tn the shnnlder tn lever the clavicle anterinrly. If thnse twn techniques fail, medial aspect nf the clavicle and pull it anterinrly while extending the abducted upper extremity. When reductinn

is nbtained, it is usually stable, and the patient requires

shnulder immnbiliaatinn in a figure-nf—B brace fnr 4 tn 6 weeks tn allnw snft-tissue healingJ‘J-‘H Reductinn can be

cnnfirmecl using an U-atm in the nperating rnnm nt CT

pnstnperatively. ID'pen reductinn and internal stabilizatinn is indicated

the recnnstructinn nf chrnnic anterinr SC jnint instability using autngraft {palmaris lnngus tendnn nr gracilis ten-

prnvement in Western Gntarin Shnulder Instability scnres.

Twn patients underwent successful revisinn surgery for

recurrent instability. A lfl13 case series repnrted nn six patients undergning SC jnint recnnstructinn using a mnd-

ified extra-articular “aan numeral 1".“ recnnstructinn using hamstring tendnn autngraft fnr anterinr instability“El (Figure 6}. All patients had substantial imprnvement in

fnr acute anterinr nt pnsterinr dislncatinns that have failed

their functinnal scnres and visual analng scale scnres at

anterinr nr pnsterinr subluxatinnsfdislncatinns that have

tient requiring revisinn surgery 4 years later fnr SC jnint

clnsed reductinn nr are unstable, pnsterinr dislncatinns in patients with an npen physis,“ and in cases nf chrnnic

becnme symptnmatic. Internal stabilizatinn can be per— fnrmed by varinus means, including suture fixatinn and ligament recnnstructinn. Wire-a nd-pin fixatinn has been

abandnned because nf fatal cnmplicatinns, and suture fixatinn has yielded subnptimal binmechanical results.

Eb Ifllii American Academy nf Urthnpaedic Surgenns

a mean fnllnw—up nf 4D mnnths. All patients returned tn preinjury activity level including spnrts, with nne paarthrnsis. Pnsttraumatic arthritis nf the SC jnint can becnme

symptnmatic in patients treated nnnsurgically nr sur-

gically fnllnwing an EC jnint injury. When nnnsurgical

treatment fails, medial clavicle resectinn, either npen nr

Drthnpaedic Knnwledge Update: Spnrts Medicine .5

a!

Section 1:1}pperExtremity

arthroscopic, can be performed to alleviate pain and im-

Key Study Points

recommended to avoid resecting more than 1.5 cm of the medial clavicle. The arthroscopic technique is advanta-

1* Type I and II AC joint injuries are treated nonsurgically, type IV, V, and VI AC joint separations are treated surgically. I Nonsurgical management of type III AC joint sep-

prove outcomesfig-‘SD To avoid recurrent instability, it is geous because it is minimally invasive, with faster rehabil—

itation possible. However, this procedure is still associated with the risk for damage to vital nearby structures such as carotid arteries, subclavian veins, and the trachea.“

Postoperative Rehabilitation

The postoperative care of patients undergoing open reduc—

1: Upper Extremity

tion and internal stabilization of unstable 5C joints is the same for anterior or posterior dislocations. The surgical

upper extremity is immobilized in an arm sling for 6 to

3 weeks to allow soft-tissue healing, and only pendulum exercises are allowed during this period. Active shoulder

RUM is started at 5 to 3 weeks postoperatively, with the

arm maintained at 90“ or less. The patient can be weaned from the arm sling over a period of 1 to 2 weeks. Full,

active ROM and strengthening exercises are initiated at 12 weeks, with return to manual labor or athletic activities allowed at 5 to 6 months.‘i‘l-‘”~i’d Summary

Managing AC joint separations, clavicle fractures, and

aration is the most common first-line treatment,

followed by surgical intervention if nonsurgical treatment fails.

1* Management of medial third and lateral third clav-

icle fractures is usually nonsurgical, except in the case of Neer type II lateral third fractures {Edinburgh type SE fractures}, which are unstable and require open reduction and internal stabilisation. 1* Surgical management of middle third clavicle fractures yields improved results, with fewer cases of nonunion and malunion and improved patient satisfaction compared with nonsurgical management. | Anterior SC joint dislocations are usually unstable, even after closed reduction, often requiring surgical

intervention. i Posterior 5C3 joint dislocations can result in in-

jury to vital surrounding structures, with surgical interventinn being associated with substantial complications.

SC joint dislocations depends on several factors, including patient age, level of activity, level of pain, presence of in-

stability or deformity, and potential complications in per—

Annotated References

plan to treat any of the injuries discussed in this chapteL

1. Maasocca AD, hrciero RA, Eicos J: Evaluation and treat— ment of acromioclavicular joint injuries. Am 1 Sports Med.

forming surgical intervention. Applying these guidelines provides the orthopaedic surgeon with an appropriate

2Ufi?;35{2}:316-329.Medline

D01

2. Kaplan LD, Flanigan DC, Norwig J,]ost P, Bradley]: Prevalence and variance of shoulder injuries in elite collegiate football players. Arr: ] Sports Med 1005 :33j3j:1141-1 146.

Medline D01

3. Johansen 1s, Grutter PW, McFarland EG, Petersen SA: Acromioclavicular joint injuries: Indications for treatment and treatment options. ] Shoulder Elbow Surg 2011;201’2, Suppl}STfl-532.Medline DID] The study reviews the pathoanatomy, biomechanics, clas-

sification, presentation, and evaluation of AC joint inju—

ries, with analysis of the literature involving both surgical and nonsurgical management.

4. Tossy JD, Mead NC, Sigmund HM: Acromioclavicular separations: Useful and practical classification for tL'eatment. CIr'rr Grtbop Rafa: Res 1963;1fljlfljflll-119. Medline

.5. Rockwood CA: Injuries to the acrornioclavicular joint, in Rockwood (in, Green DP, eds: Fractures in Adults ,ed 2.

flrrhopaodic Knowledge Update: Sports Medicine 5

El 1016 American AcadMy of Unhopaedic Surgeons

Chapter 2: Disorders of the Acromioclavicular Joint, Sternoclavicular Joint, and Clavicle

Philadelphia,1s Lippincott, 1934, pp sac-sis, ass-ass, vol 1.

Mikel: M: lazing-term shoulder function after type I and II acromioclavicular joint disruption. Arr: J Sports Med 2Uflfl;36l11}:114‘?—2150.Medline DUI Mouhsine E, ICaroi'alo R, Crevoisier K, Farron A: Grade I and II acromioclavicular dislocations: Results of conservative treatment. ] Shoulder Elbow Sarg 2!] [13:1 2151:5996(1'2. Medliue I311 Shaw ME, ivIcIuerney J], Dias J]. Evans PA: Acromioclavicular joint sprains: The post-injury recovery interval. Injury Eflfl3:34lfij:433-442. Medliue

DUI

Huber CW, Bowen MK: Arthroscopic treatment of acmmioclavicular joint injuries and results. Clir: Sports Med lflfldtlljllflfll—dllflcdliuc DUI Ill. Calvo E, Lopes-Franco M, Arrihas Ii'vl: Clinical and radio-

logic outcomes of surgical and conservative treatment of

type III acromioclavicular joint injury. } Shoulder Elbow Surg lflfldflifllfiflfl-SDS. Medline DUI

11. Schlegel TF, Burks RT, Marcus RL, Dunn HE: A prospective evaluation of untreated acute grade III acromioclavicular separations. Arr: } Sports Med lflfll;29lfij:699-Tfl3. Motllinfl

12. Liaaur A, Sana-Reig J, Unnaalea-Parrefio 3: Long-term re— sults of the surgical treatment of type III acromioclavicular dislocations: An update of a previous report. J Bone Joint Surg Br Zfllljfidlfljflflfifl-IDSE. Medliue DUI This study followed 33 patients for a mean of 24.1 years

following surgical management of type III AC joint sep—

aration, with satisfactory results and complete resolution of pain in 35 patients, and comparable outcome scores in both the surgical and contralateral shoulders. Level of

evidence: IV.

13. Nissen CW, Chatterjee A: Type III acromioclavicular separation: Results of a recent survey on its management. As: I Urtbop (Belle Mead NJ} 200?:36i2}:39-93. Medliue 14. Bannister CC, Wallace WA, Stableforth PG, Hutson MA: The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. I Bone Joint Surg Br 1939;?1l5}:343-35i}. Medline 15. Taft TH, Wilson FC, Ugleshy PW: Dislocation of the aero-

mioclavicular joint. An end-result study. _,I Bouejoint Surg Ans 193T;59[?}:1fl45-1fl51. Medliue

IE. Gstettner C, Tauber I'vI, Hitsl W, Resch H: Rockwood type III acromioclavicular dislocation: Surgical versus conservative treatment. ] Shoulder Elbow Surg 2i] flSfllhllfl125. Medline

DUI

1?. Smith TU, Chester R, Pearse EU, Hing CB: Uperative versus non-operative management following Rockwood grade III acromioclavicular separation: A metavanalysis of the

U Iflld American Academy of Urthopaedic Surgeons

current evidence base. ] Urtbop Traumatoi lflllglljllfl 9IR. Medline DUI This meta-analysis reported on surgical versus nonsurgical management of type III AC joint separation, with surgi-

cal mauagement resulting in better cosmetic appearance

but increased sick leave. No difference was reported in strength, pain, throwing ability, or incidence of AC joint osteoarthritis. 13. Rolf U, Hann von Weyhern A, Ewers A, Eoehm TD, Gohlke F: Acromioclavicular dislocation Rockwood III—V: Results of early versus delayed surgical treatment. Arch Urtbop Trauma Surg EUflSflESiIGmISS-llfil Medline DUI 19. Song T, “fan K, Ye T: Comparison of the outcome of early and delayed surgical treatment of complete acro-

E

matoi Ambrose 2fl14; Aug 14 [Epub ahead of print].

"fl 1]

mioclavicular joint dislocation. Knee Surg Sports Trau-

Medline

DUI

This review compared outcomes of early and delayed surgical management of AC joint separations, with early surgery resulting in better functional outcomes and fewer resublurationstredislocations. Uverall complication rates were comparable. Level of evidence: IV. 2.0. Krul RF, Cook 13, Hu J, Cage JIvI, Bottoni CR, Tol-tish JM: Successful conservative therapy in Rockwood type V acromioclavicular dislocations. Urtbop } Sports Med EDISflIS, suppl 1}. In a retrospective study, the authors assessed conservative treatment of type V AC joint separations in active-duty service members. In the conservative group, 11 patients

{61%} returned to full duty without surgery at an average

of 5‘13 days, whereas in the acute surgical group, 6 patients [TESS] returned to full duty at an average of 169.3 days. Level of evidence: IV.

11. Jensen G, Katthagen JC, Alvarado LE, Lill H, Voigt C: Has the arthroscopically assisted reduction of acute AC joint separations with the double tight-rope technique advantages over the clavicular hook plate fixation? Knee Surg Sports Traumutol Arthrosr: 2fl14;2 21:21:412-43 i]. This study compared 26 arthroscopically assisted AC

joint repairs with 30 book plate fixation procedures for

acute AC joint separation. Both techniques resulted in comparable clinical and radiographic outcomes as well as comparable complication rates. Level of evidence: IV. Medline

DUI

12. Venjakoh A], fialzmann UM, Gabe] F, et al: Arthroscopi-

cally assisted l—bundle anatomic reduction of acute acro-

mioclavicular joint separations: 53-month findings. Arr: j Sports Med 2013;41j3}:515-EEI. Medline DUI

This study reported outcomes following arthroscopically assisted AC joint reduction in 23 patients at a mean follow-up of 53 months. Clutcome scores showed substantial improvement: 96% of patients were very satisfied or satisfied at final follow-up. Level of evidence: IV.

Urrhopaedic Knowledge Update: Sports Medicine 5

o, F”

ii E.

I'D

a!

Sectien 1:1}pperExtremity

23. Carefine EC, Maxxecca AD: The anatemic ceracecla-

This article cempa red five classificatien systems fer clavi-

ind icatieus. } Sbeufder Elects: Surg 1010;19i5uppl Ilka?-

pregnestic value fer lateral third fractures and the Hub— insen classificatien shewed the greatest pregnestic value fer middle third fractures. Nnnuninn was mere cemmen in lateral third fractures.

vicular ligament recenstructien: Surgical technique and

46. Medline DUI.

The anthers reperted their technique fer CC ligament recnnstructinn in the treatment ef AC jnint separation in 1? patients. C'utceme sceres were substantially impreved. Three Failures were reported, twe ef which required revi— sien surgery. Level ef evidence: I‘v".

E4. Westermann RW, Martin W, Welf BR: Deuble-Ieep

Anatemic Acremieclavicular Recenstructien: Surgical Technique and Early Results. Tecil:I Sheufder Elbert: 3mg

seisassiss. net 1: Upper Extrem tty

The anthers reperted their technique fer AC ieint recen— structien using semitendinesis tenden fer AC jeint separatiens. Seven patients were included with gee-d results at final fellew—up, ne cemplicatiens, and ne less ef reductien. Level ef evidence: IV.

Tee JC, Ahn JH, 1it'een JR, Tang JH: Clinical results ef single—tunnel ceraceclavicular ligament recenstructien using autegeneus semitendinesus tenden. Am } Sperts

Med lfllflfiflifihflSfl-EST. Medline

DUI

The study reperted clinical results fellewing CC ligament

recenstructien fer AC jeint scparatieu. All 21 patients had

geed te excellent results at final fellewrup; 1? patients maintained reductien. Level ef evidence: IV.

cle fractures. The Craig classificatien shewed the greatest

33. Hanhy CK, Pasque CB, Sullivan IA: Medial clavicle physis fracture with pesterinr displacement and vascular cempremise: The value ef three—dimensienal cemputed temegraphy and duplex ultraseund. Drrhepsdr‘cs lflfl3;26|{ll:31-fi4. Medline 34. Zlewedxlti M, Zelle EA, Cele PA, Jeray K, McKee MD: Evidence-Based Drthepaedic Trauma Werlting Grnup:

Treatment ef acute midshaft clavicle fractures: systematic review ef 2144 fractures: en behalf ef the Evidence-Based Drthepaedic Trauma Werlting |Crnup. I Drthep Trauma lflfl5;19[?}:5fl4-5fl?. Medlirte DIG]

3.5. Canadian Drthepaedic Trauma Seciety: Heneperarive treatment cempared with plate fixatic-n ef displaced midshaft clavicular fractures. A multicenter, randemised clinical trial. I Ben-e Jet's: Snrg Ans 200?:3 9(1}:1-1i}. Medline DUI 36. McKee EC, Iiii'helan DE, Schemitsch EH, McKee MD: Dperative versus neneperative care ef displaced midshaft

clavicular fractures: A meta-analysis ef randemiaed clinical trials. J Hesse Jeint Su-rg An: 2012:94I3}:6?5rfifi4. Medline [101

26. Pestacchini F, Gumina S, De Santis P, Albe F: Epidemielegy ef clavicle fractures. I Shenfder Elbow Surg

This meta-analysis examined surgical and nensurgical

2?. van der Meijden DA, Gaskill TR, Millett P]: Treatment

were higher in nensu rgical cases.

2i]fl1;11{5}:451—456.Medline net

ef clavicle fractures: Current cencepts review. ] Sheulder tess' Sssrg 2fl12:21{3}:423-429. Medline DUI

This review article describes the classificatien, surgical indicatiens, and techniques fer treatment ef clavicle fractures. 23. AIlman FL Jr: Fractures and ligamenteus injuries ef the clavicle and its articulatien. ] Bette feint Surg Am

:ssvastessssss. Medline

29. Nee: CS II: Fractures ef the distal third ef the clavicle. Gin: Grtbep Relat- Res 1963;53i53}:43-Efl. Medline 3‘3. Craig EV: Fractures ef the clavicle, in Reckweed CA,

Green DP, Eucheh: RW, I-Iecltman 1D, eds: Fractures in

Adults ,ed 4. Philadelphia, PA, Lippincett-Raven, 1996,

pp nuanss.

31. Rebinsen CM: Fractures ef the clavicle in the adult. Epidemielegy and classificatinn. I Hesse Innis-st Surg Br 1993;Efl{3}:4TE-434.Medline DCII 32. ICIV‘I'tleill E], Hirpara KM, C‘Eriain D, McCarr C, Kaar

TK: lEllavicle fractures: A cemparisen ef five classificatien

systems and their relatienship te treatment eutcemes. In: Drrhep 2011:35ifi}:909-914. Medline DUI

flrthepaedic Knewledge Update: Sperts Medicine 5

management ef middle third clavicle fracnlres in 411 patients. Neuunien rates and symptematic malunien rates

3?. Rebinseu CM, Geudie EB, Murray IR, et a1: Dpen re—

ductieu and plate fixatien versus neneperative treatment fnr displaced midshaft clavicular fractures: A. multicenter, randemixed, centrelled trial. }' Bette jeint Surg Am 2fl13;95{17}:157ti-1534. Mcdline DUI This randemired, centrelled trial cempared DRIP" and nensurgical treatment ef displaced middle third clavicle fractures: IDS patients were treated nensurgically, 95 were treated with lCIRIF. Better functienal eutcemcs and reduced nenunien rates were feund in the surgical greup. Level ef evidence: I.

33. Altamimi 5A, McKee MD: Canadian Grthepaedic Trauma Seciety: Neneperative treatment cempared with plate

fixatien ef displaced midshaft clavicular fractures. Surgi-

cal technique. I Benejefnt Surg Am 2003;9{ii5uppl 1 Pt lid-E. Medline 3?. Rebinsen CM, Ceurt—Erewn CM, McQueen MM, Walte— field AE: Estimating the risk ef nenunien fellewing neneperative treatment ef a clavicular fracture. I Herrefeint

Surg Am see4,ss_a(v}:1sss_1sss. Medline

4D. Yamaguchi H, Arakawa H, Kehayashi M: Results cf the

Beswerth methed fer unstable fractures ef the distal clav— icle. In: Grtbep 1993;22{fil:366-363. Medline

DUI

El ll] 16 American Academ~y ef Drthepaedie Surge-ens

IEhapter 2: Disnrders nf the Acrnminclavicular Jnint, Sternnclavicular Jnint, and Clavicle

41. Band DW, Lui DF, Lennard M, Mnrris S, McElwain JP: Clavicle hnnl-t plate fixatinn fnr displaced lateral-third clavicle fractures [Neer type II}: A functinnal nutcnme study. I Sbnnlder Elbnw Saar-g 2fl12;21{3}flfl45-1fl43.

Medline [ll-DI

The study examined functinnal nutcnmes fnllnwing GRIP fnr displaced lateral third clavicle fractures: 35 patients were included with a mean time tn uninn nf 3 mnnths and 95% uninn rates. Hnwever, 92% nf plates required later

remnval. Level nf evidence: IV.

42.. Levy 0: Simple, minimally invasive surgical technique fnr treatment nf type 2 fractures nf the distal clavicle. I Sbnnlder Elbntn Surg1003;12[1}:24-13. Medline DUI

43. Grnh GI, 1illi'irth MA: Management nf traumatic sternnclavicular jnint injuries. I Am Acnd Grtbnp 3mg

smmstna—x Mndlinfl

This review discusses injuries tn the 5C jnint, describing

anatnmy, mechanisms nf injury, classificatinn nn 5E jnint injuries, itnaging, and management nptinns including nnnsurgical, clnsed reductinn, nr np-en reductinn and internal stabilisatinn.

44.

Martetscbliiger F, 1lili’arth R], Millett P]: Instability and degenerative arthritis nf the sternnclavicular jnint: A current cnncepts review. Am I Spnrts Med 2fl14:42{4}:999-lflfl1 Medline DUI This review examines instability and degenerative arthritis

nf the SC inint. Diagnnstic modalities and classificatinn

as well as management nptinns and cnmplicatinns are described. 45. 1r'an awegen C, 1Flil'nlf E: Suture repair nf pnsterinr sternnclavicular physeal fractures: A repnct nf twn cases.

Inwa Drtbnp J lflflfl;13:49-51. Medline

Eb Iflld American Academy nf Urthnpaedie Surgenns

46. Spencer EE Jr, Kuhn JE: Einmechanical analysis nf recnnstructinns fnr sternnclavicular jnint instability. I Butte jnint Surg Am 10134;.36 -A{1}:93-1i}5. Medline 4?. Bal-t K, ah K: Recnnstructinn nf the chrnnic anterinr unstable sternnclavicular jnint using a tendnn autngraft:

Medium-term tn lung-term fnllnw—up results. ,I Sbnnlder Elli-nit! Sflrg 2014:23i3}:245-250. Medline

DUI

The study repnrted mid-term tn lung-term results nf SC jnint recnnstructinn in 2'? patients fnllnwed for a minimum nf 2 years, with substantial itnprnvement in nutcnme scnres. Twn failures were treated successfully with revisinn surgery. Level nf evidence: IV.

43. Guan I]. 1FJilblf BR: Recnnstructinn fnr anterinr sternn-

clavicular jnint dislncatinn and instability. }' Sbnulder Elbnw Snrg 2013;11{E}:T?5-?31. Medline DUI

E

This article repnrted the results nf surgical management

"fl 1]

nf anterinr SC inint dislncatinn and instability. Six pa-

tients were fnllnwed fnr a mean nf 4i) mnnths; all patients shnwed irnprnved functinnal scnres and all had up at minitnal pain. Level nf evidence: IV. 45‘. Tytherleigb-Strnng G, Griffith D: Arthrnscnpic excisinn nf the sternnclavicular jnint fur the treatment nf sternnclavicular nstenarthritis. Artbrnscnpy 2D13;29{9]:143?— 1491. Medline DUI

This article repnrted the results nf arthrnsenpic excisinn nf the 5C jnint fnr treatment nf nstenarthritis. Uf If] patients,

all had nn nr minimal pain at final fnllnw—up, and 9 had gnnd tn excellent results. Level nf evidence: IV.

50. Enckwnnd CA Jr, Grub GI, 1It'lil'irth MA, Grassi FA: Re-

sectinn arthrnplasty nf the sternnclavicular jnint. j Hens jnint Snrg Am 199?;T’9i3}:33?—393. Medline

Drthnpaedie Knnwledge Update: Spnrts Medicine 5

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Chapter 3

Rotator Cuff Disease

Evan I. Conte. MD

Stephen F. Brockmeier, MD

Abstract

Disease of the rotator cuff is common and increases in prevalence with age in the general population. Rotator cuff disease can present as an acute injury or insidiously

with shoulder pain and weakness. Physical examination and imaging studies can help guide treatment. Surgical and nonsurgical treatment can be effective in correct-

ly chosen patient groups. The sequelae of untreated long-standing larger tears of the rotator cuff can cause joint destruction and profound disability.

Keywords: rotator cuff; impingement syndrome; rotator cuff tear; rotator cuff repair; reverse total

shoulder arthroplasty Introduction

Rotator cuff disease is one of the most commonly treated

upper extremity ailments, and management strategies continue to evolve. Modern understanding of this entity

can be traced to 1934 when rotator cuff function, pathology, and proposed treatment were first described. During

is predominantly prevalent in middle—aged and elderly

patients.‘ Treatment ranges from nonsurgical modalities focusing on rest and phased rehabilitation to arthroscopic

or open tendon repair to salvage options including reverse

total shoulder arthroplasty.

Numerous studies have reported an age-associated increase in the prevalence of rotator cuff tea rs beginning in

patients approximately 51'} years old and increasing with each decade of life {Figure 1}. Rotator cuff abnormalities

are prevalent in both symptomatic and asymptomatic

patients, and bilateral rotator cuff tears are common in patients with unilateral symptoms. The prevalence of tears has been reported to range from 13% for patients

in their 50s to SUSS for patients 3f] years or olden;3 The factors that cause an asymptomatic tear to become

symptomatic have not been completely elucidated, but

natural history data collected in recent studies have linked symptom emergence to progression from a partial- to a

fullnthickness tear, an increase in size of a fulluthickness

investigations have expanded knowledge of the natural history of rotator cuff disease and helped refine treatment younger patients after trauma or in overhead athletes, it

gical management, depending on the age of the patient.‘

options. Although rotator cuff pathology can present in

Dr. Brockmeier or an immediate famiiy member serves as a paid consultant to Biomet and MicroAire Surgical instruments; has received research or institutionai support from Arthrex, Biomet, Tornier; and serves as a board member; owner; officer; or committee member of the American firthopaedic Society for Sports Medicine and the MidAtiantic Shoulder and Elbow Society. Neither Dr. Conte nor any immediate famiiy member has received anything of value from or has stock or stocic options held in a commercialI company or institution related directly or indirectiy to the subject of this chapter:

@ lflld American Academy of Drthopaedic Surgeons

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Natural History and Societal Effect

tear, development of muscle atrophy, fatty infiltration of the muscle, or new biceps pathology.” The societal burden of rotator cuff disease can be substantial when lost days of work are factored in, and a 2fl13 study reported that a rotator cuff repair procedure could result in a cost

the next SCI years, abundant basic science and clinical

E

savings of up to -$?3,flflfl when compared with nonsur-

Eiomechanics. Anatomy. and Genetics

The rotator cuff has a dual function for the shoulder: it helps initiate and assist with active shoulder motion and

it provides dynamic stability to the glenohumeral joint during this motion. Given the short arc length of the

glenoid, the humeral head requires not only substantial

stabilisation from soft—tissue structures including the glenohumeral ligaments, but also the force-couple moment provided by contraction of the four rotator cuff muscles during motion. The supraspinatus and infraspinatus tendons, which comprise the posterosuperior rotator cuff,

Orthopaedic Knowledge Update: Sports Medicine 5

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Section 1:1}pperExtremity

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IHGT El Homear

Classification of Rotator Cuff Muscle Degeneration

all Ellis

Grade {i

or

s

hWhJ—I

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title

Doscription No fatty strea its Some fatty streaks More muscle than fat As much muscle as fat Less muscle than fat

1: Upper Extremity

The

IElsie-situation

Bills

13%

Figure 1

sees

40%

case

sex

moss

Graph demonstrates the prevalence of rotator

cuff tears {EU} in the native population lay age.

Rotator cuff tears can be described and classified based on several factors, including size, location, number of tendon

units involved, tear geometry, level of tendon retraction,

and muscle atrophy and fatty infiltration. Tears were first classified based on size in 1934;“ a subsequent classifica—

are confluent centrally and insert on the greater tuberosity of the humeral head. Studies have shown that most tears occur in the anterior portion of the supraspinatus tendon and are more likely to be larger and associated with fatty

muscle degeneration.” Additionally, the common types of

tear geometry have resulted in the “cablexrescent” con~ cept: a thickened, horseshoe-shaped region that comprises

the anteriormost 3 to 12 mm of the supraspinatus, termed the rotator “cable,” which is critical for the structural and

functional integrity of the superior cuff. The relatively stress-shielded center section is called the “crescent." Bio“ mechanical test results have shown that tears involving the cable result in increased tear gap distance and strain when compared with these in the crescent area“

The etiology of rotator cuff disease involves both in— trinsic and extrinsic factors. Most early studies focused on mechanical phenomena secondary to external impinge-

tion combined coronal and sagittal variables as well as tear thickness.” The quality of the injured myotendinous unit is also important. Atrophy of the muscle belly diam—

eter as well as the degree of fatty infiltration, as classified in 1994 (Table 1], can help indicate tendon quality during repair.” Most recently, a new classification was presented

to assist with surgeon-to-surgeon communication as well as provide prognostic and treatment considerations. This new geometric classification describes rotator cuff tears

as viewed directly via the lateral arthroscopic portal.“ The patterns include crescent-shaped, L-shaped, reverse

Lushaped, Iii-shaped, or massive contracted-type tears

that require more advanced techniques such as interval slides and marginal convergence to repair successfully {Figure 2}.

Physical Examination

ment against the undersurface of a prominent anterior or lateral acromion, eventually resulting in the develop-

tor cuff disease starts with a comprehensive history and

have suggested that rotator cuff disease is not a purely mechanical problem, but is most attributable to intrinsic

including the cervical spine, scapula, shoulder girdle, and neurologic testing of the extremity, followed by a

ment of a tear. New studies investigating genetic influence degenerative tendinopathic changes. These are thought to

involve changes in both the molecular composition of the tendon substance as well as its vascularity, which allows for the gradual development of tendinosis and eventual

structural failure and tearing. As with other degenerative tendinopathies, certain individuals may be more at risk. One study has shown a familial hereditary pattern of rotator cuff diseasef another has identified five genes found more commonly in patients with substantial disease.m

flrdmpaedic Knowledge Update: Sports Medicine 5

Initial evaluation of a patient with symptoms of rota—

physical examination. The examination should be broad, systematic shoulder exa minatioo with specific tests for the

rotator cuff and common concomitant pathology. Visual inspection of the shoulder can reveal rotator cuff muscu-

latu re atrophy as well as signs of rotator cuff dysfunction

and anterosuperior escape. Assessment of passive range of motion is important to rule out adhesive caps ulitis, which would ideally be treated before attempting surgical repair.

It is important to assess for other pathology that could be the cause of concurrent symptoms and potentially

El 1016 American deadeniy of Cirrhopaedic Surgeons

Chapter 3: Entatnr Cuff Disease

studies nbtained. The presence nf superinr migratinn cf the humeral head with a diminished acrnminhumeral interval, glennhumeral inint space narrnwing that suggests nstenarthritis, acrnminclavicular jnint arthrnsis, and features nf rntatnr cuff arthrnpathy with mnrphnlngic

changes nf the humeral head, glennid, and acrnmial arch are all detectable findings nn plain film radingraphs. MRI has prnved incredibly useful in diagnnsing rnta-

tnr cuff disease. Nnt nnly dnes MRI prnvide the surgenn with a qualitative diagnnsis, it alsn can help determine

the cnnditinn nf the muscle, the size and lncatinn nf the

tear, the amnunt nf tendnn retractinn, and perhaps mnst impnrtantly, the presence nf nther pathnlngy that shnuld be managed during surgery tn prnvide the best pnssible

nutcnme. A new methnd tn assess the quality nf the mus-

culature nn MRI is the tangent sign {Figure 3}, which is the failure nf the supraspinatus tn intersect the line

frnm the superinr bnrder nf the cnracnid prncess tn the

superinr bnrder cf the scapular spine. This methc-d is

[1

Figure 2

Measure tear

Illustratinn demnnstrates cuff tear classificatien

using genmetry. lI'IHL = cnracnhurneral

ligament. I5 - infrasplnatus. L - length,

Ftl = rntatnr interval. Eula = subscapularis,

55 = supraspinatus, W = width.

treated during rntatnr cuff repair such as biceps tendnn

disease, acrnminclavicular jnint arth rnsis, nr impingement

syndrnme.

The muscles cf the rntatnr cuff shculd be tested in-

dividually. The ae test, nr empty can test, isnlates the

quick and has been shnwn tn predict the reparability nf

rntatnr cuff tears.” The use cf ultrasnnngrapby has steadily increased in recent years, and it can be as accurate as MRI in di-

agnnsing rntatnr cuff tears. Ultrasnnngraphy has alsn been recently shnwn tn accurately assess the degree nf degeneratinn nf muscle in chrnnic rntatnr cuff tears.” It

is less expensive than MRI, and may best be used nnt as an initial diagnnstic agent but tn assess repair integrity in pnstnperative patients.

Nnnsurgical Treatment

supraspinatus and is perfnrmed with the arm at 91')“ nf abductinn, 30° nf flexinn in the scapular plane, and with

Nnnsu rgical management nf rntatnr cuff pathnlngy typi-

assessing external rntatinn strength with the arm in ad— ductinn and the elb-nw at 9i)“ nf flexinn. The subscapularis

Either tests cnmmnnly used are the external rntatinn lag sign and the hnrnblnwer sign, bnth nf which assess fnr

that fncuses nn passive and active range nf mntinn and strengthening the scapular stabilizing muscles and rntatnr cuff musculature. NSAIDs and the nccasinnal subacrnmial injectinn can alsn be cnnsidered in the painful shnulder but cnuld affect the pntential fnr pnstnperative

arm test fnr the superinr rntatnr cuff. Hn single test fnr rntatnr cuff disease has prnved tn he nf greater diagnnstic

terinr, lateral, nr pnsterinr apprnach, the anterinr and lateral apprnaches demnnstrated increased accuracy in

the fnrearm prnn ated. The infraspinatus can be tested by can be assessed by using the lift-nff and belly-press tests.

failure nf the infraspinatus and teres miner, and the drnp

value. Rather, a 2014 study validated a cnmbinatinn nf

pnsitive tests that greatly increases the specificity nf a rntatnr cuff disease diagnnsis.” Diagnnstic Imaging

A series nf plain radingraphs nf the shnulder, including

a Grashey AP view, lateral nutlet viewi'scapular T view, and an axillary lateral view shnuld he the first diagnnstic

Eb Ifllti American Academy nf Urthnpaedic Surgenns

cally cnnsists nf E tn 12 weeks nf rest, symptnm management, and physical therapy with a hnme exercise regimen

healing. Bursal injectinn can be perfnrmed using an annne recent study.”

Effnrts have increasingly fncused nn determining which patients can be mnst predictably treated nnnsurgically, and thnse whn are more likely tn be recalcitrant tn nnn-

surgical effnrts and require interventinn. The Multicenter Drthnpaedic IE'tutcnmes Netwnrlc shnulder grnup studied a grnup nf 452 patients with asymptnmatic full-thickness

rntatnr cuff tears initially treated nnnsurgically with a physical therapy prntncnl. At 2-year fnllnw-up, 3% nf

Drthnpaedic Knnwledge Update: Spnrts Medicine 5

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Section 1: Upper Extremity

outpatient treatment of rotator cuff tears has also oc-

curred.21 Numerous studies have demonstrated equiva-

lent outcomes when comparing open and arthroscopic techniques. The arthroscopic technique has become more

mechanically similar to the open technique, with the ties

velopment of a medial- and lateral-row suture bridge construct commonly,r referred to as a tra nsosseous-equivalent repair. This type of arthroscopic repair has shown

excellent outcomes with maintenance of functional out-

comes scores and strength at 5 years.ll A typical approach

to arthroscopic rotator cuff repair has been illustrated

[Figures 4 and 5}. Despite these advances, primary repair can still fail,

1: Upper Extremity

especially in the setting of large and massive, retracted

tears. Thus, the ability to augment or biologically enha nce a repair has received substantial attention. Biologic

augmentation with products in the family of platelet—rich plasma {PEP}, platelet-rich fibrin matrix {PRFM}, or

platelet-leukocyte membrane has been studied extensively.

The preparation, method of delivery, and incorporation Figure 3

Magnetic resonance image demonstrate the

tangent sign- A, Medial sagittal T1 -weighted

image depicts su praspinatus muscle atrophy and fatty infiltration just below the tangent line of the scapula (red line}. B, |Eoronal T2— weighted image depicts a corresponding large, retracted posterosuperior rotator cuff tear.

C, Medial sagittal T1—weighted image depicts

a healthy su praspinatus muscle occupying the entire su prasca pular fossa and without fatty infiltration {red line}. D, Eoronal Til—weighted image depicts a corresponding normal

so praspinatus myotendinous unit.

into repairs has not been standardized and continues to make evaluation of these new products challenging. Several recent randomized controlled studies have pro—

vided new data that could help to discern the potential benefit of biologic augmentation of rotator cuff repairs.

Longer follow—up and an assessment of patient subgroups [such as age, sex, and tear sine and location] could help

find specific indications for use of PRPIPRFM in repairs.

Several large, blinded, randomized studies have shown

no substantial difference in outcomesFl“ Additionally, a systematic review of all level I or II studies on PEP for rotator cuff repair augmentation did not identify any

patients did not go on to surgery, and most therapeutic failures occurred in the first 12 weeks.”1

benefit greater than the minimum clinically important difference?

nonsurgical treatment of rotator cuff tears have only re— cently been published. A Norwegian group compared

material can also be used to augment repairs. Kenografts, dermal or collagen grafts, and synthetic mesh-type grafts have been studied. A few short-term outcomes studies have shown promise, but further longer term review is lackingfif'lf

Large, welludesigned studies comparing surgical and

physical therapy with immediate repair in a single-center

randomized controlled study.m Small and medium {:3

cm} tears were confirmed on MRI. Overall, patients in the surgical group had slightly better Constant and American Shoulder and Elbow Surgeons scores, but the data,

although significant, were likely not clinically important.

flf note, one-third of the nonsurgically treated patients

had poor outcomes with an associated increase in rear size greater than 5 mm.

Surgical Considerations

The rate of arthroscopic rotator cuff repair has increased

dramatically since its development, with a concurrent decrease in open rotator cuff repairs. A shift toward

flrdiopaedic Knowledge Update: Sports Medicine 5

The incorporation of either synthetic or natural graft

Although most studies show that rotator cuff repairs

have successful, enduring clinical outcomes that can result in the assumption of tendon-to-bone healing, evidence increasingly shows that the integrity of many repairs may

not be what is expected. Actual tendon—to—bone healing may not always be necessary to achieve a successful clin-

ical outcome, especially in the short term. Both MRI and

ultrasonography have been used to quantify the structural success after rotator cuff repair. A systemic review identified an overall re-tear rate of 20.4%.“ Another study reported a re—tear rate for medium to massive tears of 12% to 22%, with no difference in patient outcome versus

El 1016 American AcadMy of Cirrhopaedic Surgeons

Chapter 3:1letater Cuff Disease

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Figure 5

Arthrescepic view dem enstrates a cempleted tra nsesseeus-e-qulvalent arthresceplc retater cuff re pair.

Pesteperative Cencerns

Traditienal pesteperative rehabilitatien regimens have

emphasized an immebiliaatien peried ef 6 weeks, with gradual passive range ef metien fellewed by activeassisted range ef metien starting in the early pesteperative

peried. The ratienale fer early metien has been te limit the develepment ef tissue adhesiens; extended itnmehiliillustratlen demenstrates a typical appreads te arthrescepic transesseeus—equivalent retater cuff re pair. A. The cuff tissue is viewed frern

the lateral pertal fer debridement ef bursal adheslens. The tear pattern is determined and the tissue ntebility is assessed using a

nentraumatic grasp-er. B, The greater tube resity

{G T} is deb rided ef seft tissue te allew punctate bleeding. Medial-rew anch ers are placed just lateral tn the articular margin percuta neeusly te allew a mere fave ra ble insertien angle. C. The sutures are passed th reugh the retater cuff tenden lateral to the myetendineus junctien and tied te reduce the tenden te the

medial rew anchers. D. The suture limbs are

bre ug ht te lateral revv ltnetless anchers te cemplete the repair. ALF = anterelateral pertal,

AP = anterier pertal. I5 = lnfraspinatus.

aatien enceurages tissue healing in a lewnstress enviren-

ment fellewed by subsequent return ef range ef metien. The eptimum time te start passive range ef metien has been debated censiderably. Pl. prespective randemiaed

study shewed ne difference in eutceme and final range ef metien with early versus late initiatien ef metien fer small- er medium-size tears (53 cm].“ This finding was

supperted by a recent meta-analysis, which cencluded that small- er medium-size tears have a lewer risk ef re-

test when metien is started within 1 week. Hewever, it

alse reperted that massive tears {3+5 cm} have a greater risk ef re-tear when metien is started early, suggesting that

patient-specific pesteperative pretecels can be beneficial.32

PLP = peste relateral pe rial, PP = pesterier pertal. 55 = supraspinatus. Tenden Transfers

the intact repairs.” Altheugh tenden-te—bene healing may net result frem all repairs, eutcemes remain faverable. A

Yeunger patients with massive, irreparable tea rs represent

integrity ef the repair dees net cerrespend with entceme but it dees cerrespend with strength.”

reverse tetal sheulder arthreplasty, this is net yet an accepted eptien in the middle-aged patient with a massive

meta-analysis ef seven level I er II studies suggests that the

El Ifllii American Academy ef flrfltepaedie Surgeens

a particularly difficult subset te treat. Altheugh elderly,

lew-demand patients can eften be treated effectively with

Drthepaedie Knewledge Update: Sparta Medicine .5

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Section 1:1}pperExtremity

tear that has become irreparable. Direct transfers of the latissitnus dorsi musculotendinous unit for irreparable

posterosuperior tears has been used by many authors as a salvage option for irreparable tears in patients younger than Efl years. The transferred tendon has been postu—

lated to function as a tissue augment, an external rotator

of the shoulder joint, a humeral head depressor, and to act in concert with the intact subscapularis {which is a

prerequisite for consideration of a latissimus dorsi transfer} to restore the rotator cuff force couple and assist the dcltoid in elevation and abduction. fl. successful latissimus dorsi transfer can improve patient subjective outcomes,

1: Upper Extremity

decrease pain, and improve strength and range of motion,

but not as well as that of a reparable tear.’J Poorer results

can be expected in patients with concomitant deficiencies of the subscapularis and teres minor.“ In the setting of

reverse total shoulder arthrnplasty have favorable out-

comes and should be considered on a case—by—case basis. Hey Study Points

in Rotator cuff disease is common and the incidence increases with age in patients older than 50 years.

It History and physical examination followed by MRI confirmation help guide treatment.

It lviany chronic small rotator cuff tears can be treated

successfully uonsurgically. it Both arthroscopic and open repair techniques can yield good results. 1* Postoperative therapy protocols are best when individualized based on tear size.

a tendon transfer, it is important to counsel patients not

to expect an undeliverable outcome.

Reverse Total Shoulder Arthroplasty

In patients with irreparable massive tears with a low shoulder functional demand and in the setting of rotator

Annotated References 1. Mather RC III, Koenig L, Acevedo D, et al: The societal and economic value of rotator cuff repair. ] Hone joint Surg Am .2013;95{22}:1993—1flflfl. Medline DUI

cuff tear arthropathy, reverse total shoulder arthroplasty is a proven, effective treatment. The function of the pro-

This study examined the effect of rotator cuff disease

mechanical advantage to the dcltoid muscle by medialie— ing the center of rotation and translating the humeral side

estimated at approximately $3.44 billion per year due to

cedure is to alter the joint mechanics, thus providing a

inferiorly, allowing the dcltoid to function without the

assistance of the rotator cuff musculature while replacing the wnm articular surfaces. Concerns related to longevity

should be considered in patients younger than 51'] years

because long-term implant survivorsbip is not yet clear. The outcomes for reverse total shoulder arthroplasty in

patients with rotator cuff disease have been favorable.”

Patient selection is paramount because studies including patients younger than 65 years can have less favorable long-term outcomes?5

on earnings, missed workdays, and disability payments using a Markov decision mode] to determine the economic effect of the disease on society. Societal cost savings were rotator cuff repairs.

2. “'r'amamntn A, Takagishi Ii, lElsawa T, et al: Prevalence and risk factors of a rotator cuff tear in the general population. I Sboufder Efbottr Snrg lfllfl;19{1}:116-12fl. Medline DUI This study used ultrasonography to determine the prevalencc of rotator cuff tears in a mountain village in Japan for patients of all ages. Rotator cuff tears are rare in young patients but increase steadily for each decade in life after age 5D years. 3. Ternagucbi K, Ditsios K, Middleton WI], Hildebolt CF,

Galata Ll'vi, Teefey SA: The demographic and morpho—

5 u or ma ry

Rotator cuff disease increases in prevalence with age, with many patients having both symptomatic and asy mptomatic tears. Tears typically occur in reliable patterns,

and for chronic tears in older patients, most can ini— tially be treated nonsurgically with a high success rate.

Repair is now commonly performed arthroscopically,

with equivalent outcomes to open surgery despite a less-than-ideal rate of definitive healing, especially in larger tears. Physical therapy tailored to patient- and tear-

specific factors should be started in the postoperative period. Salvage operations including tendon transfers and

flrdtopaedic Knowledge Update: Sports Medicine 5

logical features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. I Bone joint

Surg Am Zflfl6;33{31:1699-1?fl4. Medline DUI

This article investigated the correlation between symptoms and cuff tear siec progression. Larger tears were more likely to be symptomatic and be accompanied by a contralateral cuff tear.

4. Moosmayer S, Tariq R, Stiris M, Smith H-]: The natural history of asymptomatic rotator cuff tears: A three-

year follow—up of fifty cases. I Bone joint Surg Am

2013;95f14}:1249-1255.Modline not

This study followed patients with asymptomatic cuff tears using ultrasonography to determine the natural history

El ll] 16 American AcadMy of Drtbnpaedic Surgeons

Chapter 3: Entamr Cufl' Disease

of the disease and which factors were associated with

contributing to the risk for rotator cuff disease. J Bone joint Surg Am 2009:91i5]:113ti-1142. Medline DUI

symptoms. Level of evidence: II.

This study used genealogic data from a population in Utah

Mall NA, Kim HM, Keener JD, et al: Symptomatic progression of asymptomatic rotator cuff tears: A prospective study of clinical and sonographic variables. 1 Bone Joint Surg Am lfllflfllflfihlfilfi-EEES. Medline DUI

heritable predisposition to rotator cuff disease. Level of evidence: III.

symptom generation. Increase in tear size and decrease of muscle quality were associated with development of

This research study followed asymptomatic patients using ultrasonography to determine that symptoms begin with increases in tear size or progression from partialv to

full-thickness tears. Leml of evidence: III.

Kim HM, Dahiya bi, Teefey 5A, Keener JD, IIlialatz LM, Yamaguchi K: Relationship of tear size and location to fatty degeneration of the rotator cuff. I Bone joint Ens-g Ans 2010;91H}:329-339. Medline D-UI

This article determined that fatty degeneration of the

rotator cuff musculature is associated with both location and tear size. The loss of the fibers of the anterior supraspinatus tendon can result in development of fatty degeneration of the muscle.

Namdari S, Donegan RP, Dahiya bl, Galatz LM, Yamaguchi K, Keener JD: Characteristics of small to medium-sized rotator cuff tears with and without disruption of the anterior supraspinatus tendon. j Sbonfder Efbow

Snrg companies—1v. Medline nor

This article examined the results of rotator cuff tear re— pairs that involved the anterior supra spinatus tendon and those that did not. Anterior tears involving the rotator cuff cable were larger and more likely to have associated

muscle degeneration but had no influence on structural results after surgery. Level of evidence: III.

Mesiha MM, Derwin EA, Sibole SC, Erdemir A, McCa— rron JA: The biomechanical relevance of anterior rotator cuff cable tears in a cadaveric shoulder model. J Bone joint Snrg Ant lfl13;95{1fl}:131?-1324. Medline DUI

This biomechanical cadaver study showed that tears

involving the anterior 3 to 12 mm of the supraspinatus

to determine the presence of excess familial clustering for rotator cuff disease. The findings strongly supported a

11. DeUrio JK, Coiield RH: Results of a second attempt at surgical repair of a failed initial rotator-cuff repair._,I Hone joint Snrg Ant 1934,55l4]:563-561 Medline 12. Patte D: Classification of rotator cuff lesions. Cffn Urtbop Refer Res 1990;254:31—36. Medline 13. Goutallier D, Postel JM, Eernageau J, Lavau L, Voisin

MC: Fatty muscle degeneration in cuff ruptures. Pre- and

postoperative evaluation by CT scan. Cfin Urtfiop Reins Res 1994:3fl4:?3-33. Medline

The authors proposed a new classification for rotator cuff tears based on geometry of the cuff tear that was linked to prognosis and treatment technique. 15. Somerville LE, Willits K, Johnson AM, et al: Clinical assessment of physical examination maneuvers for rotator cuff lesions. An: I Sports Med lfll4:41{33:1 911—1919.

Medline DUI

This study investigated the sensitivity and specificity of various physical examination tests for rotator cuff disease when correlated with surgical evidence of rear. No test in

isolation provides enough data for diagnosis but rather

that a combination of tests improves the ability to diagnose rotator cuff disease. Level of evidence: I. 16. Kissenberth M], Rulewicz C], Hamilton SC, Bruch HE, Hawkins Ii]: A positive tangent sign predicts the

repairability of rotator cuff tears. }' Shoulder Elbow Sang

lDl4;23{?}:Ifl23-Ifl21Medline DUI

The authors proposed the tangent sign, a novel, quick method to determine muscle quality in the setting of retator cuff tears. This method was shown to be predictive

Motta CdaR, Amara] Mini, Rezende E, et al: Evidence

1?. Wall LB, Teefey 5A, Middleton WD, et al: Diagnostic

The authors investigated the link between 23 single-nu-

cleotide polymorphisms within six genes and their association with degenerative processes in the development of rotator cuff disease. These genes correlated with the presence of rotator cuff disease as well as female sex and Caucasian race. Leml of evidence: III.

ID. Tashiian RE, Farnham JM, Albright F5, Teetlink CC, Cannon-Albright LA: Evidence for an inherited predisposition

U Ifllii American Academy of Urthopaedic Surgeons

"fl 1]

s, F”

14. Davidson J, Eurkhart 55: The geometric classification of rotator cuff tears: A system linking tear pattern to treatment and prognosis. Arthroscopy lfilfl;16{3}:41?-424. Modline DUI

tendon, in which the rotator cuff cable is present, develop larger gaps when subject to loading that tears in the posterior supraspinatus, the crescent area. This supports the importance of the rotator cuff cable in load bearing versus the more stress-shielded crescent area. of genetic variations associated with rotator cuff disease. ] Shonfrier Elbow Snrg' 2fl14;13{2}:22?-235. Modline DUI

E

of reparability of cuff tears. Level of evidence: II.

performance and reliability of ultrasonography for fatty degeneration of the rotator cuff muscles. I Hone joint Sang An: ED12;94{12]:e33. Medline

DUI

This study compared the diagnostic performance and observer reliability of ultrasonography in grading fatty degeneration of the rotator cuff musculature when compared with MRI. The group found that ultrasonography and MRI were comparable. Level of evidence: II. 13. Maman E, Harris C, 1'ilii'hite L, Tomlinson C, Shashank M, Eoynton E; EranMaman: Outcome of nonoperative

Urthopaedic Knowledge Update: Sports Medicine 5

E? E.

n:

c!

Seetien 1:1}pperExtremity

treatment ef symptematic retater cuff tears meuitered by magnetic resenance imaging. ,I Ilene fefrrt 3mg Am

2UD9;91{3}:1393-19fl6. Medline DUI

This retrespective study investigated the natural histety ef patients with retater cuff disease using nensurgical metheds with MRI at d menths er lenger. After age

ED years, fatty infiltratien er the presence ef a full-thick-

ness tear were asseciated with tear pregressien. Level ef evidence: IV. 15. Kuhn JE, Dunn WE, Sanders R, et al: MUUN Sheul— der Greup: Effectiveness ef physical therapy in treating atraumatic full-thickness retater cuff tears: A multi-

ccnter prespective cehert study. I Sbeufdet Elbert! Surg

1: Upper Ertrem ity

2fl13;32{lfl):13?1-13?9.Medline

DUI

This prespective multicenter study examined the effectiveness ef physical therapy as a treatment medality fer atraumatic full—thickness retater cuff tears in a cehert ef 451 patients. All patients began physical therapy and were subsequently allewed te cheese surgery er further physical therapy. Fewer than 25% ef patients elected te underge surgery, and mest cemmenly did an between 6' and 12 weelrs. If}. Meesmayer S, Lund G, Seljem U5, et al: Tenden repair cemparcd with physietherapy in the treatment ef retater cuff tears: A randemised centrelled study in 1&3 cases with a five-year fellew-up. I BDHE fefrrt Serg Am lfl]4:96{13l:1504—1514. Medline DUI

This randemised centrelled study cernpared surgical

and nensurgical treatment ef retater cuff tears less than 3 cm in size: 24% ef patients in the nensurgical greup underwent secendary tenden repair with inferier results cernpared with these treated with primary repair. Overall, the differences in eutcemes berween the greups were small, and the clinical significance may be miner. Level ef evidence: I. 21. Iyengar J], Samagh SP, Schairer W, Singb G, Valerie FH III,

Feeley ET: Current trends in retater cuff repair: Surgical

technique, setting, and cest. Arthrescepy 2014;3fli3}:234233. Medline DUI This study reperted en current trends in retater cuff repair using a Flerida database. fl. rapid increase in arthrnscepic

repair, decrease in epen repair, and increase in the number ef cases perfenned in eutpan'ent centers were reperted.

Guletta LU, Nhe SJ, Dedsen CC, Adler RS, Altcbei: DW, MacGillivray JD; H55 Arthrescepic Retater Cuff Registry: Prnspective evaluatien ef arthrnscepic reta-

ter cuff repairs at .5 years: Part I—functienal eutcemes and radiegraphic healing rates. } Sheulder Elbert: Surg 2D11:20{6J:934-940.Medli11e DUI This prespective cehert study ef 193 patients whe underwent all-arthrnscepic retater cuff repair was fellewed fer 5 years. The midrange results were geed, with lasting functienal imprevements. The healing rate, determined using ultrasenegraphy, eentinued te increase ever n'rne. Level ef evidence: II.

Urrhepaedie Knewledge Update: Sperrs Medicine 5

23. Weber 5C, Kauffman _]I, Parise C, Weber 5], Kat: 5D: Plate-

letaricb fibrin matrix in the management ef artbrescepic repair ef the retater cuff: A. prespective, randemised,

deuble-blinded study. Am ] Sperts Med 2013:41i2i:2632T0. Medline

m

This investigatinn ef the use ef PRFl'vI in retater cuff repair shewed ne substantial difference in eutceme er structural integrity. Level ef evidence: I.

24. Castricini R, Lenge UG, De Benedette M, et al: Plate— let-rich plasma augmentatieu fer arthrescepic retater cuff repair: A randemiaed centrelled trial. Am I Sperts Med 1011;39i2}:253-265. Medliue

DUI

The anthers perfermed a randemized centrelled trial In

determine if PRP augmentatieu impreved retater cuff

repair ef small- er medium-sire tears. Ne imprevement was detected. Level ef evidence: I. 2.5. Wartb R], Deman G], James EW, Heran MP, Millett P]: Clinical and structural eutcemes after arthrnscepic

repair ef full-thickness retater cuff tears with and witheut

platelet—rich preduct supplementatien: a meta-analysis and meta-regressien. Arthrescepy 2015:31i2]:3ilE-32il. Medline DUI

This meta-analysis ef level I and II studies ef PEP aug-

mentatien ef retater cuff repairs feund ne substantial

difference in everall gain in eutceme scere er re-tear rates. Hewever, evidence supperted decreased re-tear rates fer tears greater than 3 cm, which received PEP augmentatieu

during repair. Level ef evidence: 11.

26. Ciampi I", Scetti C, Nenis A, et al: The benefit ef syn-

thetic versus bielegical patch augmentatieu in the repair

ef pesteresuperier massive retater cuff tears: A 3-year fellew-up study. Am I Sperts Med 2014;41{5l:1169-11T5. Medliue DUI

The anthers investigated mechanical augmentatieu ef retater cuff repair with twe patch types versus a centrel greup. Pelyprepylene patches were feund te impreve eutcemes at 36 menths. Level nf evidence: III. 2?. IGupta AK, Hug K, Beggess B, lGavigan M, Teth AP: Ivlassive er E-tenden retater cuff tears in active patients

with minimal glenehumeral arthritis: Clinical and radie-

graphic eutcemes ef recenstructien using dermal tissue matrix :tenegraft. Am I Sperts Med 2U13;41[4}:3T2 -3T9. Medline DUI

This study determined that recenstructien ef irreparable twe-tenden retater cuff tears with dermal senegraft ceuld impreve euteemes at 3 years. Level ef evidence: IV. 23. Slabaugh MA, Nhe 5], Grumet RB, et al: Dees the liter— ature cenfirm superier clinical results in radiegraphically healed retater cuffs after retater cuff repair? Artbrescepy IDID;IE{3}:393-4DlMedIine

DUI

This systematic review assessed the literature te deter— mine a cerrelatien between cuff healing and eutceme. The everall re-tear rate was 31.4% and the study suggested that intact cuff repairs can impreve seme eutceme sceres. Level ef evidence: I‘v'

El 1016 American AcadMy ef Urrbepaedic Surge-ens

lIEhapter 3: Rntatnr Cuff Disease 29. Kim KC, Shin HD, Lee WT: Repair integrity and functinnal nutcnmes after arthrnscnpic suture-bridge rntatnr cuff repair. I Hurts Inner Surg Am 2fl12;94{3}:e43. Medline [II-DI

This study used ultrasnnngraphy nr MRI tn assess heal-

ing rates nf rntatnr cuff repairs. The authnrs fnund an increased rate nf re-tear fnr larger tears but fnund nn

cnrrelatinn between integrity nf the repair and clinical nutcnme. Level nf evidence: I‘v".

30. Russell RD, Knight JR, Mulligan E, Khazzam MS: Struc-

delayed, suggesting that rehabilitatiun prngrams shnuld be patient-specific based nn tear size. 33. Namdari 5, Unleti P, Baldwin K, Glaser D, Huffman GR: Latissimus dnrsi tendnn transfer fnr irreparable rntatnr cuff tears: A systematic review. I Enne Inner Surg Am 1012;94[101:391-393.Medline DUI This systematic review nf available literature cnnfirmed that latissimus dnrsi tendnn transfers fnr irreparable rntatnr cuff tears imprnve shnulder functinn, strength, mntinn,

and pain relief. Level nf evidence: I‘v'.

tural integrity after rntatnr cuff repair dnes nnt cnrrelate with patient funetinn and pain: A meta-analysis. I Bursa Infra-t 3mg Am 2014;95i4}:265-2?1. Medliue DUI

34. Gerber C, Rahm 5A, |L'L‘atansarn S, Farshad l'v'I, Mnnr BK:

This meta-analysis nf level I nr II studies fnund a 213%

ble pnsternsuperinr rntatnr cuff tears: Lung-term results at a minimum fnllnw-up nf ten years. I Bees faint Sarg

nverall rate nf re—tear, nu difference in rear size between

intact and failed repairs, and nn cnrrelatinn between intact repairs and re-tnru repairs nn clinical nutcnmes. Level nf evidence: II. 31. Keener jD, Galatz Ll'vI, Stnbbs-Cucchi G, Pattnn R, Tamaguchi K: Rehabilitatinn fnllnwing arthrnscnpic rntatnr

cuff repair: a prnspective randumised trial uf immubiliaa-

tinn enmpared with early mntinn. I Bursa jurist Sarg Am 2014;95i1}:11-19.Med1ine DUI

This level I study nf patients undergning arthrnscnpic repair nf small nr medium—sized tears randnmited tn early nr delayed pustnperative range nf mntinn grnups fnund as clinical advantage tn early passive mntinn versus immnbilizatinn. Level nf evidence: I. 32. Klucsynski MA, Nayyar S, Maren JM, Eissnn L]: Early versus delayed passive range nf mntinn after rntatnr cuff

repair: A systematic review and meta-analysis. Am I Sparta Med 2015;43{3}:3fl57~2053. Medlil‘le

DUI

This study analysed the literature tn determine re-tear rates when pnstnperative passive rnntinn is started within 1 week nr delayed 3 tn 5 weeks. Gl'flllpfid level I studies found an difference in re—tear rates. Hnwever, re-tear rates were higher fur massive tears when early mntinn was initiated and higher fnr smaller tears when early mntinn was

Eb Ifllfi American Academy nf flrflinpaedje Surgenns

Latissimus dnrsi tendnu transfer fnr treatment nf irrepara-

am sulssspnasau-iass. Medline but

E

A lung-term study sf 5? shnulders fullnwed fnr at least

"fl 1]

lfl years cnnfirmed that latissimus dursi transfers are suc-

cessful and prnvide lasting imprnvement tn patients with irreparable rntatnr cuff tears. Level nf evidence: IV. 35. Wall E, Nevé-Jnsserand L, D’Cnnnnr DP, Edwards TE, Walsh G: Reverse tntal sbnulder arthrnplasty: A review nf results accnrding tn etinlngy. } Burrs jnfrtt Surg Am lDU?;39{?]:14T6—1435.Medline DUI This study stratified the nutcnmes nf reverse tntal shnulder arthrnplasty hy indicatinn, finding that patients with ratstnr cuff arthrnpathy had better clinical results that patients undergning the prncedure fnr pnsrtraumatic arthritis nr

in revisinn cases. Level nf evidence: II.

36. El: ET, Heultnm L, Catanaarn 5, lGerber C: Reverse

tntal shuulder arthrnplasty fur massive irreparable rntatnr cuff tears in patients ynunger than 65 years nld: Results after five tn fifteen years. I Sbnnfder Ebb-nu: Sing 1013:22{9]:1199-12fl3. Medline DUI

The anthers studied the nutcnme nf reverse tutal shnulder arthrnplasty fnr patients ynunger than 65 years. Substantial, lastiug imprnvement was fnund in nverall functinn up

tn ID years frnm surgery. Level nf evidence: IV.

Drrhnpaedis Knnwledge Update: Spnrrs Medicine .5

a, F”

E? E.

m

a!

Chapter 4

Superior Labrum and Biceps Pathology

Bryan G. Vopat. l'vID

Jeffrey E. Wong, l'vID

Petar Golijanin, BS

Abstract

MatthewT. Provencher. MD

Introduction

Superior labrum anterior to posterior [SLAP] tears

and pathology involving the long head of the biceps

[LHB} tendon are both common issues that can result in shoulder pain, dysfunction, and activity limitation.

However, it can be difficult to identify SLAP and LHB pathologies as the sole culprit because they are com-

monly seen with other injuries. The treatment of both issues remains controversial and a subject of continued

research. SLAP repairs have had more beneficial results in patients younger than 4!} years and when not associ-

Superior labrum tears were first described in 1935‘; they were subsequently classified in 15‘5”).i These detachment injuries, or superior labrum anterior to posterior {SLAP}

tears, also can possibly involve the long head of the biceps {LH E} tendon. The LI-IB tendon has been identified as

an important pain generator in the shoulder; however, it can be difficult to isolate the LHB involvement because it

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to

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commonly occurs with other disorders. Currently, this pa-

thology can be treated with either a tenodcsis or ten otomy.

ated with a rotator cuff repair. Ideal treatment of LHB tendon pathology is still evolving; patient desire and

s tgeoflpSela-ET: 3“” i131? dfllifliftmp31%;:Tlfflmy,

The glenoid labrum is composed of fibrocartilaginous

tenodcsis or tenotomy1smd1cated,tenodes1s should be performed in those with higher levels of physical activity patients concemed with cosmesis and workers’ co . mpensatlon cases. Several types of tenodcsis procer can be performed but the literature has not

. h I . hi tb . l I The supp in se “355E E arbortae Wt 11 E petlp era aspect of the labrum. The inner portion of the labrum is avascular1! and the superior labrum is less vascular compared with the inferior and posterior labrum 3 . . . '

1:“ hElP ldmtlfl" fl“: best treatment optlons for patients.

articular margin of the glenoid rim. This medial attach-

or fighdflffzdjo 53’ hiE:flTl'lisgl?t:ra:n1:Ffiafls not cle fl’ fionstrated agar Priors icalo tion 1-] e er its: . v 'w Pi ' upe . org? .

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j

23:11:;fiecl fl t'mal “'3‘“;a F t re research is neededt u u p1

tissue. The suprascapular artery, the circumflex scapulat branch of the subscapular artery, and the posterior humeral circumflex artery provide the labrum‘s vascular .

.

The supenor labrum is usually triangular but can have a meniscoid shape. It commonly attaches medial to the

ment at the supraglenoid tubercle creates a subsynovial

Keywords: biceps tendinopathy; SLAP; biceps tenodesis; biceps tenotomy; biceps tendinitis

recess; 40% to 60% of the LHB tendon originates from the supraglenoid tubercle, and the remaining fibers insert directly into the superior labrum. The LHB can have

an entirely posterior, posterior—dominant, or equally Dr. Vopat or an immediate family member serves as a paid consultant to DePuy. Dr. Frovencher or an immediate family

member has received royalties from Arthrex; serves as a paid consultant to Arthrex and the Joint Restoration Founda— tion; and serves as a board member; ownei: officer. or committee member of the American Academy of flrthopaedic

Surgeons. the American Grthopaedic Society for Sports Medicine. American Shoulder and Elbow Surgeons. the Arthros-

copy Association of North America. the international Society of Arthroscopy. itnee Surgery. and Orthopaedic Sports Medicine. the San Diego Shoulder institute. and the Society ofMilitary Orthopaedic Surgeons. Neither of the following

authors nor any immediate family member has received anything of value from or has stocic or stock options held in a

commercial company or institution related directly or indirectly to the subject of this chapter: Dr. vvbng and Mn Goliianin.

@ lfllfi American Academy of Drthopaedic Surgeons

Orthopaedic Knowledge Update: Sports Medicine S

e

1: Upper Extremity

Section 1: Upper Extremity

Figure 1

A. Arthroscopic view via the posterior portal demonstrates normal attachment of the long head of the biceps tendon with the patient in the decubitus position. B. Arthroscopic vievv demonstrates a cordlilte middle

glenohumeral ligament. a normal variant. which can be identified with the probe inserted via the anterior portal. This structure should not be repaired.

anterior-posterior attachment at the superior labrum. In most cases, the LHB has a posterior-dominant or entirely posterior labral insertion.‘l The LHB anchor has some

inherent physiologic motion, and overconstraint from repair can contribute to stiffness. Anatomic variants in the superior labrum must also

to where it commonly tears at the LHB pulley near the proximal groove.” Fiathophymiologirr SLAP tea rs can be caused by forceful traction to the arm,

be recognised. Variants include a sublabral foramen or absence of the superior labrum, often seen together with

direct compression loads, and repetitive overhead throw~ ing. Certain anatomic and biomechanical factors can

following labral anatomic variants were identified: 3.3% had a sublabral foramen, 3.6% had a sublabral foramen

external rotation of the shoulder in the late cocking phase increases torsional force at the LHB root, resulting in

a cordlike middle glenohumeral ligament {MEI-IL}. The

with cordlike MGHL, also called a Buford complex [Figure 1}, and 1.5% had an absent anterosuperior labrum.5

Surgical repair of these anatomic variants can result in loss of external rotation. The LHB passes intrararticularly over the humeral head before exiting the glenohumeral joint in the bicipital groove? The LHE pulley, especially the coracohumeral

ligament and superior fibers of the subscapularis, stabilize the extra-articular LHB as it enters the bicipital groove.

predispose the overhead athlete to SLAP tears. Increased

a peeluback injury to the posterosuperior labrum {Fig-

ure 2]. Iniurics can also result from repetitive contact

of the posterosuperior labrum with the nndersurface of the rotator cuff in the late cocking phase? Studies have

shown that SLAP tears are seen more frequently in the late cocking position. It has been proposed that the essential lesion is posterior capsular contracture.” Because of this,

throwing athletes have increased shoulder external rota~

A subscapularis tear should be highly suspected in the

tion and decreased internal rotation in abduction, which causes posterosuperior migration of the humeral head in

ment, and superior glenohumeral ligament comprise the

SLAP tear. Increased external rotation results in greater torsional loads across the superior labrum from the more

occurs at the LHB origin: therefore, pathology in this

a SLAP tear {Figure 3}. The proximal LHB tendon has

setting of LHB instability, and vice versa. The subscapu— laris tendon, supraspinatus tendon, coracohumeral liga-

soft—tissue sling.“ The LHB tendon is innervated by thinly myelinated sensory neurons. Most of this innervation

region can generate pain.‘I Blood is supplied to the LHB tendon from the thoracoacromial and brachial arteries via the osteotendinous and musculotendinous junctions,

respectively.|Ii A hypovascular zone found near the tendon origin at the superior glenoid attachment corresponds

flrdiopaedic Knowledge Update: Sports Medicine 5

the late cocking phase, which can result in a peel-back

posteriorly oriented LHB tendon. The labrum and LHB tendon displace medially over the glenoid rim, creating

been recognized as a source of substantial paing“ this can be difficult to diagnose because it is known to occur

with other pathologies including SLAP lesions, rotator cuff disorders, impingement, bursitis, and other acro-

mioclavicular joint disorders.

El 1016 American Academ~y of Urrhopaedic Surgeons

Chapter 4: Superior Labrum and Biceps Pathology

A

E

Figure 2

Arthroscopic views obtained via the posterior portal with the patient in the lateral decubitus position. A. View

shows the biceps attachment to the Iabrum. E, 1ii'iew shows the peel—back sign of the la brunt with abduction and external rotation.

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fill

When seen in isolation, primary LHE tendinitis usually

occurs in younger patients who participate in overhead

activities such as volleyball and baseball.H With LHB tendon instability, the patient describes a clicking or snapping

with overhead motions. In addition, a subscapulatis tear

is associated with LHB medial instability and a supraspi— natus tear is associated with posterolateral instability.” Classification

Snyder's original classification system of SLAP tears is

the most widely used and recognised? [Figure 4}. Type I lesions consist of fraying of the superior labrum with

localized degeneration [Figure 5,. A}. The superior labrum

Figure 3

Arthroscopic view obtained via the posterior portal with the patient in the lateral decubitus position demonstrates a type III superior Iabrum Ell'l'EEll' ti} FDStEl‘lDI" t-Efll". NEI'L‘E the

biceps displaced medially over the glenoicl rim

as a bucket-handle tear of the long head of the biceps tendon {arrows}.

Pathology of the LHB tendon can include tendinitis,

tears, sublustation, entrapment, delamination, and dislocations out of the bicipital groove.11 Because of the rela-

tively anterior position of the bicipital groove along the humeral head along with humeral retroversion, the ten-

don is exposed to media] instability, which can increase

degeneration.” The different variations of the bicipital groove can also increase the risk of LHB tendon pathology. However, isolated LHE tendon pathology can still

occur in isolation but is frequently associated with other shoulder pathologies, especially rotator cuff pathology.

fit Ifllli American Academy of flrfltopaedie Surgeons

and LHE anchor remain intact. Type II lesions are the most common and are characterised by detachment of the superior labrum andfor LHE anchor from the glenoid (Figure 5, B}. These lesions demonstrate abnormal

mobility of the labrum and Ll-IB anchor. Type III lesions

are characterized by a bucket-handle tear of the superior

labrum with an intact LHB anchor {Figure 5, E]. Type IV lesions have a bucket-handle tear of the superior la-

brum that extends into the LHB anchor {Figure 5, D}.

The original classification system has been expanded to include type V, a SLAP tear combined with a Bankart

lesion; type VI, a SLAP teat combined with an unstable flap tear of the labrum; and type VII, a SLAP tear that continues to the MGHL origin.” Physical Examination

The clinical diagnosis and physical examination of a

SLAP tear or symptomatic LHB tendinopathy is often challenging because the findings are similar to other

Drrhopaedie Knowledge Update: Sports Medicine 5

a!

Sectien 1:1}pperExtrernity

multiple physical examinatieu tests have been tempered with intraeperative findingsdfl"

A defermity ef the LHE tenden such as a Pepeye sign indicates tenden rupture. The mest cemmen physical

examinatien fer LHB diserder is tenderness caused by

palpating the tenden within the hicipital greeve.” An examiner can test fer synevitis that is lecalieed in the hicipital greeve by palpating the tenden medial te the

pecteralis majer insertien during internal retatien with resistance}1 Fer a mere accurate diagnesis. the examiner sheuld test the centralateral side and cempare it with

the affected side. Multiple tests have been established te identifyr LHE tendinitis and asseciated pathelegies but 1: Upper Extremity

nene have a reperted pesitive predictable value. Beth the

Yergasen and Speed tests are specific but net sensitive in detecting LHB tendinitis, rupture, and SLAP lesiens.” A painful click er tenderness te palpatien at full abductien

and external retatien indicates medial LHB instability.

If the tenden is dislecated, it can be relied under the examiner’s fingers.21 Different types ef injectiens can

be used fer further treatment and diagnesis. Mest cem-

menly, a subacremial certisene injectien is given first Figure 4

A drawing demenstrating a type I superier

te differentiate pain caused by impingement frem LHE

with fraying ef the superier labru n1, type II SLAP tear (Bl that includes detachment ef the su perier la bru n1. type III SLAP tear [E] tensist‘ing ef a bucket handle-tear ef the su perier la brurn, and a type IV SLAP tear {DJ demonstrating a bucket-handle tear that extends inte the bicep.

LHB tendinitis.

Iahrum anterier te pesterier {SLAP} tear [A]

tendinitis. If the pain persists, a certisene injectien inte the hicipital greeve can be given te diagnese and treat

Imaging

Fer all cases, typical plain radiegraphic views {scapular

pathelegies within the glenehumeral jeint.” Ne single physical examinatien finding is cempletely accurate fer

diagnesing a SLAP tear. It is impertant te inspect fer

shenldcr asymmetry and atrephy ef the retater cuff muscles. Iselated atrephy ef the infraspinatus can indicate the presence ef a spinegleneid cyst, which is eften

asseciated with a superier labral tear. Range ef metien and retater cuff strength must be assessed and both are

usually preserved. LHE-specific tests {such as the Speed

and Yergasen tests} can re-create sheulder pain in patients with SLAP tears. Apprehensien, relecatien, and lead-

and-sbift tests can be perfetmed te assess fer sheulder stability. Hewever, evert instability in the setting ef an

iselated SLAP tear is rare. Glenehumera] internal retatien

‘1’, AP, and axillary lateral} sheuld be ebtained te assess the jeint fer abnerrnalities. MRI is used te assess the bi—

cipital greeve, LHB tenden, fluid, and beny esteephytes and can help identify cencemitant pathelegies. Hewev— er, studies have demenstrated peer cerrelatien between

MRI and arthrescepic findings regarding LHB pathelegy and peer te mederate sensitivity fer inflammatien, par-

tial-thickness tears, and ruptures.23 Magnetic resenance

arthregraphy {MBA} is mere specific and sensitive for LHE pathelegy and SLAP tears {Figure 6} than MRI.“ MRA in patients with ne pathelegy shews the tenden

surreunded by centrast fluid and it resembles a kidney bean. Beth MRI and MBA are needed in the sagittal

eblique and axial planes because LHB snbluxatien and

dislecatien are asse-ciated with pa rtial— and full—thickness

deficit sheuld be assessed in everhead athletes; extreme

subscapularis tenden tears15 {Figure 7'}. Ultrasenegraphy is accurate and cest-effective in the

cempressien test is the mast cemrnenly used maneuver

ness tenden tears.“ The exact rele ef ultrasenegraphy

deficits greater than 25" re 30“ can predispose patients te internal impingement and SLAP tears.9 The D’Brien active

te evaluate fer a pessible SLAP tear.” Clinical examina— tien alene is unreliable in diagnesing SLAP tears when

flrdtepaedic Knewledge Update: Sperrs Medicine 5

diagnesis ef LHE dislecatien, subluxatien, and rupture. Hewever, it is net as accurate in diagnesing partial-thick-

fer the diagnesis ef tenden inflammatien has net been fully defined.

El ll] 16 American Academ1r ef Unhepaedic Surge-ens

fiajwasnra .ieddn :j

Chapter 4: Superior Lahrum and Biceps Pathology

C Figure 5

Arthroscopic images obtained Ivia the posterior portal with the patients in the lateral decubitus position {A through E} and the beach chair position {D}. A, View shows a type i superior labrum anterior to posterior {SLAP} lesion, with fraying of the superior labrum and localized degeneration {arrows}. B. View shows a type II SLAP lesion with the superior labrum and biceps anchor detached from the glenoid (arrows). C. View shows a type Iil SLAP lesion with a bucket—handle tear of die superior labrum and an intact biceps anchor. D. View shows a type

IV SLAP tear of more than Ellie diameter of the long head of the biceps tendon; the tear extends up the biceps

tendon.

Nonsurgical Treatment

same level. The nonsurgical protocol consisted of NSMDs

and a physical therapy protocol focused on scapular sta-

tation focused on improving posterior capsular flexibility

bilisation and posterior capsular stretching. The initial step for the treatment of LHB tendon pathol-

stabilizers. Intra—articular steroid injections can help in the diagnosis and treatment of patients with a possible SLAP

to correct scapulothoracic dyskinesia. Because the LHB is continuous with the synovium of the glenohumeral joint,

Honsurgical treatment of SLAP tears consists of rehabiliand strengthening of the rotator cuff muscles and scapular tear. In the only study reporting on the nonsurgical treatment of SLAP tests,” the authors found that functional

scores, quality-of-life scores, and pain scores all improved substantially in 19 patients at an average follow-up of 3.1 years; ?1% of athletes returned to preparticipation levels, but only 66% of overhead athletes returned to sport at the

El Ifllti American Academy of Urthopaedje Surgeons

ogy is nonsurgical and should encompass physical therapy

cortisone injections can also be used for initial treatment

in the subacromial space or the glenohumeral joint. Some authors have recommended a diagnostic and potentially

therapeutic corticosteroid injection in the tendon sheath

at the groove; however, this can increase the risk of LHE rupture if injected within the tendon itself. The authors of

Drthopaedic Knowledge Update: Sports Medicine .5

Section 1:1}pperExtremity

a 1011 study reported an 36.?% accuracy of injection in

treatment was unsuccessful for approximately 3 months.

therefore, ultrasonographic guide ncc was recommended.”

to compete and finish the season. Earlier intervention can be offered to those patients with evidence of suprascapular

the sheath using ultrasonography versus 26.?% without, and another 40.0% was injected into the tendon itself;

Surgical Treatment

Surgical treatment for SLAP tears should be considered in patients with persistent symptoms whose nonsurgical

High-level athletes with a SLAP tear are usually allowed nerve compression from a spinoglenoid cyst.

Arthroscopic surgery can he performed in the lateral decubitus or beach chair position. Type I tears are usually

debrided. Type II lesions should be repaired when the

history and examination suggest a SLAP tear and the arthroscopic examination confirms findings of a type II

tear {Figure 3}. The gold standard for the diagnosis of SLAP tears on arthroscopic examination uses the Snyder

criteria. This includes separation of the chondrolabral 1: Upper Extremity

junction, erythema at the LI-IB anchor junction, and a

minimum 5 mm of labral excursion.1 Degenerative type II tears associated with other lesions in older patients do not

require repair but can he better addressed with debride— ment, tenodesis, or tenotomy. Type III tears are treated

with either repair of the bucket handle or, depending on

size and tissue quality, a resection of the unstable labral

fragment and repair of the MGHL if it is attached to the torn fragment. Treatment of type IV tears depends on the

patient age and the extent of LHE tendon involvement. If less than 30% of the tendon is involved, these tears are

usually treated with debridement. Tears of more than

3fl% of the LI-IB tendon are usually treated with LHE

tenodesis. Although some studies have suggested superior

Iabral ring repair, what to do with the remaining poten-

tially unstable superior labrum after tenodesis remains Figure 6

Figure I"

Coronal T1—weightecl magnetic resonance arthrogram of the shoulder shows a labral tear [a rrows} on the superior aspect consistent with a superior labrum anterior to posterior tea r.

controversial.29 Eioabsorbable tacks are no longer used because of concerns about synovitis and cartilage damage caused by the

degradation and release of loose bodies.” SLAP repair

Axial TEE-weighted magnetic resonance arth rog rams demonstrate an empty bicipital groove. The biceps tendon can be seen medial to the groove {arrows}. indicating a subscapularis tear [asterisk in A).

flrfltopaedic Knowledge Update: Sports Medicine 5

El ll] 16 American AcadMy of Drthopaedic Surgeons

Segment; saddn :1

Chapter 4: Superior Lahcum and Biceps Pathology

Figure B

Arthroscopic views demonstrate a type Ii superior labrum anterior to posterior (SLAP) tear with posterior

extension via the posterior portal, with the patient in the lateral decuhitus position. A. Probe inserted via the anterior portal. B. The sutures are passed via the anterosu perior portal around the tea r. E. The repaired SLAP tear.

failure is not limited to the use of hioahsorahle tacks. A

tenodesis and rotator cuff repair have shown superior

SLAP repair, has been reported.“ Revision surgery and failure after index SLAP repair correlated with the use of

combined.5M Data suggest that the rate of SLAP repairs is increas-

ganglion cysts associated with SLAP tears can success fully be treated arthroscopically:u The authors of a 1014

464% increase in the number of SLAP repairs from Zflfll to Zflifl.” The authors of a EDIE study found that the

tenodesis for a failed repair of type II SLAP tears in a mili— tary population.M An 31% return to spurt and active duty

of li'Ciirthopaedic Surgery candidates was three times the in— cidence reported in the current literaturefifi A substantial

reoperation rate of 6.3%, with a 4.3% rate of revision absorbable poly-L-D-lactic acid suture anchors. Paralabral study examined patients who underwent open subpectoral

was reported. LHB tenodesis is a predictable, safe. and

effective treatment of failed arthroscopic SLAP repairs. Concomitant repair of rotator cuff tears and SLAP tears have shown good clinical outcomes with high pa-

tient satisfaction. In patients 5i} years and older with a degenerative SLAP tear, a combined LHB tenotom}.r or

Eb Ifllti American Academy of Urthopaedic Surgeons

outcomes compared with rotator cuff and SLAP repair ing. A statewide database study in New York reported a

percentage of SLAP repairs reported by American Board

increase in the number of SLAP repairs was also noted

in a database study.“ The authors noted that this trend is slightly worrisome given the relatively high number of SLAP repairs performed. Most studies have reported on the outcomes of patients treated for type II SLAP tears. Pain relief and return of

Drrhopaedic Knowledge Update: Sports Medicine .5

Section 1:1}pperExtremity

function can he expected after SLAP repair. However,

distal fixation; and multiple types of fixation constructs.

one study reported 9?% good to excellent clinical results and an 34% rate of return to sport in 132 patients treated

in the proximal intra-articular and middle intragroove portions in all 36 cases and up to the distal extra-articular

retuni to sports is often less predictable. The authors of with suture anchors for SLAP repair.“ flther studies have

portion in 29 {3 0.6%}.‘? Therefore, su bpectoral tenodesis

91%. Long—term outcomes after isolated SLAP repair

as superior to other techniques. It was demonstrated in

reported 90% to 94% good to excellent results, with return to preinjury athletic levels ranging from ?5% to were found to be independent of patient age, with 33%

was optimal for these patients. However, no clinical outcome studies have demonstrated any tenodesis technique

reporting good or excellent results at 5-year follow-up.~“"l'41

a 2313 study that the open subpectoral approach placed the tenodesis tunnel 2.1 cm distal to the arthroscopic su-

independent of patient vocation or sport.“1 The authors of a 2014 study reported prospective clinical outcomes of

placed the tenodesis tunnel distal to the bicipital groove, which may allay concerns about the bicipital groove as a

tive patients.” The study showed substantial improvement in shoulder outcomes. A reliable return to preinjury level

study, there were no significant differences in clinical

The authors of a 2010 study also reported favorable results

1: Upper Extremity

The authors of a 2015 study fou ud degenerative changes

arthroscopic treatment of type II SLAP tears in young, ac—

prapectoral approach.‘13 However, both of these techniques source of pain after this procedure. According to a 2.314

of activity was less predictable: a 3?% failure rate and a

outcomes when comparing arthroscopic suprapectoral and open subpectoral LHE tenodesis with a minimum

36 years. It has been reported that S?% of patients had

interference screw fixation for subpectoral tenodesisfgd"

23% revision rate were reported. In addition, an increased relative rislc of failure was reported for patients older than

2-year follow-up.” No difference was found regarding failure of fixation type when comparing unicortical and

an unsatisfactory result and 9% to 55% were unable to return to prior activity levels.“ Given these findings, the

Substantially less displacement was found during cyclic loading for the interference screw compared with the

The optimal surgical treatment of LHB tendon pa-

toral and open subpectoral LHB tenodesis techniques using an interference screw implant in a cadaver model

exists regarding LHB tenodesis compared with an LHB tenotomy.“ An increased incidence of cosmetic deformity

LHB and has a substantially decreased ultimate load to failure compared with the open technique“1 {Figure 9}.

reported outcomes after primary SLAP repair have some inconsistencies.

thology remains controversial. No definitive consensus {Popeye deformity} in LHE tenotomies was found when compared with LHB tenodesis (43% versus 3343.}:*6 For

postoperative bicipital pain, similar results were found in

the tenodesis group compared with the tenotomy group {24% versus 9%}.

Current indications proposed for LHB tenodesis in-

unicortical button.“ However, arthroscopic suprapece

were compared; arthroscopic tenodesis overteusioued the In the future, studies should define when a tenodesis is

indicated, along with the position and type of fixation used when performing an LHB tenodesis. Summary

clude degenerative SLAP tears, high-grade SLAP tears,

The treatment of SLAP tears and Ll-IB pathologies re

active, patients concerned with cosmesis, and workers’

compensation cases.‘H Relative indications for tenodesis

examination of a SLAP tear or symptomatic LHB tendinopathy is often challenging because the findings are

luxation of the LHE tendon, an hourglass {hypertrophy}

ly accurate for the diagnosis of a SLAP tear. MRA helps

failed SLAP repairs, those patients who are reasonably include a tear of 25% or more of the tendon, longitudinal tears that decrease gliding in the bicipital groove, sub-

mains controversial. The clinical diagnosis and physical

similar to the other pathologies within the glenohtuneral joint. No single physical examination finding is complete-

LHB,“ disruption of the sling, or if a concomitant sub—

diagnose LHB pathology and SLAP tears because it is

age and activity level. as well when deciding to perform tenodesis. IEither proposed relative indications include a

41:] years and if they are not associated with a rotator cuff repair. The ideal treatment of LHB pathology is also still

failed SLAP repair, a type I'lvF SLAP tear, and LHB tendi— nitis pain for which conservative management has failed.”

able treatment options, but the literature has not clearly demonstrated which surgery is superior. Several types of

scapularis tear is present.11 However, the surgeon must also consider the characteristics of the patient, such as symptomatic type II tear in a patient older than 50 years, Among LHB tenodesis procedures, no technique is

clearly superior. Tcuodcsis techniques include arthro— scopic, mini-open, and open procedures; proximal versus

flrtltopaedic Knowledge Update: Sports Medicine 5

more specific and more sensitive than MRI. SLAP repairs have had more beneficial results in patients younger than

evolving. Both tenotomy and LHB tenodesis are accept-

tenodesis surgeries can he performed and the literature

has not identified which is optimal. Future research is needed to help identify the best treatment options.

El 1316 American AcadMy of Unhopaedic Surgeons

AllL-UEUHE Jeddn :1

Chapter 4: Superior Lahnim and Biceps Pathology

‘

F

I

L I

I y {‘5' Tfe' II

Figure 9

..

j

'

i.

--r, 'I_' ‘_ .

-

l *-

l_:i-::

I

-.s. I“ . .- .

.

»_

I

I .l

H

II.

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

Key Study Points

1‘ SLAP repairs have proved more beneficial than tenodesis in patients younger than 40 years and

may be even more successful if not associated with rotator cuff repair. No clear advantage has been reported when comparing LHE tenodesis and tenotomy. An increase of Popeye deformities is seen with tenotomies. Howev—

er, current indications proposed for LHB tenodesis include patients with high levels of physical activity, patients concerned with cosmesis, and workers”

compensation cases.

Annotated References . Andrews JR, Ea rson WC; Jr, McLeod W1): Glenoid labrnm tears related to the long head of the biceps. Am I Sports Med 1935;13[5}:33T-341. Medline DUI . Snyder S], Kari-tel RP, Del Pizzo W, Feritel RD, Friedman M]: SLAP lesions of the shoulder. Arthroscopy 199D;E{4}:2?41?"). Medline DUI . Cooper DE, Arnoczlty 5P, G'Bfififl 5], Warren RF, DiCarlo E, Allen AA: Anatomy, histology, and vasculari of the glenoid lahrurn. An anatomical study. I Bone Joint Snrg

am 1991;?4{1]:4E-52. Medline

arthroscopic fixation, in which the tendon remains in the bicipital groove, or the tendon can be fixed

. Tuoheti Y, Itoi E, Minagawa H, et a]: Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohunieral ligaments. Arthroscopy 1fl05;21{1fl]:1142-1149. Medline DUI

in clinical outcomes when comparing arthroscopic suprapectoral and open subpectoral LHB tenodesis.

. Rao AG, Kim TK, lChronopoulos E, McFarland EG: Anatomical variants in the anterosuperior aspect of the glenoicl labruni: A statistical analysis of seventy—three cases. J Bone joint Surg Am lflfl3;35-A{4}:553 659. Medline

Different tenodesis techniques include proximal distally so it is removed from the groove. The location of tenodesis has shown substantial differences

Eb Ifllti American Academy of flrfliopaedic Surgeons

Drrhopaedic Knowledge Update: Sports Medicine .5

Sectien 1:1}pperExtremity

Werner A, Mueller T, Beehm D, GehIl-te F: The stabilizing sling fer the lung head ef the biceps tenden in the retater cuff interval: A histeanatemic study. Am ] Sperts Meal 2flflfl;28[1}:23-3L Medline Alpantalci K, McLaughlin D, Karagegees D, Hadjipavleu A, Kentakis G: Sympathetic and sensery neural elements in the tendeu ef the leng head ef the biceps. j Bette jeint Surg Am 2Dfl5;32{2l:153l}-1533. Medline DUI

This review article described arth rescepic and epen biceps tenedesis techniques; beth shew premising results. Level ef evidence: V.

Cheng NM, Pan WE, 1ll’ally F, Le Rena: CM, Richardsen

IS. U’Brien S], Pagnanwi M], Fealy S, McGlynn SR, 1li'lll'ilseu JB: The active cempressien test: A new and effective test fer diagnesing labral tears and acremieclavicular jeint ab— nermality. Am I Sperts Med 1993;26l5hi‘ilfl-SI 3. Medline

This cadaver study feund that the regien ef hypevascularity eene fer the LI-IB tendeu {via injectien with either a radi-

15". Parentis MA, Gleusman RE, Mehr KS, Yecutu LA: Au evaluatien ef the prevecative tests fer snperier labral anterier pesterier lesiens. Am I Sperts Med 2Dfld;34{2]:255-263. Medliue DUI

cm frem the tenden erigin, extending frem midway threugh the glenehumeral jeint te the presimal intertubercular greeve. Altheugh this was feund te be a vital reasen fer tendeu rupture, mechanical facters alse play an imp-ertant rele. Level ef evidence: IV.

2B. Ceelt C, Beaty S, Kissenberth M], Siffri P, Pill SG, Hawkins R]: Diagnestic accuracy ef five erthepcdic clinical tests fer diagnesis ef snperier labrum anterier pesterier [SLA P} lesiens. J Sheafdsr Elbmv Sarg 2012:21{1]:13-22. Medline DUI

Keener JD, Brephy RH: Superier labral tears ef the sheulder: Pathegenesis, evaluatien, and treatment. I Am Aced Urtbep Snrg 2009;12flflhfi22- 53?. Medline

This study analysed five clinical tests fer SLAP lesien diagnesis. The Biceps Lead II test demenstrated efficacy fer diagnesing SLAP-enly lesiens. The results had a pesitive predictive value ef 26 {95% ceniidence interval [CI]: 13—31], negative predictive value ef .93 {95% CI: 34-92}, pesitive

MD: The arterial supply ef the lung head ef biceps tendeu: Anatemical study with implicatiens fer tendeu rupture. Gifts Aunt 201 U;23I{E):633-592. Medline DUI

epaque lead esidei'milk mixture er India ink} was 1.2 te 3.0

1: Upper Eatrem ity

1?. Nhe S], Strauss E], Leuart EA, et al: Leng bead ef the biceps tendinepathy: Diagnesis and management. I Am Acud Urtbep Surg 2B1ii;13i11}:645— 656. Medline

This review discussed the advances in surgical techniques fer secure SLAP injuries repair. This is supperted by re-

cent eutcemes demenstrating geed functieual results and

an acceptable rate ef return te athletic activities. Level ef

evidence: V.

Ii}. Burkhart SS, Mergan CD, Kibler WE: The disabled threw-

ing sheulder: Spectrum ef

thelegy. Part I: Patbeanate-

my and biemechanics. Art rescepy 2flfl3;19{4}:4i}4-42D. Medliue DUI

likeliheed ratie ef 1.? {95% |IEI: 1.1-2.6}, and negative lilce-

liheed ratie ef 0.39 [95% ISI: 0.14-0.91}. Ne ether tests demenstrated diagnestic utility fer SLAP lesien diagnesis, including these with cencemitant diagneses. Lewl ef evidence: III.

21. Sethi N, Wright 11, Tamagucbi K: Diserders ef the lung head

ef the biceps tenden. I Sbeufder Eibete Strrg I 999$ [51:644 -

654. Medline DUI

11. Hitchceck HH, Bechtel CU: Painful sheulder: |Dbservarieus

22. Heltby IL, Rasmjeu H: Accuracy ef the Speed’s and ‘fer-

brachii in its causatien. ] BDHE jeini Surg Am 1943;30AiE}:263—223. Medline

sieus: Cemparisen with arthrescepic findings. Arifvrescepy 2flfl4;2fl[3]:231-23ti.Medline DUI

en the rele ef the tendeu ef the leng head ef the biceps

I2. Seabe I, Beileau P, Walch G: The presimal biceps as a pain generater and results ef tenetemy. Sperts Med Artbresc 2flflfifldfilflflfl-Iflfi.Medline DUI 13. Ahrens PM, Beileau P: The leng head ef biceps and asseciated tendinepathy. ] Beac jeiat Sarg Br 2flfl2:39[3}:10i}1Ii] [19. Medline DUI 14.

Patten WC, McCluskey GM III: Biceps tendinitis and sublustatien. Cfin Sperts Med 2flfl1;2fl(3}:5fl5-529.

Medliue DUI

15. Lafesse L, Reila nd Y, Baier GP, Teussaint B, Jest B: Aute-

rier and pesterier instability ef the lung head ef the biceps

tena in retater cuff tears: A new classificatien based en arthrescepic ebservatiens. Artivrescepy 2flfl2;23{1}:23-3fl. Medline DUI

1-6.

Maffet MW, ISartsman GM, Meseley B: Superier la-

brum-biceps tenden cemplesc lesiens ef the sheulder. Am I Sperts Med 1995;23il}:93-93. Medliue DUI

Urdtepaedic Knewledge Update: Sperts Medicine 5

gasen‘s tests in detecting biceps pathelegy and SLAP le-

23. Mehtadi HG, Vellet AD, lClark ML, et al: A prespective, deuble-blind cemparisen ef magnetic resenance imaging and arthrescepy in the evaluatien ef patients presenting with sbeulcler pain. }' Sbealder Eibew Sarg 2flfl4:13[3]:253265. Medline

D-UI

24. Pfirrrnann CW, Zanetti M, 1|iii-"'eishaupt D, Gerber C, Hedler J: Subscapularis tendeu tears: Detectien and grading at MR arthregraphy. Rediefegy 1999;213l3}:2fl9v214. Medline DUI 25. Gambill ML, Melegne TS, Prevencher MT: Dislecatien ef the leng head ef the biceps tendeu with intact subscapularis and supraspinatus tendens. __I Sbeuider Eibew Sarg 2Dfld;15{£]:e2D-e22.Medline

DUI

2d. Wall LB, Teefey SA, Middleten 1WD, et al: Diagnestic perfermance and reliability ef ultrasenegraphy fer fatty

degeneratien ef the retater cuff muscles. 1' Benejeiat Ssrrg Am 2012;94{12}:e33. Medline DUI

El 2016 American Academy ef Urthepaedic Surge-ens

Chapter 4: Superior Labrum and Biceps Pathology

This study analyzed diagnostic performance and reliabilit

of nltrasonography for fatty degeneration of the rotator f muscles by comparing it with MRI. Ultrasonography can be used as the primary diagnostic modality. The agreement between MRI and ultrasonography was substantial for the supraspinatus and infraspinatus {It = [US and 0.?1, respectively} and moderate for the teres minor {11: = 0.437}.

Lew] of evidence: 11.

2?. Edwards SL, LeejA, Bell, et al: Nonoperative treatment

of superior lahrum anterior posterior tears: Improvements

in pain, function and quality of life. Am I Sports Med 201B;SS{?}: 14515-1451. Medliue DUI The outcomes of nonsurgical treatment of SLAP tears in 39 patients were analysed. Honsurgical treatment can he trialed in patients with an isolated superior lahral tear. Uverall, mean American Shoulder and Elbow Surgeon

scores increased from 53.5 to 345', Simple Shoulder Test

scores increased from 3.3 to 11.1}, and visual analog scale pain scores decreased from 4.5 to 2.1. In overhead athletes end in those patients where pain relief and functional improvement is not achieved, surgical treatment should be

considered. Level of evidence: IV.

ES. Hashiuchi T, Sa lturai G, Morimoto M, Komei T, Taltaltura Y, Tanalta Y: Accuracy of the biceps tendon sheath injection: Ultrasound-guided or unguided injection? A randomized controlled trial. I Shoulder Elbow Surg 2011;2[liflflildfl— 1013. Medline

DUI

This study analyzed the accuracy of ultrasonographically guided or unguided biceps tendon sheath injection in 30 patients. Injection into the LHB tendon sheath is more accu-

rate under ultrasonographic guidance. Level of evidence: 11.

29. Chalmers PH, Tromhley It, Cip J, et al: Postoperative res— toration of upper extremity motion and neuromuscnlar control during the overhand pitch: Evaluation of tenodesis and repair for superior labral anterior-posterior tears. Am I Sports Med 2014:42i12}:ESES-ESSS. Medline DUI This study evaluated shoulder motion in overhand pitch— ers after biceps tenodesis and SLAP repair in 13 patients. SLAP repair and biceps tenodesis can restore physiologic neuromuscnlar control, but pitchers who undergo SLAP repair may have altered thoracic motion when compared

with control patients. Level of evidence: IV.

SD. Sassmannshausen G, Sultay Ivi, Mair SD: Broken or dislodged poly—L4actic acid bioabsorbable tacks in patients after SLAP lesion surgery. Arthroscopy Zfifldtllldltdlfi619. Medline DUI

superior lahral anterior posterior repairs. A111] Sports Med 2014;41j4}:320-325.Medline

DUI

This study prospectively evaluated revision biceps tenod-

esis after failed arthroscopic repair for type II SLAP tear. Most patients obtained good to excellent outcomes using validated measures with a substantial improvement in range of motion. Level of evidence: IV.

34. Franceschi F, Longo LTU, Rustini L, Ritcello G, la ffulli N, Denaro 1'1": Ho advantages in repairing a type II superior labrum anterior and posterior {SLAPJ lesion when associated with rotator cuff repair in patients over age 5D: A randomized controlled trial. A111] Sports Med lflflS;SE{1}:14?-ESS. Medliue DUI 35. Unyeltwelu I, Khatih U, clterman JD, Roltito AS, Kwon YW: The rising incidence of arthroscopic superior Iabrum

anterior and posterior {SLAP} repairs. J Shoulder Elbow Surg 2D12;21{S}:?23-?31. Medline

DUI

The study analysed the increase of arthroscopic SLAP re-

pairs in New York state from 20111 to 201D. Substantial increases in the number of arthroscopic SLAP repairs {464%} and in the age of patients treated with ard'troscopic SLAP repairs were noted. Level of evidence: V.

SS. Weber SC, Martin DF, Seiler JG III, Harrast J]: Superior lahrum anterior and posterior lesions of the shoulder: Incidence rates, complications, and outcomes as reported by American Board of Urthopedic Surgery. Part II: candidates. Am J Sports Med lfl]1;4D{7j:1533-1543. Medline DUI A database of cases was examined for board certification

on the demographics of SLAP lesion repair. A concerning

number of repairs was noted in middle-aged {9.4% of all shoulder cases, increased to 111.1% in EMS} and elderly patients and emphasized the importance of educating orthopaedic surgeons to appropriately recognise and treat

symptomatic SLAP lesions to reduce the rate of SLAP repairs. Level of evidence: III.

3?. Zhang AL Kreulenf:,Ngo SS, Hame SL ,Wang JC, Gamradt SC: Demographic trends In arthroscbpic SLAP rcpair

in the United States. A111 ,1 Sports Med 2fl12-,4fl[5}: 11441141 Medline

DUI

Demographic trends in arthroscopic SLAP repairs were

examined. From 2004 to 2009, the findings show substantially more arthroscopic SLAP repairs were performed each year, with the highest incidence rates in the 211- to 29-year— olds {2 9.1 per 111,013 El} and Afl- to 49-year-olds {27.3 per ID,fl{lfl}I and in men. Level of evidence: ‘1’.

311. Pa rlt l'vi], Hsu JE, Harper U, Sennett B], Huffman GR: Poly-LfD-lactic acid anchors are associated with reoperation and failure of SLAP repairs. Arthroscopy Efll1:2?{1fl}:13351341}. Medline DUI

SS. Morgan {3D, Eurkhart SS, Palmeri M, Gillespie M: Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. A1I'tfsrosr.".op}r

33. Abboud JA, Silverherg D, Glaser DL, Ramsey IvIL, 1|i'l'i'illiams UR: Arthroscopy effectively treats ganglion cysts of the shoulder. Clio Urtfaop Relat Res lflflfit444f44411129-133. Medline DUI

35'. Sch render GP, Sitare U, lISrjengedal E, Uppheim G, Reikeras U, Bron JI: Long-term results after SLAP repair: A 5-year follow-up study of If}? patients with comparison

33. McCormick F, Nwaclmltwu BU, Solomon D, et al: The efficacy of biceps tenodesis in the treatment of failed

4D Ifllti American Academy of Urthopaedie Surgeons

1393;14f5}:553-555.Mcdlinc

DUI

of patients aged over and under 40 years. Arthroscopy 1fl12;23{11}:16fl1-Ifii}1Medline DUI

4D. Ide ], Maeda S, Taltagi IL: Sports activity after arthroscopic superior labral repair using suture

Urrhopaedie Knowledge Update: Sports Medicine 5

E "fl 1]

g F”

ii 3.

fit

a!

Section 1:1}pperExtremity

anchors in overhead-throwing athletes. Am J Sports Med 2005;33l4l:5fl?r514.Medline DUI 41. Kim SH, Ha KI, Kim SH, |IEhoi H]: Results of arthroscopic treatment of superior labral lesions. j Bone JIor'nt Sntg Ant 2flfl2;S4-A{6}:SSl-SSS. Medline 42. Friel NA, Karas V, Slabaugh MA, Cole E]: Gutcomes of type II superior labrum, anterior to posterior {SLAP} repair: Prospective evaluation at a minimum two—year follow-up. J Shoulder Elbow Sarg 2010;19l6}:SSS-36?. Medline DUI

1: Upper Extremity

The outcomes of SLAP II lesion repairs via bioabsorbable sutures were examined. At an average 3.4-year follow-up, this type of suture anchor provided a significant improvement in functional capacity and pain relief {mean American Shoulder and Elbow Surgeon scores improved from

59.49 to 33.32; mean Simple Shoulder Test scores improved from 2.23 to 19.20; visual analog scale 3.93-1.52}. Level

of evidence: IV.

43. Provencher MT, McCormick F, Dewing C, McIntire 5, Solomon D: A prospective analysis of 129 type 2 superior labrum anterior and posterior repairs: Clurcomes and factors associated with success and failure. An: I Sports Med 2fl13;41[4]:SSD-SS6.Medline [ID]

This prospective analysis of SLAP I] repairs in 1?? patients

examined factors associated with success and failure and found a 37% rate of returning to previous athletic activity

and a 23% rate of failure. Patients aged 36 years and older

have higher risk of failure. Level of evidence: III.

44.

Kate LM, Hsu S, Miller SL, et al: Poor outcomes after SLAP repair: Descriptive analysis and prognosis. Arthroscopy

lflfl9515{3}:349-355. Medline not

This study examined failed SLAP repairs in 39' patients {41“.} shoulders}. After revision, 32% of patients still had suboptimal results. Conservative treatment resulted in poor outcomes {21% of patients: mean patient age, 43 years} after

failed repair. Level of evidence: V.

45. Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Each

ER: Biceps tenotomy versus tenodesis: A review of clinical outcomes and biomechanical results. J Shoulder Elbow Stu-g 2611;20l2}:326-332. Medline DUI

This review compared biceps tenotomy and tenodesis for biceps tendon rupture from 1966 to 2010. Higher cosmetic deformity and lower load to tendon failure were found in patients who underwent tenotomy {40%}. Level of evidence: V. 46. Slenlter NR, Lawson K, Ciccotri MG, Dodson CC, Cohen SE: Biceps tenotomy versus tenodesis: Clinical outcomes.

Arthroscopy sorenempsrs-sss. Medline not

This systematic review analyzed clinical outcomes of biceps tenodesis versus tenotomy and found that tenotomies result

tenodesis: The subpectoral portion as the optimal tenodesis site. Am I Sports Med 2flIS;43[I}:63r63. Medline DUI This study examined the optimal tenodesis site by analyzing

the extension and delamination of extra-articular lesions in

the retrieved biceps after subpectoral biceps tenodesis in 36 patients. Lesions were observed beyond the bicipital groove,

extending to the distal extra—articular portion {313%}. The

subpectoral portion may be the optimal tenodesis site. Level of evidence: IV. 4E. Johannsen AM, Macalena JA, Carson ESV, Tompkins M:

Anatomic and radiographic comparison of arthroscopic

suprapectoral and open subpectoral biceps tenodesis sites. Art: I Sports Med 2H13;41[I2]:2919-2924. Medline DDI

The authors conducted anatomic and radiographic evaluation of arthroscopic and open subpectoral biceps tenodesis. In 20 specimens, the open subpectoral approach placed the tunnel 2.2 cm distal to the arthroscopic suprapectoral

approach. Thus, patients undergoing the arthroscopic su-

prapectoral approach may still have postoperative bicipital groove pain. Level of evidence: V. 49. Buchhols A, Marretschléiger F, Siebenlist S, et al: Biome-

chanical comparison of intramedullary cortical button fixation and interference screw technique for subpectoral biceps tenodesis. Arthroscopy 2GlS;29I{S}:S4S-SSS. Medline DUI

This study analysed intramedulla ry cortical button fixation and interference screw technique for subpectoral biceps

tenodesis. Intramedullary cortical button fixation showed

no failures during cyclic tcsting; however, a 30% failure rate

was reported for screw fixation. Cortical button fixation provides an alternative technique for subpectoral biceps tenodesis with comparable and, during cyclic loading, even superior biomechanical properties to interference screw

fixation. Level of evidence: V.

Si]. DeAngelis JP, Chen A, Wexler M, et al: P-iomechanical characterization of unicortical button fixation: A novel technique for proximal subpectoral biceps tenodesis. Knee Sarg Sports Tranmatol Arthrosc EMS. [Epub ahead of print] Medline

This study analyzed mechanical properties of unicortical

metal buttons and interference screws in proximal biceps tenodesis in six pairs of fresh-frozen shoulders. The ultimate load to failure and stiffness for both methods were the same. A unicortical button provides a reliable alternative method of fixation with a potentially lower risk of postoperative humeral fracture and a construct that permits early mobilieation following biceps tenodesis. Level of evidence: IV.

51. Werner BC, Evans CL, Holegrefe RE, et al: Arthroscopic suprapectoral and open subpectoral biceps tenodesis: A comparison of minimum 2—year clinical outcomes. Am 1' Sports Med 2fl14t42[11}:2533-259fl. Medline DC]

in cosmetic deformities {43%} more often than tenodesis.

This cohort study compared open subpectoral {32 patients} and arthroscopic suprapectoral {fill patients} biceps tenod-

versus tenodesis for the treatment of LHE lesions. Level of evidence: V.

excellent clinical and standardized outcomes: no clinical

No consensus was reported regarding the use of tenotomy

4'2. Moon SC, Cbo NS, Rhee TC: Analysis of “hidden lesions“ of the extra-articular biceps after subpectoral biceps

Drthopaedie Knowledge Update: Sports Medicine 5

esis at a minimum 2-year follow-up. Both groups had differences were seen in clinical or standa rdized outcomes. Level of evidence: III.

El 2016 American AcadMy of Urthopaedie Surgeons

Chapter 5

Adhesive Capsulitis, Cartilage Lesions, Nerve Compression

Disorders, and Snapping Scapula Joshua A. Greenspoon, BSc

Peter I. Millett, MD. MSc

Abstract

The most common shoulder pathologies in sports medi-

Introduction

llfi‘rlenohutneral instability, rotator cuff tears, pathologies

and acromioclavicular joints, and tears of the long head

of the long head of the biceps tendon, and instability of the acromioclavicular joint represent most shoulder disorders.

stiffness, focal chondral lesions, neural compression, and pathologies of the scapulothoracic joint can cause

defects, suprascapular nerve entrapment, and snapping scapula syndrome are less common, they can cause sub-

adhesive capsulitis, cartilage lesions, nerve compression

of these pathologies is necessary to establish the proper diagnosis. flpen and arthroscopic surgical treatments

cine are rotator cuff tears, instability of the glenohnmeral

of the biceps tendon. However, other disorders such as

pain and loss of function for patients. It is important to be cognizant of the current concepts for treatment of

disorders, and snapping scapula syndrome for optimal outcomes.

Keywords: adhesive capsulitis: cartilage lesions;

nerve compresslon disorders: suprascapular nerve entrapment: snapping scapula

Although disorders such as adhesive capsulitis, chondral

stantial disability in patients. Comprehensive knowledge

can be used to manage these disorders. Clinical outcomes

studies have primarily been conducted as case series {level IV evidence}; comparative studies are challenging because

each entity is relatively rare. However, good to excellent

results can be achieved with appropriate patient selection and surgical technique. Adhesive Capsulitis

Adhesive capsulitis, commonly lrnown as frozen shoulu

der, is characterised by spontaneous onset of pain and progressive restriction of shoulder movement. A cascade

of inflammation involving abnormal tissue repair and

Dr. Petri or an immediate family member has received nonincome support (such as equipment or services), com-

mercially derived honoraria. or other non-research-reiated

funding {such as paid travel} from Arthreir. Dr. Miliett or an immediate family member has received royalties from Arthrerr; serves as a paid consuitant to Arthrerr and MYtJS; has stock or stock options held in Game Ready and Vuivtedi: and has received research or institutional support from

Arthrerr, (Tissue Siemens. and Smith a Nephew. Neither Mr:

Greenspoon nor any immediate family memhm has received anything of value from or has stock or stock options held

in a commercial company or institution related directly or indirectly to the subject of this chapter.

@ lfllfi American Academy of Drthopaedic Surgeons

fibrosis modulated by abnormal production of growth factors and cytoltines is pathogenetic.1~l Adhesive capsulitis can be idiopathic in origin {pri-

mary} or occur secondary to systemic diseases such as cliabetes mellitnsi or hypothyroidism. Additional secondary

causes include previous trauma or an rgery.‘ Breast cancer

treatment with surgery and radiotherapy has also been linked to the development of adhesive capsulitis.5 The

condition is generally self-limiting; however, it often has

a prolonged course, ta king more than 2 years to resolve.‘ The diagnosis for primary adhesive capsulitis is usu-

ally established by sudden onset of pain without history of major trauma, infection, or surgery of the affected

shoulder, combined with a global limitation of both active

Orthopaedic Knowledge Update: Sports Medicine 5

humans; .raclcln :j

Maximilian Petri. MD

Section 1:1}pperExtreenity

and passive range of motion. Similar findings apply for

pain relief were reported in 1?! patients who underwent

vious trauma or surgery or medical disease. Differential diagnoses include calcific tendinitis, glenohumeral and

contrast material and lidocaine.” This approach provides both a therapeutic and diagnostic intervention in

secondary adhesive capsulitis, but with a history of pre—

acromioclavicular osteoarthritis, rotator cuff tendinopa—

thy or tear, and lesions of the long head of the biceps tendon. Imaging modalities such as radiography, MRI, and ultrasonography should support the clinical diagnosis."5

Nonsurgical Treatment

Nonsurgical management should be recommended to patients initially; reported success rates range from ?D% 1: Upper Extremity

to 90%.? Adhesive capsulitis is commonly treated with

physical therapy and exercise in primary cases. A recent

randomised controlled trial found that group exercise classes for physical therapy achieved substantially higher Constant and Oxford Shoulder scores than both individ— ual physical therapy sessions with a therapist and home exercises completed by the patient alone.til

treatment with distension arthrography using radiopaque

depicting rotator cuff tears by extrusion of the contrast

agent. A recent randomised controlled clinical trial found no difference in outcomes between ultrasonographically

guided posterolateral capsular distension and fluoroscop-

ically guided anterior capsular distension.” Differences between corticosteroid ancl hyaluronate

injections in patients with adhesive capsulitis were in-

vestigated in a randomised clinical trial.“' Both groups

demonstrated improvements in clinical outcomes scores and range of motion, however no significant differences

were found between the two groups. Nonsurgical treatment of adhesive capsulitis conuuonly

consists of manual therapy and exercise, often with the

addition of NSAID s. Corticosteroid injections and disten-

sion arthrography can effectively improve patient pain,

NSAIDs and corticosteroid injections have proved to

satisfaction, and range of motion, but is associated with

nonsurgical management for at least I5 months before

poreal shockwave therapy, and pulsed radiofrequency

be useful adjuncts to therapy? Calcitonin has also been suggested as an adjunct therapy. Patients should attempt considering surgical intervention.""”

Electrotherapy, Extracorporeal Shock Wave Therapy,

the inherent risks of invasive procedures such as bleeding, infection, and nerve damage. Laser therapy, extracorstimulation of the suprascapnlar nerve can be considered if standard nonsurgical treatments fail.

Electrotherapy aims to reduce pain and improve func-

Surgical Treatment If nonsurgical management fails to relieve symptoms,

and thermal energy into the body. Two recent Cochrane reviews-“1 found no evidence regarding the addition of

alleviate pain. For surgical intervention, regional anesthesia with an interscalene nerve catheter is particu-

and Suprascapular Nerve Stimulation

tion by means of an increase of electrical, sound, light, pulsed electromagnetic field therapy and other electrothers

apeutic modalities to the standard regimens of manual therapy and exercise, corticosteroid injection, or NSAIDs.

However, low~level laser therapy combined with exercise

appeared to be more effective than exercise alone for pain and function.” In a recent randomised clinical trial of 36

surgical treatment can improve range of motion and

larly important postoperatively. This allows aggressive

physical therapy with aggressive rangerofrmotion and

stretching exercises.‘

Manipulation under anesthesia {MUM is often com-

bined with local anesthetic and corticosteroid injections,

to substantially improve pain and range of motion.‘1 Given that the suprascapnlar nerve accounts for 713%

and good results have been reported? However, because MUA does not allow a controlled release of adherent tissues, this procedure is associated with the risk of humeral fractures and labral and rotator cuff tears.‘

stimulation of the suprascapnlar nerve guided by ultra— sonography represents a new therapeutic approach. This

the treatment of adhesive capsulitis, particularly the extent of capsular release.“HF Ho benefit has been proved

therapy provided better and faster pain relief and im— proved passive range nf motion compared with physical

releases compared with anterior capsular release sinned-"d“ The contractnres of the coracohnmeral ligament and ro-

patients, extracorporeal shock wave therapy was shown

of shoulder capsule sensitivityfir'“ pulsed radiofreqnency suprascapnlar nerve stimulation combined with physical therapy alone.”

Distension Arthro-graphy Arthrographic joint distension with corticosteroids and

saline improves patients’ pain, satisfaction, and active range of motion?!” Improvements in range of motion and

flrfltnpaedic Knowledge Update: Sports Medicine 5

Various surgical techniques have been suggested for

with combined anterior, inferior, and posterior capsular tator interval must be treated. Most shoulder specialists

advocate for selective capsular release, starting anteriorly and with the rotator interval. If the shoulder is still right, posterior and inferior releases are performed. Extra-ar-

ticular releases also can be performed, particularly in secondary adhesive capsulitis.

El ll] 16 American AcadMy of Drthnpaedic Surgeons

Chapter 5: Adhesive l'Iiapsulitis,I Cartilage Lesions, Nerve Compression Disorders, and Snapping Scapula

The authors of a 2014 study compared arthroscopic

capsular release and subacromial decompression with

can provide symptomatic pain relief. However, these procedures do not restore cartilageEl-il"MET

surgical treatments substantially improved glenohumeral

Repa rative Treatment Microfracture has been performed in the shoulder with

subacromial decompression combined with MUA and selective arthroscopic capsular release and reported that all range of motion.” No substantial difference was found between the techniques.

good success. The hyaline cartilage of the humerus is 1.2 to 1.3 mm thick at the center, thinning to 1.0 mm in the

and without diabetes at 2-year follow-up were prospectively comparedfi Both groups had substantial improve-

fracture in the shoulder. Interest has recently increased in the outcomes of microfracture for treating focal gleno-

results in diabetic patients were substantially inferior. Similarly, nonsurgical treatment and MUA yielded fewer

mean American Shoulder and Elbow Surgeons scores have been noteiflla along with substantial improvement

Currently, the literature lacks studies detailing longterm outcomes on the treatment of adhesive capsulitis. In

were seen in humeral lesions, and even bipolar lesions improved.”

Arthroscopic capsular releases between patients with

ments in modified Constant scores; however, the clinical

good results in diabetic patients.

a cohort of 1D patients with refractory adhesive capsulitis,

arthroscopic treatment substantially improved range of motion at a minimum 6-year follow-up? Cartilage Lesions |Chondral lesions of the shoulder can result from trauma, instability, osteonecrosis, osteochondritis dissecans, os—

teoarthritis, or iatrogenicalljrfilt21 Fecal cartilage lesions

should be suspected in patients with previous shoulder

trauma or surgery, dislocations, mechanical symptoms

periphery.12 Thin cartilage can limit the use of micro-

humeral cartilage defects:11 Improvements in pain and

in mean Constant scores” (Figure 1]. The best results

Restorative Treatment

Restorative treatment attempts to re-create the damaged

or absent cartilage. The two treatment options for restor-

ative treatment are osteochondral grafting and autologous chondrocyte implantation. Both procedures require open surgery and can potentially result in donor site morbidity.

Patient selection is important for success: the ideal patient is young, active, and has isolated cartilage defects.“ As

with microfracture, these procedures have been investi-

such as clicking or catching, pain, interrupted sleep, wealt-

Cartilage lesions are graded according to the In teruational Cartilage Repair Society, or Guterbridge

Good clinical results with osteochondral grafts in the shoulder have been demonstrated; however, a significant

classification, with grade IV a full-thickness lesion?"12 Fullrthickness chondral lesions are encountered in 5%

to 29% of patients undergoing arthroscopy.“~11 Differ-

entiating between focal chondral lesions and generalized

glenohtuneral osteoarthritis is important because treatr ment varies between the two.

Honsurgical Treatment Nonsurgical treatment options include activity modification, physical therapy, NSAIDs, steroid joint injections,

and viscosupplementation {such as hyaluronic acid}. These

the knee can help treat both bone and cartilage defects. incidence of donor site morbidity was reported. 31 Auto-

]ogous chondrocyte implantation eliminates the risk of donor site morbidity. Due case report of this technique

performed in the shoulder of a young baseball player was

published.Ell Recently, use of a ICTrmatched medial tibial plateau surface has been suggested for osteoarticular allograft reconstruction of the glenoid.“

Nerve Compression Disordersl'Suprascapular Nerve Entrapment

options can mitigate symptoms; however, nonsurgical treatment cannot fill cartilage defects or alter the progression of osteoarthritis.“ Also, if loose bodies are associated

Suprascapular Nerve Entrapment Patients with supra scapular nerve entrapment usually

mitigate the effects of third-body wear.

ities. Atrophy of the infraspinatus andfor supraspinatus

with the defect, surgical treatment is recommended to

Surgical Treatment Palliative Treatment For older patients with lower physical demands, palliative treatment consisting of débridement and chondroplasty

El Ifllri American Academy of Urthopaedic Surgeons

"fl 1]

g F”

gated in the knee with good results, but the shoulder is much less studied. flsteochondral grafts obtained from

ness, or loss of range of motion.”-

E

present with vague posterolateral shoulder pain and may report rapid onset of muscle fatigue with overhead activmuscles with weakness in external rotation andfor abduc— tion may be noted, depending on the location of the lesion.

However, patients can also be asymptomatic. Differential

diagnoses of peripheral nerve injury of the shoulder include central neurologic disorders such as cervical spinal

Drthopaedic Knowledge Update: Sports Medicine 5

E? E.

m

a!

1: Upper Eittrem ity

Section 1: Upper Extremity

Arthroscopic views of a 2 v: E-cm glenoid lesion in a 55-year-old man before {A} and after {B} microfracture. {Reprod uced with permission from van tier Meijden IDA, Gaskill TH, Millett PJ: Gle nohumeral joint preservation: A review of management options for young, active patients with osteoarthritis. Adv Grthop 2012:1012:150923. doi: “ll 155f2fl12i16fl923. Epub Mar 2?, 2012.}

disk protrusion, cervical spine instability, and spinal cord

improvement in pain and subjective shoulder values were

Suprascapular nerve entrapment can occur at several

decompression. The shape and size of the suprascapular notch are

contusion, as well as transient brachial plexopathy.

locations. If the nerve is compressed pronimally at the

transverse scapular ligament, both the supraspinatus and

infraspinatus are involved. If the nerve is compressed dis—

tally by the spinoglenoid ligament or a structural lesion

reported following arthroscopic suprascapular nerve

among the most important risk factors for suprascapular

nerve entrapment. A fiverpart classification of entrapment according to morphologic features and anatomic varia-

at the spinoglenoid notch such as a paralabral cyst, only

tions has been suggested.“ A narrow, deep suprascapular

tion alone. For appropriate diagnosis and localization

pose a patient to suprascapular nerve injury by repeated microtrauma resulting from "kinking” the nerve.

the infraspinatus is involvedEH {Figure 2}. Most diagnoses can be made using physical examina-

of the lesion, electromyography and nerve conduction velocity can be helpful. However, sensitivity and specific-

ity of these tests are not lflfl‘l’b and their results must be

correlated with clinical findingsfi‘hi'f Three—dimensional soft-tissue imaging using MRI can help measure the de-

gree of atrophy of the infraspinatus andfor supraspinatus

muscles, and more importantly, help determine whether a compressive lesion such as a ganglion cyst exists. MRI

also provides information about other concomitant shoul-

dcr pathologies, such as superior labrum anterior to pos— terior tears, which are often associated with spinoglenoid

notch (type I} with sharp bony margins could be predis-

Nonsurgical Treatment

Acute injuries to the suprascapular nerve can be treated

with rest and pain control, followed by physical therapy

with progressive range-of-motion and strengthening est-

ercises as tolerated. Iiii'verhead athletes should be followed for IE to 12 months with recommended activity restriction and periscapular therapy. Periodic electromyographiclf nerve conduction velocity studies should be performed

to monitor clectrophysiologic nerve recoveryfi“1

notch cysts.“

Surgical Treatment

intact supraspinatus and infraspinatus muscles caused by

21305.“ After standard diagnostic arthroscopy, the ar-

Suprascapular nerve entrapment can also have idio— pathic causes. Four cases of complete fatty infiltration of suprascapular neuropathy without any traction or com— pression mechanisms have been reported.” Immediate

flrdtopaedic Knowledge Update: Sports Medicine 5

Nerve decompression is usually performed arthroscopically. The surgical technique was described in detail in throscope is briefly placed in an antcrolatcral portal, and accessory anterior and posterior portals are established.

El 1016 American deadeniy of Cirrhopaedic Surgeons

Chapter 5: Adhesive l'IIapsulitisjl Cartilage Lesions, Nerve Compression Disorders. and Snapping Scapula

“mm at

Wren my

lbemsfl

Wm Iorn

The coracoid process is visualized with dissection car-

1W

process. The supraspinatns muscle hell}? is posteriorly

atenoie nnmh oroaelierl

ned medlall}? along the posterior aspect of the coracold

retracted to visualize the coracohnmeral and coracocla-

vicular ligaments. The suprascapular notch is identified at

the medial base of the coracoid. The suprascapular artery is cauterized with the radiofregnenctr ablation device, and the ligament is released using handheld arthroscopic

tissue punches. The nerve is probed to ensure full decompression {Figure 3]. Good to excellent outcomes can he expected following arthroscopic decompression, with

decreased pain and improved function for releases at both the spinoglenoid notch and the snprascapnlar notchci‘m‘El

E "fl 1]

Snapping Scapula

Snapping scapula syndrome is uncommon and likelyr

underdiag nosed. It can produce substantial pain and disability; however, the precise origin remains unknown. Potential factors causing snapping scapula syndrome in-

e F”

ii E.

fill

a?

clude hon}: changes at the superomedial scapular angle, Figure 2

Illustration of the anatomy of the su prascapular “ENE 35 i1 passes through the suprascapular spinoglenoirl notches. Common

and mechanisms are depicted at compression

each site. {Reproduced with permission from

M'IIE“ Fir Harm" “5- Pachem ”*1 EDIE-"IF fl: Suprascapular nerve entrapment: Technlque for arthroscopic “gleam Tech Shoulder ElbowSurg measures-94.}

dFSbfllflm-ifl ”E the F'EriSCQPUI-flr 1111153135: and Napalm-110' racic hursitisfil‘” Patients often present with decreased .

. athletic performance and Increased pain svtth overhead

act1v1tles. Crepitus also can he reported.“ Plaln radio-

graphs and CT scans provide detailed information about . . . osseons ahnormahttes; MRI characterizes hnrsal and other soft-tissue pathologies.“

A Figure 3

Arthroscopic views of the suhacrornial space via the posterolateral portal. A. Suprascapular nerve {red arrowi is

under the transverse scapular ligament {arrow}. B, Elevator is in the anterolateral portal. exposing the nerve {short

arrow} after releasing the transverse scapular ligament (long arrow} at the notch [red arrow]. {Heprod need with permission from Millett Fl, Barton H5. Pacheco IH, teaie It: 5n prasca pular nerve entrapment: Technique for arthroscopic release. Tech Shoulder Elbow Surg 2m;1[2]:flE-Ea.}

El Ifllii American Academy of Urthopaedie Surgeons

Drthopaedic Knowledge Update: Sports Medicine 5

e

Section 1:1}pperExtreenity

Nonsurgical Treatment Nonsurgical management remains the first treatment

option;‘“"l1 surgery is recommended after 6 months of nonsurgical treatment with no improvement. Strengthening weal: periscapular muscle groups combined with

simultaneous stretching of contracted muscles and training of antagonistic muscle groups can yield good clinical results.3“5"‘11 In addition. physical therapy. injections with local anesthetics andJ'or steroids, and NSAIDs can be

useful. Nonsurgical treatment will “ii-Ely fail if scapu-

lothoracic masses such as osteochondromas of the rib or

1: Upper Eatrem ity

scapula are present."1 Surgical Treatment

Scapulothoracic bursectomy with or without partial scapulectomg.r is currently the most effective primary method

of treatment in patients whose nonsurgical therapy is Figure 4

Illustration of the right posterior shoulder demonstrates the gross location of

neurovascular structures important in

scapulothoracic articulation. Black dots indicate typical portal locations, noting the distance

from the medial scapular border. {Heprod uced with permission from Millett PJ. Gaskill TR,

Horan MP, van der Meijden DA: Technique

and outcomes of arthroscopic sca pulothoraclc

hursectomy and partial scapulectomy. Arthroscopy 2m 2;:EI1 21:1116-1 133.]

unsuccessful. This procedure can be performed open...”I1 artl‘uoscopica11y.it’d‘f'di'i‘E or using a combined approach.“ Detailed knowledge of neurovascular anatomy of the

periscapular region is crucial. The main branches of the

spinal accessory nerve are at risk if portals are placed

above the scapular spine. The dorsal scapular nerve and

accompanying dorsal scapular artery run 1 to 2 cm medial to the medial border of the scapula, deep to the major and

minor rhomboid muscles. Therefore, portals or incisions

should be placed 2 to 3 cm from the medial scapular borderih‘” {Figure 4}. The amount of resection of the

superomeclial angle is still debated, ranging from 1 to T cm‘fl-‘i’i {Figure 5}.

-

‘ We» e

.‘

Lit?"

.

i'

i

I

1..

'

I

‘ 4a.

Supe ', '"__L-‘i' at'angie '

A Figure 5

Arthroscopic views of a left scapula viewed from the inferomedial portal demonstrate the superomedial scapular

border- A, Before resection. B. Completed resection of the superomedial border. Note the absence of the hooked

su pe ro medial border of the scapula; the supraspinatus musculature {*l also can be visualized. {Reproduced with

permission from Millett PJ. IL-‘iaslcill Tl-'t. Horan MP, van der Meijden DA: Technique and outcomes of arthroscopic

scapulothoracic bursectomy and partial scapulectomy. Artitroscopy 2012:23lllldTT6-1Tflll

flrdtopaedic Knowledge Update: Sports Medicine 5

El 1016 American Academ~y of Unhopaedic Surgeons

Chapter 5: Adhesive Capsulitis, Cartilage Lesions, Nerve Compression Disorders, and Snapping Scapula

Table‘i

Results of Surgical Treatment of Snapping Scapula Syndrome Authors and Year

Treatment

No. of Patients

Results

Nicholson and Duckworth“ 2002

Open

1? (all with bursectomy, 4 also with bony scapular

ASES score, VHS, and simple shoulder test all

resection}

Lien et al" 20113

Combined

Harper et al” 1999

Arthroscopy

Favliit et al“ 20:13

Arth roscopy

substantially improved after 2.5 years

12

ASES score. VAS. and

simple shoulder test all substantially improved after 3.1 years

Successful outcome in 6

patients {asst}

10

Mean HAS

postope ratively 2.5 of 10; UCLA score: 4

excellent. 5 good, 1 fair Fearse et al‘” sans

Arth roscopy

13

Nine improved with mean Constant score of B? of 10D; four unchanged or worse, with mean

|IEonstant score of 55 of we

Millett et al“ 2m:

Arthroscopy

23 {2 with bursectomy only, 21 with bu rsectomy + scapuloplasty}

ASES, SAME and QuickDASH scores all substantially improved at mean 2.5 years follow—up

Merolla et al“ 21114

Arthroscopy

1O

Substantial improvement

for WGRC and Constant score after 2 years {P -c [1.01]

ASES - American Shoulder and Elbow Surgeons score, qu icicDASi-I - quid: Disabilities of the Arm. Shoulder and Ha nd. SAME - single assessment

numeric evaluation, UCLA = University of California - Los Angeles score. VAS = visual analog scale. WEIR: = Western Dntario iiotator Cuff indent.

A recent review identified 31 articles dealing with snapping scapula syndrome, including 9 level IV outcomes studies.” The results of the relevant studies after surgical therapy are sunnnarised in Table 1. The largest series reported on 23 shoulders and found substantial

compression, and pathologies of the sea pulothoracic joint are relatively uncommon. However, these disorders can be

bursectomy and scapuloplasty.” Although most patients improve after surgical treat-

A sound awareness and working knowledge of these pathologies is necessary to arrive at the appropriate diagno-

disability. Further studies are needed to investigate the modifiable factors associated with poor outcomes after

surgical techniques can be used to treat these disorders. A thorough understanding of the local anatomy including

ula syndrome.

cal treatment. Good to excellent results can be achieved with appropriate patient selection and surgical technique.

pain and functional improvement following arthroscopic

ment, some patients continue to experience shoulder surgical and nonsurgical management for snapping scap-

Eb 2fl1ii American Academy of flrfliopaedic Surgeons

Summary Glenohumeral stiffness, focal chondral lesions, neural

debilitating for the patient and require specific treatment.

sis. If nonsurgical treatment fails, open and arthroscopic

neurovascular structures is crucial for success with surgi-

Drrhopaedic Knowledge Update: Sports Medicine 5

E "fl 1]

s, F”

E's 2.

m

e2

Section 1: Upper Extremity

Hey Study Points

' It is important to include adhesive capsulitis, focal chondral defects, suprasca pular nerve compression, and snapping scapula syndrome in the differential diagnosis of shoulder pathologies.

' Nonsurgical treatment has a success rate of I'll'i‘ir to was in patients with adhesive capsulitis.

' Micrnfract ure yields good clinical results for glerin-

hum‘i’fl] filial “hflfldml lis‘flfli'

_

' AHhTDEEUPIC 5"q35:311‘1131' 1131'“? dECflmPT'ESElflfl

1: Upper Extremity

yields good results when nonsu rgical treatment fails.

I Arthroscopic scapulothnracic bursectomy with partial scapulectorny is currently the most effective treatment in patients ““1105: nonsurgical till-"HP? for snapping scapula syndrome is unsuccessful.

Treatment for idiopathic adhesive capsulitis using intra-articular injection of hyaluronate or corticosteroid

for idiopathic adhesive capsulitis both showed substan-

tial improvement in clinical scores and range of motion without substantial differences between groups. Lavel of evidence: I.

z Levine was, Kashyap cs, ask ss, Ahmad cs, Elaine Ta,

Bigliani LU: Nonoperative management of idiopathic ad-

hfiii’fl fiaPfiuliflS-l Shall-HE?" Ellifi'w Suits 2i] W515i5hit-'39-

53' Medllne DUI 3. Russell 5, jariwala A, game.“ It, salts J, Richards J, 1Walton M: A blinded, randomized, controlled trial assessiog conservative management strategies for frozeo

shoulder. ,l Shoulder Elliottr Snag 2fl14;23{4_l:5l}fl-5ll?. Medline DDI

Hospital-based exercise classes result in rapid recovery from a frozen shoulder with a minflum number of hospital visits and were more effective than individual physical therapy or a home exercise program. Level of evidence: I.

Annotated References Bunker TD, Reilly], Baird KS, Hamblen DL: Expression

of grnwrh factors, cytoltines and matrix metalloproteinas-

es in frozen shoulder. J Bone joint Sarg Br Elli] [1:3251:?633'11 Medliue DUI

. Mullett H, Byrne D, Colville J: Adhesive capsulitis: Human fibroblast response to shoulder joint aspirate from patients with stage II disease. I Shoulder Elbow Snrg

2UD?;16[3}:29fl-294.Mcdline onr

. Mehta SS, Singh HP, Pandey R: Comparative outcome of arthroscopic release for frozen shoulder in patients with and without diabetes. Bone Joint ,l 2fl14:96-B{10}:1355-

1353. Medliue DUI

Patients with diabetes had substantially worse results than

nondiabetic patients after arthroscopic release for frozen

shoulder. Level of evidence: III.

s

5. Lim TE, Koh EH, Shoo M5, Lee 5W, Park YE, Too JC: Intra-articular injection of hyaluronate versus corticosteroid in adhesive capsulitis. Orthopedics 2014:3Tj1ill:eEED-elifi.5.Medline DUI

,

Fflrflflfldfifi MRI? lifilnrthrUECU'Pli: trflatmfint DE [EffflCtfl'l-EF

adhesive capsuhtis at: the Eh‘lulder- R3” Cfli 3”” C"

2014;'4I{Il:3fl-35. Medline DUI

Arthroscopic treatment is effective in refractory adhesive capsulitis of the shoulder resistant to nonsurgical treatmerit. Level flf Evjdgncfi; IV.

Page M], Green S, Kramer 5, et al: Manual therapy and exercise for adhesive capsulitis [frozen shoulder}. Cochrane Database Syst Rev 2fl14:3:CDl}112?5. Medline Oral NSAIIJs, glucocorticnid injections, and arthrngraphic joint distension with glucocorticoid and saline are effective treatment options for adhesive capsulitis. The role of

manual therapy, exercise, and electrnthcrapy as adjuncts is still debated. Level of evidence: I.

10. Tastn JP, Elias DW: Adhesive capsulitis. Sports Med Arthrosc 100?:15j4lfllfi-221. Medline

DUI

11. Page MI, II'fireen 5, Kramer S, Johnston RV, Mclilain B, Bflfihbifldfl' R: Electrotherapy modalities f0? EdhEEiVE El'13"

Efllitifi lfmzflfl EhflUldfl'l- gflflbfflflfi [lamb-153 31'“ RE”

lfllat10=CDflll3l4- MBEIIII'IE

Duly low to moderate evidence exists that shows low-level

laser therapy and Pulsed elmmmagnetic field therapy tn.

be effective adjuncts in the treatment of adhesive capsulitis.

Level of evidence: I.

12* VflhdfltPDl-lf E": Taheri P: Zfldfl AZ:— Moradian 5: Effi"ll-”“31" of extracorporeal shockwave therapy in frozen shoulder. last I Prev Med 1014;5{T}:3?5-331. Medlinc

LEDF'dfl“ 3: WDfldE D31: 5 PrEhmmflrl' “'1l ”I "13m?

Extracnrporeal shnckwave therapy showed quicker return

2014i95i2l3111'115- Medlme D01 MUA, corticosteroid injection and subsequent physio-

shoulders. Level of evidence: I.

ulatron under anaesthesia for secondary frozen shoulder following breast cancer treatment. Ann R Coll Sang Engl

therapy showed gnnd results in a series of patients with adhesive capsulitis secondary to breast cancer treatment. Level of evidence: III.

to daily activities and qualitrflgjife impmwmeflt com[Jared with sham shocltwave in [he ”fitment Bf gum]

13- WU YT, Hfl CW: Chfifl TL:— Li TY: LEE KC: Chm LC: Ultrasound-guided pulsed radiofrequency stimulation of the suprascapular nerve for adhesive capsulitis: A prospective, randomized, controlled trial. Anesth Analg 1fl14;119j3}:635-692.Medline

flrtltopaedic Knowledge Update: Sports Medicine 5

DUI

El 1016 American AcadMy of Cirrhopaedic Surgeons

Chapter 5: Adhesive Capsulitis. Cartilage Lesions. Nerve Compression Disorders. and Snapping Scapula Ultrasonographically guided pulsed radiofrequency stimv ulation of the suprascapular nerve combined with physical therapy provided better and faster relief from pain.

reduced disability. and improved passive range of motion

compared with physical therapy alone in patients with adhesive capsulitis. Level of evidence: I.

14. Buchbinder R. Green 5. Youd JM. Johnston RV. Compston M: Arthrographic distension for adhesive capsulitis [frozen shoulder}. Cochrane Database Syst Rev EUUH;I:CDUUTUGS. Medlinc

15. Waters D. IUollins J: Distension arthrogram improves pain and range of movement in adhesive capsulitis of the shoulder. for] Sarg lflififliiflhfifl. DUI The distension arthrogram can provide good improvement in range of motion and pain for patients with adhesive

capsulitis at 3 months. providing both therapeutic and diagnostic intervention. Level of evidence: IV.

15. has JH. Parlt Y5. Uhang H]. et al: Randomised controlled trial for efficacy of capsular distension for adhesive capsulitis: Fluoroscopy-guided anterior versus ultrasonography-guided posterolateral approach. Ann Rehabif Med 2014:33{3}:36fl-3Efi.Medline DUI

Ultrasonographicallj.r guided capsular distension using a posterolateral approach has similar effects on patients with adhesive capsulitis compared with a fluoroscopically guided anterior approach. Level of evidence: I. 1?. Chen J. Chen 5. Li Y. Hua Y. Li H: Is the extended re-

lease of the inferior glenohumeral ligament necessary for frozen shoulder? Arthroscopy 201G;26H}:529—535. Medline DUI

An additional posterior capsular release did not improve patient function or range of motion over an anterior cap-

sular release alone in patients with frozen shoulder. Level of evidence: I. 13. Snow M. Eoutros I. Funk L: Posterior arthroscopic capsu— lar release in frosen shoulder. Arthroscopy 2i] 09:25{1}:1913. Medline

DUI

Arthroscopic capsular release for primary and secondary frozen shoulder results in an overall rapid substantial clinical improvement. An additional posterior release did not substantially affect the overall outcome. Level of evidence: III. 19'. Walther M. Blanke F. 1ilion Wehren L. Majewski M: Frozen shoulder—comparison of different surgical treatment

options. Aera Urtfiop Belg 1014;30{11:1?1-1??. Medline Arthroscopic capsular release. alone or with subacromi—

al decompression. showed better results postoperatively compared with subacromial decompression combined with MUA. Level of evidence: III.

2t}. McCarty LP III. Cole E]: Nonarthroplasty treatment of glenohumeral cartilage lesions. Arthroscopy 3005;31i9}:1131-1142.Medline

DUI

Eb Ifllti American Academy of Urthopaedic Surgeons

El. van der Meijden UA. Gaskill TR. Millett P]: Glenohumeral joint preservation: A review of management options for young. active patients with osteoarthritis. Ad's: Urthop lfl12;2fl12:150913.Medline DUI

Arthroplasty may not be a practical treatment option in

young. active patients with osteoarthritis of the shoulder. Arthroscopic joint débridement with a capsular release. humeral osteoplasty. and transcapsnlar axillary nerve decompression seems promising when humeral osteophytes are present. 22. Elser F. Eraun S. Dewing CE. Millet: P]: |Glenohumeral joint preservation: Current options for managing articular cartilage lesions in young. active patients. Arthroscopy

lDlfl.26[5}:EEE-596.Medline not

Substantial controversy persists regarding the repair of

glenohumeral cartilage lesions in young. active patients. Applicable techniques include microfracture. osteoarticular transplantation. autologous chondrocyte implantation.

bull: allograft reconstruction. and biologic resurfacing.

23. de Beer JF. Ehatia Dbl. van Rooyen KS. Du Toit DF: Ar-

throscopic debridement and biological resurfacing of the

glenoid in glenohu meral arthritis. Knee Snag Sports Tranmatof Arthrosc 2U1I];13{12]:1?6?—1T?3. Medline DUI

Arthroscopic debridement and biologic resurfacing of the glenoid is a minimally invasive therapeutic option for glenohumeral osteoarthritis that can provide pain relief and improved function and patient satisfaction in the intermediate term. Level of evidence: IV. 24. Kerr B]. McCarty EC: IUntcome of arthroscopic dEhridement is worse for patients with glenohumeral arthri-

tis of both sides of the joint. Clio Urtfaop Refer Res

lflflfl;4fifi{3l:534~533.Medline

DUI

25. Richards DP. Eurkhart 55: Arthroscopic debridement and capsular release for glenohumeral osteoarthritis. Arthroscopy 2fl0?;23[9}:1i}19-1fl22. Medline

DUI

26. Van Thiel GS. Sheehan 5. Frank RM. et al: Retrospective analysis of arthroscopic management of glenohumeral degenerative disease. Arthroscopy 2i] 1i];16{11}:1451-1455. Medline DUI Arthroscopic dEbridemcnt for glenoh umeral osteoarthritis can potentially help avoid arthroplasty and increase function with decreased pain. Grade 4 bipolar disease.

joint space less than 2 mm. and large osteophytes are

substantial risk factors for failure. Level of evidence: IV.

1?. Millett P]. Huffard EH. Horan MP. Hawkins It]. Steadman JR: Outcomes of full'thiclrness articular cartilage injuries of the shoulder treated with microfractnre. Artbroscopy Zflflflglflfllflfifiuflfil Medline DUI Microfracture for full-thickness cartilage lesions of the shoulder showed the greatest improvement for smaller lesions of the humerus: the worst results were in patients with bipolar lesions. with a total failure rate of 19%. Level of evidence: IV.

Urrhopaedic Knowledge Updare: Sports Medicine 5

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fit

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Section 1:UpperExtremity

23. Frank HM, Van Thiel GS, Slabaugh MA, Romeo AA, lBole E], Verma NH: Clinical outcomes after micrefracture of the glennhumeral joint. An: 1 Sports Merl 2fl10;33{4j:??l-

3?. Polguj M, Sibil'lslti M, Graegertewski A, I2'3reelalt P, Mains A, Topel M: 1llariation in morphology of suprascapular notch as a factor of suprascapular nerve entrapment. Int Uri-“bop 2fl13t3?l{11}:2135-2192. Medline DUI

Micrnfracture of the glenohumeral joint resulted in substantial improvements in pain relief and shoulder function

Knowledge of the anatomic variations of the suprascapular notch is important for both endoscopic and open procedures of the suprascapular region.

731. Medline

DUI

in patients with isolated, full-thickness chondral injuries at a mean follow—up of 23 months. Level of evidence: W.

29. Snow M, Fuel: L: Micrefracture ef chendral lesions of the

33. Uiaumi N, Suenaga N, Minami A: Snapping scapula

caused by abnormal angulatien of the superior angle of

1: Upper Ettrem lty

glenohumeral joint. Int I Shoulder Snrg lflfl3;2{4}:?2-?6. Medline DUI

the scapula. J Shoulder Elbow Surg 2i] fl4:13{1]:1 15-113. Medline DUI

3d}. Cole B], “faults A, Prevencher MT: Nonarthroplasty alternatives for the treatment of glenohumeral arthritis. J Shoulder Elbow Surg lflfl?;16[5uppl 51:5231-524fl. Medline DUI

39. Harper GD, McIlrny 5. Bayley JI, Calvert PT: Arthroscopic partial resection of the scapula for snapping scapula: A new technique. I Shoulder Elbow Surg 1999;3{1}:53-5?. Medline DUI

31. Scheibel M.I Eartl C, Magosch P, Lichtenberg S, Habermeyer P: Usteochondral autelegous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder. ] BorteJolnt Surg Br Eflfl4;36{?]:991-991

41!}. Millett P], Pacheco IH, Gob-eaie Ft, 1Warner J]: Management of recalcitrant scapulothnracic bursitis: Endoscop— ic scapulothnracic bursectnmy and scapulnplasty. Tech Shoulder Elbow Surg lllfliififlflfl-ZDS. DUI

32. Romeo AA, Cole H], Maaaecca AD, Fest JA, Freeman

41. Gaskill T. Millett P]: Snapping scapula syndrome: Diagnosis and management. I Arr: deed Urtlrop Surg

defect in the humeral head. Arthroscopy lflfllflfllflhfllj9'29. Medline DUI

Neesurgieal therapy is the initial treatment of choice for

33. Rios D. Jansson KS, Martetschliiger F, Beyltin RE. Millett P], Wijdiclts CA: Normal curvature of glenoid surface can be restored when performing an inlay esteochondral al-

structures surrounding the scapula is critical to avoid

Medline

DUI

KB. Joy E: Antelogeus choudrocyte repair of an articular

2fl13;11{4}:214—124.Medliue DUI

snapping scapula syndrome. If nonsurgical treatment fails. open and endoscopic techniques have been used with satisfactory results. Familiarity with the neuroanatomic iatrogenic complications.

legraft: An anatomic computed tomographic comparison.

Knee Sang Sports Tranmarol' Arrbrnsc lfll4:22{2]:44244?. Medline DUI The radius of curvature of the glenoid and the medial tibial plateau surface have a statistically similar relationship as measured using three—dimensional CT. This can allow the medial tibial plateau tn be used as a donor for names rticular allograft reconstruction of the gleneid. 34. Millett P]. Barton R5. Pacheco ICH. Unbeaie FL: Suprascapular nerve entrapment: Technique for arthroscopic release. Tech Shoulder Elbow San-g 1006;?{2}. DUI 3.5. Post M: Diagnosis and treatment of suprascapular nerve entrapment. Elia Urtlrep Rslet Res 1999;363:92-100.

Medline

36. LeClere LE, Shi LL, Lin A, 1t‘annepoules P, Higgins LD.

1Warner J]: |Eemplete Fatty infiltration of intact rotater cuffs caused by suprascapular ueuropathy. Arthroseopy 1fl14;3fl{5}:539-E44.Medline

DUI

Suprascapular neuropathy with complete neurogenic fatty infiltration can also occur in the absence of traction or compression mechanisms. Arthroscopic supra scapular nerve decompression resulted in immediate improvement in pain and subjective shoulder values in all four patients.

Level of evidence: IV.

Urrhnpaedic Knowledge Update: Sports Medicine 5

41. Nicholson UP. Duckwerth MA: Scapulethoraclc bursectomy fer snapping scapula syndrome. I Shoulder Elbow Sui-g lflfllflilllflfl-BS. Medline DUI 43. Merolla G. Cercielln 5. Paladini P. Porcellini U: Scapulothoracic arthroscopy for symptomatic snapping scapula: A prospective cohort study with two—year mean follew‘up. Mascalesltelet Surg 2014 March 2013. Epub ahead of print. Medline DUI Arthroscopic decompression showed substantial clinical improvements in 1H patients with snapping scapula syn-

drome at 1-year follow-up. Level of evidence: I‘v’.

44.

Pearse EU, Eruguera J, Massoud SN, Sferaa U, Cope-

land SA, Levy U: Arthroscopic management of the pain—

ful snapping scapula. Arthroscepy lflfln:22{7]:?55-?61.

Medline DUI

4.5. Millett P]. Gaskill TR, Heran MP, van der Meijden UA: Technique and outcomes of arthroscopic scapulotberacic bursectnmy and partial scapulectomy. Arthroscepy 2D]2;23{11}:1??fi—1?33.Modline DUI Although substantial pain and functional improvement can be expected following arthroscopic bursectnmy and scapuloplasty in patients with snapping scapula syndrome,

the mean postoperative American Shoulder and Elbow

U 1016 American AcadMy of Urrhnpaedic Surgeons

Chapter 5: Adhesive Eapsulitisjl Cartilage Lesiuns, Nerve Cumpressic-n Diserders. and Snapping Scapula Surgeeus and Single Assessment Numeric Evaluaticn scnres remain luwer than expected. Level nf evidence: IV. 46. Pavlil: A, Aug K. Cughlau J. Bell 5: Arthruscupic treatment c-f painful snapping {if the scapula by using a new superinr pnrtal. Arthrnscnpv 2003;19i6}:5i]fl-612. Medline DUI 4?. Lien SB, Sheri PH, Lee CH, Lin LC: The effect {if endnscnpic hursectnlnv with mini-npen partial scapulectnrnv nn snapping scapula svudrume. 1 Surg Res 200 3:1 Sflillfldfi— 242. Medline DUI 43. Lehtiuen JT, Tetreault P, Wflrfltr J]: Arthruscupic management pf painful and stiff scapulutheracic articulatiun. Aflisrnscnpy 2fl03;19{4):E13. Medline DUI 45'. Uiaumi N. Suenaga N. Funaltushi T. Tamaguchi H, Min-

ami A: Recnverv pf scnsnrj.r disturbance after arthrnscnpic

decpmpressiun nf the suprascapular nerve. ] Sbeuider Eihuu: Surg 2D12;21{6}:?59-?E4. Medline DUI The sensnrj.r disturbance at the pnsternlateral aspect [If the shnulder can he a diagnpstic critericrn fcrr snprascapnlar

nerve palsy. Arthroscupic release cf the suprascapular

nerve is useful tn treat nerve entrapment at the suprascapular nntch. Level pf evidence: IV.

50. Wart}: R]. Spiegl U]. Millet: P]: Scapulethcracic hursitis and snapping scapula svndrnrne: A critical review Inf current evidence. Am } Spurts Med 2915;43[1}I:236-145. Medline DUI Snapping scapula svudrume is a liltel}r underdiaguused cunditirm and can prc-duce substantial sheulder dysfunctipn. Scapulnthnracic hursectclrn‘g.‘r with nr withput partial

scapulectemv is currently.r the must effective prin'larj,r meth—

od uf treatment in patients whuse unnsurgical therap}r is unsuccessful.

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Eb Ifllii American Academy pf Urthapaedic Surgeans

Unhppaedic Knuwledge Update: Sparta Medicine 5

Chapter 6

Elbow Arthroscopy and

the Thrower’s Elbow

Ekaterina Y. Urch, MD

Lucas S. McDonald. MD. MPHStTM

The throwing athlete is at increased risk for various elbow injuries clue to the substantial repetitive forces

exerted on the joint during the throwing motion. The management of these injuries requires a resolute understanding of the underlying biomechanics involved

in this complex motion. Surgical intervention is often required to attain acceptable clinical outcomes and to

allow the athlete to return to his or her sport. Along

with the various open surgical techniques available, elbow arthroscopy.r has quickly come to the forefront of surgical treatment in these athletes. Keywords: elbow arthroscopy; thrower's elbow;

valgus extension overload; lateral epicondylitis; posteromedial impingement ulnar collateral ligament

Ioshua S. Dines, MD

David W. Mtchek, MD

with inconsistent outcomes and an unacceptably high complication rate. Since the initial outcome studies, improved instrumentation, advanced surgical technique,

and better understanding of arthroscopic elbow anatomy have made arthroscopy a safe, effective treatment for elbow pathology.

Indications and Contraindications

The advantages of elbow arthroscopy include decreased surgical morbidity and improved joint visualization, mak-

ing the technique an excellent option for numerous elbow

conditions. However, the small size and compartmentaliaation of the joint, along with the proximity of portals

to neurovascular structures, makes the procedure techs

nically challenging. The treating surgeon must not only be familiar with the anatomy and surgical technique, but

also must be proficient in identifying patients most likely

to benefit from the procedure. Classically, the indications for elbow arthroscopy include the removal of loose bod-

ularized in 1935; the first study on the topic described

ies, olecranon osteophyte excision, synovectomy, capsular release, and the evaluation and treatment of osteochondrir tis dissecans {0CD} lesions} More recently, indications have expanded to include treatment of septic arthritis,

supine.I Historically, elbow arthroscopy was associated

Arthroscopy is contraindicated in patients with dis-

Introduction

Elbow arthroscopyr is a modern surgical technique pop-

visualisation of the elbow joint through anterolateral, anteromedial, and posterolateral portals with the patient

Dr. Dines or an immediate family member has received

royalties from Biomet; is a member of a speakers' bureau

or has made paid presentations on behalf of Arthreie and serves as a paid consultant to Arthrex and CDNMED

Linvatec. None of the following authors or any immediate

family member has received anything of value from or has stoclr: or stocir options held in a commercial company

or institution related directly or indirectly to the subject of this chapter: Dr. Aitchelc Dr. McDonald, and Dr. Urch.

@ lfllfi American Academy of Drthopaedic Surgeons

lateral epicondylitis, intra—articular fracture management, and plica excision.“

torted soft tissue or osseous anatomy, precluding safe portal placement. Such situations include anlcylosed

joints, history of prior elbow trauma or surgical intervention, soft—tissue pedicle flaps, skin grafts, burns, and

the presence of heterotopic ossification!” Additionally,

soft-tissue infection at the portal sites is an absolute contraindication. Because of the increased risk of ulnar nerve

injury, elbow arthroscopy is relatively contraindicated in

patients with prior ulnar nerve transposition. If arth ros-

copy is performed in these patients, it is critical to visualice the ulnar nerve before establishing the medial portal.5

Orthopaedic Knowledge Update: Sports Medicine 5

E "fl 1]

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Sectinn 1: Upper Extremity

Patient F'nsitinning

Patient pnsitinning is based primarily nn surgenn prefer—

ence. Advantages and disadvantages at the varinns methnds have been described. Classically, elbnw arthrnscnpy

was perfnrmed supine with the surgical arm draped acrnss

the chest ever a bnlster.5

The modern cnnccpt nf arm suspensinn frnm the supine

pnsitinn, keeping the arm in 9i)“ nf shnulder abductinn and 911]“ cf elbnvv flexinn, was intrnduced in 1935.1 The advantages nf the supine pnsitinn include simplified airway access, familiar nrientatinn, and ease nf cnnversinn 1: Upper Eittrem ity

tn an npen prncedure. Disadvantages include elbcnv in-

stability during the prncedure and difficult access tn the

pnsterinr cnmpartment.5 Tn address these cnncerns, the mndified supine pnsitinn was develnped, suspending the arm nver the chest with the elbnw in 90“ nf flexinn while the fnrearm, wrist, and

hand are secured in a cnmtnercially available mechani-

cal hnlder [Figure 1}. This pnsitinn facilitates easy arm

adjustment, prnviding access tn bnth the anterinr and pnsterinr cnmpartments nf the elbnw. Furthermnre, this

arm pnsitinn decreases the risk nf injury tn the anterinr

neurnva scular structures by allnwing them tn drnp away frnni the anterinr capsule.1 |Either nptinns include the lateral decubitus and the

r

"i

a II

.

--

,

.3

“r -.5 Ph etngraph demnnstrates the modified supine pnsitinnI which suspends the arm nver the chest with the elbnvv in IBITl nf fleainn, and

the fnrearm. wrist. and hand secured in a

cnmmercially available mechanical hnlder. The medial elbnvv pnrtal is marked relative tn the underlying essenus anatnmy. The prnsimal medial pnrtal is 2 cm prmtimal tn and 1 tn 2 cm anterinr tn the medial epicnndyle. The transtriceps pnrtal is visible pnsterinrly.

Pnrtal Placement

prnne pnsitinns. In the lateral decubitus pnsitinn, the pa~ tient is pnsitinned laterally an a beanbag with the surgical

Print tn pnrtal cre atinn, the elbnw jnint is insu filated with

Jnint distractinn is prnvided by a weight attached tn the hand. The advantages cf the lateral pnsitinn include im-

center nf a triangle created by the radial head, the lateral epicnndyle, and the tip cf the nlecrannn. This distends

easy airway management. The disadvantages include nrientatinn challenges frnm reversed anatnmic landmarks

away frnm the jnint and facilitating easier access tn the space. Anatnmic landmarks are marked, including the

prnne pnsitinn, the arm is suspended nff the table in an arm hnlder with the arm in 9G“ nf shnulder abductinn

and nlecrannn. Althnugh many different methnds and lncatinns are

lateral decubitus pnsitinn. The advantages nf the prnne

prefer tn first create the prnrcimal lateral pnrtal, lncated 1 tn 2 cm prnrtimal tn the lateral epicnndyle and 1 cm

arm flexed tn PH“ and suspended nver a well-padded pnst.

prnved arm stability, pnsterinr elbnw access, and relatively

and difficult access tn the anterinr cnmpartment. In the and the elbnw in 90" nf fleainn in a similar pnsitinn tn the pnsitinn include natural tractinn, easy access tn the pnsterinr cnmpartment, and a thenretically increased space

3d mL nf saline th rnugh the lateral snft spnt lncated in the

the capsule, mnving the neurnvascular structures further medial and lateral epicnndyles, ulnar nerve, radial head,

used fnr pnrtal placement, the authnrs nf this chapter

anterinr tn the humerus {Figure 2}. The radial and pns-

between vascular structures and the anterinr capsule. The disadvantages include the necessity fnr general anesthesia,

terinr antebrachial cutanenus nerves are at greatest risk during creatinn nf this pnrtal; therefnre, nnly the skin is

tn the anterinr cnmpartment. Irrespective nf the pnsitinn used, it is crucial tn assess

meral jnint.5 This pnrtal is primarily used as a viewing pnrtal. Tn access the anterinr cnmpartment, a prmtimal

sites befnre starting the prncedure. Pressure cm the an— tecubital fnssa shnuld be avnided tn decrease the risk nf

tn 2 cm anterinr tn the medial epicnndyle {Figure I}, it is impnrtant tn stay anterinr tn the medial intermuscular

is placed as prnrtimal cm the arm as pnssible and can be insufflated as needed.

ditinnal wnrking anternmedial pnrtal can be established 2 cm anterinr and 2 cm distal tn the medial humeral

difficult airway access, reversed anatnmy, and pnnr access the elbnw fnr access tn each cnmpartment and tn pnrtal

injury tn anterinr neurnvascular structures. A tnurniquet

flrfltnpaedic Knnwledge Update: Sparta Medicine 5

incised sharply, and a trncar is used tn enter the ulnnhumedial pnrtal can be established 2 cm presima] and 1

septum, minimizing the risk nf ulnar nerve injury. An ad-

El 1016 American AcadMy nf Cirthnpaedic Surge-ans

Chapter 6: Elbow Arthroscopy and the Thrower’s Elbow

epicondyle. This portal is near the medial antebrachial cutaneous nerve and should be localized first under direct visualisation with a spinal needle. Diagnostic arthroscopy of the anterior elbow is performed while viewing through the proximal lateral portal.

Trochlear and coronoid fossa articular cartilage lesions,

coronoid process osseous spurs, synovitis. and loose hodies can be identified. The anterior radiocapitellar joint is

Complications

Elbow arthroscopy has historically been associated with complication rates as high as 20%.”

The most common complication is neurovascular in-

jury resulting from surgeon inexperience, poor technique, and lack of knowledge of elbow anatomy. Compression

evaluated for osteochondral lesions and any concomitant pathology.r of the radial head. If débridement is performed in this area, extreme caution must be used because of the

proximity of the radial nerve to the anterolateral joint capsule. If ulnar collateral ligament {UCL} insufficiency is fljwansa .ladtln :j

suspected, an arthroscopic valgus stress test is performed.

A standard 3.4-m111 hook probe is inserted through the proximal medial portal to help measure gapping, and based on a 1996 cadaver study. a gap of only 1 or 2 turn

suggests a complete anterior bundle UCL injury. Large increases in gspping suggest injury to the posterior bundle as well‘ {Figure 3].

For visualisation of the posterior compartment, the posterolateral portal is created 1 cm posterior to the

lateral epicondyle at the level of the olccranon tip {Fig-

ure 2}. To access the posterior compartment, a midlateral portal can be created through the lateral soft spot or a

Figure 2

Photograph demonstrates the lateral elbow portals marked relative to the underlying osseous anatomy. The proximal lateral portal is l to 2 on proximal to the lateral epieondyle and 1 cm anterior to the humerus. The

transtriceps portal {the portal preferred by the authors of

this chapter) can be created in the midline of the triceps just proximal to the tip of the olecranon {Figure 2}. The

posterolateral portal is 1 cm posterior to the

lateral epicon dyle at the level of the olerra non tip. The tra nstn'ceps portal is marked posteriorly

posterior compartment is evaluated for olecra non osteophytes. posterior recess loose bodies, capitellar GED, and chondral injuries.

in the midline of the triceps tendon just

proximal to the tip of the plane non.

no my!" 7.‘1u.M '1 ..

Figure 3

‘

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

El Ifllli American Academy of flrfltnpaedie Surgeons

Drthnpaedie Knowledge Update: Sports Medicine 5

Sectien1:Upperlintreruit'f,r

frem cannulas, fluid extravasatien inte surreunding seft

tissues, le-cal anesthesia, and laceratien with the scalpel

svmptems. 0CD lesiens are mest cemmenl‘f.r seen at the

deficit. Impreved surgeen training, better understanding

mere than 9H”. Use ef a TB“ arthrescepe can assist with

er cannula are the mest cemmenl}.r cited insults.‘ Mest ef these injuries are transient, reselving witheut residual

pestereinferier aspect ef the capitellum, an area best visualized via the pestcrelateral pertal with the elbew flexed

ef elbew anatemv, and surgical technique standardisatien have all increased the safety.r ef clhevv arthrescepv.

visualiaatien. The midlateral pertal is used fer cartilage flap déhridement, leese bedv remeval, and percutaneeus

including weund healing and infectien, are new these ubiquiteus te flfil‘lfflSCflPT ef ether jeints.lfl Specifically,

Lateral Epicendylitis

A recent stud}:r demenstrated that mest cemplicatiens,

an increased risk ef pesteperative infectien was neted in patients receiving an intra-articular stereid injectien at

1: Upper Estrem ftv

treatment, the presence ef leese bedies, and mechanical

drilling.

Lateral epicendvlitis affects between 1% te 3% ef the pup-

ulatien and is an angiefibreblastic hyperplasia ef the ex-

the end ef the precedure, and the anthers ef this chapter de net recemmend this treatment. |Currently, nerve injuries are exceedingly rare, with reperted transient nerve injury,r rates ranging frem 1.73%

teuser carpi radialis tenden {ECRB}, a neninflammaterv, dvsvascular degenerative precess caused by repetitive

scepic precedures including cemplete svnevectemv,

sicallv, the precedure is perfermed threugh a small incisien, fecusing en debridement ef the degenerative tenden;

te 23% .“L” Despite the advent ef mere temples; arthre—

radial head resectien, esteecapsular arthreplastv, and medial epicendvlectemv, ne substantial asseciatien

has been feund between cemplicatien rate and surgical cempleaitv.”l I{Hither knewn cemplicatiens include artic-

ular cartilage injury, svnevial fistula fermatien, instru-

ment breakage, and tissue injury secendar},r te use ef a teurniquet.

Specific Precedures

Leese Bedies Leese bedies are esteechendral er chendral fragments caused by either traumatic insult re the elbew er underly-

ing patheleg}.r such as flCD. Leese bed}r remeval frem the

micretrauma.”'13 Up te 90% ef cases are self-limiting, reselving within 1 re 2 years.” Patients whese nensurgical

therapv fails are candidates fer surgical treatment. l['Jlas— repair ef the tenden te the lateral epicendvle sheuld be

censidered. After the advent ef elbew arthrescepv, seme surgeens advecated arthrescepic treatment te include debridement ef beth the tenden and the anterelateral capsule. The advantages include the abilityr te visualize the entire jeint and re treat cencemitant pathelegv, including svnevial plicae, which can mimic lateral epicendvlitis.”*”‘

Arthrescepic release is perfermed using a medial visuali~ aatien pertal and a lateral werlcing pertal. The medial pertal is placed preitimallv eneugh te ensure visualizatien

ef the entire ECRB insertien. The lateral pertal is placed directly.r threugh the site ef the damaged ECRB tenden

{the Hirschl lesien}, 2 cm anterier tn the intermuscular

elbew jeint is the must cemmenl},r perfermed arthrescepic therapeutic interventienfi The su rgeen sheuld perferm a

septum. The jeint is entered just preJcimal te the artic— ular margin ef the capitellum.12 The capsule is débrided

ments fer leese bedies, chendral injurv, and an}? ether pathelegv. Leese bedies are mest cemmenlv lecated in

healthy,r tissue is visualized. The lateral epicendvle is de— certicated with a shaver, werlcing anterier te the equater

thereugh diagnestic arthrescepv, assessing all cempartu the pestetier recess. Prier te cempletien ef the precedure, an intraeperative arthrescepic valgus stress test te assess

first, fellewed by débridement ef the ECRB tenden until ef the radial head te aveid injurv re the lateral cellateral

UCL insufficiencyF is recemmended.

ligament cemples. The ECRB tenden can be plicated te the everlving eatenser carpi radialis lengus tenden er

{JED Lesiens 0CD is mest eften seen in feung athletes ranging be-

using a suture ancher.“1 Arthrescepic débridement ef lateral epicendvlitis

secured te the anterier aspect ef the lateral epicendvle

tween 11 and 21 vears ef age.j It classically,F affects the

demenstrates substantial imprevement in svmptems with

Repetitive leading ef the lateral cempartment ef the el-

rial imprevement in functienal entcemes when cempared

capitellum and is caused bv repetitive micretrauma tn the vulnerable epiphvsis, which has a tenue us bleed sulrilalv.1

bew results in sub-chendral bene degeneratien causing cartilage fragmentatien. Management ef 0CD depends en the integrity.F and stabilitv ef the everlving cartilage, as

well as the size and lecatien ef the lesien. Indicatiens fer arthrescepic débridement include failure ef nensurgical

flrrhepaedic Knewledge Update: Sparta Medicine 5

geed everall eutcemes.‘1=”~”' Furthermere, it has been suggested that arthrescepic treatment prevides substanwith the epen methed.” The same stud};r feund ne differ~ ence in cemplicatien er failure rates between epen and arthrescepic treatment.” Ca reful patient selectien remains

parameunt: manual laberers and patients with werkers’ cempensatien claims are asseciated with a EUh-Stflfltlflll?

El 1016 American Academv ef Drrhnpaedic Surgenns

Chapter 6: Elbow Arthroscopy and the Thrower's Elbow

.l

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Illustration depicts the throwing motion divided into six distinct stages: windup, early arm cocking, late coclrlng,

Th rovver's Elbow

Biomechanics of Throwing The overhead throw involves coordination of the upper

a valgus force as high as 64 him is generated in the elbow

by the forward rotation of the upper trunk and pelvis

with associated external rotation of the shoulder.'.1‘-'1 Con-

comitantly, up to Sill] Hm of compression can be placed

on the lateral radiocapitellar joint?“I As the arm is driven forward into acceleration, the elbow is rapidly extended

as the humerus adducts and internally rotates. The trunk

extremity, trunk, and lower extremity in one fluid motion. Elbow static and dynamic stabilizers play a critical role

and upper extremity shift forward. During this time, the elbow accelerates at up to fiflflfiflfl“ per second.“

include the anterior joint capsule, the UCL complex, and the radial collateral ligament complex. Dynamic stabilis-

opposes the valgus torque created by shoulder external rotation and rapid acceleration. The UCL has been found

throughout this motion. Static stabilizers of the elbow

A countering varus torque generated through the elbow

ers include the flexor pronator mass made of the pronator

to supply almost 50% of the force required to oppose the

understand the biomechanics of overhead throwing, the

the UCL and over time result in attritional changes. The

arm cocking, late cocking, acceleration, deceleration, and follow-through‘fl” {Figure 4}.

occurs at a rate of Sflflfiflfl“ per second over a span of approximately 51'} ms.” During this stage, maximum el-

tion. In early cocking, elbow flexion and pronation are

shoulder reaches maximum internal rotation, the elbow is extended to roughly 2|)“, and the flexor-pronator muscles

teres, the flexor carpi radialis, the palmaris, the flexor dig— itorum superficialis, and the flexor carpi ulnaris. To better motion is divided into six distinct stages: windup, early During wind—up, the elbow is flexed with the forearm in pronation. The arm is moved overhead and into adducmaintained while the shoulder is abducted and externally rotated. The leading lower extremity is advanced forward. In late cocking, elbow flexion is increased to between

90" and 120°. The forearm is pronated with maximum shoulder abduction and external rotation. At this stage,

4D Ifllti American Academy of flrfltopaedic Surgeons

"fl 1]

o, F”

acceleration. deoeleratlen. and follow-through. {Reproduced from lplsvastl fl. ElAttrache H5. lobe rw: Understanding shoulder and elbow injuries in baseball. IAm Atari Drthop SuryaI 2Dfl?;15[3]:139-14?.]

increased risk of poor functional outcomes following arthroscopic treatment.”

E

valgus force when the elbow is in 9H“ of flexion."1r Such high loads exceed the ultimate tensile strength of deceleration phase is initiated at ball release. Deceleration

bow extension velocity can reach 2,?flfl“ per second.” The

contract to prevent posteromedial impingement of the olecranonflflfl The arm moves into the follow-through stage, marking the end of the throwing motion.

Drrhopaedic Knowledge Update: Sports Medicine .5

ii E.

fill

a!

Sectiun 1: UpperExtremity

Va’lgus Extensiun Dverluacl

athletes are at risk fur chundrumalacia, luuse budies, and

acceleratiun stage in which high valgus furces are cuuntered by rapid elbuw extensiun. This mutiun results in

Management

Must thruwing injuries uf the elbuw uccur during the three distinct pathulugic furces: a tensile furce un the

The management uf elbuw injuries in thruwing athletes

in the pusteriur cumpartment.”

per year are 3.5 times mure likely tu sustain an elbuw

injury pattern is the must cummun diagnusis requiring

pitching mure than Bi] pitches per game, and thruwing

medial stabilising structures, a cumpressiun force at the radiucapitellar juint, and a medially directed shear force

These furces cause a spectrum uf injuries cumprising the valgus extensiun uverluad WED} syndrume. This

surgical treatment in baseball players and uther uverhead thruwing athletes.2 Because must uf these injuries uccur 1: Upper Extremity

lateral usteuphyte furrnatiun.

during the late cucking and early acceleratiun stages, it is

begins with preventiun. Yuuth pitchers are must susceptible tu this injury. Athletes lugging mure than IUD games

injury.l3 Dther facturs knuwn tu increase the risk uf elbuw injury are playing baseball mure than 3 munths per year, faster than 35 miles per huurF‘l UEL Injuries

nut surprising that 35% uf uverhead athletes with VED experience symptums during the acceleratiun phase uf

Nunsurgical management is indicated in yuung athletes with acute injuries and athletes with partial UCL injuries

elbuw pain and cuncumitant changes in perfurmance, including decreased pitch speed and stamina. Sume re-

tive rest fur 5 tu 12 weeks. Nunsurgical mudalities include physical therapy emphasizing elbuw and shuulder range

maneuvers include the muving valgus stress test and the milking maneuver. Evaluatiun fur ulnar neuritis ur sub-

therapy. The gual uf nunsurgical treatment is tu address any issues with pitching mechanics. shuulder kinematics,

thruwing}I Athletes usually present with ch runic medial purt elbuw clicking ur lucking. Key physical examinatiun luxatiun is critical fur future surgical planning.

Pathupuhysiulugyr u'f UED The large valgus force exerted un the elbuw in uverhead

{grade I ur II sprains)?” These patients are placed un ac-

uf mutiun and strengthening, NSAIDs, bracing, and cryu— shuulder mutiun deficits, as well as cure strengthening.“

After painless range uf mutiun is established, the pa» tient is prugressed tu an isumetric prugram fulluwed by

an isutunic upper arm and furearm—based strengthening

thruwing, created by humeral turque and trunk rura— tiun, is cuuntered by rapid elbuw extensiun. As repetitive,

prugram with cluse attentiun given tu flexur—prunatur mass training.” An integrated gradual thruwing pru-

ligament is subjected tu micrutrauma and subsequent attenuatiun cf the anteriur bundle. The anteriur bundle

chain deficits have been treated. Appruximately 40% uf patients return tu spurts participatiun at ur abuve their

near—failure tensile stresses are exerted un the UCL, the

uf the UCL is the must impurtant static stabilizer uf the

medial elbuw and damage tu this structure results in valgus instability. Even subtle UCL laxity results in stretch uf uther medial structures, including the ulnar nerve and

gram is initiated after pain has resulved and all kinetic preinju ry level uf play after an apprupriate rehabilitatiun

prutuculfi“r A 2D 1D study repurted successful nunsurgical treatment uf prufessiunal fuutball quarterbacks with UCL injuries.“ Must cases were cuntact injuries, suggesting an

the flexurrprunatur mass causing ulnar neuritis and flexur mass tendinitis ur tears. In skeletally immature athletes,

acute, traumatic UCL rupture. The study cuncluded that these types uf injuries cunld be amenable tu nunsurgical

a result uf UCL incumpetency, usseuus cunstraints uf the pusterumedial elbuw becume key stabilizers during

UCL injury seen mure uften in baseball pitchers. The use uf platelet-rich plasma (PEP) can be cunsidered as

Valgus laxity secundary tu UCL stretching further ex-

rate uf return tu preinjury play in athletes treated with PEP.“ Althuugh scattered repurts appear prumising, data

tween the medial humeral crista and the ulecranun?-I The abnurmal nlnuhumeral cungruency results in increased

nut recummended because uf the risk uf tendun rupture. Athletes whuse nunsurgical treatment was unsuccess-

medial epicundyle apuphysitis can uccur. Similarly, as

thruwing. The repetitive shear stresses frum cuntinued thruwing cause pusteriur cumpartment impingement.

acerbates the cunditiun by altering the cuntact area becuntact pressures causing pusterumeclisl impingement.

management. Huwever, this dues nut apply tu chruuic

an augment tu healing, with une study repurting an 33%

un the efficacy uf PEP remain limitedfimfl Steruids are ful ur thuse preferring tu quickly return tu their prein-

With chruuic impingement, athletes bccume susceptible tu synuvitis, ulecranun tip usteuphyte furmatiun, ulecranun

jury level uf play are candidates fur surgical treatment. Sume studies have suggested the value uf diagnustic elbuw

pusterumedial truchlea. Finally, because uf the high cum— pressiun fumes exerted un the lateral radiucapitellar juint,

and luuse budies, as well as fur usteuphyte ddbridement and capsular release?!” Additiunally, an intrauperative

stress fractures, luuse budies, and chundral lesiuns cf the

flrrhupaedic Knuwledge Update: Spurrs Medicine 5

arthruscupy tu evaluate fur articular cartilage lesiuns

El 1016 American AcadMy uf Drrhupaedic Surge-nus

Chapter 6: Elbow Arthroscopy and the Thrower’s Elbow

arthroscopic valgus stress test can confirm UCL insuffi-

ciency. However, with a thorough clinical history, accu—

rate physical examination, and corresponding imaging, diagnostic arthroscopy is rarely needed and is recom-

mended only if presentation suggests intra-articular

pathology. Direct repair of the UCL is indicated in the flaw patients

with acute avulsion injuries, with good outcomes reported

in young, nonprofessional athletes.“ The surgical management of choice for a chronically injured, attenuated

UCL is reconstruction using an ipsilateral palmaris ten-

don autograft. Alternative graft options include the gracilis tendon or contralateral palmaris tendon.

In 19?”, UCL reconstruction of the elbow, commonly

referred to as Tommy john surgery, was popularised. This “Li-ply technique” used two convergent bone tunnels in the ulna and two divergent bone tunnels in the humerus.

Autograft tendon was passed through the tunnels and sutured to itself for tensioning. Concerns over graft fixation and appropriate tensioning prompted several modifica-

tions, including the Jobe modification {a muscle-splitting approach without ulnar nerve transposition}, the Amer-

E .I'

lntrao berative photograph demonstrates the

medial approach performed through a 1lJ-cn'l incision from the distal intramuscular septum to

the sublime tubercle. flare is taken to identify and protect the medial antebrachial cutaneous nerve.

mndon is delivered out of the incision using two mosquito

ican Sports Medicine Institute modification {a posterior

clamps. A locked Krakow stitch is run along the tendon

ulnaris, flexor-pronator elevation without takedown, and ulnar nerve transposition}, the docking technique

tendon stripper. The wound is irrigated and closed with

tunnel with graft clocking in a single proximal tu nnell, the

is approached through a llJ—cm incision from the dis-

approach between the two heads of the flexor carpi

{a muscle~splitting approach, reconstruction performed via converging tunnels distally and a Y—shaped humeral hybrid technique {humeral fixation with suture anchors), and the Tommy john DANE T] modification.”

using No. 1 nonabsorbable, braided suture and the tendon is cut distal to the suture before harvesting with a closed

interrupted nylon sutures. Under tourniquet for visualization, the medial elbow

tal third of the intramuscular septum to 2 cm distal to the sublime tubercle, protecting the medial autebrachial

The DANE T] method uses a muscle-splitting ap

cutaneous nerve {Figure 5 l. The flexor pronator mass

ulnaris. The procedure reconstructs the deep central fi-

remaining anterior to it. The native UCL is identified and

proach through the posterior one third of the common flexor mass, within the anterior fibers of the flexor carpi

hers of the UCL. After the remnant of the ligament is taken down, the ulnar side of the graft is fixed by placing an interference screw into a single drill hole at the UCL

insertion. 0n the humeral side, the docking technique is used, with the limbs of the graft secured within a single

is split through the posterior third of the muscle belly, taking care to identify the ulnar nerve by palpation and the anterior bundle is split, longitudinally exposing the joint. Two bone tunnels are made in the ulna 4 to 5 mm distal to the sublime tubercle. A 3-mm bu tr is used create the tunnels, one anterior and one posterior to the tuber-

15-mm bone tunnel made using a 4-mm burr. The graft

cle. The tunnels are connected with small curved curet, maintaining a 2-cm osseous bridge. For humeral fixation,

epicondyle.

violating the posterior cortex. On the upper border of the

is secured with two suture limbs that are passed through two divergent drill holes and tied over the top of the The illliuthors'r Preferred Technique

Preoperatively, the patient is evaluated for the presence of

an ipsilateral palmaris tendon; if absent, gracilis tendon autograft is used. If present, the palmaris tendon graft is harvested first through a 1-cm transverse incision just

proximal to the volar wrist crease, where the tendon is easily identified and isolated. Using blunt dissection, the

Eb Illlti American Academy of Urthopaedic Surgeons

a 4-mm burr is used to create a longitudinal tunnel along the axis of the medial epicondyle. Care is taken to avoid epicondyle, at the proximal end of the tunnel, two small anterior exit points are made using a 1.5-mm drill or a small burr. These points are positioned anterior to the intramuscular septum {LE to Ll} cm apart. The native

UC L is repaired using a 2-H absorbable, synthetic suture. For graft passing and fixation, the forearm is maintained in supination with a mild varus stress applied to the elbow. The graft is passed from anterior to posterior

Drthopaedic Knowledge Update: Sports Medicine 5

"fl 1]

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fill

a!

Section 1:1}pperExtremity

through the ulnar tunnel. The previous placed trac-

tion sutures are passed into the humeral tunnel and out

through one of the two exit holes. This litub is held taught

while the elbow is moved from flexion to extension to

confirm isometry. Optimal graft length is determined

using the exit hole as a reference point. This point is marked on the graft, and a second locked Krakow stitch is placed into the free end of the graft just proximal to

the mark before trimming excess graft. The second limb of the graft is passed up into the humeral tunnel and

through the empty exit hole, completely docking the graft

{Figure 6}. The sutures are tied over the osseous bridge on

1: Upper Extremity

the humerus, securing the graft in place. Subcutaneous

ulnar nerve transposition is performed only if clinical

symptoms are present preoperatively or it is found to be unstable at the time of surgery. |lifiutcemes following UCL reconstruction are favorable.

Figure 6

Intraoperative photograph demonstrates final graft placement after shuttling through

the ulnar tunnel and decking into the humeral tunnel. The native ulnar collateral ligament remnant is incorporated into the reconstruction.

In 2010, a large case series evaluated clinical outcomes in 7’43 athletes using the American Sports Medicine Institute modification“ and found that 33% of athletes returned to the same level of competition after surgery or higher, with an average time of 11.6 months from sur-

toms manifesting as the final stage of a chronic pathelegic process. More commonly, flexer-pronater injuries occur

functional outcomes in 90% of patients following the decking technique with a trend to greater rates of return

tendinitis to partial tears. These injuries are often associated with UCL attenuation, exposing the muscles

gery to competition. lEither studies have found excellent to play when compared with the Jobe modificatieufilrfl The DANE TJ modification has also been shown to have

excellent outcomes, with 36% of athletes returning tn preinjury level of play.“

The most common complication following UCL re— construction is ulnar nerve neurapraxia, which usually resolves over the course of several months.” Rates of ulnar nerve neurapraxia can be as high as 16%, although these results are associated with older surgical techniques

most cases, acute rupture is preceded by prodromal symp-

on a spectrum ranging from mild overuse and chronic

to increased stress.” Similarly, age is a substantial risk

factor for combined UCL and flexor~pronator injuries.” Nonsurgical treatment of these injuries is the mainstay

of management. Treatment with active rest, ice, NSAIDs,

and physical therapy with gradual return to throwing is almost always curative. Surgical management, consisting of débridement and repair, is indicated in patients whose nonsurgical treat-

ment has failed. This commonly presents as recurrence

in which transposition of the ulnar nerve was regularly

of weakness andi'er pain with throwing. In such cases, a

postoperative neurapraxia secondary tn limited handling

evaluation of the athlete and imaging are critical.

performed.31 |D‘utcemes studies involving the decking and DANE T] methods have shown a substantial decline in

of the nerve. |Either reported complications are rare and include iatrogenic fractures, wound complications, and stiffness.25

Flexer-Prenator Mass Injuries The flexor-pronater muscles are key dynamic stabiliz-

ers in the elbow, countering the high valgus load during the throwing motion. During the acceleration phase of the throwing motion, these muscles cnntract repetitively

missed underlying pathology such as a UCL injury may be the cause.” A high level of suspicion and careful reRadiocapitellar Joint IE'iverl ead

Radincapitellar joint overload is a phenomenon caused

by the tremendous compression forces exerted on the joint during the overhead throw. Although the underlying pathophysiolngy is thought to be the combination of re-

petitive compressive trauma, ischemia, and genetic predis— position, the distinct cause remains unclear.” The injury most commonly presents with less of elbow extension,

tn stabilise the elbow. Similarly, the muscles contract eccentrically to protect the elbow from pesteromedial

swelling, joint effusion, and lateral elbow pain with both palpation and valgus stress. Radiocapitellar joint over-

into extension. Acute rupture, although rare in overhead athletes, can occur during such forceful movements. In

capitellum. A trial of nonsurgical treatment is indicated

impingement in the deceleration phase as the elbow moves

flrdtopaedie Knowledge Update: Sports Medicine 5

load can manifest in various injury patterns, including

marginal osteophytes, chondremalacia, or GED of the

El 1016 American Academy of Cirrhopaedic Surgeons

Chapter 6: Elbew Arthrescepy and the Threwer's Elbew

E "fl 1]

e, F”

ii E.

m

Figure i"

Arthrescepic views depict an esteech en dritis disseca ns {GED} Iesien ef the elbevur befere {A} and after {B}

mirrefracture.

fer patients in whem early {stage I] DIED lesiens have been

immature athletes, radial head enlargement can develep

chend ral bene invelvement, and geed elbew functien are

creased risk fer early arthritis and are thus less likely te

these with advanced [stage II and III} 0CD lesiens are

te manage leng—tertn geals and expectations.

diagnesed. Yenng patients with epen capitellar grevvth plates, lecaliaed flattening er radielucency witheut subprime candidates fer nensurgical care.” Patients whese nensurgical treatment has failed and

indicated fer surgery. Stage II lesien are unstable, parr

daily detached fragments ef cartilage with lateral buttress

and may predispese these patients te early esteearthritis. Similarly, patients with large lesiens can alse be at in-

report geed leng—term eutcemes.” It is imperative fer treating physicians te educate patients abeut these risks

invelvement.3 Treatment censists ef arthrescepic débride-

Pesteremedial lrnpingernent Cemmenly, symptematic pesteremedial impingement

scribed, healing rates are unpredictable.” Alternatively,

graphic signs ef impingement and wbe remain asymptem-

diameter”5 {Figure 7"}. Mesaicplasty can be perfermed fer

the intensity er frequency ef play, can defer te nensurgical

ment using the lateral and pesterelateral pertals. Altheugh fracture fixatien ef acute grade II lesiens has been defragment eacisien and arthrescepic er mini—epen micrev fracture can be perfermed fer lesiens smaller than 7’ mm in

defects greater than T' mm, with geed early eutcemesF‘E'E-a? In these cases, graft can be harvested frem the far lateral er medial edges ef the lateral femeral cendyle.

in everhead athletes is treated surgically. Hensurgical management is reserved fer everhead athletes with radie-

atic. Similarly, symptematic individuals whe medify their sperts activity, either by changing pesitiens er reducing management, including rest and physical therapy with dynamic stabilizing and strengthening exercises. Rehabilitatien fer cempetitive athletes with symptem-

Stage III lesiens are unstable, fully detached cartilage fragments that present as intra-articular leese bedies.

atic pesterier medial esteephytes er intra-articular leese hedies is usually unsuccessful and surgery is indicated. As

and grafting can be censidered fer larger lesiens. Reperts

quently secendary te underlying UCL insufficiency. Treatment ef impingement witheut apprepriately treating the

These injuries are treated in a manner similar te stage II lesiens; micrefracture is indicated fer smaller lesiens demenstrate geed early eutcemes with impreved range

ef metien and a high rate ef return te spurt in preperly selected adelescent athletes. I.'.Zlverall, appreitimately 35% ef patients return te their preiniury level ef play?!” Clutcemes in yeunger patients with epen radial physes and these with large lesiens are less censistent.“l In skeletally

Eb Ifllti American Academy ef flrdiepaedie Surgeees

described previeusly, pesteremedial impingement is fre-

UCL injury results in peer functienal eutcemes. There-

fere, arthrescepic management ef pesteremedial impingement is preferred because it allews surgeens te evaluate

the integrity ef the UCL using the arthrescepic valgus

stress test and perferming recenstructien if necessary. The pesterelateral and pesterier pertals previde visualizatien

Drthepaedic Knewledge Update: Sperts Medicine 5

a!

1: Upper Extremity

Sectinn 1: Upper Extremity

A Figure 3

Arthrnscnpic views of pnsternrneclial nlec rannn nstenphytes nbtainecl frnrn the pnsternlateral pnrtal befnre (All and after {I} resectinn at the nstenphytes tn the level at native bnne. avnirling excessive resectinn and instability.

nf the pnsterinr recess and the entire nlecrannn. Resectinn at the pnsternmedial nlecrannn nstenphytes is perfnrmed

injury during capsulectnmy and débridement nf the elbnw, including the use at blunt retractnrs tn sweep neurnvas-

the shaver in the transtriceps pnrtal {Figure I]. A small.

curved nstentnme can else be used. Resectinn shnuld

supine pnsitinning using an arm hnlder limits pressure en the antecubital fnssa. allnwing critical neurnvascular

nf native bnne because excessive nlecrannn resectinn is assnciated with valgus elbnw instability in the setting at

lEllecrannn Stress Fractures

with the arthrnscnpe in the pnsternlateral pnrtal and

be limited tn the nstenphyte itself withnut débridement

cular structures nut nf the wnrlting field.“‘l Additinnally. structures tn fall away frnm the surgical field.

cnncnmitant chrnnic UCL insufficiency“ (Figure 3}. Mule

Dlecrannn stress fractures result frnm repetitive micrn-

specific type nf resectinn; hnwever, a 1936 study demnnu

presents as pnsternmedial nlecrannn pain during and after

tiple studies have demnnstrated the rnle nf the prnrtimal nlecrannn in elbnw stability. Studies vary based cm the

trauma and errcessive tensile stress frnm the triceps tendnn and pnsterinr impingement nf the nleerannn. The injury

strated that resectinn nf the prnrtimal 25% nf the nlec— rannn reduces cnnstraint by 3fl‘3‘rh in eatensinn and 59%

thrnwing and has a prevalence nf 5.4% in baseball—related elbnw injuries.“ The same study found that TD% tn 90%

pnsternmedial resectinn caused changes in valgus angn— latinn.“El An intranperative arthrnscnpic valgus stress test

limiting full eatensinn tn allnw the heme tn heal.

in 9D“ nf flexinn.“ A lflflfi study fnund nnly 3 mm nf must be perfnrmed tn avnid missing any underlying UCL

nf these injuries nccur cnncnmita ntly with a UCL injury. Firstrline treatment cnnsists nf rest, immnbiliaatinn, and Surgical treatment is perfnrmed in patients with

injury. The pnsternmedial gutter must be de'brided with cautinn tn avnid iatrngenic injury tn the ulnar nerve. In

persistent pain after prnlnnged rest and in cnmpetitive thrnwers with cnmplete fractures. The basic principles

ulnar nerve transpnsitinn is indicated. Snme thrnwing athletes demnnstrate mnre advanced

fracture is the primary gnal. Dpen reductinn and internal fixatinn using a cannulated screw has high success rates

patients with prenperative ulnar neuritis, a cnncnmitant

arthritic changes assnciated with pnsternmedial impinge-

nf fracture fixatinn apply, and cnmpressinn thrnugh the

in returning athletes tn their previnns level nf prelnjury

ment. Treatment can be challenging because nf cnntrac— tures and the prnsrimity nf neurnvascular structures tn

play nr higher” {Figure 9}. The mnst cnmmnn cnmplicatinn fnllnwing surgery is painful hardware, with 33%

release can assist with mntinn and pain relief. A 21313 study described a stepwise apprnach tn prevent nerve

Fracture nnnuninn. althnugh rare, can be seen in ynung patients with undiagnnsed chrnnic elbnw pain nr in these

the anterinr elbnw. Ussenus spur remnval and capsular

flrdmpaedie Knnwledge Update: Sparta Medicine 5

nf patients requiring additinnal surgery fnr remnrral.“E

El 1016 American AeadMy nf Drthnpaedie Surgetms

Chapter 6: Ell'revrr Arthrescepy and the Threwer's Elhew

Annotated References

I. Andrews JR, Earsen WE: Arthrescepy ef the elbew. Arthrescepy 1935;1{2}:9?—101 Medline DUI it. Dedsen CC, Nhe 5], Williams E] III, Altchelt DW: Elbew arthrescepy. I Am Acad firthep Surg lflflflflfijlflltfiT’d535. Medline 3. Ahmad CS, ElAttrache NS: Treatment ef capitellar es-

teechendritis dissecans. TechI Shenlder Elbert! Sung lDflE;?:169—l?4. DUI

4. Bennett Jl'vl: Elhew arthrescepy: The basics. I Hand Surg Am 2013;33lllflfi4—161 Medline DUI This article fecuses en the basic surgical setup and technique fer elhew arthrescepy. The anther discusses current indicatiens and centraindicatiens fer the precedure, as

well as cemmen cemplicatiens.

Figure 9

Lateral radiegraph demenstrates healed

elecranen stress fracture fellewing fixatien with a partially threaded, cannulated screw.

5. Eyrarn IR, Kim HM, Levine WM, Ahmad C5: Elhew

arthrescepic surgery update fer sperts medicine cenditiens. Am I Sparta Med 2013;41l9l:2191-22fl2. Medline [Hill This article prevides an update en the current indicatiens,

treated nensurgically. In such cases, surgical fixatien with

a cannulated screw has been shewn te be an excellent treatment eptien.“ Summaryr

Elbew injuries are a premine nt phenemenen ameng ever—

head athletes. As athletes heceme cempetitive at yeunger ages, the incidence ef these types ef injuries will centinue

te grew. Censequently, research needs te be directed ter ward impreving en and develeping new treatment metheds fer the va rieus pathelegies asseciated with cempetitive

threwing. Currently, arthrescepic management is a viable treatment eptien fer many ef these injuries, previding

premising functienal eutcemes and minimal merbidity.

As surgical techniques evelve and surgeens beceme familiariaed with the arthrescepic methed, the applicatiens ef clbew arthrescepy will centinue te expand.

medern techniques, and eutcemes fellewing elhew ar-

threscepy. The anthers describe the meat cemmen surgical techniques te treat the mest cemmen pathelegies within the elbew jeint. The irupertauce ef apprepriate indicatiens and preper technique are highlighted. 6. Field LD, Altchelt 13W: Evaluatien ef the arthrescepic

valgus instability test ef the elbew. Am ,i' Sperts Med 1995;24llltlTr'T—lfll.Mcdline DUI

T. Baker CL Jr, Jenes GL: Arthrescepy ef the elbew. Am ,i' Sperts Meal 1999;2Tl2]:251-264. Medline 3. Kelly EW, Merrey BF, G‘Driscell 5W: Eemplicatiens

ef elhew arthrescepy. } Hesse jer'm Surg Am 2001;33Aill:25-34. Medline

9. Saveie FH III, Field LD: Eemplicatiens ef elbew arthrescepy, in Saveie FH, Field LD, eds: AANA Advanced ArIbrescepy: The Wrist and Elia-1w. Philadelphia, Saunders! Elsevier, lfllfl, pp 14E-15fl.

Key Study Feints

The testheelc cevers basic and cemples elbew pathelegies that can be treated using arthrescepy. A thereugh review ef arthrescepic indicatiens, surgical techniques,

I Elhew arthrescepy, altheugh technically challeng-

elbew arthrescepy is alse discussed.

ing, is an impertant reel in an elbew surgeen’s armamentarium.

1* Knewledge ef threwing hiemechanics is crucial fer

understanding injuries seen in everhead athletes.

1* Injury te the UCL must be ceusidered in an ever-

head athlete with elhew pain.

Eb Ifllti American Academy ef flrdtepaedjc Surgeens

eutcemes, and cemplicatiens are reviewed. The future ef 1D. Nelsen GM, Wu T, Galata Ltvt, Yamaguchi K, KeenerJD: Elbew arthrescepy: Early cemplicatiens and asseciated risk facters. I Sheulder Elbew 3mg 2fl14;23{2l:2?3-2T3.

Medline DUI

This case series ef 417ir elhew arthrescepies evaluated

early cemplicatiens fellewing the precedure and reviewed asseciated risk facters. The study feimd an everall

Drrhepaedic Knewledge Update: Sparta Medicine 5

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cemplicatien rate cf 14%. Mes: cemplicatiens were miner and transient in nature. l'viajer cemplicatiens. the mest cemmen ef which was deep infectien. eccurred in 5% cf

cases. Lewl ef evidence: IV.

11. Marti D. Spress C. Jest E: The first 100 elhew arthrescepies ef ene surgeen: Analysis ef cemplicatiens. I Shealder HittersI 5mg 2313;12j4}:56?—5 T3. Medline DUI This case series ef 1'30 censecutive elbew arthrescepies

analysed cemplicatiens seen fellewing elbew arthrescepy.

The everall cemplicatien rate was 5%. with ne majer cemplicatiens eccurring. Ne asseciatien was seen between cemplicatiens and the cemplexity ef the precedure er the

1: Upper Extrem tty

surgeen's learning curve. Level ef evidence: IV.

12. Saveie FH III. 1|Itl'anflice W. U’Brien M]: Arthrescepic tennis elhew release. I Shenl‘der Elbert! Sarg 115110519112. Suppljfil-Se. Medline DUI This review details surgical technique fer treating lateral epicendylitis using elbew atthrescepy. The results ef recent studies evaluating functienal eutcemes are discussed. The anthers cenclude that arthrescepic release ef lateral epicendylitis is an excellent eptien fer patients whese nensurgical treatment has failed. 13. Hirsch] RP. Ashman ES: Elbew rendinepathy: Tennis elbew. Cite Sperts Med 2333;22j4j:313- 335. Medline DUI 14. |Ceenrad KW. Heeper 1WK: Tennis elbew: Its ceurse. natural histery. censervative and surgical management. I Ilene faint 5mg Arr: 13T3;55[E]:1 1??—1 132. Medline 1.5. Kim DH. Gambardella RA. Elattrache H5. Yecum LA.

jehe FW: Arthrescepic treatment ef pesterelateral elhew

impingement frem lateral synevial plicae in threwing athletes and gel fers. Art: I Sperts Med 2936;34j3j:433-444. Medline DUI

16. Latterma an E. Remee AA. Anbari .31. et al: Arthrescepic debridement ef the extenser carpi radialis brevis fer recalcitrant lateral epicendylitis. j Shealder Elbert: Snrg 201D;19{5}:551-556. Medline DUI This retrespective review cf 36 patients with lateral epicendylitis treated with surgery assessed the eutceme ef

arthrescepic release ef the ECRE with a mean fellew—up

ef 3.5 yea rs. The results shewed substantial imprevement in pesteperative pain and a mean return te I'ull activity ef 7-" weeks. He majer cemplicatiens were identified. Level ef evidence: III. 1?. Selbeim E. Hegna J. fiyen J: Arthtescepic versus epen tennis elhew release: 3— re 6-year results ef a case-centrel series ef 305 elbews. Arthrescepy lfllfiilfljflmfl-ESE. Medline DUI This case-centrel study cempared the eutceme ef arthrescepic and epen treatment eF lateral epicendylitis in 3!] patients at a minimum fellew—up cf 3 years. Patients were evaluated using the QuickDASH scale. Substantially better sceres were reperted in the arthrescepic greup.

13. Grewal R. MacDermid JC. Shah P. King '3]: Functienal eutceme ef arthrescepic extenser carpi radialis hrevis tenden release in chrenic lateral epicendylitis. } Hand Surg Am 2339;34l51:349-351 Medline DUI This case series cf 36 patients with chrenic lateral epicendylitis treated with athrescepic release reperted en pesteperative Functienal eutcemes. Thirty patients impreved with surgery: mest reperted geed te excellent results. Werlters’ cempensatien and heavy laher were asseciated with substantially werse eutcemes. Level ef evidence: IV. 19. Jenes Iii]. Usbahr DC. Schrumpf MA. Dines J5. Altchelt DW: Ulnar cellateral ligament recenstructien in

threwing athletes: A review ef current cencepts. FLAGS exhibit selectien. I Berra jetnt Snrg An: 2312:94t31m49. Medline DUI

This review article details the anatemy and functienal

biemechanics ef the UCL. Werlt—up and management ef

the th rewing athlete with UCL injury is described, and a thereugh review ef surgical techniques and clinical eutcemes was cenducted.

20. Patel RM. Lynch T5. Amin NH. Calahrese G. Grysle 3M. Schickendantx MS: The threwer’s elbew. Urthep C'It'n Netti: Arr: 2314;45{3j:355-3?6. Medline

DUI

This cemprehensive everview includes the functienal anat—

emy ef the elbew. the biemechanics ef th rewing. and the varieus pathelegies incurred with repetitive threwing in everhead athletes. Clinical ptesentatien. werlc-up. and

management ef the mest cemmen injuries are cevered in detail.

21. IL‘allaway GH. Field LD. Deng IH. et a1: Eiemechanical evaluatien ef the medial cellateral ligament ef the elbew. I Bette Ieirtt Surg Am 199?;T9j3l:1213-1231. Medliue

12. IEtshahr DC. Dines JS. Ereaseale NM. Deng EH. Altchelt DW: Ulnehumeral chendral and ligamenteus everlead: Biemechanical cerrelatien fer pesteremedial chendrelnalacia ef the elhew in threwing athletes. Hm ] Sperm Med 2313;33j13}:2535-2541.Medline DUI This cad aver study evaluated the pathelegic hiemecha nics ef an elbew with valgus laxity in six specimens subjected

te static valgus lead. Centact ferces and centact area shift

acress the pesteremedial elhew were measured hefere and after sectiening ef the anterier bundle ef the UCL. The results shew abnermal centact acress the pesteremedial

elhew secendary te valgus laxity.

13. Fleisig U3. Andrews JR. Cutter GE. et al: Risk ef serieus injury fer yeung baseball pitchers: A. Ill-year pre— spective study. Aer I Sperts Med 2311:39t2):253-25T. Medline DUI This cehert fellewed 431 yeuth pitchers ever 13 years te

quantify the cumulative incidence eI threwing injuries.

The everal] incidence ef injury was feund te he 5%. A sub stantial increase in risk ef injury was seen in athletes pitching mere than 133 innings per year. Level ef evidence: III.

Level ef evidence: III.

Urrltepaedic Knewledge Update: Sperts Medicine 5

El 1016 American Academy ef Urrhepaedic Surge-ens

Chapter IS: Elbow Arthroscopy and the Thrower's Elbow 24. Dlsen 5] II, Fleisig GS, Dun S, Loftice J, Andrews JR: Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am] Sports Med lflflfiflflfijflifl #11. Medline DUI 25. Bruce JR, Andrews JR: Ulnar collateral ligament injuries in the throwing athlete. J Am Acad firthop Strrg 2fl14:22{5j:315-325.Medlitte DUI This review provides a comprehensive overview of UEL injuries in overhead athletes and the treatments used for these injuries. 26. Will: KE, Macrina LC, Cain EL, Dugas JR, Andrews JR: Rehabilitation of the overhead athlete's elbow. Sports Health 2012;4{Sj:4fl4-414. Mcdiinc DUI This review article discusses the basic principles behind rehabilitation following elbow injury. The authors review the various phases of a standard rehabilitation protocol

and describe specific nonsurgical and postoperative re—

habilitation guidelines for common elbow injuries and procedures. 2?. Rettig AC, Sherrill E, Snead DS, Mendler JC, Mieling P: Nonnperative treatment of ulnar collateral ligament injuries in throwing athletes. Arr: J Sports Med lflfllfiSHJflS1?. Medlinc

23. Dodson CC, Slenker H, Cohen SB, Ciccotti MG, DeLuca

P: Ulnar collateral ligament injuries of the elbow in professional football quarterbacks. J Shoulder Elbow Sarg Efllfl;19{3l:12?fi-123fl.Medline DUI The article reviewed 11] cases of UCL elbow injury in

NFL quarterbacks, describing the type and mechanism

of injury, player demographics, method of treannent, and return tn play. In nine athletes, nonsurgical management resulted in successful return to play at an average of 16.4

days. Level of evidence: I‘v'.

29. Podesta L, lErow SA, 1|vlolhmer D, Bert T, Yocum LA: Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma. Am J Sports Med Efl13;41{?l:1639-1694.Medline DUI This case series reported on the functional outcomes of S4 overhead athletes with partial-thickness UCL tears treated with PRP. At an average follow-up of PD weeks, 33% of athletes had returned to their previous level of play at an average time of 11 weeks. The authors concluded

that PRP is an effective treatment option for partial UCL tears. Level of evidence: IV. 3t]. Savoie PH 111, Trenhaile SW, Roberts J, Field LD, Ramsey

JR: Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: A case series of injuries tn the proximal and distal ends of the ligament. Am J Sports Med lflflS:36{6]:1066—1W2. Medline DUI

31. Cain EL Jr, Andrews JR, Dugas JR, et al: Clutcome of

This case series evaluated the functional outcomes of T43.athletes treated with surgical UCL reconstruction using

a modified Jobe technique. At a minimum follow-up of

1 years, results demonstrated an 33% rate of return to previous level of competition less than 1 year after surgery. Level of evidence: IV.

32.. Bowers AL, Dines JS, Dines Dlvl, Altchek DW: Elbow medial ulnar collateral ligament reconstruction: Clinical

relevance and the docking technique. J Shoulder Elbow Sarg lfllflfl BjSuppl 21:11fl-11Ti. Medline [1-01

This case series documented the treatment course of .11 overhead athletes with UCL insufficiency. A modified version of the docking technique for UCL reconstruction

was used to treat the injury. At follow-up, 90% of athletes

had excellent results. No complications occurred. Level of evidence: I‘v".

SS. Watson IN, McQueen P, Hutchinson MR: A systematic review of ulnar collateral ligament reconstruction techniques. Am J Sports Med 2D14;42{1flj:251fl-251£. Medline DUI

"fl 1]

This systematic review of 21 studies reported on outcomes following various UCL reconstruction techniques. The overall complication rate was 13.6%.; the most common complication was ulnar nerve neuraprascia. The overall rate of return to play was 13.9%. Level of evidence: W.

a!

34. Dines JS, ElAttrache NS, Conway JE, Smith W, Ahmad CS: lElinical outcomes of the DANE TJ technique to treat ulnar collateral ligament insufficiency of the elbow. Am J' Sports Med 200?;35j12}:2fl39-1fl44. Medline DUI 35. Dsbabr DC, Swaminathan SS, Allen AA, Dines JS, Coleman SH, Altchelt DW: IIEombined flexor-pronator mass

and ulnar collateral ligament injuries in the elbows of older baseball players. Ara J Sports Med lfllflflflfljfifl-TSR Medline DD]

This case series of 13'? baseball players undergoing UCL reconstruction evaluated the athletes for concomitant

fleaor—pronator mass injury, with 3 players undergoing

flesor-pronator debridement. Athletes older than 30 years were substantially more likely to sustain combined UCL and fleaor—pronator mass injuries. Level of evidence: I'v'. 36. Jones KJ, Wiesel BE, Sanka: WM, Iflanley TJ: Arthroscopic management of osteocbondritis dissecans of the capitellum: l'vlid—term results in adolescent athletes. J Pediatr Drrhop 2010:3flj1]:S-13. Medline DUI This case series of 25 adolescent athletes undergoing arthroscopic treatment of capitellar DCD evaluated func-

tional outcomes. Patients were treated with arthroscopic

dEbridement, drilling, andior bone grafting. At a mean follow-up of 4 years, patients were found to have substantially improved range of motion and a high rate of return to sports.Level of evidence: I‘r'.

ulnar collateral ligament reconstruction of the elbow

3?. Talcahara l‘vi, l'viura bl, Sasalti J, Harada M, Ggino T:

1-year follow-up. Am J Sports Med 2010;33i11jtl4-Efi14-34. Medline D01

dissecans of the humeral capitellum. J Boasjairir Sarg Am 1|]fl?;3 9i=1 EDS-1 214. Medline DUI

in 1231 athletes: Results in P43 athletes with minimum

Eb Ifllti American Academy of flrfltopaedic Surgeons

E

Classification, treatment, and outcome of osteochondritis

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Section 1:UpperEartrernit'jr

38. Iwasalti H, Kato H, Ishiltawa _], Masulto T, Funaltoshi T, Minami A: Autologous osteochondral mosaicplasrv for osteochondritis dissecans of the elbow in teenage athletes. I Bone Joint Snrg An: 2UD9:91i1fli:2359-2366. Medline DUI This study reported on the functional outcomes of 15‘ adolescent competitive athletes undergoing mosaicplast].r for elbow QED. At a mean follow—up of 45 months, 13 athletes had excellent or good clinical results, and all but I returned to their previous level of play. Level of evidence: IV. 39. Yamamoto Y, Ishibashi Y, Tsuda E, Sato H, Toh 5: Usteo-

1: Upper Eatrem ity

chondral autograft transplantation for osteochondrifis dis-

secans of the elbow in juvenile baseball players: Minimum 2-year follow-up. Am I Sports Med 2i] fl6:34{5}:T14-T2l}. Medline Dfli

4|]. Mivalce J, Masatomi T: Arthroscopic debridement of

the humeral capirellum for osteochondriris dissecans:

Radiographic and clinical outcomes. 1 Han-:1r Snrg Ans lfll’lfifilflhlflffl-HES.Medline DUI

This retrospective review reported on outcomes of arthroscopic débridement of the capitellum in 1'36 adolescent patients diagnosed with 0CD. At an average follow-up of 13 months, 34% of patients were pain free and 35% had returned to their previous level of play. La rge lesions or an open proximal radial phvsis at the time of surges]:r

were associated with poor outcomes. Level of evidence: III.

41. Kamineni S, ElAttrache N5, D’driscoll SW, et al: Medial

collateral ligament strain with partial posterornedial olec—

ranon resection. A biomechanical studv. I Bonejor'nt Surg Am lflfl4;36-A{11}:2424-243i]. Medline 42. An KN, jl'viorreyr BF, lIZhao ET: The effect of partial removal of proximal ulna on elbow constraint. Cffn Drtbop Refer?

Res 1935,2fl9:1?i}—2?9. Medline

44.

Blonna D, Woli, Fitasimmons J5, fl'Driscoll SW: Prevention of nerve injurv during arthroscopic eapsulectomyr of the elbow utilising a safetv~driven strategv. ] Bone joint Surg Am 2013;95i15]:13T3-1331. Medline DUI This retrospective review reports on the incidence of nerve injurvr in a series of Sill arthroscopic elbow contracture releases. Twenty—five patients {5%} had nerve palsies associated with prolonged tourniquet time, ulnar nerve transposition, or retractor use. All deficits had resolved at 2-year follow-up. Level of evidence: III.

45. Furushima K, Itoh Y, Iwabu S, Yamamoto ‘1’, Huge R, Shimiau M: Classification of olecranon stress fractures in baseball players. An: 1 Sports Med IOI4;42{6}:1 343-1351. Medline DUI This case series of EDIE] baseball players diagnosed with olecranon stress fractures evaluated the orientation of the fractures using various imaging modalities. A novel classification system was presented for these fractures based on the origin and direction of the fracture plane. Level of evidence: IV. 46. Paci JM, Dugas JR, Gov JA, et al: Cannulated screw fixation of refractoryr olecranon stress fractures with and without associated injuries allows a return to baseball. Am I Sports Med 2013:41l2l:3flE-312. Medline DUI This case series reported functional outcomes in 13 patients treated with open reduction and internal fixation for an olecranon stress fracture. All 13 fractures went on

to union, and 94% of athletes returned to their previous

level of play. fit an average follow-up of 6.2 years, six patients had undergone removal of hardware, two of which for infection. Level of evidence: IV. 4?. Rettig AC, 1|ifii'urth TR, Mieling P: Nonunion of olecranon

stress fractures in adolescent baseball pitchers: ii. case series of 5 athletes. Am I Sports Med EU Dd:34{4}:653—656.

Medline DUI

43. Kamineni S, Hirahara H, Pomianowslti S, et al: Partial poeteromedial olecranon resection: A. kinematic study. J Bone joint Snrg An: lflflfifijarea [11215-1011. Medline

flrrhopaedie Knowledge Update: Sports Medicine 5

El 1016 American Aeademv of Cirrhopaedic Surgeons

Chapter 1

Acute/Traumatic Elbow Injuries Iohn P. Haverstoclt, MD, FRCSC

lGeorge S. Athwai, MD. FRCSC

Abstract

out fracture in the acute setting. It is a sensitive screening

Fractures and dislocations around the elbow range from

tool {96.8%} to identify patients who would benefit from further radiographic assessment. The elbow extension test

and sports medicine physicians may encounter several

and supinated forearms to flex his or her shoulders to fill“ and fully extend and lock both elbows. In a study of

simple isolated injuries to complex injuries of multiple bony and ligamentous stabilizers. Ililrthopaedic surgeons patterns of elbow injuries. Thorough knowledge of classic studies and recent evidence for the diagnosis

and treatment of radial head fractures, simple elbow

dislocations, complex elbow instability, triceps and biceps injuries is necessary for optimal outcomes.

Keywords: elbow trauma: acute elbow injury: elbow dislocation: radial head fracture: terrible

triad: PLHI: posterolateral rotatory instability: coronoid fracture; posteromedial rotatory instability; complex elbow instability: triceps rupture; biceps rupture Introduction

The elbow is a complex assembly of joints that requires

prompt diagnosis and treatment after acute injury to maximize outcomes and avoid instability, stiffness, and

pain. Physical examination in combination with radio graphs, and frequently advanced imaging, is required for adequate assessment of complex fractures or soft-tissue injury patterns.

Most physical examination special tests are more ef-

fective after initial inflammation and pain have settled;

however, the elbow extension test can be used to help rule Dr. Athwai or an immediate family member has the potential to receive royalties from imascap; serves as a paid consultant to DePug Smith 5 Nephew, and Tornier; and has received research or institutionai support from DePug Exactech. Smidi s Nephew. Tomiec and simmer. Neither Dr. Haverstocir nor any immediate family member has received anything of value from or has stocir or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter:

@ lfllfi American Academy of Drthopaedic Surgeons

is performed by asking the seated patient with exposed

patients who were unable to perform the elbow extension

test, almost 5fl% had sustained a fracture.‘ The negative predictive value for fracture in adults and children able to extend the elbow was 93.4% and 95.3%, respectively.

The elbow is a commonly injured joint in the upper extremity. At the lflll Summer Diympics Games more

than one-half of elbow injuries occurred in judo and

weightlifting; elbow injuries in throwing athletes were less common} Surveillance of National Football League

injuries over a 10—year period revealed that the elbow

was commonly injured {53% of 359 upper extremity injuries]; 76% of elbow injuries occurred in offensive and

defensive lineman, and most were ligament and instability

problems.El

Elbow stability depends on the bony and soft-tissue

stabilizers, which must be assessed with every elbow in-

jury. Primary stabilisers include the nlnohumeral joint,

the lateral ulnar collateral ligament (LUCL) and the anterior bundle of the medial collateral ligament {MCL}.

Secondary stabilizers include the radial head, the common extensor origin, and the common flexor origin, which

become increasingly important after injury to the primary

stabilizers.4

Radial Head Fractures

Radial head fractures, the most common fracture around the elbow, were classified by Mason in l954 and modified

further in 19915 Type 1 fractures are displaced less than 2 mm without a mechanical block to forearm rotation and

can be effectively treated nonsurgically. Type 2. fractures

are displaced greater than 2 mm, may block forearm motion, and are not substantially comminuted. The treatment of type 2 fractures is controversial; however, most authors agree that with the best available evidence and without a block to rotation, this group can be effectively

Orthopaedic Knowledge Update: Sports Medicine 5

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treated nonsurgically. In patients with a block to forearm

rotation that can be attributed to the fracture, surgical

intervention is indicated. Type 3 fractures are severely

comminuted and typically require surgical intervention

to restore elbow and forearm function. In type 3 frac—

Simple elbow dislocations include those without fracture,

in which the medial and lateral ligament complexes are ruptured or avulsed. Elbow dislocations most often occur

tures associated with instability, radial head excision is contraindicated. Although type 3 fractures are highly

in adolescent males participating in football, wrestling, and basketball; or in females participating in gymnastics

the younger, active athletic population an attempt at open

reduction and internal fixation should be considered.

dislocations showed that the typical injury occurs with the arm in near-full extension with a valgus force, which

to the capitellum. When complete loss of cortical con-

mechanisms are described.” Treatment of simple elbow dislocation includes closed

occurs, one study reported that 91% of these fractures were associated with complex elbow instability patterns."

traction, correction of varnsfvalgus angulation, and flexion. Alternatively, the physician can use one hand to grasp

fractures, 10 had sustained chondral injury? Chondral injury to the capitellum was most common in higher-grade radial head fractures. Treatment of radial head fractures depends on the character of the fracture, blocks to pronation and supi-

other hand to grasp the distal humerus, while using the thumb to push the olecranon anteriorly to obtain reduc-

comminuted and typically indicated for arthroplasty, in

Injuries commonly associated with radial head frac— tures include ligamentous injuries, and chondral injuries

1: Upper Extremity

Simple Elbow Dislocations

tact of at least one fragment from a radial head fracture In a series of SD surgically treated Mason type 2 and 3

nation, and associated injuries {elbow dislocation, MEL,

and Essex~Lopresti injuries}. Controversy exists regarding

the best memod of treating type 1 fractures, and a large prospective trial is underway" Stable, displaced partial

articular fractures and those with minimal comminution and displacement can be treated nonsurgically as long

as range of motion recovers and no associated elbow or

forearm stability exists-911” The nonsurgical treatment of minimally displaced tadial head fractures without a block to rotation includes a brief period of immobilization preceding range of motion and active therapy. A prospective randomized controlled

trial of 130 patients with simple radial head fractures

reported that immobilization for 2 days with a sling fol— lowed by active mobilization had superior results in motion, strength, and functional outcomes compared with

and skating.” A review of video footage of 62 elbow

suggests MCL rupture is common, although numerous reduction beginning with stabilization of the humerus,

the patient’s wrist to apply traction and use his or her tion. An examination for stability should be documented

to guide rehabilitation by gradually extending the elbow from flexion with the forearm in pronation, neutral, and supination, noting the angle where subluxation begins.

Radiographs obtained before and after reduction should be scrutinized for radial head fractures, coronoid frac-

tures, intra—articular fragments, or a nonconcentric re-

duction. These occult findings can result in substantial

instability, stiffness, or pain if missed.

Therapy for elbow dislocations with a concentrically

reduced joint must begin within “F to 1|} days. Dverhead motion protocols have been shown to decrease the “drop sign," a radiographic finding of ulnohumeral subluxation

that is worsened by gravity and extra forearm weight {larger arms and elbow hinge braces}.” Isometric exercises

and protective splinting with forearm rotation {pronation for lateral collateral ligament [LCL] insufficiency and

supination for MEL insufficiency} can facilitate protected range of motion. Therapy using this protocol allows heal-

immediate mobilization and immobilization for 3 days.“1 In addition, a fragment displaced more than 4 mm or

ing in the reduced position and decreases the incidence of recurrent instability.lil Elbows with both MEL and LCL

Radial head fractures with more than three fragments are often not amenable to open reduction and internal

neutral pronationl'supination of the forearm, and with the humerus oriented vertically or horizontally to minimize

and osteopeniag,12 however, in the younger, active pop—

A review of Hi} patients at a mean follow—up of 33 months following simple elbow dislocation revealed that

angulated more than 3D” impaired outcome.

fixation because of small fragment size, comminution,

ulation, an initial attempt at fixation is appropriate. To maximize elbow stability, radial head arthroplasty is an

option, which is especially important for complex in— atahility patterns.” The early results of metallic smooth

stem and bipolar radial head implants have been good,

with minimal posttraumatic arthritis and high rates of good to excellent patient-rated outcomes at follow-up.“

flrrhopaedic Knowledge Update: Sports Medicine 5

injuries should undergo rehabilitation with active motion,

forces that promote rotational subluxation1l {Figure I}.

although outcomes are generally good with appropriate treatment, 62% have residual pain, 56% report subjective

stiffness, and 3% have subjective instability.m Additionally, a reduced elbow flexion-extension are predicted

poorer overall satisfaction, with reduced flexion influencing patient outcome more than reduced extension.

El 1016 American AcadMy of Unhopaedic Surgeons

Chapter 1': AcutefI'raumatic Elbow Injuries

In elbows that remain unstable after successful reduction attempts or become unstable subacutely, surgical

treatment should be considered. In a series of 15 patients

with persistent instability following simple elbow dislor

cation, 11 were treated with LUCL repair alone and 3 required the addition of hinged external fixation.21 Elf

those treated with LUCL repair alone, 5 experienced

resubluxation: 1 required later external fixation and 4

were treated with physical therapy alone, all of whom eventually achieved a concentric and stable reduction.

Patients in whom persistent posterolateral rotatory

instability {PLRI} develops have several treatment options. If PLRI is identified subacutely within IE weeks from in-

jury, an attempt at nonsurgical management is reasonable

with splinting at 90° in full pronation. Extension range of motion can be blocked to 45" to El)“, and increased 10“ per week. In patients whose nonsurgical management is

unsuccessful or who present delayed with symptomatic instability, surgical intervention to repair or reconstruct the LUCL is indicated. Posterolateral Ftotatory Instability

lIIZ'lriginally described in 1991, PLRI occurs following injury to the LUCL, allowing rotatory subluxation of the ulnohumcral joint and dislocation of the radiohu— meral joint with a combination of extension, valgus, and supination.fl

The diagnosis of I’LRI can be difficult because symptoms of painful locking or snapping and apprehension

are hard to elicit. The lateral pivot—shift test is best per—

formed with the patient lying supine with the arm overhead, maximal external rotation at the shoulder, and with

I:

Figure 1

Lateral radiograph of the ulnohumeral joint demonstrates the drop sign, which indicates a nor-congruent reduction. This finding usually occurs because of periarticular muscle pain—

related atony and hemarthrosis. If only axial distraction {no medial or lateral translation of

the joint} exists, the elbow can be treated with isometric exercises and overhead rehabilitation can be considered. The patient should be followed with weekly radiog ra phs to ensure improvement. {Reproduced with permission from Pipicelli JG. Chinchalltar SJ. Grewal Ii. King (31: Therapeutic implications of the radiographic

“drop sign" following elbow dislocation. J Hand Ther 2u12;25[3]:346-353. quiz ass. http:i'idx.dol. orgi'1fl.1fl16i'j.jht.2fl12.fl3.flfl3.}

In a study of 19 patients with acute I’LRI treated by LCL repair using nouabsorbable, braided suture or a su-

ture anchor,” Mayo Elbow Performance Score was 36.9 of 1th.], with 12 excellent results, 5 good results, and 1

fair result. Reported complications included heterotopic

the examiner grasping the wrist and forearm to provide a

ossification in five and knot irritation in one. In a study

test result presents as subluxation in extension, and as the elbow is flexed, it pops or slides in to reduction at

anchors to fine-tune the tension of collateral ligament repair, good outcomes in two patients were reported.“

valgus and supination force in full extension. A positive

3D“ to 4i)“. Although poorly tolerated by patients who

are awake, the test is reproducible at various levels of

training with full muscle rela xationfii' The posterolateral drawer test, chair sign, and the inability to do a push-up with the forearms in supination are also useful special tests. Terminal forearm supination {hypersupination}

by the examiner while palpating the radiocapitellar joint

can reveal subtle instability in patients both awake and

under anesthetia. PLRI can be treated in the acute setting as described for simple elbow dislocations, with rehabilitation performed

with the arm in pronation. For those patients with ongo' ing symptoms or instability, repair or reconstruction of the LUCL with tissue plication or tendon graft is recom— mended“ {Figure 2).

IE: lfllfi American Academy of flrrbopaedic Surgeons

of a technique describing the use of tensionable suture

1'I'iilii'ben treating chronic PLRI, the best results are obtained with ligament reconstruction with tendon graft.” However, LUCL reconstruction can also fail. A 21114

study reported that revision of failed LUCL reconstruc-

tion is challenging and that the outcomes are guarded:

one half of patients at follow-up had persistent instability and poorer elbow scores.“ Complex Elbow Instability Complex elbow dislocations include those with associ-

ated fractures and are typically classified into three broad groups: radial head fracture-dislocations {including terrible triad injuries], varus posteromedial rotatory instability ([PMRI] with anteromedial coronoid fractures} and

Drtbopaedic Knowledge Update: Sports Medicme 5

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Section 1: Upper Extremity

head.“ It is recommended that all patients with radiographic findings of a possible coronoid fracture should

undergo advanced imaging using CT to fully characterize

the fractures and instability pattern.

Strict indications for the successful nonsurgical treatment of terrible triad injuries have enabled good results.

Nonsurgical treatment is only advised in patients with a

concentric joint reduction, a radial head fracture without block to rotation, a smaller coronoid fracture {Regan-

Morrey type 1 or 1}, and a stable arc of motion to a

minimum extension of 30” to 45", allowing active range

1: Upper Extremity

of motion within 1i} days.3‘=31 Surgical treatment should be considered for most pa-

tients with terrible triad injuries. A stepwise approach

Figure 2

Illustration deoicts the lateral collateral ligament complex, including the primary

stabilizer, the lateral ulnar collateral llgament, running from the geometric center of the capitellum to the crisis supinato rus. Suture marks indicate a transosseous repair or a

suture anchor proximally, which can be used

to repair acute injuries. {Heprod uced from Mehta. 1A. Bain GI: Fosterolateral rotatory

instability of the elbowJ Am Aced' flrthop 5mg

20-04;11[E]:dfl5-415.l

fracture-dislocations of the proximal radius and ulna {including transolecranon and Monteggia—type injuries). flutcomes following treatment of complex elbow insta-

bility are guarded and poor general health, lack of coopa

to fixation results in good results with minimization of complications.“ Typically, a posterior skin incision with full—thickness fascia-cutaneous flaps is advised for versatil—

ity and to avoid injury to the superficial cutaneous nerves; however, a direct lateral slcin incision is also acceptable.

If the radial head fracture is not reconstructable, the

coronoid fracture can usually be accessed via the lateral

approach following radial neck osteotomy in preparation for radial head arthroplasty. lIZlzherwise, a medial

approach can be suitable for exposure, depending on the fracture configuration. Irrespective, repair of a type 2 or 3 coronoid fracture should be performed to stabilize the elbow to varus loading, which is encountered with shoulder abduction during daily activities.“

Coronoid fracture fixation is accomplished with sotures, screws, or plates, depending on the size, approach,

and comminution of the fragment. During the surgical

eration, obesity, delayed surgery, and high-energy trauma are all poor prognostic factors.”

approach, the coronoid fragment will appear larger than measured on preoperative CT scan; cartilage is a mean 3

Terrible Triad A terrible triad injury is named for the historically poor results seen after an elbow dislocation combined with radial head and coronoid fractures. A more complete

and length associated with thicker cartilage.” For smaller

cruciate ligament drill guide to create two tunnels from

of the elbow and treatments that allow early range of motion following surgical stabilization has substantially

with a nonabsorbable suture. Larger fragments should be fixed with screws in a dorsal to volar trajectory. The

understanding of the primary and secondary stabilizers

improved outcomes. Biomechanical and clinical research

mm thick at the coronoid tip, with greater ulnar height

or comminuted fractures unlikely to be repaired with screw fixation, the authors of this chapter use an anterior

the dorsal ulna and secure the capsule and fragments

biomechanical strength of two different screw trajecto-

has resulted in the development of successful surgical treatment protocols that also have improved patient outcomes. Diagnosis is often clear using plain radiographs, al— though subtle avulsions of the coronoid can be difficult to

ries was assessed in coronoid fixation and the posterior

is possible. {in radiographs, these areas should be assessed carefully, as well as the shape of the posterolateral capital-

head arthroplasty is indicated to provide elbow stability.l1 Because the radial head is a primary stabilizer to PLRI,

instability, as would a Hill-Sachs lesion on the humeral

thopaedic surgeon should not hesitate to proceed with

detect and spontaneous reduction of the elbow dislocation

lum, where an Usborne-Coterill lesion can indicate elbow

flrdsopaedic Knowledge Update: Sports Medicb'ie 5

to anterior screw was found to be stronger, stiffer, and technically easier to use.3'5

In the younger, athletic population, after the coronoid is secured, all radial head fractures should be fixed.

However, if stable fixation cannot be obtained, radial

especially in the context of a coronoid fracture, the or—

fl lflld American Academy of Orthopaedic Surgeons

Chapter 3": Acutefl'raumatic Elbow Injuries

arthroplasty to restore stability. A review of 24 patients treated for terrible triad injuries compared the results for those who underwent radial head open reduction

and internal fixation with arthroplasty.” Good results were noted for the entire group, and patients in the radial head arthroplasty group scored higher in the Disabilities

of the Arm, Shoulder and Hand assessment. Although

these outcomes may not translate to the younger athletic

population, they stress the importance of a radial head Stabilized using either fixation or arthroplasty. Varus PMHI

Anteromedial coronoid facet fractures are associated

with varus PMRI.” This fracture pattern is described

in D’Driscoll’s comprehensive coronoid facturc classification,Jiil which is based on the anatomic location of the main fragments: the tip, the anteromedial facet, and the basal coronoid, often as noted on CT. Anteromedial

facet fractures are further subclassified based on tip and sublime tubercle involvement. A biomechanical study reported that PMRI increases with the sire of the anteromedial cornnnid fracture.“ The instability associated with small D’Driscoll subtype 1 an— teromedial coronoid facet fractures can be improved using LUCL repair alone, whereas larger fractures require bony

1’

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_

e

Figure 3

Illustration dopicts the dome—shaped triceps insertion on the posterior olecranon [outlined] following dissection. The distal triceps tendon should be repaired to reapproximate this footprint.

are useful to confirm and characterize the rupture location in cases that are nuclear or to assess for other pathology. An anatomic cadaver study was performed to quantiinsertion is a confluence of the long, lateral, and medial heads on the posterior surface of the olecranon in a dome

Type 2 anteromedial coronoid fractures were assessed and a treatment algorithm created based on the fragment

head is deep to both the long and lateral heads. The mean triceps insertion footprint was 20.9 mm wide and 13.4

size and the stability to varus and pronation stress testing

under fluoroscopy. Selective fixation of the anteromedial

cornnoid, LUCL repair, or a combination of both were indicated for increasingly unstable patterns.“ Distal Triceps Injuries

fy tendon insertion characteristics.“ The triceps tendon

shape. At the insertion site on the olecranon, the medial mm long {Figure 3}.

Partial triceps tendon ruptures of the medial head in-

sertion have been reported. Following an appropriate trial of nonsurgical management for patients with persistent

pain and dysfunction, surgery can be suggested. Surgery is typically performed open; however, an arthroscopic

Distal triceps tendon injuries are less common than

repair technique has been described that uses suture anchors. Surgical repair for partial triceps tendon injuries

missed acutely because of edema and pain. Patients report weakness and pain, but may have some active elbow

improving strength.“ Complete distal triceps tendon avulsions are debil-

distal biceps tendon ruptures, and diagnosis is often extension because of an intact lateral triceps expansion.

has been reported as successful at eliminating pain and itating and result in pain and weakness. Presently, in

[in clinical examination, patients will have difficulty with extension against gravity and a palpable defect

the younger athletic population, primary repair allows for early rehabilitation and predictably good outcomes.

radiography should be performed because avulsion of an associated olecranon traction spur with the distal triceps tendon can be seen on the lateral view as a sign of proximal tendon retraction. Ultrasonography or MRI

anchors have both been described. In addition triceps repair, the lateral triceps expansion, if disrupted, should

in the extensor mechanism may be present. Standard

IE! lfllfi American Academy of flrthopaedic Surgeons

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fixation in addition to LCL repair to achieve stability. Exposure of an anteromedial coronoid fracture is possible via the approach through the floor of the ulnar nerve, flexor carpi ulnaris splitting, or Hotchkiss over—the—top approaches, although access to the proxirnal ulna for plate application is limited in the over—the top approac .41

'oi 1::ru

Primary open repair with tra nsosseous tunnels or suture be repaired because it constitutes a substantial portion

of the total tendon width.” To re-create the full depth

Drthopaedic Knowledge Update: Sports Medicine 5

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Section 1: Upper Extremiti'

of the triceps tendon insertion, a double-row repair has been described using Keith needles and nonabsorbable,

of flexion strength.” In a more recent, larger study of 13 patients treated nonsurgically at a median of 33 months,

Repair is most successful when performed within the first 3 weeks; all patients in a 2003 series regained 415

to 93% compared with the uninjured side.“ In the only prospective randomised controlled trial,

braided sutures with anchors fer the superficial Iayer.‘*5

manual strength, but a mean of 113""r of terminal extension was lost.“ Distal Biceps Injuries

1: Upper Extremity

Distal biceps tendon avulsion injuries are common and

occur most frequently in the dominant extremity of middle-aged men. Typically, the mechanism of injury is a sudden eccentric muscle contraction that occurs while lifting heavy leads. The underlying pathophysiology is most likely related to degenerative changes to the modon at its insertion on the bicipital tuberosity. 1i.i'ascular,

inflammatory, and mechanical factors are thought to be associated with biceps avulsion injuries. Patients will often hear an audible snap or pop at the

time of injury and report pain and weakness to resisted

elbow supination and flexion. Physical examination usu-

ally identifies an elevated muscle belly, an abnormal hook test result, and loss of the normal rise and fall of the biceps

muscle with forearm rotation. Recently, a study suggested

supination strength recovered to 63% and flexion strength

the outcomes and complications of single— versus dou—

ble-incision distal biceps tendon repair were compared.“

At 2-year follow-up, no clinically substantial differences

were reported in the Disabilities of the Arm, Shoulder and Hand score, the Patient-Rated Elbow Evaluation score, the American Shoulder and Elbow Surgeon elbow

score, or elbow range of motion. Additionally, no differ—

ences were found in supination, pronation, or extension strength; however, the double—incision repair group had

substantially greater flexion strength at follow-up. Furthermore, the complication rate was significantly higher in the single—incision group. Most complications were

transient neurapraxias of the lateral antebrachial cotaneous nerve. Excellent clinical outcomes and advances in fixation techniques have enabled a resurgence of single-incision

technique; however, some concern exists that supination

strength may not be fully reestablished. Single—incision repairs place the insertion of the distal biceps tendon more anteriorly and midline than the native insertion};1

that three physical examination special tests to diagnose complete distal biceps tendon ruptures can expedite di-

The radial tuberosity is oriented at a mean of 56" ulnar to the midsagittal plane of the radius {ra age, 43“ to 6?“).

Positive hook test results, passive forearm pronation, and biceps crease interval test together had lflfl‘it- sensitivity

radial tuberosity could not be re-created using an anterior incision, and that this may be responsible for supi-

results were negative or equivocal, MRI was performed to detect partial injuries.”

techniques for distal biceps tendon ruptures found that bone tunnel [10.4%] and cortical button {fl} methods had

agnosis and avoid the need for MRI or ultrasonography.

and specificity for a complete distal biceps rupture. If test Partial rupture of the distal biceps tendon can also

produce pain and weakness and often results in a delay

in diagnosis. The direct radial tuberosity compression test, in which the examiner compresses 2.5 cm distal to

the radiocapitellar joint to elicit pain with passive pronation and supination of the forearm,“ was performed in patients with a presumed partial rupture. MRI can assist with the diagnosis by visualizing the biceps insertion. The flexed, abducted, supinated view is a method of patient

positioning in the MRI unit, with the shoulder fully ab-

ducted so the arm is beside the head, the elbow flexed to PD“, and the forearm fully supinated. These images along

l[Zine study showed that the anatomic insertion on the

nation weakness.“ A recent systematic review of repair

substantially lower complication rates compared with sorare anchors {16.4913} and intraossous screws {44.3%}55-5‘ {Figure 4). Irrespective of the approach or type of fixation used,

surgeons should be confident in their knowledge of the

anatomy and the best exposure to minimize injury to the lateral antebrachial cutaneous nerve of the forearm, the

posterior interosseous nerve, and the rec orrent branch of the radial artery. Repairs are easiest in the first 2 weeks

following avulsion before scarring of the tendon track has occurred. In sobacute and chronic cases, a primary repair should still be attempted even if up to 5'0” to 100”

the long axis of the tendon from the musculotendinous junction to the insertion ease interpretation and reduce

of elbow flexion is required to reduce the tendon to the tuberosity. Repairs in extreme flexion eventually lengthen

Nonsurgical management can be considered in patients with acute distal biceps tendon injuries. Good results have

primary repair is not possible, aotologous or allograft

errors due to volume averaging.”

been reported with nonsurgical management and historic

reports suggested a 4fl‘i'rfi loss of supination and MPH:- loss

firthopaedic Knowledge Update: Sports Medicine 5

and still yield good results.” In chronic cases in which

distal biceps tendon reconstruction is an option that yields satisfactory outcomes.

fl lflld American Academy of Orthopaedic Surgeons

Chapter 5': Acutea'Traumafic Elbow htjuries

Hey Study Points i'ror'rtirnierii r Complex elbow fractures and instability cases should be assessed with CT to fully delineate the

bony injury and plan fixation strategies. ' 1‘vi'arus PMRI typically requires fixation of the anteromedial eoronoid facet, andfor repair of the LUCL to regain stability.

Annotated References

l. Appelboam A, Reuben AD, Eenger JR, et al: Elbow extension test to rule out elbow fracture: Multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BM} ZflflS;33?:a2-4ZS. Medline DUI Figure 4

illustration depicts an axial schematic of the

forearm at the level of the radial tuberosity.

A, Drill placement from an anterior approach with the forearm in full su pination. The results indicate a limited ability to repair the tendon to

its anatomic footprint. B, Drill trajectory for the

double-incision with the forearm in pronation, re-creating the anatomic insertion of the biceps brachii tendon.

Summary

Acute elbow injuries require a thorough physical exam-

ination and often advanced imaging to determine the full extent of injury and instability patterns. Examination under anesthetia and intraoperatively helps to determine the

plan of sequential repair of primary and secondary stabilizers and dictates postoperative rehabilitation. Achieving a concentric reduction and allowing early range of motion

is critical to maximizing outcomes of acute elbow injuries. Hey Study Points

1* Primary stabilizers of the elbow include the ulnohu-

meral joint, LUCL, and the anterior bundle of the

MCL. Secondary stabilizers include the radial head,

the common flexor and extensor origins, and the

joint capsule. These structures should be assessed with every elbow injury. I Simple elbow dislocations benefit greatly from an early rehabilitation protocol started within “.7 to 1D days and routine imaging to ensure concentric reduction. 1* PLRI of the elbow can be difficult to diagnose, and

patients presenting with locking or snapping should be assessed for subtle instability findings.

IE! lfllfi American Academy of flrchopaedic Surgeons

This multicenter prospective development and validation of a study was performed to rule out elbow fracture in both children and adults as they present to the emergency department. Level of evidence: I. 2.. Eethapudi S, Robinson P, Engebretsen L, Budgett R, 1idanhegan IS, D’Connor P: Elbow injuries at the London 2012 Summer Diympic Games: Demographics and pictorial imaging review. AJR Am ] Roentgenol' 1013;1fl1j3}:535549. Medliue DUI This review analyzed elbow injuries sustained during

the 2012 London Summer IEllympic Games. Level of evidence: III.

3. Carlisle JC, Goldfarb CPL, l'vlall N, Powell JW, lvlatava M]:

Upper extremity injuries in the National Football League:

Part II: elbow, forearm, and wrist injuries. An: 1 Sports

Med 2H03;36i10}:1945—1952. Medline DUI

4-. IIC'P'Driscoll SW, Jupiter JE, King G], Hotchltiss RN, Mor-

rey BF: The unstable elbow. Instr Course Leer lflfll:5fl:39102. Medline

5. Hotchkiss RN: Displaced fractures of the radial head:

Internal fixation or excision? } rim dead Orthop Surg 199?;5i1}:1—1{l. Medliuc

ti. Rineer CPL, Guitton TG, Ring D: Radial head fractures: Loss of cortical contact is associated with concomi-

tant fracture or dislocation. ] Shoulder Elbow Surg lfllD;19{1}:21-25.Medline DD] This retrospective review of a large series of radial head

fractures was performed to determine the clinical signifi-

cance of loss of cortical contact in Mason type 31 injuries.

Level of evidence: IV.

3". Halbantoglu Ll, Gereli A, Kocaoglu B, Alttas S, altmen

M: Capitellar cartilage injuries concomitant with radial

head fractures. J Hand Surg Am 2Ufl3:33l9}:1602-lofl?. Medline DUI

Drthopaedic Knowledge Update: Sports Medichie S

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Section 1: Upper Exuemiry

Bruinsma W, Rodde I, de Muinck Reiaer RJ, et al: A randomiaed controlled trial of nonoperative treatment versus open reduction and internal fixation for stable, displaced, partial articular fractures of the radial head: The RAMEU trial. EMU Musculosireiet Disord' 2D14:15l1}:14?. Medline

DUI

This study describes the RAMEU trial to determine opti-

nial treatment of Mason type 2 radial head fractures; the results of this trial are pending.

Lindenhovius AL, Felsch Q, Ring D, Kloen P: The longterm outcome of open reduction and internal fixation of

stable displaced isolated partial articular fractures of the

1: Upper Extremity

radial head. } Trauma lflfl9;d?{1}:143—146. Medlirle DUI

This study reported on long-term follow-up of surgically treated I'vlason type .1 radial head fractures in 16 patients. Level of evidence: IV. 11“.}. Furey M], Shops DM, 1|l'lli'hite N], Hildebrand RA: A retro-

spective cohort study of displaced segmental radial head fractures: Is 2 mm of articular displacement an indication

for surgery?} Shouirier Elbow Surg 101 3:21l5l:636 4541.

Medline DD]

This retrospective cohort study reported on whether suc— cessful nonsurgical treatment of radial head fractures is influenced by displacement greater or less than 2 mm. No evidence was found to support 2 mm of fracture displacement as an indication for surgery. Level of evidence: II. 11. Paschos NR, Mitsionis GI, Vasiliadis HS, Georgoulis AD: Comparison of early mobilization protocols in radial head fractures. I Urtisop Trauma 2913;2?{3]:134-139. Medline DUI This prospective, randomized controlled study compared two early motion protocols with 1 week of cast immobilization after radial head fracture. Level of evidence: I. 12. Ring D, Quintero],]upiterJE: Open reduction and internal fixation of fractures of the radial head. I Bone Joint Surgflrn 2fl02;S4-A{10l:1311-1SIS. Medline 13. Ring D, Ring G: Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. Surgical technique. I Bone joint Surg Arn lflfl S;Sfl{Suppl 2 Pt 1}:63-?3. Medline 14. Zunkiewica MR, Clemente JS, Miller MG, Earata ME, 1illiysocl-ti RW, Cohen MS: Radial head replacement with a bipolar system: A minimum 2-year follow-up. f Shoulder Eiivour Surg lflllfllfllflS-ID‘L Medline DUI The short-term clinical and radiographic results of 19' patients with a bipolar radial head prosthesis were reported. Level of evidence: IV. 15. Stonebaclt JW, Uwens BD, Syltes J, Athwal GS, Pointer L, 1Wolf JM: Incidence of elbow dislocations in the United States population. ] Bone joint Sui-g Arn 2fl12:94{3}:24l}245. Medline

DUI

Drthopaedic Knowledge Update: Sports Medichie 5

The epidemiology of simple elbow dislocations was recorded by the National Electronic Injury Surveillance System database. Lavel of evidence: II. 16. Schreiber J], Warren RF, Hotchkiss RN, Daluislri A: An online video investigation into the mechanism of elbow dislocation. J Hand Surg An: lfllfiififlldlflflfl-dflil. Medline DGI

This video analysis reviewed arm position and deforming forces during elbow dislocations from YouTuhemom and noted that most elbow extensions occur with the elbow in relative extension. Level of evidence: IV. 1?. Lee AT, Schrumpf MA, Ghoi D, et al: The influence of gravity on the unstable elbow. J Shoufder tou: Singr lfl13;22{1}:SI-S?.Medline DUI This biomechauical assessment of seated, overhead, and hinged-brace elbow rehabilitaiton protocols reported on the optimal protocol for unstable elbows. 13. Pipicelli JG, Ghinchallrar S], Grewal R, King G]: Therapeutic implications of the radiographic "drop sign“ following elbow dislocation. I Hand Titer 2312;25l3lfl46 {3.53, quiz 3.54. Medline DUI A description of the ulnohumeral drop sign and a therapeutic program to aid in a congruent joint reduction is based on ligament injury pattern. 19. Alolabi B, Gray A, Ferreira Ll'vl, Johnson JA, Athwal GS, King G]: Rehabilitation of the medial- and lateral collat-

eral ligament—deficient elbow: An in vitro biomechauical study. } Hand Titer 2012;25i4}:363— 3?3. Medline

D-DI

This biomechauical study used cadaver elbows in an el-

bow motion simulator to describe safe positions for the rehab1htat1on of complex elbow lflluI'lE'S.

ll]. Analtwe RE, Middleton SD, Jenkins P], McQueen MM, Court-Brown CM: Patient-reported outcomes after

simple dislocation of the elbow. I Bone Jloint Surg Am

ternssustaaao-raas.Mean-1e not

A trauma center review of 11f]I patients with simple elbow

dislocations descnbed outcome and patient satisfaction. Level of evidence: IV. 21. Duckwortb AD, Ring D, Kuliidian A, McKee MD:

Unstable elbow dislocations. J Shouider Eibow Surg lflflfl;1?{2j:ESI-ESE. Medline

DUI

22. U’Driscoll SW, Bell DF, Morrey BF: Posterolateral ro-

tatory instability of the elbow. ] Bone joint Surg Am 1991,?3l31fl—40-44E. Medline

23. Lattanza LL, Chu T, Ty JM, et al: Interclinician and intraclinician variability in the mechanics of the pivot shift test for posterolateral rotatory instability {PLRI} of the elbow. j Sbouider Elbow Surg 2010,19{Sl:1 fill—1156. Medline DUI Biomechanical testing was performed to determine the influence of training level on the performance of the lat. eral pivot shift test.

D lfllri American Academy of Orthopaedic Surgeons

Chapter I": Acutei'Traumafic EIb-nw Injuries 24. I'vIehta Jill, Bain |GI: Pnsternlateral rntatnryr instability nf

the elbnw. I Am Accc' Urtfrnp Sui-g lflfl4:11j6}:4fi$ -41 5. Medline

2.5. Him 135, Park KH, Snug HS, Park ST: Ligamentnus repair nf acute lateral cnllateral ligament rupture nf the elbnw. I Shenl'der Efbnte Snrg 2013:12j11}:1469—14?3.

Medline DUI

Clinical nutcnmes nf lateral ligament repair fnr 19 patients

with acute PLEI were repnrted. Level nf evidence: Dr".

33. Pugh Dlvl, 1|iilli'ild ll, Schemitsch EH, King G], McKee

MD: Standard surgical prntncnl tn treat elbnw dislnca—

tinns with radial head and cnrnnnid fractures. j Enne Inn-rs Surg Am 20fl4;36—A{E}:I 1 22—1130. IvIedline

34. Hartaler RU, Llusa—Perea lid, Steinmann 5P, Mnrrey BF, Sanchez-Enteln J: Transverse cnrnnnid fracture: When dnes it have tn be fixed? {Ilia Urtiinp Refer Res 2014;4?2{?}:2063-20?4.Medline DUI

26. Lee YE, Eng K, Kengh A, McLean Jhd, Eain |GI: Re-

This binmechanical cadaver study assessed the effect nf a 30% cnrnnnid fracture and fiaatinn nn elbnw stability with and withnut an intact radial head.

anchnrs. Tee}: Hand Up Entree: Snrg 2011;16i4]:125-219.

35. Rafehi 5, Lalnne E, Jnhnsnn M, King G], Athwal G5:

pair nf the acutely unstable elbnw: Use nf tensinnable Medline DUI

A technique fer the use nf tensinnable suture anchnrs fer

An anatnmic study nf cnrnnnid cartilage thickness with special reference tn fractures. ] Shnnidev Effsnse Snrg 2fl12:21[?}:951-953.Medline DUI

2?. Sanches- Snteln J, Mnrrey BF, U’Driscnll SW: Ligamentnus

A CT study was perfnrrned tn determine the thickness nf cartilage an the cnrnnnid tip.

the repair nf cnllateral ligaments is described.

repair and recnnstructinn fnr pesternlateral rntatnry insta-

bility cf the elbnw. } Bessejnfnt Sa-rg Er 1fl05:3?{1}:54— 61. Medline

23. Baghdadi TM, I'vlnrrey BF, U’Driscnll SW, Steinmann SP, Sanchez—Enteln J: Revisinn allngraft recnnstructinn cf the lateral cnllateral ligament cnmplea in elbnws with previnus

failed recnnstructinn and persistent pnsternlateral rntatnr ry instability. Elie Urn'rnp Refer. Res 2fl14:4?2{?}:2061206 ?. Medline DUI A case series dncumented the nutcnmes nf elbnws treated with revisinn allngraft reennstructinn cf the LCL fnr persistent PLRI after failure nf index surgery. Level nf evidence: IV.

29. IGiannicnla G, Pnlimanti D, Bullitta G, Seacchi M: Hegative prngnnstic factnrs in cnmpleic elbnw instability: A prnspective study nn TE patients. _,I Urtfenp Traumatnf 2013;14j5uppl I}:533. A cnhnrt nf T3 patients with cnmples: elbnvvr instability was reviewed tn determine negative prngnnstic factnrs. Level nf evidence: III. 3D. Jenn IH, Micic ID, Yamamntn N, Mnrrey BF: Usbnrne-cntterill lesiun: An nssenus defect nf the capitellum assnciated with instability nf the elbnw. AJR Am I Rneutgennf 2033;191Ij3}:?2?—?23. Medline

DUI

36. Mnnn JU, Enbits I'vIE, An KN, U’Driscnll 5W: Uptimal

screw nrientatinn fnr finatinn nf cnrnnnid fractures. J Urtfmp Trauma lflfl?:23{4l:2??—lflfl. Medline DUI

This binmechanical study assessed nptimal screw nrientatinn fnr the finatinn nf cnrnnnid fractures. 3?. Leigh WE, Ball EM: Radial head recnnsttuctinn versus replacement in the treatment nf terrible triad injuries nf the elbnw. ] Sbnufder Eibnse Surg EDI 2:2H1fllfl 33 6—1 341. Medliue DUI

The results fnllnwing surgical repair nf terrible triad injuries were reviewed in 23 patients. Level nf evidence: III.

33. Dnnrnberg 1N, Ring DU: Fracture nf the anternmedi-

al facet nf the cnrnnnid prncess. j Hesse jnfns Snrg An: Iflfl6:33{1fll:2215-2224.Medline DUI

39. U’Driscnll 5W, Jupiter JB, Cnhen M5, Ring D, McKee

MD: Difficult elbnw fractures: Pearls and pitfalls. Instr Unnrse Leer lflfl3:52:1 13—134. IvIedline

4D. Pnllnck 1W, Ernwnhill J, Ferreira L, Mcnald UP, Jnhn—

snn J, King I133: The effect nf anternmedial facet fractures cf the cnrnnnid and lateral cnllateral ligament injury nn

clbnw stability and kinematics. ] Hesse faint Surg Am 2Dfl9;91{fij:1443-1453.Medline

DUI

A binmechanical study assessed the effect nf varinus sizes nf anternmedial cnrnnnid facet fracture and the influence nf LCL repair nn elbnw stability.

Case series repnrted nu fnur patients with terrible triad injuries treated nnnsurgically. Level nf evidence: IV.

41. Huh J, Krueger {3A, Medvecky M], Hsu JR; Skeletal Trau— ma Research lEll-:Imsnrtium: Medial elbnw espnsure fnr cnrnnnid fractures: FED-split versus nver-the-tnp. j Urtfsnp Trauma 2013:2Tllllfl30-7’34. Medline DUI

Specific indicatinus fnr nnnsurgical treatment nf terrible triad injuries and the results nf titatment were repnrted

fnr 11 patients. Level nf evidence: IV.

IE! lfllii American Academy nf Urthnpaedic Snrgenns

1

s: m

”'1

31. Guittnn TU, Ring D: Nnnsurgically treated terrible triad injuries nf the elbnw: Repnrt nf four cases. ,I Hand Surg Am lflIiI;35{3j:4-E4-4ET. Medline DUI

32. Chan K, IvIaeDermid JC, Faber E], King G], Athwal [35: Can we treat select terrible triad injuries nnnnperativelyi‘ Cfirr Urtl'snp Refer Res lflI4;4?2{?}:Ei}92-1fl99. Medline DUI

I:

'n 'nm

A cadaver dissectinn cnmpared the eapnsure nbtained by the flexnr' carpi ulnaris-splitting versus the Hntchkiss nver-the-tnp apprnach. 42.. Rhynu II-I, Kim KC, Lee JH, Kim 53’: Strategic apprnach tn U'Driscnll type 2 anternmedial cnrnnnid facet

Urthnpaedic Knnwledge Update: Spnrts Medicine 3

H H

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Seeders 1: Upper Extremity

fracture. I Shenlder Elbew Sarg 2fl14:23{?]:924-932. Mcdline DUI The authers suggested a strategic appreach te dealing with fractures ef the anteremedial cereneid facet based en the |IiZiI‘IIriscell classificatien and the degree ef lateral seft-tissue injury. Level ef evidence: IV. 43. Keener JD, Eha filr. D, Kim HM, Galats LM. Yamaguchi K: Insertienal anatemy ef the triceps brachii tenden. ] Sherifder Elbert: Sui-g 201 fl:19(3}:399-4 :15. Medline DUI A cadaver dissectien study detailed the triceps tenden anatemy and the lateral triceps expansien.

1: Upper Estrem ity

44.

. Freeman CR. McCennick KR. Maheney D. Earata M, Lubahn JD: Neneperative treatment ef distal biceps tenden ruptures cempared with a histerical centre] greup. I Hens jeint Surg Am 1009;91{1{}]:2329-2334. Medline

DUI

The results ef surgical and nensurgical treatment are cempared: nensurgical treatment results in ELISE ef the supinatien strength that surgical treatment dees; fleetien strength is the same. Level ef evidence: IV. 52. Grewal II... fithwal GS, MacDermid JC, et al: Single versus deuble-incisien technique fer the repair ef acute distal biceps tenden ruptures: A randemiaed clinical trial. I Benej'eirtt Surg Am 1012:94{13J:1156—11?4. Medline DUI

Athwal GS, McGill RJ, Rispeli DIM: Iselatcd avulsien ef the medial head ef the triceps tenden: An anatemic study and arthrescepic repair in 2 cases. Artbreseepy

This is the enly prespective, randemiaed centrelled trial te evaluate the eutcemes ef distal biceps tenden repair

The anthers described the insertien ef the triceps tenden and an arthrescepic repair technique fer iselated medial head triceps avulsiens. Level ef evidence: IV.

53. Schmidt CC, Dias VA, Weir DM, Latena CR, Miller MC: Repaired distal biceps magnetic resenance imagi

2fl09;25(9}:933-933.Medline

DUI

45. Kekltalis ET. Mavregenis AF, Spyridenes S, Papagelepeules P]. Weiser 11W. Setereanes DIG: Triceps brachii distal tenden reattachment with a deuble-rew technique. Urtfiepedies 2013;36llifllfl-116. Medline DUI The anthers described a technique fer a deuble-rew repair ef the triceps tenden using Keith needles and suture anchers, and the results fer a series ef patients were reviewed. Level ef evidence: IV. 46. van Riet RP. Merrey BF, He E, U’Driscell SW: Surgical treatment ef distal triceps ruptures. I BDHE jeint Surgrilm 2fl03;35—A{10}I:1961—1961 Medline 4?. Devereaust MW, ElMaraghy AW: Impreving the rapid and reliable diagnesis ef cemplete distal biceps tenden rupture: fl. nuanced appreach te the clinical examinatien. An: }' Sperts Med 2fl13g41[9}:1993 4004. Medline DUI The physical examinatien fer distal biceps tenden ruptures and an evidence—based diagnesitic algerithm are described. Level ef evidence: II. 43. Abbeud JA, Ricchetti ET, Tjeumaltaris FP, Earteleezi All, Hsu JE: The direct radial tuberesity cempressien test: A sensitive methed fer diagnesing partial distal biceps ten— den ruptures. Carr Urtbep Peter 20] 1;22{1}:?6 -3IJ. DUI The anthers describe and validate the direct radial mber-

esity cempressien test te diagnesc partial biceps tenden

injuries. Level ef evidence: II.

49. Uiuffre EM, Mess M]: Uptimal pesitiening fer MRI ef the distal biceps brachii tenden: Pleated abducted supi-

nated view. EUR Am I Reentgenef 2004;131{4}:944—946. Medline DUI

using a single- versus deuble-incisien technique. Level ef evidence: I.

anatemy cempared with eutceme. I Seeefder Elbert: 3mg 2D12;11{12J:1623-1631.Medline DUI A substantial decrease in strength at EU“ ef supinatien

appears te be an effect ef an anterier tenden reattachment lecatien. Level ef evidence: III. 54. Hansen '3, Smith A, Pelleclc JW, et al: finatemic repair

ef the distal biceps tenden cannet be censistently per—

fermed threugh a classic single-incisien suture anchet technique. I Shenider Elbew Sarg 2014:23{12]:13931904. Medline DUI

This retrespective review ef single-incisien distal biceps repairs with CT was perfermed te determine if the anatemic insertien en the radial tuberesity can be re-created. Level ef evidence: IV.

SS. Watsen IN. Meretti VM. Schwindel L. Hutchinsen MR: Repair techniques fer acute distal biceps tenden ruptures: A systematic review. I Berte- jefrrt Surg Am lfll4;96{24}:2036-2fl9fl.Medline DUI The anthers cenducted a systematic review ef techniques fer distal biceps tenden repair with a feces en cemplicatien rate. Level ef evidence: IV. 56. Schmidt CC. Jarrett CD, Brewn ET: The distal biceps tenden. JI Hand Surg Am 2G13:3S{4]:311-321, quiz 32.1. Medline DUI 5?. Merrey ME, fibdel MP, Sanchez-Setele J, Merrey BF:

Primary repair ef retracted distal biceps tenden ruptures in

extreme flesien. ] Sbeelder Elbew Snrg 2fl14;13{51:6??-

SSS. Medline DUI

This retrespective case-centrel study examined the eutcemes ef distal biceps repairs requiring repair in greater than 60” cf flexien. Level ef evidence: III.

Si}. Merrey BF, fishery LL An KN, Debyus JH: Rupture ef

the distal tenden ef the biceps brachii. A biemecbanical

study. I Benejeint Serg Am 1535:6?{3]:413-421. Medline

Urthepaedic Knewledge Update: Sperts Medicine 5

U lflle American Academy ef Urthepaedic Surge-ens

Chapter 3

Chronic/Overuse Elbow Disorders

Champ L. Halter III, MD

Champ I.. Halter Ir, MD

Abstract

fiveruse disorders of the elbow are common and can be a substantial cause of pain and disability to the

athlete. Despite increased understanding of the causes

and pathoanatomy of elbow tendinopathy, a lack of consensus remains regarding optimal management. Many different nonsurgical and surgical interventions

have been reported with varied outcomes. Irrespective of the methods chosen, nonsurgical treatment typically allows safe return to sport. Surgical intervention is reserved only for the few cases with recalcitrant symptoms. Keywords: medial epicondylitis: lateral epicondylitis; tendinopathy Introduction

procedures have been described for those patients with recalcitrant symptoms despite appropriate nonsurgical

treatment. lDptimal management of elbow tendinopathy requires a thorough understanding of the pathophysiol-

ogy, clinical evaluation, available treatment options, and reported outcomes.

H

Medial Epitondylitis Elbow tendinopathy of the flertor pronator origin aris-

ing from the medial cpicondylc is commonly referred to

as medial cpicondylitis. Although lateral cpicondylitis is

diagnosed up to T to 10 times more frequently, medial elbow tendinopathy can cause substantial disability to athletes and those individuals with repetitive occupational

requirements."1 Athletes who are particularly susceptible to the development of medial epicondylitis include baseball players, golfers, and those involved in racquet sports

and office workers engaged in repetitive upper extremity activities are all susceptible to this painful, sometimes

Pathophysiology The primary etiology appears to be repetitive overuse of

activity restriction, with lost time from sports, recre-

cocking and early acceleration phases of the overhand

or stress to the flercor pronator muscle origin. In the late

ation, and occupation. Despite increased understanding of the causes and pathos natomy of elbow tendinopathy,

throwing motion, high medial tensile forces and lateral

agement. Multiple treatment options have been described,

collateral ligament and the flexor pronator muscle group,

a lack of consensus remains regarding its optimal man-

with most patients ultimately responding to nonsurgical care over an extended period. Many different surgical

compression forces are generated at the elbow. The etc-

treme valgus forces are transmitted medially to the ulnar which acts as an important secondary and dynamic stabiliner of the elbow. The repetitive stress and loading over time can result in tendon degeneration and tendinopa-

thy in throwers. Similarly, overuse injuries are common Dr. Champ L. Halter ill or an immediate family member has

stoclr or stoclr options held in Arthreir. or. {Champ t. Salter,

it; or an immediate family member has received royalties from Arthreir; serves as an unpaid consultant to Arthreir and Smith d Nephenc has stoclr or stool: options held in Arthrex; and serves as a board member, owner, officer; or

committee member of the American Orthopaedic Society for Sports Medicine.

fl lflld American Academy of Drrhopaedic Surgeons

in: m

H

Elbow tendinopathy is the most common cause of elbow

disabling condition. It remains a substantial cause of

1

m

such as tennis.El Medial epicoudylitis primarily affects patients in the fourth or fifth decades of life.

pain. Competitive and recreational athletes, laborers,

I:

'oi 'om

in golfers, especially those who have poor technique. A recent electromyographic {EMG} analysis of amateur

and professional golfers demonstrated substantially increased activity in the pronator teres in the trailing arm of the amateur golfers during the forward swing phase

and a trend toward increased activity of the pronator teres during the acceleration phase compared with the professional golfers.“l In tennis players, EMG analysis has

showed substantially increased activity of the pronator

Drthepaedic Knowledge Update: Sports Medicine 5

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a?

Sectinn 1: Upper Extremitl'

teres and flexnr carpi radialis during the acceleratinn phase ef the everhand serve?

demnnstrating tendinnpathy, fncal anechnic areas indicating partial cummen flexer tendnn tears, cnrtical irregular-

flexnr prnnatnr nrigin with subsequent tendinnus repair

in the nffice setting is increasing recently, especially in the treatment cf medial and lateral elbow tendinnpathy with

Repetitive nveruse results in micrnscnpic tears nf the

and replacement with immature reparative tissue. Histnlngically, the tissue is characterised by the absence nf

inflammatnry cells and the presence nf fibrnblasts, disnr-

Treatment

tissue mnst cnm mnnly invnlves the prnnatnr teres and the

al epicnndylitis, relatively little is dedicated specifically

flexnr carpi radialis. In nne study nf surgical treatment nf 50 elbnws, the degenerated tissue was lncalized at t

injectinns and nther prncedures.

ganieed cellagen, and vascular hyperplasia. This tendnn

degeneratinn has been termed anginfibrnblastic tendinnsis.3-5~I In medial epicnndylitis, the pathnlngic tendinnsis

1: Upper Extrem

ities, and tendnn thickening. The use nf ultrasnnngraphy

the flexnr carpi radialis—prnnatnr teres interval in 56% nf cases, the flexnr carpi ulnaris in 12%, and diffuse

Althnugh the existing literature is replete with repnrts nf widely varied nnnsurgical treatment nptinns fnr later-

tn medial epicnndylitis. Reperted nnnsurgical treatment nptinns include rest, activity mndificatinns, cnunterfnrce

bracing, physical therapy, nral and tnpical NSAIDs, and

changes were nnted in the cnmmnn flexnr nrigin in the

injectinns with cnrticnsternids in additinn tn the mere recent use nf platelet-rich plasma {PRP} and autulugnus

Evaluatiun

randnmized dnuble-blind study cnmparing an injectinn nf methylprednisulune with an injectiun cf saline in patients

gradual nnset nf elbnw pain lncalized tn the medial epi-

in pain relief at 5 weeks fnr patients in the methylpred-

remaining 32%.}

Patients with medial elbnw tendinnpathyr tend tn repnrt a

cnndyle and ever the flexnr prnnatnr muscle mass. Pain is

blnnd. Althnugh cnmmnnly used in clinical practice, a

with medial epicnndylitis fnuud nnly shnrt—term benefit

nisnlnne grnup. He substantial differences were fnu nd re-

increased with the nffending activity such as thrnwing nr playing gnlf. Physical examinatinn typically reveals ten-

garding pain relief at 3 mnnths nr 1 year after injectinn.” One case series investigated the use nf dry needling and

tn the medial epicnndyle. Pain nu resisted prnnatinn nf the fnrearm has been found tn be the mnst sensitive physical examinatinn finding.” Pain can alsn be reprnduced frnm resisted wrist flexinn. Grip strength can be decreased as well. The examinatien cf the athlete with medial elbew

guidance in 2G patients with medial elbnw tendinnpa— thy.” At final fnllnw—up nf 1D mnnths, 3 patients were

integrity nf the ulnar cnllateral ligament and assessment

treatment nf lateral epicnndylitis, tn date, nn repnrts are available en the treatment nf medial elhuw tendinnpathy.

derness ever the flexer prnnatnr nrigin antericr and distal

pain shnuld alsn include a cnmplete evaluatinn nf the

fer ulnar neuritis, hnth uf which can cnexist with medial epicnndylitis. Ulnar neuritis has been repnrted in up tn

injectinns cf autnlngcus blend under ultrasnnngraphic

cnnsidered tn have unsuccessful results and the remaining

patients demnnstrated substantial decreases in their visual analug scale WAS} pain sceres and medified Hirsch] pain scnres. Althnugh the use nf PRP has been studied in the

Successful nnnsurgical treatment has been repnrted in

60% nf patients ultimately requiring surgery fnr medial epicnndylitisfi‘f'11

35% tn 90% nf cases.3-" Surgical treatment is reserved fnr these patients with refractnryr symptnms even after

cificatinns can snmetimes be seen adjacent tn the medial

numernus repnrts nf surgical treatment nf lateral elbnw mndinupathy, few repnrts regarding surgical management nf medial epicnndylitis are published. Althnugh percuta— nenus and npen flexnr releases” have been described, the

Plain radingraphs are typically nnrmal, althnugh cal—

epicnndyle. Althnugh primarily a clinical diagnusis, ad-

vanced imaging can help evaluate fnr suspected assnciated cnnclitinns. Cine study evaluated the MRI findings nf 13

at least 5 mnnths nf nnnsurgical care. In cnntrast tn the

patients with a clinical diagnnsis nf medial epicnndyli-

current cnnsensus fnr surgical treatment is npen resectinn

the presence nf intermediate tn high T2hweighted signal

substantially influenced by the presence nf cnncurrent

tis.”- Cnmpared with age-matched cnntrnl patients, the must specific MRI findings fnr medial epicnndylitis are intensity nr high Til-weighted signal intensity within the cnmmun flexur tendnn and the presence ef paratendinuus

snft—tissue edema. Annther study fnund a sensitivity nf

nf pathnlngic tendinnsis tissue frnm the flexnr prnnatnr nriginf‘rfl'h'fi {Figure 1}. The success nf débridement is

ulnar neuritisfi-m Overall, 3?% gnnd tn excellent results were repnrted in 30 patients treated with flexur prnnatnr

95% and specificity nf 92% for ultrasnnngraphy in the

nrigin débridement at a mean fnllnw—up nf 7*" years; hnwever, the status nf the ulnar nerve cnrrelated with the

cnmmnn pnsitive ultrasnnngraphic findings in patients

nf patients with nn nr assnciated mild ulnar neurnpathy

diagnusis cf clinical medial epicnndylitis.13 The must

with medial epicnndylitis were fncal hypnechnic reginns

firthupaedic Knnwledge Update: Spnrts lvledichie 5

eutcume.“ Geed te excellent results were feund in 96%

cnmpared with nnlyr 4fl% gnnd tn excellent results in

fl lfllfi American Academy nf Orthnpaedic Surge-ens

fincuanaa .iaddn :1

Chapter 3: Chroniol'flveruse Elbow Disorders

.1:

Figure 1

-_

L

h

l

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

those patients with moderate to severe ulnar neurop-

athy. Currently, no studies have evaluated the results of ulnar nerve decompression versus anterior transposition in patients with associated ulnar neuritis. Most case series

detail high rates of pain relief and success with various

outcome measures. |liilverall rate of return to the same level of spurt ranges from 69% to 95%.3-*" A recent case

improved to the levels of the general, healthy population {mean improvement, 51.6 to 3.0}, with 90% of patients overall satisfied with their outcome. Lateral Epicondylitis Lateral elbovi.r tendinopathya or tennis elbow, is the most

series of 22 elbows treated with open flescor pronator tendinosis resection detailed 93% improvement in mean

common cause of lateral elbow pain in the adult population. Although it can occur in up to 5D% of recreation-

and 33% improvement for pain with heavy activity at a mean follow-up of 36 months? The patient’s perception

affects other athletes and workers whose occupation requires repetitive wrist extension activities.” The dom-

VAS scores for pain, 94% improvement for pain at rest, of their arm function as measured by the Disability of the Arm, Shoulder and Hand (DASH) scores substantially

El lfllfi American Academy of flrchopaedie Surgeons

al tennis players, lateral elbow tendinopathy frequently inant arm is most commonly involved with an equal in-

cidence in men and women in the general population.

Drthopaedic Knowledge Update: Sports Medichae S

Section 1: Upper Extremitl'

Acute onset of symptoms can be seen in young athletes, whereas chronic, recalcitrant symptoms typically occur in

older patients. It primarily affects patients in their fourth or fifth decades of life.‘3~“'

severity of MRI signal changes consistent with tendon de-

generation did not correlate positively with patient symp-

Pathophysiology

toms.23 Ultrasonography has been described as a useful diagnostic tool and as an adjunct to treatment of lateral

pears to be repetitive overuse or stress to the wrist ex-

eral epicondylitis that underwent ultrasonographic assess-

The primary etiology for lateral elbow tendinopathy ap-

tensor origin. The extensor carpi radialis brevis {HERB} is most commonly affected, although portions of the extensor digitorum communis can also be involved. Sev-

1: Upper Extremity

findings have been shown to correlate well with surgical and histologic findings.“ However, one study noted that

epicondylitis. fine study reported on 62 elbows with lat-

ment of the common extensor tendon at diagnosis and after 5 months of physical therapy.“ Pain and functional

disability were assessed using a validated tennis elbow

eral authors have promoted the most commonly accepted theory of the pathogenesis of lateral epicondylitisfi?!”

questionnaire. The presence of a large intrasubstance tear was found to be predictive of a poor outcome and less

ECRB. Attempted repair and failure of healing results in degenerative changes in the tendon characterised by fi-

Treatment

with an absence of inflammatory cells. The degenerated angiofibroblastic tendinosis tissue is similar histologically

one type of treatment}:T However, the increasing literature of myriad proposed nonsurgical treatment options

Repetitive overuse results in microscopic tears of the broblasts, disorganized collagen, and vascular hyperplasia

to that found in medial elbow tendinopathy. One study

noted increased rates of cellular apoptosis and autophagic cell death in surgical specimens of ECRE tendon with

associated collagen deterioration and breakdowns”-fl A recent cadaver study demonstrated impingement of the

ECRB origin on the lateral edge of the capitellum during

extension as a potential anatomic contribution to the development of lateral epicondylitis.21

likely to respond to noninvasive treatment.

In 1936, it was proposed that tennis elbow have only

with sometimes conflicting results, different outcome measurements, and varied levels of evidence makes di-

rect comparison difficult. A recent systematic review of randomised controlled trials of nonsurgical treatment concluded no conclusive evidence exists of one preferred method of nonsurgical treatment of lateral epicondyli-

Patients with lateral elbow tendinopatby report lateral

tis.” An assessment of all nonsurgical treatment options must also consider the favorable natural history of the condition with resolution of approximately Sfl‘if- of cases within 1 year.” In general, nonsurgical treatment options have included benign neglect, rest, activity modification,

ally, the patient may recall a specific injury to the area, but the history is typically of a gradual, progressive nature.

medications including NSAIDs, extracorporeal shockwave therapy, and injections of corticosteroid and newer

Evaluation

elbow pain that can radiate down the forearm. Occasions

Symptoms include weakness of grip strength affecting

physical therapy, bracing or splinting, oral and topical biologic alternatives. Irrespective of the type of nonsur‘

work activities, sports performance, and sometimes even activities of daily living. Difficulty picking up objects and

gical care, almost 90% of patients ultimately respond

tenderness is located at and just anterior and distal to the

arthritis, posterolatera] rotatory instability, radial tunnel syndrome, osteochondritis dissicans of the capitellum,

employment involves manual labor, who have dominant arm involvement, and who have higher levels of baseline pain.” Initial treatment includes active rest and refraining from the repetitive offending activity. Modifications to improper technique, if contributory, must also be made. Physical therapy with stretching in conjunction with modalities

Plain radiographs are typically normal, although cal— cifications can sometimes be seen adjacent to the lateral

phy, and electrical stimulation can be instituted, although the efficacy of these modalities remains unproved. The

vanced imaging can be useful in patients with symptoms refractory to treatment and those with atypical symp-

vestigated based on prior success with patellar and Achilles tendinopathy.-15' A recent systematic review evaluating the

shaking hands may be noted. Un examination, point

lateral epicondyle. Pain is reproduced on resisted wrist

extension, which can be greater with the elbow extended than with the elbow flexed. The differential diagnosis for lateral elbow pain includes synovial plica, radiocapitellar and cervical radiculopathy.

epicondyle. Although primarily a clinical diagnosis, ad—

toms or presentation. MRI may demonstrate increased

Til-weighted signal and extensor tendon thickening. MRI

firthopaedic Knowledge Update: Sports Medicine 5

successfully, sometimes after an extended period. Poor overall improvement has been noted in patients whose

including iontophoresis, friction massage, ultrasonograu

addition of eccentric extensor strengthening has been in—

utility of eccentric extensor strengthening supported its

inclusion as part of a multimodal treatment program for

fl lflld American Academy of Orthopaedic Surgeons

Chapter 3: Chronicfflveruse Elbow Disorders

improved outcomes in patients with lateral epicondylitisfiml Forearm counterforce straps and wrist extension splints

other treatment arms at short-term evaluation of 4 to 6 weeks. No benefit remained at 12-month follow-up.

surgical treatment regimen. Few studies have evaluated the use of orthoses, especially in comparison with other

in the treatment of lateral epicondylitis found no substantial benefit of glucocorticoid injections versus pla-

are two common orthoses prescribed as part of a non— treatment modalities; however, the authors of a 2'31!) ran—

domized trial compared a counterforce brace with a wrist extension splint and found greater pain relief in the wrist extension splint group after 6 weeks of treatment despite no functional differences between the groups}1 Although the pathology of elbow tendinopathy does

not support an inflammatory component, both oral and topical NSAIDs are commonly prescribed. In a EH13

|Cochraue review, 15 clinical trials were examined to de—

termine the benefits and disadvantages of both oral and topical l_”*~lS.e5tI[ZIIs.3*1 Although firm conclusions were not drawn from the available evidence, data suggest that top—

A recent network meta—analysis of injection therapies

cebo in outcomes greater than 3 weeks.” Potential side

effects from steroid injections include subcutaneous fat atrophy and skin dEpigmentation. In this same network meta-analysis, botulinum toxin was found to have a mar-

ginally significant reduction of pain intensity compared

with placebo. Several high-level studies have evaluated the use of PRP injections. In one study, an injection of

leukocyte-rich PRP was compared with an injection of

corticosteroid using a peppering technique in a random-

ized controlled trial of ICE] patients.“ Outcomes were determined by PAS pain scores and DASH scores. The PEP cohort demonstrated substantial improvements in

ical NSAIDs are more effective than placebo in providing short-term pain relief in patients with lateral epicondylitis,

with baseline and the corticosteroid cohort. These re-

evidence regarding the use of oral HSAIDs precluded

PEP-treated patients demonstrated 69% improvement

with a small risk of a transient skin rash. Conflicting

any recommendations, although gastrointestinal side

pain and function at 6 months and at 1 year compared sults were maintained in a follow—up study at 2 years:

in pain versus 36% improvement in the corticosteroid

effects were noted in several studies.”- Tbe use of other topical agents has been described, including compound-

cohort. Similarly, the PRP cohort maintained substantial differences in improvement in function: almost 63% in

double—blinded clinical trial compared patients receiving therapyr and a glyceryl trinitrate transdermal patch with

the corticosteroid group.“ In a multiccnter randomised, controlled trial of 23C! patients, a leukocyte-rich PRP

ing creams and nitric oxide. A prospective, randomised, those receiving therapy and a placebo patchf‘3 Patients in

the DASH outcome measurement versus only 15% in

injection was compared with a control group of needliug

the glyceryl trinitrate group demonstrated substantially decreased elbow pain, reduced epicondyle tenderness, and

without PEP.” Substantial differences were not noted until final follow-up at 14 weeks when 34% of the PRP

cebo group. At 6 months, 31% of the treated patients were asymptomatic with activities of daily living versus 60% of those treated with rehabilitation alone. These results were not maintained in a follow-up study at 5 years after discontinuation of treatment, with no differences seen

pared with 53% of the control group. A 2013 a systematic review of the use of PRP in the treatment of lateral epicon-

improved wrist extensor strength compared with the pla—

between groups, although both had improved compared

with baseline.“ Extracorporeal shockwave therapy has been proposed as an effective treatment option, but evidence remains mixed with one systematic review finding that most trials showed no benefit over placebo.35 Multiple injection therapies have been described, in-

group was determined to have successful treatment coma

dylitis suggests PRP has been shown to be of benefit over

corticosteroid treatment,“ and a network meta-analysis

concluded PRP and autologous blood injections were all substantially more efficacious than placebo.“ Import-

ant questions remain regarding the cost-effectiveness of PP. P, optimal preparation, and the timing and frequency of intervention, although these early results of biologic enhancement of healing appear promising. Surgical treatment is recommended in patients with

cluding the use of glucocorticoids, PEP, autologous blood, autologous tenocytes, sodium hyaluronate, botulinum

recalcitrant symptoms even after 6 months or more of

The use of glucocorticoid injections are common in clin" ical practice despite the lack of inflammation seen in

techniques used; the most common currently include percutaneous extensor tendon release,“~” open tendino-

toxin, polidocanol, and glycosarninoglycan polysulfatefif

nonsurgical care. Numerous reports of surgical management have been published with a wide variety of

chronic elbow tendinopatby. Randomised studies com—

sis resectionfldfidi‘r‘H and arthroscopic resection.” Most

paring glucocorticoid injection with naproxen or placehoEll or with physiotherapy or a wait-and-see approach“

studies detail high rates of success with limited follow-up. A paucity of well-designed controlled studies support one

function with glucocorticoid injection compared with

used should be based on surgeon comfort and experience.

demonstrated substantial improvements in pain and

IE! lfllfi American Academy of flrthopaedic Surgeons

technique over another; therefore, the type of procedure

Drthopaedic Knowledge Update: Sports Medicme S

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ggefiasedEEFI-IB __ 1;; .

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El Figure I

Arthroscopic images of treatment of lateral epicondylitis obtained from the proximal anteromedial portal- A, The capitellum, radial head, and capsular tears are visualized. B, After capsular déhridement, the deep extensor carpi

radialis longus is exposed. C. The diseased extensor carpi radialis brevis origin is resected off its origin using a radiofreci uency probe. {Heprod uced from Baker EL Jr: Arthroscopic release for lateral epicondylitis. in Ta mag uchi

it, King GJW, McKee MD, D'Driscoll SWM, eds: Advanced Reconstruction: Elbow. Hosemont, lL, American Academy

of lElrthopaedic Surgeons, IDDT, pp lE-EDJ

Currently, open treatment includes resection of the ECRE

concurrent intra-articular pathology. Elf (ill patients at a

rate of 93% in a cohort of 33 elbows, with 35% of patients

Mayo Elbow Performance Index; 23 {THE} reported pain as “much better,” 5 (Zfl‘ihl as “better,” and 1 [3%] as the

technique reported 34% good to excellent results based

procedure and 23 {93%} stated they would undergo the

arthroscopic resection similarly detail high rates of suc—

of recalcitrant lateral epicoudylitis. High rates of early

tendiuosis tissue with or without repair of the extensor tendon origin. {line study reported an overall improvement returning to full activities including sports."r A long—term follow-up study of the Nirschl open tendinosis resection

on outcome measurements, with 93% of patients available at 10-year follow-up returning to sports.” Proponents of cess with additional benefits of identifying and treating

flrdsopaedic Knowledge Update: Sports Medicine 5

mean follow-up of 13D months,” none reported pain at rest, with overall high function demonstrated using the

same. Twenty-six patients {3?‘lisl were satisfied with the

surgery again if necessary. Arthroscopic resection of tendinosis tissue was determined to he an effective treatment success are maintained at long-term follow-up {Figure 2}.

fl lflld American Academy of Orthopaedic Surgeons

Chapter 3: Chronictflveruse Elbow Disorders

A Zflflfi study compared 13 percutanenus releases, 41 arthroscopic procedures, and 33 open Hirsch] procedures,

all with a mean follow—up of 43 months.43 No significant

differences were reported among the groups regarding

complications, recurrences, failures, VAS pain scores, or

preoperative or postoperative Andrews-Carson scores.

The rate at which these patients returned to their activities

of daily living and work without discomfort could not be

measured. Each method is considered a highly effective way to treat recalcitrant ECRE tendinosis.

Ollivierre CU, Hirschl RP, Pettrone FA: Resection and repair for medial tennis elbow. A prospective analysis.

Arn I Sports Med 1995;23l2}:214-221. Medline

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Farber A], Smith JS, Kvitne RS, Mohr K], Shin SS: Electromyographic analysis of forearm muscles in professional and amateur golfers. Am J Sports Med 2009;3?{2}:395-

4131. Medline

DD]

This fine-wire electromyographic study noted differences in prnnator teres activity during golf swings between

professional and amateur golfers.

Morris M, Jobe FT, Perry J, Pinlt M, Healy BS: Electro-

Summary

Elbow tendinopathy is a common cause of pain and dis—

ability resulting from repetitive overuse activities. Honsurgical treatment is successful in most cases, with surgical intervention reserved for those patients with continued

symptoms after 6 months or more of treatment. Many treatment options are available, but currently, no consensus exists regarding optimal management. Additional

well-designed comparative studies are needed to better evaluate an ideal treatment algorithm with comparison with the natural history of the condition. Itey Study Points

1* Uveruse disorders of the elbow are common and can be a substantial cause of pain and disability, resulting in loss of time from worlt and spurt. - Elbow tendinnpathy is not an inflammatory condition but rather tendon degeneration resulting from continued microtrauma and failed attempts at healing. ' Many nonsurgical treatment options are available; rest and activity modification are paramount. I The current literature provides no definitive recommendations regarding efficacy of nonsurgical interventions. e Regardless of treatment type, most symptoms improve.

myographic analysis of elbow function in tennis players.

Am I Sports Med 1939;'l?{2]:341~241 Medline

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Kraushaar BS, Hirsch] FtP: Tendinosis of the elbow [tennis elbow}. Clinical features and findings of histological, immunohistochemical, and electron microscopy studies.

I Bone joint Sirrg An: 1999;31l1}:259-1?3. Medline

1. Leach RE, Miller JK: Lateral and medial epicondylitis of the elbow. Ciin Sports Med 193?;6l2}:259-2?2. Medline 2. Eiccotti MC, Schwartz MA, Ciccotti MG: Diagnosis and treatment of medial epicnndylitis of the elbow. Ciin Sports

Med lflfl-‘lflSHlfifl-Tflfi, xi. Medline D01

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Nirschl RP, Pettrone FA: Tennis elbow. The surgical treatment of lateral epicnndylitis. ,7 Bone joint Snrg Arn 19?5;51-A[6]:332-339. Medline lE'iabel GT, Morrey BF: Operative treatment of medical epicondylitis. Influence of concomitant ulnar neuropathy at the elbow. j' Bone joint Snrg Arn 1995;??{T}:1065-1069. Medline

Kwnn EC, Kwon TS, Eae K]: The fascial elevation and tendon origin resection technique for the treatment of chronic recalcitrant media] epicnndylitis. Am } Sports Mari 2fl14;42{?l:1?31-1?3?. Medline DflI The authors of this case series noted substantial improve-

ments in 1|tAS and DASH scores and improvements in grip

strength using their tendinosis resection technique in 22 elbows at a mean 3-year follow-up. Level of evidence: IV. 10'. Kurvers H, Verhaar J: The results of operative treatment of medial epicnndylitis. J Bone joint Surg Am

1995;??[9J:13?4—13?9. Medline

11. Vangsness CT Jr, ae FW: Surgical treatment of medial epicnndylitis: Results in 35 elbows. } Bonejotnt Sing Br 1991;?3l3):4fl9-411. Medline 12.. Kiiowslti 11, De Smet AA: Magnetic resonance imaging findings in patients with media] epicnndylitis. Sitsfstai

Radio! 20fl5;34{4]:196-1fl2. Medline DUI

Annotated References

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13. Park GT, Lee SM, Lee MY: Diagnostic value of ultraso-

nngraphy for clinical medial epicnndylitis. Arcfr Phys Med Rehabii lflfl3;39{4j:?33-?41. Medline DUI

14. Stahl S, Kaufman T: The efficacy of an injection of steroids for medial epicnndylitis: A prospective study of sixty elbows. ] Bone Joint Surg Arn 199?;T9lllltlfi4S-1652. Medline

Drrhopaedic Knowledge Update: Sports Medichse S

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Sectian 1: Upper Extremity

15. Suresh SP, Ali FEE, Janes H, Cannell DA: Medial epicendylitia: Is ultrasaund guided autc-lagaus bland injectian an

effective treatment? Hr]Sparta Med1flfl6;4l}{11}:935-939, discussian 939. Medline

DUI

16. Schipper UN, Dunn JH, Uchiai DH, Danavan J5, Nirschl RP: Hirsch] surgical technique far cancarnitant lateral and medial elhaw tendinasis: A retraspecn've review at SS elbows with a mean fallaw-up at 11 .1 years. Am 1 Sparta Med1fl11:39{5l:911-916. Medline DUI

1: Upper Extremity

The authars at this case series repartcd substantial II'I'I— pravements in Hirsch] tennis elbaw scares, American Shaulder and Elhaw Surgeans scares, and 3.5% gaacl ta excellent results with apen cambined medial and lateral tendinasis resectian at lung-term fallaw-up: 96% at patients returned ta spurts. Level af evidence: IV. 11'. Hirschl RP: Elbaw tendinasisi'tennis elbaw. Cilia Sparta Med 1991;11l4}:35 1-STIJ. Medline 13. Baker CL Jr, Baker CL III: Lang-term fallaw-up af arthroscapic treatment at lateral epicandylitis. Am I Sparta Med 1flfl3;36{1}:154—160.Medfine DUI 19. Dunn JH, Kim J}, Davis L, Nirschl RP: Ten- ta 14-year fallaw—up at the Hirsch] surgical technique far lateral epicandylitis. Am J Sparta Med 1DDS;SS{1]:1SI-1SS. Medline DUI 11]. Chen], Wang A, Kn J, Eheng M: In chranic latetai epicandylitis, apaptasis and autaphagic cell death accur in the

extensar carpi radialis brevis tendaa. j Shaat'der Ethan! Stttg 101D;19l3}:355-361. Medline

DUI

Ten lateral epicandylitis surgical specimens were examined histalagically. Increasing rates af tenacyte apaptasis and

autaphagic cell death were nated with assaciated increas— ing callagen degradatian.

11. Bunata RE, Brawn DS, Capela R: Anatamic factars re—

with pain and functianal disability. Am I Sparta Med 1fl1flt33lfilfl109-1114.Medline

DUI

In this cahart study, 61. elbaws with lateral epicandylitis were evaluated ultrasanagraphically and with Patient—Rated Tennis Elbaw Evaluatian {PRTEE} scares. After 6 manths at physical therapy, PRTEE scares were again determined. Large intrasubstance tears and lateral

callateral ligament tears seen an initial ultrasanagraphy were predictive at a paar autcame with this farm at nansurgicai treatment. Level at evidence: II.

15. EyriaxJH: The pathalagy and treatment af tennis elbaw. j Banefaint Sarg Am 1936;113:911-940.

1S. Sims SE, Miller E, Elfar JC, Hammett WC: Nan-surgical treatment af lateral epicandylitis: A systematic review at raadamiaed centralled trials. Hand (N 1’} 1i] 14,9{4l:41 9-

446. Medline DUI

In a systematic review at SS randamired, cantralled trials evaluating nansurgical treatment aptic-ns far lateral epicandylitis, the authars determined na canclusive evidence at ane preferred aptian. IZarticaateraid injectians can pravide shart-term pain relief with lang-term advantages. Level af evidence: II. 1?. Smidt N, van der Windt DA, Assendelft W], Devillr‘i WL, Karthals-de Ens IE, Banter LM: Earticasteraid injectians, physiatherapy, at a wait-and-sec palicy far lateral epicandylitis: A randamised cantralled trial. Lancet 1Dfl1;359{93fl1}:651—SS1.Medline DUI 13. Haahr JP, Andersen JH: Pragnastic factars in lateral epi-

candylitis: A ra ndamiaed trial with ane—year fallaw—up in

166 new cases treated with minimal accupatianal inter— venn'an ar the usual appraach in general practice. Rheumatal‘agy (Uxfardj 1flfl3;41{1fll:1116-1115. Medline DUI

19. Tyler TF, Thamas GC, Nichalas S], McHugh MP: Additicin at isalated wrist extensar eccentric exercise ta

lated tn the cause at tennis elbaw. I Harte Jlair-rt Snag Arr: 1flfl1;39{9}:1955-1963.Medline DUI

standard treatment far chranic lateral epicandylasis: A praspective randamiaed trial. ] Sbaatder Elhata Sta-g 1fllfl;19{5}:911-911.Medline DUI

Patter HG, Hannafin JA, Marwessel EM, DiCarla EF, U’Brien S], Altchelc DW: Lateral epicandylitis: Carrelatian

In a small trial at 11 elhaws, patients with lateral epicen-

af MR imaging, surgical, and histapathalagic findings. Radialagy 1995:196l1}:43'46. Medline

DUI

13. Waltan M], Mackie K, Fallan M, et a]: The reliability and validity af magnetic resanance imaging in the assessment af chranic lateral epicandylitis. ] Hand Sari-g Am 1fl11;35l3J:4?5-4T9. Madlirle DUI

There was substantial interabserver reliability and in—

traabserver agreement in the MRI evaluatian af11 elbaws with clinical lateral epicandyiitis. A negative carrelatian with tendinasis severity an MRI was seen with patient aymptams as repartcd by quick DASH and maximum pain levels. 14. Clarke AW, Ahmad M, lCurtis M, Cannell DA: Lateral elbaw tendinapathy: Carrelatian af ultrasaund findings

Drthapaedic Knawledge Update: Sparta Medichie S

dylitis were randamiaed ta treatment graups at standard physical therapy and standard physical therapy with the additian af eccentric wrist extensar exercises. Patients in the eccentric exercise graup impraved substantially in all autcame measures at VAS, DASH, tenderness, and strength campared with cantral patients.

30. Cullinane FL, Baacack MG, Trevelyan FE: Is eccentric exercise an effective treatment far lateral epicandylitisi'l A systematic review. CH1: Rehahii 1D14;13{1}:3-19. Medline DUI

In a systematic review at eight randamiaed trials evaluating eccentric exercise, the authars reparted mast studies demanstrated impraved clinical autcc-mes with the addi-

tian af eccentric exercise campared with these treatment pragrams withaut eccentric exercise.

D 111115 American Academy at Drthapaedic Surge-ans

Chapter 3: Chroniclflverusc Elbow Disorders

31. Garg R, Adamson G], Dawson PA, Shankwiler JA,

Pink MM: A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. ,l Shoulder Elbflw Sarg

2313;19H]:503-512.Medline DDI

In a randomised clinical trial of 44 elbows, patients receiv—

ing a wrist splint compared with a forearm counterforce brace demonstrated improved pain relief after I5 weeks,

although no functional differences were seen between

of elbow in primary care. BM,r 1999,319{y115),954-953_ Mcdline DUI S3. Peerbonms JC, Sluimer J, Eruiin D], Gosens T: Positive

effect of an autologons platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: Platelet-rich plasma versus corticosteroid iniectiou with a 1-year follow-up. Am } Sports Med 231 fl:33{2}:2 SS -2 ES. Medline DUI

groups based on American Shoulder and Elbow Surgeons or Mayo Elbow Performance scores.

This randomised, controlled trial compared leukocyte-rich PRP and corticosteroid injections. The PEP cohort demon-

32. Pattanittnm P, Turner T, Green S, Buchbinder E: Non-steroidal anti-in flammatory drugs {NSAIDs} for treating

demonstrated T333 success in substantial pain reduction versus 49% in the corticosteroid group. Based on DASH scores, the PRP cohort demonstrated substantially more success at T333 versus 51%. Level of evidence: I.

lateral elbow pain in adults. l|.'3o.r:.l:rrarse Database Syst Ree lfllSfitflflflflfififlfi. Mcdline

A Cochrane review concluded that topical NSAIDs ate more effective than placebo in providing short-term pain relief in patients with lateral epicondylitis, with a small

risk of a transient skin rash. Eonflicting evidence regarding

the use of oral NSAIDs prevented any recommendations, although gastrointestinal side effects were noted in several studies.

strated progressive improvement. At 1 year, the PEP cohort

39. Goscns T, Peerbooms JC, van Laar W, den |Eludstctl

31.: Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: A

double-blind randomized controlled trial with laycar follow—up. Am ] Sports Med lfll];39{3}:1233—1133.

Medline DIG]

33. PaoloniJA, Appleyard RC, Nelson], Murrell GA: Topical

At 2-year follow-up of a randomised, controlled trial, PEP-treated patients demonstrated 39% improvement in

sor tendinosis at the elbow: A randomised, double-blinded, placebo-controlled clinical trial. Arr: I Sports Med lflflS;Sl{S}:915—91ll. Medline

Similarly, the PEP cohort maintained substantial improvement in function of almost 63% in the DASH outcome versus only 16% in the steroid group. Level of evidence: I.

nitric oxide application in the treatment of chronic exten-

pain versus 36% improvement in the corticosteroid cohort.

34. l'vlcCaIIum SD, Paoloni JA, l'vlurrell GA: Five-year pro-

4D. Mishra AK, Skrepnik NV, Edwards 5G, or al: Efficacy

treatment of chronic lateral epicondylosis at the elbow.

ble-blind, prospective, multicenter, randomized controlled trial of 233 patients. rim } Sports Med 2014;42lllt463431. Medline DUI

spective comparison study of topical glyceryl trinitratc Br ] Sports Med 2011;45{5}:416-4lfl. Medline

DUI

In this prospective follow-up study of a prior report, the authors reported no sustained benefit .5 years after treatment with a topical glyceryl patch compared with those treated with physical therapy alone. SS. Euchbinder E, Green SE, Tend JM, Assendelft W], BarnslEy L, Smidt N: Systematic review of the efficacy and safety

of shock wave therapy for lateral elbow pain. I eeumatol

2333;333:1351—1363. Medline

36. Krogh TP, Barrels EM, Ellingsen T, et al: Comparative ef—

fectiveness of injection therapies in lateral epicondylitis: A systematic review and network meta-analysis of randomized controlled trials. Arr: f Sports Merl 1313;41l51fl4351443. Medline DUI

In this systematic review and meta-analysis of inieetion therapies for lateral epicondylitis.. the anthers concluded glucocorticoids were no better than placebo beyond 3

weeks, bctnlinum toxin was marginally better than place—

bo with risk of estensor paresis, and PEP and autologons blood were substantially better than placebo; however, most studies were associated with risks of bias.

3?. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P: Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis

IS! 2313 American Academy of flrrhopaedic Surgeons

of platelet—rich plasma for chronic tennis elbow: A dou—

In a multicenter randomized controlled trial of 233 patients, a leukocyte-rich PEP injection was compared with a control group of needling without PEP. Substantial differences were not noted until final follow-up of 24 weeks

when 34% of the PEP group was determined to have

successful treatment compared with 63% of the control group. Level of evidence: II. 41. Ahmad Z, Brooks E, Eang SN, et al: The effect of platelet-rich plasma on clinical outcomes in lateral epicondylitis. Arthroscopy 1313;19{11):13Sl-1362. Medline DUI

In a sysmmatic review of the clinical efficacy of PEP in the

treatment of lateral epicondylitis, the authors concluded limited evidence in the use of PEP. Recommendations regarding future studies involving its use were made. Level of evidence: III.

41. Eaumgard SH, Schwarts DE: Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am

] Sports Med 1932;10l4}:233-236. Medline DUI

43. Saabo SJ, Savoie FH III, Field LII}, Eamsey JE, Hosemanu CD: Tendinosis of the extensor carpi radialis brevis: An evaluation of three methods of operative treatment. I Shoulder Elbow Serg 2336;15{61:?21-?l?.

Medline DUI

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Chapter 9

Hand and Wrist Injuries

Ieifrcy Taylor Iobe. MD A. Hobby lEhhabra. MD

Athletes commonly sustain injuries to the hand and wrist. An understanding of both common and uncom-

mon injuries, diagnostic modalities and treatments of the athletes’ hand and wrist, along with the most recent

published data and treatment methods, are important to maximize treatment outcomes. Keywords: hand and wrist injuries: hand

fractures: carpal fractures; wrist instability: finger dislocations; return to play; skier's thumb; mallet finger; central slip: flexor pulleyr rupture: hook of

hamate fractu re; triangular fibrocartilage complex: scapholunate ligament: Bennett fracture: sagittal band: extensor carpi ulnaris tendinitis: flexor carpi

Not only are the hands used in almost every sport for sport-specific ta sits, but they are also instinctively used to protect the body from the initial impact of a fall or con-

tact with another person. Hand injuries are common in

athletes and occur in almost every sport played. Neglected

injuries can have detrimental consequences; therefore, it

is important to quickly and accurately identify and treat hand injuries.‘

Metacarpal and Phalangeal Fractures Metacarpal and phalangeal shaft fractures are the most common fractures and are frequently encountered in athletes. Most injuries can he treated nonsurgically in the general population, but athletes require special con-

sideration. When treating hand fractures, “Deformity follows nndertreatment, stiffness follows overtreatrnent,

radialis tendinitis; extensor carpi ulnaris instability: jerseyr finger; intersection syndrome: de Quervain:

and deformity and stiffness follow poor treatment."1

thrombosis

common hand fractures and require only short periods

ganglion; ulnar tunnel syndrome; ulnar artery

Introduction

Hand and wrist injuries in the athlete are frequently en-

Distal phalanx fractures {tuft fractures} are the most

of immobilization lid to 14 days]. The nail bed should

be inspected because this is a common associated injury. Substantial nail bed injuries require meticulous repair

technique to avoid nail plate abnormalities.

More proximal fractures in the phalanges and meta-

countered by orthopaedic surgeons. Although treatment of many of these injuries is effective, management of these

carpal bones can usually be treated with approximately 3 weeks of immobilization followed by early protected

derstanding of diagnosis and treatment of com mon hand

ment and no rotational deformity exist. Early edema control, along with motion and elevation, should be in-

injuries can present a challenge to the physician. An un-

and wrist injuries in the athlete, along with guidelines for rerurn to play will help the physician provide optimal care for a specific injury. Dr. Chhahra or an immediate famiiy member has received nonincome support {such as equipment or services). commerciaiiy derived honoraria. or other non—research-reia ted funding [such as paid traveiJ from DePuyiSynthes. Neither

or. .iohe nor any immediate famiiy member has received

anything of vaioe from or has stock or stock options heid in a commerciai company or institution reiated ciirectij.»r or indirectiy to the subject of this chapter.

fl lflld American Academy of Drrhopaedic Surgeons

range of motion to prevent stiffness if minimal displace-

eorporated into therapy. Fractures of the metacarpal head are rare intro-articular fractures, most commonly occurring in the index finger. Surgery with Kirschner wires or minifragment plate and screws is required if more than 1 mm of intrauarticular stepuoff exists. These injuries are

commonly associated with fight bites, which should he treated with appropriate irrigation and debridement and a course of antibiotics. Metaearpal neck fractures jboxer’s fractures} usually occur in the ring and little fingers, although other metacarpal bones can be involved. Lateral radiographs are

necessary to evaluate the amount of angular deformity;

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15“ of deformity can be tolerated in the index and middle finger metacarpals, 3G” to 4D” in the ring finger, and 5CI“

to 6E!" in the little finger. The interossei are the deform—

ing forces that cause dorsal angulation. Traditionally, an

ulnar gutter splint has been applied for 2 to 3 weeks, but

data from lflfl? showed no difference in Disabilities of the Arm, Shoulder and Hand scores with buddy taping alone.2 Malunion is common after metacarpal neclt fractures, but is rarely a functional deficit in the athlete}3

In rare circumstances, open reduction and internal fixan

tion {GRIP}, closed reduction and percutaneous pinning [CRPP], or an intramedullary technique can be considered

1: Upper Extremity

if malunion is not tolerated, such as for a tennis player in whom the metacarpal head prominence in the palm can

make gripping a racquct difficult. For metacarpal shaft fractures, less angular deformity

is tolerated than for metacarpal neck fractures: 10" for

the index and middle fingers, and 3f)“ for the ring and little fingers. Malrotation is unacceptable because 5“ of malrotation results in 1.5 cm of digital overlap. Short-

ening is acceptable up to 5 mm, but F“ of extensor lag occurs with eyeryr 2 nun of shortening. DRIP is commonly

performed in athletes with metacarpal shaft fractures if surgical criteria are met, but CRPP can be considered.“-" Metacarpal base fractures are uncommon, usually

stable, and minimally displaced. Displaced fractures at the base of the metacarpal can result in arthrosis. Fourth and fifth carpometacarpal {CMC} fracture-dislocations are unstable injuries and require pinning of the CMC joint. Proximal phalanx shaft fractures result in solar angulation because the proximal fragment is flexed by the

interossei, and the distal fragment is extended by the central slip. Middle phalangeal shaft fractures can have yolar or dorsal angulation, depending on the location

of the fracture. Malrotation is unacceptable, and only lfl" of angulation in any plane is tolerable. CRPP can be considered, but DRIP with a plate in the athlete may be

a better option. Dbliquefspiral fractures can be treated with interfragmentary lag screws if the fracture line is twice the bone diameter? Phalangeal head fractures can be unicondylar or bi-

condylar. The collateral ligament attachment provides

blood supply. Surgery must be considered with displaced unstable fractures, usually with DRIF with interfragmen-

tary screwsf‘

Figure 1

{Reproduced from Erewal R, Faber Hi], Graham

Tl, Rettig LA: Hand and wrist injuries, in flibler

WEI. ed: Orthopaedic Knowiedge Update:

Sports Medicine. ed 4. Basement. IL, American Acade my of flrthopaedic Surgeons, 2M9, pp 59-30.}

to ensure adequate healing. Bennett fractures are intra-articular fractures that inyolye the base of the thumb and occur when an axial load

is applied to the flexed and adducted thumb {Figure 1]. The abductor pollicis longus displaces the metacarpal

base proximally, and the anterior oblique ligament pulls

the Bennett fragment to the base of the second meta-

carpal. Bennett fractures are surgical injuries and require CRPP or DRIP if the fragment is large enough. Extraarticular thumb metacarpal base fractures can tolerate up

to 30° of angulation as a result of EMC joint hypermobility and most cases can be treated nons urgically, but DRIP or CRPP should be considered in the high—level athlete

for earlier rehabilitation and return to play.

Athletes can return to play with appropriate protection after the fracture is stable and sport-specific range of motion is obtained. Recent data have shown successful early return to play {less than 1 month} after DRIP for metacarpal and phalangeal fractures with appropriate

Dorsal dislocations of the proximal interphalangeal [PIP] joint are the most common finger dislocation. Simple dis-

tection {casting or splintingj until 5 to 3 weeks after injury

middle phalanx followed by distal translation. The yolar

protection? Contact sports are not allowed without pro—

firthupaedic Knowledge Update: Sports Medicine 5

Finger Dislocations

locations are usually reducible with hyperextension of the

fl lflld American Academy of Orthopaedic Surgeons

|Iiiihapter .9: Hand and 1|i'lfrist Injuries

I:

Figure 2

Phetugraph demonstrates pin and rubber band

tractien used tc- treat middle phalanx pilen

fractures.

Figure El

Radiegraphs shevv a retatery subluxatien ef the proximal interphalangeal jeint. A. Lateral view. B, Dhlique vievv. IE, PA view.

Is I:m 1

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plate can bleclt reductien. If stable after reductien, buddy

taping and range ef metien are initiated. If unstable, :1

dersal bleclcing splint is applied. Avulsinn fractures ef

the velar plate sheuld be menitered carefully because a fies-den centracture can develepfi‘ Early return te play is

pessible with buddy taping based en cum fnrt and stability after reductien. Dersal fracture-dislecatieus eften invelve fracture ef the velar base ef the middle phalanx. The Hastings classificatien summarises these iniuries and guides treatment,

eccur, leaving the central slip intact, but the cendyle but-

tenheles threugh the central slip and lateral band {Figure 3]. These injuries eften require surgical interventien fer reductien.

Skier's Thumh Injury re the ulnar cellateral ligament ef the thumb metacarpephalangeal iMCP) jeint is referred te as ski-

er‘s thumb, er gamekeeper‘s thumb. A cempetent ulnar

and is based en the size ef the middle phalanx articular

cellateral ligament is critical fer effective pinch. It is impnrtant re ebtain radiegraphs befere stressing

ef the articular surface is censidered stable. Type II fractures have sass te sass articular invelvement and are

placed fracture. Physical examinatien is perfermed with a valgus stress applied re the thumb in beth extensinn

fragment. Fer Hastings type I fractures, less than 39%

censidered tenueus. Type III fractures have mere than 5fl% articular invelvement and are censidered unstable.

If reducible, types I and [I can be treated with a dersal

the MCP jeint te aveid displacing an etherwise nendis-

{testing the accessery ligament} and fill!"u flexien {preper

ligament}. The ulnar side ef the jeint sheuld be palpated

extensien bleck splint, carefully decreasing the ameunt

fer a Stener lesien {beth the preper and accessery ligament are retracted and lie en the adducter apeneuresis}.

treated surgically using DRIP er hemihamate arthrnplas-

ligament healing witheut surgery. Mere than 35” pi lax-

ef flexien by 10" every week. Unstable fractures must be tyfiW Chrenic fracture—dislecatieus are treated using velar plate arthreplasty er hemihamate arthreplasty.11 Pilen fractures ef the base ef the middle phalanx are treated using leugitudinal tractien (pin and rubber band tractien}

and immediate metien.11 |Heed results have been ebtained using pin and rubber band tractien”I [Figure 2}. Velar PIP dislecatieus are less cemmen and are assew

The adducter apeneuresis interpesitien prevents direct ity alene er mere than 15“ ef laxity cempared with the centralateral side is censidered a pesitive test result. Stress

radiegraphs are useful fer identifying Stener lesiens, as

are Mills and ultraseuegraphs.” Incemplete acute tears and nendisplaced av ulsien fractures are treated with a thumb spica cast fer 4 weeks, fel-

ciated with a central slip disruptien. After reductien, the

lewed by remevable pretective splinting fer 3 mere weeks with active range-ef—metien exercises. Cemplete tears

a beutenniiere defermity and allew healing ef the central slip. If the dislecatiun is still unstable after reductiun,

placed at the site ef the avulsien, which mest cemmenly is the preximal phalanx. Altheugh cemplete minimally

Retatery subluxatien-dislecatiens ef the PIP alse can

tear will net heal in the setting ef a Stener lesien because

PIP sheuld be splinted in extensien fer 6 weeks te prevent pinning fer 3 weeks is required.

IE! Efllli American Academy ef flrthepaedic Surgeens

require epen repair with suture anchers er bene tunnels

retracted tears can heal with nensurgical treatment, the

Drthepeedic Knewledge Update: Sperts Medicine 5

a?

Section 1: Upper Extremitl'

of adductor aponeurosis interposition. Strenuous activity

is avoided for 3 months, with unrestricted return to sport usually at 2 to 3 months. Recent data have reported good

long-term outcomes following repair with two suture an—

chors in collegiate football players. Skill position players

were repaired acutely; lineman were able to complete the

season with bracing or casting before undergoing repair.I ‘

Extensor Tendon Injuries Mallet Finger l'vlallet finger occurs when the extensor tendon attachment

1: Upper Extremity

to the distal phalanx becomes incompetent, resulting in inability to extend the distal phalanx. This can be either

"I—

I

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

treated with S to 3 weeks of extension. A slight residual extensor lag of approximately lfl‘” should he expected after treatment. A bony mallet should be assessed with

lateral radiographs, both without external force and with the joint held in extension tn assess if the fracture reduces appropriately. Bony mallet injuries also are treated with IS

weeks of extension splinting. If the distal interphalangcal [DIP] joint is subluxated or the fragment is large and results in substantial articular incongruity, DRIP or dorsal block pinning should be considered [Figure 4}. Chronic mallet fingers result in swan neck deformities. Recent data

have shown good outcomes with splinting for soft—tissue mallets that were treated within 6 weeks of injury.” Pre-

viously, splinting at night for 1 month after cessation of

fullvtime splinting has been performed, but recent data reported equivocal outcomes without night splinting.”

--L'.-

Figure 4

Late ral radiog ra ph demonstrates the pinning technique for a bony mallet finger. The ohlitjue pin is used to block the fragment and provide

anatomic reduction.

Sagittal Band Injury

gration of the lateral bands. Dn examination, the PIP

If an extensor lag of the finger is present, laceration or rupture of the sagittal band should he considered, which results in ulnar sublu xation of the extensor tendon. This injury, also known as boxer’s knuckle, also can be associ-

intact and splinting usually provides good outcomes. The

the patient is unable to initiate MCP joint extension, but

Central Slip Injury {Acute Boutonniere Deformity]

A houtonniére deformity is the result of a central slip rupture, triangular ligament attenuation, and volar mi-

joint is passively placed in extension; if the patient can maintain PIP extension, the triangular ligaments are likely Elson test is used to assess a central slip rupture. The PIP

is flexed to 9D“ and blocked while extension of the PIP is attempted and the DIP is assessed. The test result for

ated with a capsular injury of the MCP joint. The middle finger is the most commonly affected. On examination,

can maintain extension after passive finger extension.

or actively extends to neutral. Radiographs may show an avulsion fracture. A closed acute houronniii-re injury

The extensor tendon dislocates to the cnntralateral side when the MCP joint is flexed and reduces when the joint is extended. The mainstay of treatment of acute injuries in the general population is flexion block splinting of the MCP joint for 3 weeks, but in athletes, surgical

followed by 5 weeks of night splinting. Surgery is indi— cated if closed treatment fails, for open injuries, for large

season the injury occurs and the athlete’s preferences.” Numerous techniques can he used for repair, depending

a central slip injury is positive if the DIP becomes rigid

is treated with extension splinting of the PIP for 6 weeks displaced avulsion fractures, or in the setting of an un— stable volar PIP dislocation {Figure 5}. For large fracture

fragments, IKiln]: can he performed or the fragment can be excised and the tendon repaired with suture anchors.“

firthopaedic Knowledge Update: Sports lvledich'ie 5

repair must be considered, depending on when in the

on the local soft—tissue availability and need for recon-

struction. Patients with chronic injuries can undergo a trial of splinting, but surgery is required more often than for acute injuries.

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 9: Hand and Wrist Injuries and tendon retraction to the pahn. lE'IRIF is performed, as well as tendon repair, and should he done within 1!] days as in type 1 injuries.”

Pulley Rupture Flexor tendon pulley ruptures occur when a sudden ex-

tension force is generated on a flexed finger. This is most commonly seen in rock climbers when they slip and frequently affects the ring and middle finger. The patient will have acute pain over the flexor tendon. Dn examination, bowstringing may be visible if the A2 or A4 pulleys are

involved and the patient will have difficulty making a full fist. Dynamic ultrasonography and MRI are useful

in diagnosis.

Single-pulley ruptures should he immohiliaed for If] to 14 days, followed by therapy for motion and taping or rings to support the pulleys. Multiple ruptured pulleys

should he treated surgically. Repair can be performed

with extensor retinaculum sutured to the remnant of the

pulleys. If no pulley edges remain for suturing, a triple

loop repair is performed using tendon autograft [Fig-

ure 6}. Return to sport is permitted at e? to 3 weeks with

Figure 5

Lateral radiograph shows central slip avulsion and resultant Boutonniére deformity.

[Reproduced from Grewal Fl. Faber it]. Graham

TJ, Fiettig LA: Hand and wrist injuries, in itihler WE, ed: Drthopeedic Knowledge Update:

Sports Medicine. ed 4. Easement. IL. American

Academy of flrthopaedic Surgeons, 2W9. pp Gil-ED.)

continued pulley protection. Full sports participation begins at 3 months. Taping or pulley ring use should he continued for at least 6 months.” Scaphoid Fractures

Scaphoid fractures are a common problem encountered

by orthopaedic hand surgeons. A high index of suspicion is necessary to make the diagnosis because radiographs

are often negative at initial presentation. Any history of

Flexor Tendon injuries

Jersey Finger

Jersey finger is the result of a flexor digitorum profundus avulsion from its insertion on the distal phalanx. The ring finger is most commonly involved. Physical examination

reveals inability to flex the DIP. Ultrasonography can help

assess the level of tendon retraction in a timely fashion,

although MRI also has good results if performed soon enough postinjury. The Leddy classification is based on the level of retraction. In type I injuries, the flexor digitorum profundus is retracted to the pahn and the vincula {blood supply] is compromised. Primary early repair {within lfl days} is warranted. Type II injuries involve a tendon that is retracted but still in the flexor sheath, at

|the level of the A2 pulley. Surgical repair is warranted and

should he performed in a timely fashion, usually within

4 weeks. Type III injuries include a bone fragment that is caught on the A4 pulley. DRIP is performed on the

fragment that involves the tendon insertion. Type IIIA

injuries are less common and involve a bone fragment

IE! lfllfi American Academy of flrrhopaedic Surgeons

wrist trauma and tenderness should increase suspicion. On physical examination, tenderness over the anatomic snuffhox prevents the surgeon from ruling out a scaphoid

fracture. Resisted pronation also elicits pain on exam-

ination. In addition to standard wrist radiographs, a scaphoid view should he obtained, with the wrist in 30" of extension and 1D“ of ulnar deviation. In the athlete, an MRI is useful if radiographs are inconclusive. This can

allow earlier return to play if no fracture is identified. MRI is also used to assess osteonecrosis of the proximal

pole of the scaphoid, a common complication of these

injuries, and can help assess for a scapholunate ligament injury, another common cause of radial-side wrist pain

in the athlete after a fall. Scaphoid fractures are often a missed injury. Fractures treated less than 28 days from injury result in a 5 “if. non-

union rate. If treatment is delayed longer than 23 days, the nonunion rate increases to 23%. It is imperative that

the surgeon educate all trainers and other athletic staff

about scaphoid fractures; any suspected injury should be

promptly evaluated and treated.

Drthopoedic Knowledge Update: Sports Medicine 5

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Sectien 1: Upper Extremiqr

unpretected play until evidence ef radiegraphic unien is eenfirrned. Healing is assessed by tenderness en clinical

examinatien and using radiegraphs and CT scans. CT

is the mest reliable imaging study fer assessing unien.‘ Arthrescepically assisted reductien and fixatien has been perfermed in athletes, but substantial fluerescepy is alse required fer this precedure.m

Heel: ef Hamate Fractures Heek ef hamate fractures are eften a seurce ef chrenic ulnar-side hand pain in baseball players, heckey players,

gelfers, and these whe play racquet sperts. Patients present with vague ulnar-side pain in the palm. Tenderness 1: Upper Extremity

is elicited ever the hamate, and ulnar nerve symptems

may be present. The fracture can alse cause Heater tenden irritatien er rupture. Standard hand radiegraphs usually

will net reveal the fracture, se a carpal tunnel view is

necessary. Because diaguesis is difficult, a CT scan sheuld he ebtained if a fracture is suspected.

Acute injuries can be treated with IS weeks in a shert

arm cast; hewever, the risk ef nenunien is high. Surgical

excisien ef the fragment is the mest reliable eptien fer a pain—free eutceme in athletes. DRIP has been described,

but hardware preminence is a cemmen cemplicatien. Af-

ter fragment excisien, range ef metien and strengthening

Figure E-

Photograph demenstrates an A2 pulley recenstructien with a triple-lee ped tenden graft.

Scapheid fracture treatment depends en the lecatien

and displacement ef the fracture, as well as the skills required fer the spert andfer pesitien. If clinical suspicien is high fer fracture, but the radiegraphs are negative,

the athlete sheuld be placed in a shert arm thumb spica

splint and an MRI sheuld he ebtained. Nendisplaced fractures ef the scapheid waist can be treated with thumb

spica casting in feetball lineman with frequent fellew-up

repeat radiegraphs, hut percuta neeus cempressien screw

fisatien is strengly censidered fer mere skilled pesitien players such as receivers. IEasting generally lasts fer at least 3 menths er until healing is cenfirrned en sequen-

tial radiegraphs er a CT scan. Displaced scapheid waste

fractures are treated using GRIP with a cempressien screw. Prereimal pele fractures are treated using DRIP

with cempressien screw fixatien in all cases because ef the high rate ef esteenecresis and nenunien fer these fracture patterns. Other surgical indicatiens include 15" humpback defermity, cemminuted fractures, and dis-

placement greater than 1 mm. In general, surgical fixatien decreases the time te unien, thus allewing a quicker return re spert. Athletes are net allewed re return re

firthepaedic Knewledge Update: Sperra Mediehte 5

can begin immediately. Baseball players are eften able re return re play by ti weeks after surgery. [In return re

sperrs, a gleve with a denut-shaped pad can he wern fer

prerectien until the scar is ne lenger tender.11

Differential Diagnesis ef Wrist Pain in the Athlete

Radial Wrist Pain lntersectien Syndreme

Intersectien syndreme is acute bursitis at the intersectien ef the first and secend extenser cempartment tendens in the ferearm. This injury is mest cemmenly seen in rewers

and gelfers. It presents with tenderness 5 cm prettimal re the radial styleid, and must he differentiated frem de Quervain tenesynevitis, which is mere distal. A charac— teristic crepirus is lecared at the site ef intersectien. Treatment censists ef splinting in a thumb spica hrace, activity medificatien, HSAIDs, and semetimes, stereid injectiens.

Surgery is rarely indicated, and is reserved fer these in

whem nensurgical treatment has been unsuccessful fer

at least 3 menths. Surgery includes hursal débridement and secend estenser cempartment release. de Quervain Tenesynevitis

de Quervain tenesynevitis is an everuse syndrerne that

invelves inflammatien ef the tenesynevium ef the first extenser cempartment tendens and is seen in racquet

fl lfllfi American Academy ef Urrhepaedic Surge-ens

Chapter 9: Hand and Wrist Injuries sport athletes and golfers. Symptoms include dorsoradial wrist pain and swelling, with crepitus over the tendons detected with thumb circumduction. Individuals with de Quervain tenosynovitis will have tenderness over the first dorsal compartment and a positive Finldestein test result. Pain is also elicited with resisted thumb MCP extension. Treatment is similar to intersection syndrome, but with

20% of ganglious recur. Arthroscopic excision allows direct visualization of the scapholunate ligament as well

time of surgical release of the first dorsal compartment, careful inspection for a separate subsheath that contains

Scapholunate ligament injuries also cause dorsal wrist pain. As with scaphoid fractures, scapholunate ligament

a novel four—point steroid injection teclmique for recal— citrant cases in high-resistance athletes was described

challenging for the orthopaedic hand surgeon to treat if they present in a delayed fashion. Examination will reveal

injection technique.m

tive scaphoid shift test result. 1Fl'lfrist radiographs should be

a lower threshold level for surgical intervention. At the

the extensor pollicis brevis tendon is needed.” In 2011, that yielded better outcomes than the standard two-point Volar Wrist Ganglions

Volar wrist ganglions can cause pain on the radial aspect of the wrist, usually emanating fmm the joint via a tear in the radioscaphocapitatc ligament. Pain is caused by

compression of the surrounding structures. If the cyst is appreciable on physical examination, it will transilluminate. Usually, no correlation is found with underlying pathology, although other diagnoses, such as a radial

as the remainder of the wrist joint, and debridement of

the capsular stalk at the base of the cyst. Arthroscopic excision has a slightly lower recurrence rate than open cxcisiond-u" Scapholunate Ligament Injuries

injuries are often missed on initial presentation and are

tenderness at the scapholun ate interval, as well as a posi-

obtained and include a clenched list view to evaluate for

widening between the scaphoid and lunate. More than 3

mm of widening {the Terry Thomas sign] suggests a ligament tear. On the lateral view, an increased scapholunate

angle may be appreciated {greater than 90“]. Dynamic

widening of the interval is appreciated when the widening only occurs with the clenched list view {Figure 7"}. Static widening can be seen on all views, is usually associated

with a chronic injury, and will result in arthritis over

artery aneurysm, should be excluded before undertaking

time. MRI can be helpful in the diagnosis, although it

should not be aspirated or injected with steroid because

undergo surgical treatment acutely when possible, with

surgical excision. The cyst should be excised if painful, although Zfl‘l’h recur. A volar cyst [versus a dorsal cyst}

only has ?fl% to 31% accuracy.” Arthroscopy is the gold standard in diagnosis“ {Figure 3}. Acute tears should

of the proximity of the radial artery and potential for injury to this structure.”

open reduction of the scaphoid and lunate with dorsal wrist capsulodesis or ligament repair and percutaneous

Flexor Carpi Hadialis Tenclinitis

been described for static chronic injuries more than 6 weeks post-injury. More recent data have shown better

Athletes engaging in forceful, repetitive wrist flexion can

develop inflammation of the wrist flexors, especially the

flexor carpi radialis. Symptoms include volar radial and] or ulnar wrist and forearm pain, and are elicited with resisted wrist flexion and radial or ulnar deviation. Lo— caliaed tenderness is present over the involved tendon.

pin fixation. Numerous reconstruction techniques have

radiographic outcomes with ligament reconstruction over

wrist capsulodesis for chronic injuries'” Ulnar Wrist Pain

Extensor Earpi Ulnaris Tenclinitis

Splinting and steroid injections into the tendon sheath are

Exten sor carpi ulnaris {ECU} tendinitis is seen in racquet sport athletes and baseball players. The sixth extensor compartment is a unique fibro-osseous compartment that

Dorsal Wrist Pain

As the forearm is supinated, the sheath prevents ulnar translation of the tendon. Tenderness is elicited directly

the first line of treatment. Surgical release of the flexor carpi radialis sheath has good results in 313% of cases.”l Dorsal Wrist Ga nglions Approximately ?fl% of dorsal wrist ganglions emanate

from the scapholunate wrist ligament. Pain associated with a dorsal wrist ganglion should increase concern for a scapholunate ligament injury. Ganglions not associat—

holds the ECU tendon tight against the ulnar groove.

over the ECU tendon on examination. Radiographs are

obtained to rule out fractures of the ulnar styloid and other bony pathologies. MRI sometimes shows splits in the tendon or increased signal intensity in the tendon

ed with pain may be observed. They can be aspirated if painful, but have recurrence rates of 20% to 50%. Steroid

on T2-weighted images. Nonsurgical management is preferred using HSAIDs, splints, and restricted activity.

usually successful at relieving symptoms, although up to

management fails, the ECU tendon can be débrided. The

injection of the cyst has no benefit. Surgical excision is

IE! Efllfi American Academy of flrthopaedic Surgeons

Steroid injections can help relieve pain. If nonsurgical

Drthopaedic Knowledge Update: Sports Medicine 5

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1: Upper Estrem ity

Section 1: Upper Extremity

A Figure 3’

FA radiographs demonstrate dynamic widening of the scapholunate interval. A, Clpen fist view shows normal space between the scaphoid and

lunate. B. Clenched fist view shows less than 3

mm of wicl ening. corresponding to a complete scapholunate ligament tear. {Reproduced from Eurrus MT, Dacus AH: Carpal instability, in [layer MI, ed: AACIE Comprehensive flrthopaeci'ic

Review, ed 2. Hosemo nt, IL, American Academy of Clrthopaedil: Surgeons. 21114. pp toss-toss.)

retinaculum of the sixth esctensor compartment must be repaired carefully to prevent instability.

Figure B

Arthroscopic view of the rnidcarpal space-

The probe in the scapholunate interval demonstrates scapholunate ligament tearing. {Reproduced from Burrus MT, Dacus AR: Carpal instability, in Boyer l'vll, ed: M05 Comprehensive Drthopaedic Reviews ed 2. Rose mont, IL, American Academy of Orthopaedic Surgeons, 211114, pp 1D55-1DE-4J

symptoms or both. Paresthesias are noted in the ring and little fingers, and the intrinsic muscles are often weak.

E-CU Tendon Sublustation ECU tendon sublurcation is most commonly seen in tennis

This condition is often caused by a mass lesion such as

don painfully snaps out of the groove with supination

fracture, ganglion {most common] or lipnma, inflammatory arthritis, bone anomalies, or continuous pressure.31

players, usually resulting from a hypersupination andfor ulnar deviation injury. Du examination, the ECU tenand ulnar deviation. The displaced tendon is palpable.

Acute treatment is with a long arm cast in pronation and slight radial deviation. Chronic instability requires

compartment reconstruction performed with direct repair supplemented using a radial-based sling of retinaculum

or a free graft from the retinaculum. The ulnar groove can also he deepened to further stabilise the tendon. This is strongly {almost Sfl‘iis} associated with triangular fi-

brocartilage complex [TFCQ tears.“ Wrist arthroscopy should be considered at the time of surgery if a TFEC

an ulnar artery thrombosis or aneurysm, book of hamate

Nerve conduction velocity studies and electromyogtaphy can support the diagnosis, and MRI can be helpful if a mass lesion is suspected. Nonsurgical therapy includes

wrist splints and avoidance of aggravating activities. Sutgery involves nerve decompression and removal of any masses or lesions. If the patient has concomitant carpal tunnel syndrome, release of the carpal tunnel is sufficient

for release of the ulnar tunnel as well.

teat is suspected.

Ulnar Artery Thrombosis Ulnar artery thrombosis, also known as hypothenar ham-

Ulnar Tunnel Syndrome Ulnar tunnel syndrome consists of entrapment of the

Symptoms include pain, cramping, and sensory distur—

mer syndrome, can occur in baseball catchers because of repetitive impact to the ulnar artery while catching.

ulnar nerve in the Guyon canal at the wrist. Also known as handlebar palsy in cyclists, it can be associated with

bance. The Allen test should be performed if diagnosis is suspected, with delayed reperfusion appreciated while

the compression, patients can have motor or sensory

with interposition vein grafting is required.33

carpal tunnel syndrome. Depending on the location of

C'Irthopaedic Knowledge Update: Sports Medicine 5

occluding the radial artery. Ulnar artery reconstruction

fl lflld American Academy of Orthopaedic Surgeons

Chapter 9: Hand and 1|i'lfrist Injuries

TFEC Injury

The TFCC is the primary stabilizer bf the distal radibul-

Summary

nar jbint and is cbmpbsed bf a central disk and peripheral

Hand and wrist injuries bf the athlete prbvide a substan-

tears can be degenerative br acute. Injury tb the TFCC causes pain br perceived instability

number and diversity bf injuries seen in this patient pepulatibn. Furthermbrc, many injuries are initially missed,

disk—carpal ligaments that are mbre vblarly based. TFCC

tial challenge tb the treating physician because bf the sheer

that can prevent athletic participatibn. Peripheral injury

presenting the challenge bf treating a chrbnic injury in

has the best blbbd supply. Tenderness bvcr the fbvea bf

make diagnbsis difficult; thus, it is imperative tb have a deep understanding bf all types bf injuries that can bccur

has the best likelihbbd bf healing because this pbrtibn

the ulna {a pbsitive fbvea sign} is evident bn examinatibn. Radibgraphs are bbtained tb assess ulnar variance and

an athlete. The cbmplexity bf the hand and wrist can in the hand and wrist. With the apprbpriate knbwledge

rule but ulnar stylbid fractures. MRI helps determine a diagnbsis, althbugh studies have shbwn magnetic resb-

base, brthbpacdic hand surgebns can usually cbnlirm the diagnbsis bf athletic injuries bf the hand and wrist and

cbpy cbnlirms the diagnbsis {Figure 9}. Classificatibn is

return tb his br her spbrt as quickly and safely as pbssible.

nance arthrbgraphy tb be mbre helpful.“ Wrist arthrbs—

based en the lbcatibn bf the tear and chrbnicity. Type 1

prbvide the apprbpriatc therapy tb allbw the athlete tb 1

tears are traumatic {Table 1]; type 2 tears are degenera— tive. Treatment cbnsists bf rest, splinting, NSAIDs, and

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sterbid injectibns versus arthrbscbpic surgical debride-

a?

ment br repair.

Ulnar-side peripheral tears shbuld be repaired; central

and radial tears can truly be debridedfij Ulnar tears that

are repaired within 3 mbnths regain Edit: bf mbtibn and strength.35 The surgebn shbuld be aware that a knbt tied in the fiber bf the EEU sheath can cause ECU tendinitis. If a central tear is débrided, a 2-mm peripheral rim bf the TFCC shbuld be preserved after debridement tb maintain a stable jbint. Partial-thickness tears bf the ulnar fuvea

db well with repair and patients whb play racquet spbrts

are bfteu able tb return tb spbrt. Hewever, athletes whn

bear weight thrbugh the wrist have less favbrable return-

tb-spbrt butcbmes.“ If ulnar variance bf mbrc than 2 mm exists, resulting in symptomatic ulnbcarpal abutment, an ulnar shbrtcning prbcedure shbuld alsb be pcrfbrmed.

Excellent results have been achieved with ulnar shbrtening

bstebtbmy because this stabilizes the distal radibulnar jbint, reduces the effect bf ulnbcarpal abutment, and de— creases fbrces bn the TFCC.”

Figure 9

Arthrbscbbit view bf the triangular fibrbcartilage cbm pleat (TFCE) seen frbm the

radial side bf the wrist. The TFCE is detached

from the radius.

Table ‘1

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

Lbcatibn

Characteristics

1A

Ce ntral

Traumatic tears bf articular dislt

IB

Ulnar

Ulnar avulsibn

1C

Ublar distal

Distal traumatic disruptibn bf the ulnblunate br ulnbtricjuetral ligaments

1D

Radial

Traumatic avulsibn frbm sigmbid nbtch bf radius

{Heprbduted frbm t‘ibldfarb CA: Wrist erfllrbscbpy, in Buyer Ml, ed: AAflS Cbmprehensive flflbbpaedic Review, ed 2. Basement, IL, American Academy bf Orthbbaedlc Surgeuns, IDH, pp net-tree.)

IE! lfllfi American Academy bf Urchbpaedic Surgebns

I:

'bi 'bm

Drthbpaedic Knuwledge Update: Sperrs lvledichie .‘i

Sectien 1: Upper Extremity

Hey Study Feints

I Metacarpal and phalangea] fractures are at risk ef defermity and functienal less if net treated appre-

priately. The handffingers are at high risk ef stiffness if immehiliaed fer extended perieds ef time. Directien ef finger PIP ieint dislecatien is important in guiding treatment. l Acute pain in the snuffbesr regien in an athlete sheuld he treated aggressively with immehiliaatien fer 3 weeks and then reassessment te rule eut a scapheid fracture. Uccult scapheid fractures may 1: Upper Extremity

net be visible en radiegraphs until 3 weeks pastin-

iury. Per early evaluatien and diagnesis, an MRI is beneficial in the diagnesis ef an eccult scapheid fracture if return te play is critical fer a high-level athlete. Untreated scapheid fractures can have dire censequences te the patient. I Advancements in wrist arthrescepy have lewered the recurrence rates ef dersal wrist gangliens. l Ulnar-side peripheral tears ef the TPCC sheuld be rcpaired as eppesed te debrided.

Annetatecl References

. Swansen AB: Fractures invelving the digits ef the hand. Grrlhep Cfirr- Hersh Arr: 19?fl;1[2}:261-2?4. Medline

. van Aalren J, Kampfen 5, Eerli l'vl, Fritschy D, Della Santa D, Fusetti C: Clutceme ef bexer’s fractures treated by a seft wrap and buddy taping: A prespective study. Heard

as v; 200?:2i41:212—11?.Medline net

Seeng M, lI'fiet C, Katarincic J: Ring and little finger meta-

carpal fractures: lvlechanisms, lecatiens, and radiegraphic para meters. 1 Hand Sari-g Am. ae1e;ss{s}:1ass-1ass.

Medline

DUI

The anthers reviewed Ifll ring and little finger metacarpal

fractures and reperted that punching iniuries usually cause

a neck fracture ef the little finger versus a shaft fracture ef the ring finger. The isthmus ef the ring finger is narrewet. Level ef evidence: IV.

. Reth J], Auerbach DM: Fixatien ef hand fractures with hicertical screws. } Hand Sarg Aer 2005;3fllll:151—153. Medline DD] . Hardy MA: Principles ef metacarpal and phalangeal fracture management: A review ef rehabilitatien cencepts. I Drrhep Sparta Phys Ther 2Ufl4;34{12}:?31—T99. Medline DUI

E. Eirre M, Shin AT: Treatment ef acute scapheid fractures in the athlete. Carr Sperts Med Rep lfl‘flfiriffi l:242-243. Medline

DD]

Kedama N, Tal-temura T, Ueba H, Imai 5, Matsusne

Y: Dperative treatment ef metacarpal and phalangeal

fractures in athletes: Early returu te play. I Drrfrep Sci 2014:19i51fl29-T36.Medline Ill-DI 0f lfll metacarpal er phala ngeal shaft fractures, 2G were

treated with DRIP se athletes ceuld return fer impert-

ant event. All 2i] returned by 1 menth and eventually achieved unien with excellent range ef metien. Lewl ef evidence: III. Arera FL, Angermann P, Fritz I}, I-Iennerhichler A, Gabi M, Lute M: [Derselateral dislecatien ef the preximal in-

terphalangeal ieint: Elesed reductien and early active metien versus static splintingl.[Article in German] Haedcfrrr Mikreclar'r Plasr Elvin: 2f! fl?;39{3}:215-223. Medline DUI

Elfar J, Mann T: Fracture-dislecatiens ef the prestimal interphalangeal jeint. ] Aer Acird Drtbep Srrrg

1fl13:21[2}:33—93.Medline net

The authers reviewed dersal, velar, and pilen PIP fracture-dislecatiens in this review article. Acceptable eutcemes were achieving a well-aligned jeint and reestablishing metien. Anatemic articular cengruity is preferable but net abselutely necessary fer geed eutcemes. If]. Pagenis T, Ditsies K, Teli P, Givissis P, Christedeuleu A: Impreved certicestereid treatment ef recalcitrant de Quervain tenesynevitis with a nevel I'-lr-peint injectiee technique. Aer }' Sperrs Med 2011,39{2]:393-4fl3. Medliue DID]

The authers cempared twe similar grenps ef 14 athletes treated with ene- te twe-peint injectien technique versee their new feur-peint technique. Symptem relief was better in the fenr-peint greup at 1 and 51 weeks. Level ef evidence: II. 11. Williams RM, Kiefhaber TR, Semmerltamp TG, Stern PJ: Treatment ef unstable dersal preeimal interphalangeal fracturefdislecatiens using a hemi-hamate autegraft. 1 Head Serg Arrr lflfl3;13{5]:355-365. Medline DUI 12. Nilssen JA, Eesberg HE: Treatment ef preJtiInal iriterphalangeal jeint fractures by the pins and rubbers tractien system: A fellew—up. j Pleat Sarg Hand Snug 2014:43l4}:259-264.Medline DUI Petty-twe patients with cemplea: PIP jeint fractures were treated with a pins-and-rnbber band system. The device

was easy te apply and well telerated. Vela: lip fractures

had the best eutceme. flsteearthritis and less ef metien are still cemmen. Level ef evidence: III.

13. Kiral A, Erlcen HY, Altmaa I, ‘r'ildirim C, Erler K: Pins and rubber band tractien fer treatment ef cemmiriuted

intra—articular fractures in the hand. I Hand Surg Aer 2fll4;39[4}:69fi~?fl5.Medliue DUI

This retrespective review ef 33 patients treated with pins-and—rubber band system at the PIP, DIP, thumb

firthnpaedic Knewledge Update: Sperts Medicine 5

fl lfllfi American Academy ef Orthepaedic Surge-ens

Chapter 9: Hand and Wrist Injuries interphalangeal, and thumb MCP jeints reperted satis-

eutcemes. Mean return tn play was 5.? weeks. Level ef evidence: IV.

14. Heyrnan P: Injuries tn the ulnar cnllateral ligament nf the thumb metacarpnphalangeal jnint. I An: Aced Urthnp

12. Stein AH Jr, Ramsey RI—I, Key JA: Stennsing tendnvaginitis at the radial styleid prncess {DeQuervain's disease}. AMA

1.5. Werner BC, I-Iadeed MM, Lyens ML, lILIrluck 15, Didnch DR, Chhabra AB: Return tn feetbaIl and leng-term clinical eutcemes after thumb ulnar ceIlateral ligament sutnre anchnt repair in cnllegiate athletes. I Hand Snrg Ans lfl14:39[1i}}:1992-1993.I'vIetlline DUI

2.3. Liddet 5, Ranawat V, Ahrens P: Surgical eacisien nf wrist ganglia,-I literature review and nine-year retrespective study

factnry results. Level nf evidence: IV.

Snrg manganese-see. Medline

The anthers reperted en a twe-suture anchnr technique ef ulnar cellateral ligament repair perfermed en 13 cellegiate fnnthall players. All returned tn at least their eriginal level ef play. Skilled players returned in 7' weeks, nnnskilled returned in 4 weeks. Level ef evidence: IV.

IE. Altan E, AIp NB, Baser R, Yalctn L: Seft-tissue mallet injuries: A cemparisen ef early and delayed treatment.

mane Snrg An: 2014;39i1fl]:1932-1935. means: DUI

1?. Gruber J5, Bet AG, Ring D: A prespective tandemized cnntrnlled trial cemparing night splinting with nn splinting after treatment nf mallet finger. Hand {N Y} 1fl14;9{2}:145-15i}.Medline DUI In this study, 51 patients were enrelled in a prespective trial tn either receive night splinting after 6 tn 3 weeks nf cnntinuens splinting fer mallet fingers er ne splinting. Ne difference in extenser lag was reperted between the twe

grnnps at final eutcnme. Level ef evidence: II.

13. Lin JD, Strauch R]: Clesed seft tissue extenser mechanism injuries (mallet, beutenniere, and sagittal band}. I Hand Snrg Arn 2fl14;39{5}:1fl05-1011. Medlitle DUI The anthers summarise mechanism and treatment nf clesed seft-tissue injuries in aene I, III, and V extenser mechanism injuries. Level nf evidence: V. 15'. Freilich AM: Evaluatien and treatment ef jersey finger and pulley injuries in athletes. Elfin Spnrts Med 2U15;34{1}:I 51— 155. Medline

DUI

Arcfr Snrg 1951;63i2}:215-228. Medline

DUI

ef recurrence and patient satisfactien. Urinep Rev {Fania} 2i] flflglflltefi. Medline

DUI

The anthers fnllnwed up 1'1?r patients whn underwent velar er dersal wrist ganglia excisien. An everall recurrence ef 41.3% was reperted; it was cencluded that surgery may have better results with a hand specialist. Level ef

evidence: IV.

24. Sauvé P5, Rhee PC, Shin AT, Lindau T: Eaaminatien ef the wrist: Radial-sided wrist pain. I Hand Snrg Arr: 2fl14;39{19j:2fl39-1D92.Mcine

DUI

The anthers previded a thereugh review ef causes uf radial-side wrist pain. Level nf evidence: V. 15. Fernandes EH, Miranda CD, Des Santns JE, Falnppa F: A systematic review nf cnmplicatinns and recurrence rate ef arthrescepic resectinn nf velar wrist ganglien. Hand Snrg 2014;19i3}:4?5-43i]. Medline DUI

Uf 232 wrists treated with arthrescepic velar wrist ganglinn eacisien, 14 had recurrence. Recurrence rates in the papers reviewed ranged frem fl tn 20%. The prncedure was reperted as technically difficult, and had higher rates

nf assnciated cnmplieatiens than epen excisinn. Level ef evidence: III.

16. Kang L, Akelman E, Weiss AP: Arth rescnpic versus npen

dntsal ganglien excisinn: A prnspective, randnmised enmparisen ef rates ef recurrence and ef residual pain. I Hand Snrg Arn 2003:33i4]:4?1-4?§. Medline DUI

2?. Spaans A], I'innen Pv, Prins I-I], Kerteweg MA, Schuur—

man AH: The value nf 3.fl-tesla MRI in diagnesing scapheIunate ligament injury. I Wrist Snrg 3fl13;2[1}:69T2. Medline DUI

The anther discussed fleanr tenden injuries and pulley injuries in the athlete. Level ef evidence: V.

The anthers reviewed the sensitivity and specificity ef

ll}. Geissler WE: Arthrescepic management ef scapheicl fractures in athletes. Hand Ciin lflflfljlfijdjfiEE-JEQ.

the imaging findings with arth rescnpic findings. Level nf evidence: II.

This article discussed the indicatinns and treatment strat-

23. Schadel-Htipfner M, Iwinska-Zelder J, Braus T, Behringer G, Klese K], Getaen L: I'vIRI versus arthrescepy in the

Medline

DUI

egy fer arthrnscnpic management nf scaphnid fractures and nenuniens in athletes. Level ef evidence: V.

21. Bacheura A, Wreblewski A, Jaceby SM, Usterman AL, *3q RW: Heels ef hamate fractures in cempetitive baseball players. Hand (N I? 2013;3{3}:3i}2—3fi1

Medline DUI

The anthers presented their experience with hnnk ef hamate fractures in baseball players treated surgically. Ulnar

tunnel decnmpressinn with hnnk excisien prnvides gned

IE! lfllfi American Academy ef Urthnpaedic Snrgenns

3.0-T MRI in the diagnnsis nf TFCE‘ tears by cemparing

diagnesis ef scapheIunate ligament injury. ,I Hand Snrg Hr lflfliflfilIHT-ZI. Mcdlinc DUI

29. Pappen IP, Easel J, Deal DH: Scaphnlunate ligament injuries: A review ef current cnncepts. Hand {N ‘1’} 2fl13;3{2}:146-156.Medline

DUI

The anthers reviewed classificatien ef and treatment ep-

tiens fer scapheIunate injuries, fecusing en stages in which tecnnstrnctinn prncedures may wnrk as eppnsed tn salvage precedures. Level ef evidence: V.

Urthnpaedic Knnwledge Update: Sperts Medicbie 5

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Sectiun 1: Upper Extremity

30. Ruhman EM, Agel J, Putnam MD, Adams JE: Scaphulu-

nate interusseuus ligament iniuries: A retruspeetive review uf treatment and uutcumes in 32 wrists. I Hand SurgAm

2fl14;39{1fl]:102D-2026.Medliue DUI

The authurs reviewed 1? acute and SD chrunic scaphulu— nate tears treated surgically. Chrcnic injuries had better radiugraphic uutcumes with ligament recuustructiun cum-

pared with capsuludesis. Acute repair within 6 weeks was preferred. Level uf evidence: III.

31. MacLenuan A], Hemechelt NM, Waitayawiuyu T, Trum—

hle TE: Diagncsis and anatumic recunstructiun uf extensur carpi ulnaris suhlui-tatiun. ] Hand SurgAm lflfl3;33{1}:5964. Medline

DUI

1: Upper Etttrem

t

31. Jayakurnar P, jayaram V, Hairn D5: Cumpressive neurup-

athies related te gangliuns cf the wrist and hand. Hand

Strrg 2fl14;19{1]:113-116. Medlirte DUI

The anthers discussed the pathuanatc-my uf wrist and hand gangliuns that cause cumpressive neurupathies. Mutur andl'ur sensury deficits can be encuuntered and currelate tn the lueatiun cf the gangliun. Level cf evidence: V.

33. Dreiain D, Juse J: I-Iyputhenar hammer syndrume. Am I Urtbup {Belle Mead NI} 2012;41{3}:33fl-332. Medline Hyputhenar hammer syndreme was discussed in this study, including the impurtance uf early diagnusis and

imaging studies. Definitive evaluatiun was made with cath—

etervdirected angiugraphy. Management uptiuns were alsu discussed. Level uf evidence: V.

34. Berna-Berna JD, Martinez F, Reus M, Alunsu J, Duménech G, |ICIampcus M: Evaluatiun uf the triangular fihrucartilage

Urthupaedic Knuwledge Update: Spurts Medicine 5

in cadaveric wrists by means uf arthrugraphy, magnetic resunance {MR} imaging, and MR arthrugraphy. Acre Radial lDflfi-‘lflfllflfi -1 [13. Medline

DUI

The authurs examined the value uf arthrugraphy, MRI, and magnetic resuuauce arthrugraphy in diagnusing TFCE tears, and their ability tu identify the lueatiun cf the tear. Level uf evidence: II. 35. Estrella EP, Hung LK, Hu PC, Tse WL: Arthruscupic repair uf triangular fihrucartilage cumpletlt tears. Artistescupy 10H?:23[?}:?29-?31e1. Medline DUI The authurs reviewed 26 patients whu underwent repairs cf partial-thickness TFCC fuvea tea rs. Patients were mere lilcely tu return tu racquet spurts and less likely tu return

tu spurts that required weight bearing thruugh the hands. Lewl uf evidence: 1|v’I.

36. Ruch D5, Papaduuiltulaltis A: Arthruscupieally assisted repair ef peripheral triangular fihrceartilage cumplex tears: Facturs affecting uutcume. Arthruscupy EDGE;11{9']:112tii1131]. Medline DUI

3?. Wysuclci KW, Richard M], Cruwe MM, Leversedge F],

Ruch D5: Arthreseupic treatment uf peripheral triangular

fihrueartilage CUIIIPIEII’. tears with the deep fibers intact. 1 Hand Sat-g Am 2012:3Tl3}:5fl9-515. Medline DUI

33. Cunstantine K], Tumainu MM, Herndun jH, Entereanus DIG: Cumparisutt uf ulnar shuttening usteuturuy

and the wafer resectiun prueedure as treatment fur ulnar impactiun syndrumeJHaud Surg Am lflflflglillifij-fil}.

Medline DUI

U zeta American Academy at Urthupaedic Surge-ans

Hip and Pelvis

Chapter 10

Athletic Hip Injuries Richard Charles Mather III, MD, MBA

Michael S. Ferrell, MD

abstract

Indications for hip arthroscopy are rapidly expanding and include pathology in the central, peripheral, and

peritrochanteric compartments. The anterolateral and anterior portals are the primary portals with several

described accessory portals. The most common surgical

complications include iatrogenic chondrolabral injury, transient neurapra xia, and the inadequate resection of femnroacetabular impingement. The acetabular labrum

is a critical structure and should be repaired or recon-

Keywords: hip arthroscopy; Iahral tears: ligamentum teres: hip instability Introduction

Hip arthroscopy has been one of the most rapidly devel-

oping fields in orthopaedic surgery over the past decade.1

As improved equipment and evolving techniques have made the procedure safer and relatively easier to perform, indications have continued to expand. Furthermore, as

source of chronic hip pain and disability with several

the understanding and appreciation of femoroacetahular impingement {FAD—the most common indication for hip arthroscopy—have evolved, the diagnosis has become better recognized and surgical outcomes have improved.1

capsular management, including capsular repair and

pathology in the central, peripheral, and peritrochanteric compartments of the hip joint. Central compartment

structed whenever possible to preserve its function,

especially that of creating negative pressure seal to the femoral head. Hip microinstability is proving to be a soft-tissue structures, including the ligamentum teres, playing key roles in maintaining stability. Appropriate

plication in indicated cases, is proving to be a key step in preserving or establishing hip stability and optimizing surgical outcomes. Tears of the ligamentum teres are a source of pain in the hip and require a high index of suspicion to make the diagnosis. Ddhridement of partial—thickness ligamentum teres tears has demon— strated good clinical outcomes. Ligamentum teres reconstruction in instability cases may prove to be a useful

adjunct along with capsular plicatinn in certain setting

but is still unproved at this point.

Dr. Mather or an immediate family member serves as a paid

consuitant to ENG Heaith Consuiting, Pivot Medicai, Smith

.5 Nephevn and Stryirec has stock or stocir options held in forfMDL' and serves as a board member; owner. officer; or committee member of the Arthroscopy Association of North America, the American Academy of Orthopaedic Surgeons, and the North Caroiina Urthopaedic Association. Neither Dr. Ferreii nor any immediate famiiy member has received anything of value from or has stuck or stock options held in a commerciai company or institution reiated directiy or indirectiy to the subject of this chapter.

fl lflld American Academy of Drthopaedic Surgeons

The current indications for hip arthroscopy address

pathology includes labral tears, loose bodies, ligamentum teres {LT} tears, chondral defects, and pincer lesions as—

sociated with FAI. Peripheral compartment pathology

includes cam lesions associated with FA], capsular laxity

associated with hip instability, loose bodies, and recalcitrant internal snapping hip secondary to chronic iliopsoas

bursitis. Peritrochanteric compartment pathology includes

recalcitrant trochanteric bursitis, tears of the gluteus medius and minimus, and painful external snapping hip.

Successful surgical outcomes in these compartments have

expanded the application of endoscopic techniques to other conditions, including proximal hamstring repairs and sciatic nerve decompression in the deep gluteal space. The portals for hip arthroscopy have evolved to improve access and safety {Figure 1}. In general, the central

and peripheral compartments can be accessed through two or three portals. The anterolateral portal is typically the first portal established, using anatomic landmarks

and fluoroscopy to determine the appropriate trajectory with which to enter the joint. Typically, this portal is 2 cm anterior and 2 cm distal to the greater trochanter and has

the objective of entering the joint parallel to the sourcil without violating the labrum. The anterior portal typically is made next, using a spinal needle for localization

via an inside-out technique through the anterior triangle,

Drthopaedic Knowledge Update: Sports Medicine 5

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Section 2: Hip and Pub-Pia

V use onus

fl

®

esp

‘3 AP

__

asis

Q @PMAF-

®AL ® PAL“

—_ Complications Associated With Hip Arthroscopy

Iatrogenic chondrolahral injury hleurapraxia FAI underresection Sequela of FAI overresection, including iatrogenic

instability and femoral neck fracture

Heterotopic ossification

@PL

Deep vein thrombosis

# Illustration shows the positions of the portals for hip arth roscopy. The anterolateral portal {at} is a mainstay of hip arthroscopy access and visualization. and most surgeons use some variation of an anterior portal [AP] for

instrumentation. Several accessory portals also have been described. DALA = distal anterolateral accessory portal; MAP = mid-

anterior portal; ASIS = anterior superior iliac

spine; PMAP = proximal midanterior portal: FA LA = proximal anterolateral accessory portal: PL = posterolateral portal: P5P posterosuperior portal.

Pulmonary embolism flsteonecrosis Abdominal compartment syndrome FAl - femoroacetahular lmpl ngement.

steep learning curve associated with the procedure, the

techniques required to access the deep, highly congru—

ent joint through its thick soft-tissue envelope, and the longer surgical times [Table 1}. Iatrogenic chondrolabral

injury can occur while the surgeon is gaining access to the central compartment; it was the most reported com-

plication in one systematic review.3 Another common

as in other joints. The key landmark is a line parallel to -E

2

to o. 1: I: as EI

H

the femur extending distal from the anterior superior iliac

spine {ASIS}. Remaining lateral to this line will minimize

the risk to the femoral neurovascular bundle, and the more lateral the portal is, the farther away it is from

the lateral femoral cutaneous nerve. The position of the anterior portal varies and can be placed farther distal

and lateral to facilitate anchor placement, particularly

but transient complication following hip arthroscopy is neurapraxialan with incidence approaching 5fl% in one

series.‘1 The lateral femoral cutaneous nerve iLFCN} is

most commonly involved. It is unclear whether LFCN neurapraxia is related to direct injury from portal place-

ment, traction from the portals and cannulas, swelling

associated with arthroscopy, or a combination of causes, but LFCH neurapraxia is now considered by many hip

arthroscopists to be a sequela of hip arthroscopy rather

for two-portal approaches. Additional portals include the distal anterolateral por-

than a complication. Permanent injury is less than 5%, however. Pudendal neurapraxia also can occur, even with

portal. This portal provides a safe trajectory for anchor

Traction injuries related to the post, which are substantial

for cam resection in PAL The Dienst portal is placed a few centimeters proximal to the anterolateral portal and offers a different trajectory into the central and peripheral compartments. The trochanteric space can be accessed via the same anterolateral portal as well as via

Inadequate resection in FAI surgery, more commonly on the femoral side, is the most common reason for revision hip preservation surgery? Fluoroscopy, hip rotation,

and the performance of a T—capsulotomy allow visualixation of the cam lesion in its entirety and minimise the

distal to the greater trochanter. A third portal distal to the vastus ridge insertion of the vastus lateralis provides

for reoperation following hip arthroscopy is conversion to a total hip arthroplasty {THAI} Whether conversion

tal, which is typically 4 to 5 cm distal to the anterolateral

placement in the acetabulum and provides easy access

a posterolateral portal, which is 2 cm posterior and 2 cm a good viewing angle for gluteus medius and minimus

repairs while working through the anterolateral and posterolateral portals. Hip arthroscopy has a unique set of complications that differ from those of other joints because of the

firthopaedic Knowledge Update: Sports Medicine 5

short traction times, especially in stiff, prearthritic hips.

but avoidable, also include skin and soft-tissue necrosis.

risk of an inadequate resection. The most common reason

to THA is a complication related to hip arthroscopy or

merely a progression of the natural history of FA] remains unclear. Rare but catastrophic hip arthroscopy complications include femoral neck fracture, abdominal compartment

fl lflld American Academy of Orthopaedic Surgeons

Ehapter til: Athletic Hip Injuries

A Figure 2

A. Arthroscopic view shows an acetabular labral tear. which is a common finding at arth roscopy and typically occurs anteriorly andror ante rolaterally. E, Arthroscopic view shows aceta hular labral repair. which is essential to restore the multiple functions of the lab rum. {Courtesy of F. Winston Gwath mey, MD, Charlottesville. VA.)

syndrome, iatrogenic instability including hip dislo— cation, thromboembolic disease, and fatal pulmonary embolism?” Acetobular Labral Tears

Acetabular labral tears have been shown to be a substantial source of pain and disability and comprise the most common pathologic finding at the time of hip arthros—

copy11 [Figure 2}. The acetabular labrum is a triangular

fibrocartilaginous ring, which is attached firmly to the

the femoral head and acetabulum analogous to those seen in a shoulder dislocation. Sports that require a great deal

of hip torsion can lead to capsule attenuation and laxity

secondary to repetitive microtrauma. Attenuation of the capsule leads to mieroinstability of the joint, in which

the femoral head suhluicates anteriorly and rides on the

anterior superior labrum.” Microinstability can also occur outside of sports in patients with collagen disorders

such as Ehlers—Danlos syndrome, Marfan syndrome, and

Down syndrome. Degenerative labral tea rs are analogous to degenerative meniscus tears in the knee and are fre-

acetabular rim and encompasses nearly the entire ace-

quently associated with diffuse articular changes in an

bridged by the transverse acetabular ligament. The 1abrum deepens the acetabulum, increases coverage of the

early in the arthritic process.

tabulum, except for the most inferior aspect, which is femoral head, and plays a role in shock absorption, joint

lubrication, and pressure distribution. Its most critical role

arthritic joint. Degenerative labral tears are thought to be extremely common in the aging hip and likely occur Iliopsoas impingement on the anterior hip joint recently

has been suggested as an additional mechanism for labral

may be the creation of a negative pressure seal with the femoral head, which aids in joint stability. Removal of the

tears. The authors of a 2011 study”i described an atypical labral tear pattern in a series of patients in which the

contact point toward the acetabular rim, a decrease in intra-articular fluid pressurization, and a loss of lateral restraint to femoral head motion. It also has been shown to increase contact stresses between the articular cartilage of the femoral head and the acetabulum by 92%.”"4

beneath where the iliopsoas tendon crosses the hip joint, unlike the common location in FA] and dysplasia, which

labrum has been shown to lead to a shift in the femoral

The labrum is injured most often in FAI and acetabular

dysplasia. Hip trauma leading to a labral tear generally

involves a high-energy contact mechanism, which results in a frank dislocation or subluication. Traumatic hip in—

stability is frequently associated with chondral lesions to

IE! Efllfi American Academy of flrthopaedic Surgeons

labral tear occurs on the anterior acetabulum directly is more superior on the anterior acetabulum. The pre-

sentation was similar to that of FAI, with groin pain in flesion, adduction, and internal rotation. These patients

were successfully treated with an iliopsoas lengthening

and a labral débridement or repair. in the pediatric literature, several case series describe labral tears in association with avulsions of the rectus femoris. The reflected head of the rectus femoris is near

Drthopaedic Knowledge Update: Sports Medicine 5

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the anterior labrum and inferior to the A515. It is theorized that a traction injury of sufficient energy can tear the labrum in this location.” Several labral tear classification systems exist based on tear morphology, histology, and location. Tear patterns based on morphology have been described.” Stable

—_ Tests for Labral Tears During the Physical Examination

Anterior tears

tear patterns include radial, fibrillated, and longitudinal

peripheral tear patterns. Radial flap tears occur with an

intra—articular free—edge disruption. Radial fibrillated tears are degenerative tears with fibrillated free margins. Longitudinal peripheral tears are stable labral separations

Lateral tears

tear classification based on location is described by the tear position in relation to the acetabulum. Anterior labral tears have been prevalent in most of the studies because

Flexion, abduction, external rotation {FABER} tIE'St

Dynamic external rotation impingement test

histology have been described.” Type I tears occurred at various pla ucs within the substance of the labrum. Labral

internal rotation {FADIRJ test Dynamic internal rotation impingement test

from the acetabular margin. Unstable tears include the bucket-handle tear. Two types of labral tears based on

the junction between the fibrocartilaginous labrum and the articular hyaline cartilage. Type .1 tears occurred in

Flexion, adduction,

Hip instability

Extension and external rotation test

External rotation log-roll test

Liga ITIE'I'TI‘UITI tE'l'E'S tE'EII'S

Liga mentum te res test

of their association with FA].

The diagnosis of a labral tear often can be made clini-

cally. Patients may report mechanical symptoms, such as clicking and catching, as well as groin pain in positions

of hip flexion. It is not uncommon to feel pain laterally or

posteriorly with anterior labral tears. Pain with prolonged sitting is another common symptom. Physical examina-E

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tion findings can include pain in the provocative position of flexion, adduction, and internal rotation if the tear is

anterior or pain in flexion, abduction, and external rotation if the tear is lateral. Table 2 describes the tests used to detect a labral tear. Imaging includes plain radiographs and magnetic resonance arthrography. The most valuable

diagnostic sign is a positive response to an intra-a rticular

joint injection that brings complete pain relief, even for a brief period. This assessment is especially helpful in patients with atypical referred pain locations to confirm

the joint as the source of pain.

Treatment options for labral tears include debridernent,

repair, and reconstruction, with the goal of restoring or preserving the function of the native labrum {Figure 3}.

results in the débridement group.m In addition, radiographic signs of osteoarthritis were significantly more prevalent in the débridement group at final follow—up. Furthermore, superior clinical outcomes and patient

satisfaction were seen with arthroscopic labral repair

versus labral débridement, with 6TH: good or excellent results in the debridetneut group versus 90% in the repair group.“ Labral repair and débridement were compared

in a randomised controlled trial and significantlyr greater improvement in the hip outcome score in the repair

group was found, although both groups demonstrated

improvement from the preoperative states"1 In addition, Tide of the patients in the repair arm self-rated their hips as normal versus 23% in the débridcment arm. Labral reconstruction traditionally has been reserved for revision cases in which the primary labral repair has failed. Reconstruction may be considered in young athletes with an irreparable tear or a hypoplastic labrum that renders

Débridement is reserved for tear patterns that are stable

the labrum incompetent, especially in a high-demand

in which excision would render the labrum incompetent.

instability. lGood outcomes and high patient satisfaction

and in which the function of the labrum will be maintained. Repair is appropriate for unstable tear patterns,

Several studies have shown improved results with repair versus débridement in groups treated with an open surgical hip dislocation as well as an arthroscopic repair.

A comparison of labral débridement versus repair in open surgical hip dislocation for FAI showed substantial improvement in clinical outcomes, with Sfl% excellent results in the labral repair group versus 23% excellent

firthopaedic Knowledge Update: Sports Medicine 5

sport that requires cutting and pivoting at high speed or repetitive rotational maneuvers or for patients at risk of

were seen with labral reconstruction using iliotibial band autograft; better results occurred in younger patients with no joint space narrowing less than 2 mm.3

fl lfllii American Academy of Orthopaedic Surgeons

Chapter 1D: Athletic Hip Injuries

Figure 3

arthroscopic views show hamstring allog raft Ia brum reconstruction for iatrogenic instability after hip arth roscopy. A. Point A shows a normal labrum. Point B shows labral insufficien cy. Point C shows an iatrogenic cartilage injury of the femoral head. B. Restoration of the suction seal after hamstring allograft labral reconstruction is shown.

Hip Instability

Hip instability has been increasingly recognized as a

pathologic entity and a source of chronic pain and dis-

ability over the past decade, especially in cases of more

subtle atraumatic instability. Unlike these in the shoulder,

the major stabilizers in the hip are the static restraints and include both nsseous and soft-tissue structures. The nsseous components consist of the highly constrained femoral head inside the concentric acetabulum. The degree of acetabular coverage and the femoral and acetabular

version are key determinants of stability. It is in the set-

ting of diminished acetabular coverage and alterations in normal version that the hip joint increasingly relies on

soft-tissue structures to maintain stability.“ The soft-tissue static restraints include the labru m, the capsule, and the ligaments. The labrum is a triangular fibrocartilaginous ring encompassing the acetabulum at all but its most inferior aspect, which is spanned by the

transverse acetabular ligament. The labrum deepens the acetabulum, increases the coverage of the femoral head, and enables the joint to have a negative suction seal,

pubofemoral ligament {PFL} is inferior to the IFL, originates on the pubis, and blends in with the [FL at its medial

attachment, extending along the femoral intertrocha nteric line. The PFL has been shown to limit external rotation and abduction. The ischiofemoral ligament {ISL} is locat-

ed posteriorly, connecting the posterior acetabulum to a portion of the posterior femoral neck. The ISL provides

some support to the posterior femoral neck. Because of

their helical orientation, the three ligaments twist when they are taut and are thought to provide a “screw home”

mechanism to the joint when the hip is in extension. The xona orbicularis is a circumferential structure that forms a collar around the base of the femoral neck and is thought to resist hip distraction. The LT appears to play a sec-

ondary role to these soft-tissue restraints, having been shown to restrict the motion of the femoral hea .1”? Furthermore, isolated tears of the LT have been found

in hip dysplasia, in which it may play a more prominent role in stabilisation}E

Hip instability is thought to have traumatic and atraumatic origins {Table 4}. Traumatic origins include

highuenergy and low~energy mechanisms. Highuenergy

which increases stabilityflf'“ Three primary ligaments span the joint and blend with the capsule {Table 3}. The

mechanisms can lead to nsseous disruptions and an unstable hip joint, as in a posterior acetabular rim fracture.

inverted Y-shaped ligament that originates iust inferior to the anterior inferior iliac spine and attaches distally along the femoral intertrochanteric line. The [PL has been shown to limit hip extension and external rotation.“ The

the knee strikes the dashboard, resulting in a posterior hip dislocation. High-energy mechanisms also can lead

strongest is the iliofemoral ligament lIFL}, which is an

IE! lfllfi American Academy of flrthopaeclic Surgeons

The classic example is the motor vehicle accident in which to disruptions of the soft tissue, such as labral tears and

ligament sprains, resulting in instability in the absence

Drtbopaedic Knowledge Update: Sports Medicbte 5

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Section 2: Hip and Pelvis

-— Hip Ligaments and Their Motion Restrictions

Risk Factors for Hip Instability

lliofemoral ligament

Extension and EH

Acetahular dysplasia

lschiofemoral ligament

Flexion and IR

Abnormal femoral and acetabular version

Extension and IR

Generalized ligamentous laxity

Pubofemoral ligament

Abduction and ER

Iatrogenic capsular insufficiency

namentum teres

Flexion and ER

Sports requiring extreme hip motion

Extension and IR Ell. = external rotation. IF. = internal rotation.

Figure 4

Images depict assessment of the iliofemoral ligament. A, Coronal magnetic resonance arthrogram demonstrates a large capsular defect after hip arthroscopy. B. Photograph shows the external rotation log-roll test for iliofemoral Iiga me nt insufficiency. The examiner externally rotates the leg at the foot. A normal ligament will display spring back. C, Photograph shows capsular plication of the left leg with an end point in external rotation, whereas the rig ht leg shows the preoperative iliofemoral ligament instability.

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of fracture. Sports with repetitive torsional movements

and feelings of instability, especially in hip positions

can produce softatissue attenuation due to repetitive mid

that rely more on softatissue restraint like hip extension

amounts of hip motion and rotation, such as gymnastics,

simple as walking. Secondary iliopsoas tendinitis, result-

crotrauma to the capsule and ligaments. A common example is the athlete engaged in a sport requiring extreme ballet, and golf. Atraumatic origins also can be seen in

patients with congenital soft-tissue deficiency or laxity, such as the capsular and ligamentous laxity seen in

Ehlers-Danlos syndrome, Marfan syndrome, and Down

syndrome. The atraumatic mechanism most recently de-

scribed is a seguela of a large cam—based deformity in PM. In this case, impingement of the cam lesion inside the acetabulum in flexion levers the femoral head posteriorly, which can cause a posterior contreconp cartilage lesion, with posterior subluxation and instability.”

and external rotation. These patients tend to be highly symptomatic in pain and can have difficulty with tasks as ing from strain on the iliopsoas as it attempts to stabilize

the anterior hip joint, can develop in these patients. 0n examination, these patients may show global signs

of generalized ligamentous laxity. The log-roll external rotation test may show a capsular laxity, with diminished spring back during external rotation {Figure 4}. The results of this test can be compared with those of the contralateral hip. These patients also may have pain and

apprehension during hip extension and external rotation if the primary component of instability is anterior. This

The concept of atraumatic hip instability has led to

pain and apprehension can be improved with a posteriorly

dysplasia superimposed on ligamentous laxity during

a maneuver comparable to the Jobe relocation test in the

the emerging idea of hip microinstability. This type of instability can occur in athletes with mild osseous hip sports requiring high degrees of hip motion. In the setting of hip dysplasia, the individual is much more reliant on soft—tissue structures to stabilise the hip. The athlete with

hip microinstability may report mechanical symptoms

firthopaedic Knowledge Update: Sports Medicine 5

directed force to the proximal femur in this position of anterior instability with external rotation and extension,

shoulder. Patients with hip microinstability in whom nonsurgical treatment has failed may benefit from a hip arthroscopy to address ligamentous and capsular laxity as well as

fl lflld American Academy of Orthopaedic Surgeons

Chapter ll]: athletic Hip Injuries labral tears. The labrtun can be repaired after addressing any assnciated rim pathnlngy using a mattress suture,

which will restnre the suctinn seal. Several prncedurcs

have been described tn address the capsule in instability,

including thermal capsulnrrhaphy and capsular plicatien. Thermal capsulnrrhaphy was described in 95 patients

having a mnnnpnlar radinfrequency prnbe tn reduce capsular redundancy, with resnlutinn nf hip instability in lflfl% nf his patients at 12 mnnths and imprnvement in their mndified Harris Hip Scnres.” Tn date, nn repnrts have been recnrded cf chnndrnlysis secnndary tn ther-

ilincapsularis and the gluteus minimus. This lnngitudinal

cnmpnnent typically is stepped just prnximal tn the snna nrbicularis tn prntect the lateral femnral circumflex ar-

tery. This expnsure typically allnws ample visualisatinn nf a cam lesinn. Hip rntatinn prevides visualization frnm

the medial tn lateral synnvial fnlds, which are landmarks

fer the synnvial vessels. Bnth limbs nf the T-capsulntnmy

are repaired at the cnmpletinn cf the case with several

side-tn-side stitches. The capsule can be plicated at this stage, if indicated, by resecting a pnrtinn nf the capsule befnre repair nr by taking bigger bites in the side-tn-

mal capsulnrrhaphy in the hip, as has been described in the shnulder. Capsular plicatinn alsn has been described

side clnsure tn tighten the capsule. In general, three nr fnur sutures are used nn the lnngitudinal pnrtinn, and

dundancy. A technique has been described, in which the medial and lateral limbs cf the [FL were tied tngether tn

Typically, the patient is placed in a brace fnr 6 weeks pnstnperatively tn limit extensinn and external rntatinn,

by several authnrs as a methnd tn reduce capsular re— reduce capsular laxity.“ Annther technique, in which the

capsule is plicated by including it in a labral repair using dnuble-inaded suture anchnrs at the acetabular rim, has

been described.31 This secnnd technique is thnught tn

restnre nnrmal anatnmy and apprnpriately tensinn the

twn nr three sutures are used cm the interpnrtal pnrtinn.

with a perind nf prntected weight bearing as indicated

fnr nther prncedures.

The Ligamenturn Teres

nf risk factnrs fnr instability in hip arthrnscnpy perfnrmed tn address nther pathnlngy. This cnncept has been reinfnrced by recent case repnrts nf hip dislncatinns fnllnwing hip arthrnscnpy. The authnrs nf nne study repnrted hip subluxatinn in a patient with a dysplastic hip 3 mnnths

The LT can be a cnmmnn snurce nf hip pain and has been fnund tn be turn at arthrnscnpy in 8% tn 51% cf ca ses.”38 It is a pyramid-shaped structure, with its brnad base at the pnsterninferinr acetabular fnssa and its pnint attaching tn the femnral fnvea capitis. It fnrms snme attachment tn the transverse acetabular ligament at its base and transitinns tn a rnund and nvnid attachment tn the femur. It has been shnwn tn cnntain free nerve endings with both nncinceptive and prnprinceptive innervatinn cnncentrated

lntnmy}3 A case nf a traumatic anterinr hip dislncatinn was repnrted in a pnstnperative patient fnilnwing a fall

as a pntential pain generatnr in the hip.“ The functinn and pathnlngic rnie cf the LT remains

capsule with gnnd shnrt-term results.

The evnlutinn cf the cnncept nf capsular laxity as a snurce nf hip instability has led snme authnrs tn stress the

impnrta nce cf capsular management and the recngnitinn

fnllnwing an arthrnscnpic labral resectinn and capsu— dnwn stairs that was successfully treated with a revisinn

capsular repairs“ The authnrs nf annther study repnrted a hip dislncatinn in the recnvery rnnm in a patient whn had undergnne an arthrnscnpic capsulntnmy fnr a cam

primarily in the center cf the ligament, cnnfirming its rule

cnntrnversial. Currently, it is thnught tn serve as a sec-

nndary restraint tn hip stability. The first suggestinn that the LT might play a rule in hip stability surfaced in an

early cadaver study demnnstrating that sectinning the LT

resectinn and rim trimming; the dislncatinn was successfully treated with mini-npen anterinr capsulm-rhaphy.fl Recently, imprnved nutcnmes have been demnnstrated in patients undergning hip arthrnscnpy with a cnmplete

during hip mntinns and she-wed the greatest excursinn during hip external rntatinn and flexinn, which nccurs

a partial repair nnly.35 The cnmplete repair grnup demnnStrated superinr spnrt—specific nutcnmes and had a 0%

which nccurs when crnssing nne leg under the nther.“ The LT mnved intn an anterinr and inferinr pnsitinn arnund

rate in the partial repair grnup. Current recnmmenda— tinns fnr capsular management invnlve perfnrming an

prnvide a sling—like effect, analngnus tn the actinns nf the cnnje-int tendnn in the cnracnid transfer prncedure

capsular repair versus a matched cnhnrt that underwent revisinn rate cnmpared with a 13% arth rnscnpic revisinn

interpnrtal capsulntnmy between the standard anterinr

resulted in increasing amnunts nf hip abductinn and ad-

ductinn.“ A string mndel was used tn assess LT excursinn in squatting, and during internal rntatinn and extensinn,

the femnral head during a squat.“fll This was thnught tn in the shnulder. Further, in a survey nf 161 pnstnperative

and anternlateral pnrtals tn address central cnmpartment Pathnlngy. This prncedure is fnllnwed by adding

patients whn had undergnne a surgical hip dislncatinn, which includes resectinn cf the LT, it was repnrted that

dnwn the neck nf the femur in the interval between the

experienced feelings nf instability!”1 The LT may play a

a lnngitudinal capsulntnmy tn fnrm a T—capsulntnmy

IE! H116 American Academy nf flrthnpaeclic Surgenns

35% cf patients described pnpping and lncking, and 24%

Drthnpaedic Knnwledge Update: Spnrrs Medicine 5

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Section .3: Hip and Pelt-fie

more important role in stability in dysplastic patients lacking acetabular coverage. These patients may be more

anatomy.” Their ability to diagnose LT tears ranged from 42% to east. Finally, a sensitivity of 34% and a specificity

brum, capsule, and ligaments. If one or more of these

also using 3-T Il'vllR.I.“'5

reliant on primary soft—tissue restraints such as the la—

soft-tissue restraints also is compromised, increased reliance on the LT to maintain a concentric hip joint may occur with certain motions. Injury to the LT is thought to occur from one of several

mechanisms. The LT is at risk with any major hip trauma causing a hip dislocation. It has been torn with lower levels of trauma, however, including a case report of a tear occurring while a patient pushed a shopping cart.“2 LT tears also can occur from repetitive mierotrauma in sports requiring extreme amounts of hip motion such as

dance, gymnastics, and martial arts. Microtrauma to the LT may be exacerbated in patients with ligamentous

laxity or insufficiency, in which the LT is thought to play

a larger role in instability. Finally, a degenerative tear can occur due to abrasive wear against osteophytes in osteoarthritis.“ The clinical assessment of LT tears traditionally has been difficult. Patients may report an injury during a twisting mechanism, a fall onto a flexed knee, or a hy— peradduction mechanism. Patient reports may include pain, mechanical symptoms, and feelings of instability

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of 53% in identifying pathology in the LT was found,

Treatment options for LT tears include debridement and reconstruction. A systematic review compared the

short-term benefit of the two modalities. ‘T The iii-patient

reconstruction group was compared with 31 patients in

the debridement group. The debridement group showed

an increase in modified Harris Hip Scores from poor

(63.?3; 95% confidence interval [CI], 4?.fl-T4.4ti} to good

(33.4; 95% CI, 35.95—93.32} and showed an improvement

in pain and function in the mean nonarthritic hip score from 55.1 [95% CI, 6234—6125] to 36.35 {95% CI, 3166-3134}. Although having very small numbers, the reconstruction group also showed improved subjective

and objective outcome scores despite using different graft

sources and fixation techniques. The indications for repair

versus reconstruction are not yet defined clearly.“ S u m m a ry

Hip arthroscopy continues to evolve rapidly along with

the understanding of pathology in and around the hip joint. The indications for surgery include pathology in the

with giving way, especially during squatting and when crossing the affected leg behind the other when stand-

central, peripheral, and peritrochanteric compartments, and the indications are expanding to include pathology in

symptom. Physical examination findings in patients with LT tears are consistent with findings in other tests for

critical structure and should be repaired or reconstructed whenever possible to preserve its function, especially the

pain with flexion and internal rotation, log rolling in extension, and during the McCarthy test, in which the hip

to be a source of chronic pain and disability. Soft-tissue structures, including the LT, play a key role in main-

rotation and then external rotation. A test called the LT

bony morphology. Appropriate capsular management,

ing. Some patients may present with pain as their only intra-a rticular pathology. These nonspecific tests include is alternately taken from flexion to extension in internal

test was recently described that may aid in the diagnosis.“ The LT test is performed by placing the patient supine,

the surrounding soft tissues. The acetabular Iabrum is a negative suction seal function. Hip instability has proven

taining stability, especially in the setting of abnormal

including capsular repair and plication in indicated cases, is proving to be a key step in preserving or establishing

flexing in the hip to T3“, abducting it 33“, and rotating it into maximum internal and external rotation. This test was found to have a sensitivity of 93% and a specificity of 35%.

hip stability and optimizing surgical outcomes. Tears of the LT are a source of pain in the hip and require a high index of suspicion to make the diagnosis. The LT test is a new physical examination tool to aid in making the

difficult traditionally. The authors of one study noted that only 2 of 23 LT tears in their series were diagnosed

demonstrated good clinical outcomes. LT reconstruction in instability cases may prove to be a useful adjunct along

Imaging to identify LT pathology also has proven

preoperativelyfif In an attempt to distinguish partial LT

tears from normal anatomy, the authors of a 2012 study found similar radiographic findings on 3-T magnetic res-

diagnosis. Débridement of partial-thickness tears has

with capsular plication in certain settings but is still un-

proved at this point.

onance arthrography between the partial tear and normal

firthopaedic Knowledge Update: Sports Medicine 5

fl 2315 American Academy of Orthopaedic Surgeons

Chapter II]: Athletic Hip Injuries

lie-y Study Pnints

The anthers reviewed 51 censecutive hip arthrescnpy pa-

i Acetahnlar la bral tears are the mest cemmenly nnt—

46% repert symptems ef nerve dysfunctien during the first pestnperative week, which decreased In 23% at 6 weeks

paired er recnnstrncted whenever pessible te restere the labral functien nf creating a negative pressure seal tn the femeral head. Hip micreinstability is an increasingly recegnized

net different in patients with and witheut symptnms ef nerve dysfunctien. Level nf evidence: I‘v'.

tients frem March tn |fictnber liilfl and determined that

ed pathnlngy at hip arthrescnpy and sheuld be re-

snurce ef pain and instability because nf snft—tissue

restraint incempetency in the herderline dysplastic hip. The acetabular lahrum, the ligamentum teres, and the jeint capsule play critical secendary reles tn heny restraint. Tears ef the ligamentum teres can he an impertant senrce nf pain and disability, which require a high index nf suspicinn tn diagnese but are suc-

cessfully treated with surgical débridement and reconstruction.

The anthers reviewed a prespective, multicenter hip preservatien database et 2,336 surgery cases tn identify 352 patients, er 15%, whe had prier surgery. Inadequately cerrected structural disease was the mest cemmen reasen

fer secendary surgery. Level ef evidence: IIl.

Ayeni CIR, Eedi A, Lerich DG, Kelly ET: Femeral neclr fracture after ardtrescnpic management nf femnrnacetabular impingement: A case repert. ] Hesse jeinr Sin-g An: 2fl11;93{9]:e4?.Merlline Dfll

subcapital femeral neck fracture after arthrescepic man-

Celvin AC, Harrast], Harrier C: Trends in hip arthrescepy.

I Hens Inns-t Surg Am 2fl12;94{4}:e23. Medline DUI

The anthers determined that the number ef hip arthrescnpy cases submitted by American Heard nf flrthnpaedic

Surgery Part 11 candidates during the perie-d item 1999 tn

Elli}? increased lfl-feld, with mest perfermed by spnrts medicine fellnwship—trained candidates Eerie K], Chan V, Valene FH III, Feeley ET, Vail TP: Trends in hip arthrescepy ntiliaatien in the United States. ] Arthrepiesty 1fl13;23{3, Snpplfld-D—HJ. h'IedIine [101

The authers determined that the incidence ef hip arthres-

cepy precede res ameng American Heard Of Drthepaedic Surgery Part II candidates increased ever fiflfl‘h’s frem EDDIE te 2131i], with an everall cnmplicatien rate ef appreitimately 5%.

HarrisJD, hrIc'Cnrmiclt Fl'vI, Abrams GD, et al: Cemplica‘ tiens and rcepcratiens during and after hip arthrescepy: A systematic review nf 91 studies and mere than 65,306! patients. Arthrnsenpy 2fl13;19{3]:539-595. Mcdline DUI The anthers reviewed 9'2 studies, ef which 33% are level IV evidence with shert-tenn fellew—up at a mean ef 2.0 years. The rate ef majer cemplicatiens after hip arthrescepy was fl.53% and miner cemplicatinns was 15%.

The renperatien rate was 6.3% at a mean cf 16 menths. with the mest cemmen reeperatien being cenversinn tn tetal hip arthreplasty. Level ef evidence: I‘v’.

Dippmann C, Therbnrg K, Kraemer D, Wings- 5, Hellmich P: Symptems nf nerve dysfunctinn after hip arthres-

cepy: An nnder-reperted cnmplicatinn? Arthreseepy 2014:3fllllflfll—EGIMndline

Clnhisy JC, Nepplc J]. Larsen EM. Zalts I, lviillis M;

Academic Netwnrlt ef Cnnservatien Hip Clutceme Research {AHCHGR} Members: Persistent structural disease is the mest cem men cause nf repeat hip preservatinn surgery. Chit firthnp Reina? Res 2fl13;4T1{12}:3T33-3?94. Medlinc DUI

The anthers present a case repert ef a nnndisplaced,

Annetated References 1.

and 13% after 1 year. Tractinn time during surgery was

DUI

IE! ants American Academy et' flrthepaedic Surgeens

agement nf femernacetabular impingement. Level ef evidence: IV. Fewler J, Dwens ED: Abdeminal cempartment syndreme after hip arthrescepy. Arthrnscepy lfllfififiillfllfla-l 3i]. Medline DD]

Authers present a case repert ef abdeminal cempartment

syndreme resulting frnm fluid extravasatinn fellnwing hip arthrescepy fer FAI. A distended abdemen was neted at time nf drape remeval, and a decnmpressive Iaparntemy

was perfermcd. Level W evidence.

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Matsuda DH: Acute iatregenic dislecatien fellewing

hip impingement arthrescepic surgery. Arrhrescepy 2fl09;25{4]:4flfl-4fl4.Medline DUI The anthers discuss a case repert ef an iatregenic hip

dislecatien after arthrescepic hip surgery fer femernace-

tabular impingement. hinted in the repert is suprannrmal hip distractien re extract a leese bedy. A mini-epen capsnlnrrhaphy was required tn restere hip stability. Level nf evidence: 11.".

Salve JP, Treitell CR, Dnggan DP: Incidence nf veneus thrembecmbnlic disease Fellewing hip arthrescepy. Cirrhepedics lfllflfifiifllmfi-i. Medline The anthers retrespectively reviewed 31 censecutive patients nndergeing standard hip arthrescnpy and deter-

mined a 33% incidence nf clinically symptnmatic veneus

thrembnembnlic disease, which was suspected clinically and cenfirmed with the use nf apler nltrasnnngraphy. He patients develeped symptnmatic pnlmnnary embnli.

1G. Bushnell ED, Dahners LE: Fatal pnlmnnary emhnlism

in a pelytraumatiscd patient fellewing hip arthrescepy. flrrhepsdics eneseemes. Medline

DUI

Drthepeedic Knewledge Update: Sperrs Medicine 5

Sectinn 2: Hip and Pel'lde

The authnrs present a case repnrt nf a fatal pulmnnary embnlism after hip arthrnscnpy perfnrmed tn remnval multiple intra-articular lnnse bndies fnllnwing a closed

reductinn and percntanenus fixatinn nf an acetahular fracture secnndary tn a gunshnt wnund.

11. Kelly ET, Weiland DE, fichenker ML, Philippnn MJ: Arthrnscnpic lahral repair in the hip: Surgical technique and review ed the literature. Artbrnscnpy 1fl05;11{11}:145l'fi15fl4. Medline DflI 11. Fergusnn SJ, Bryant JT, Gan: R, Itn K: The acetahular Iabrum seal: A pnrnelastic finite element mndel. Clair: flinmecb (Bridal, Anne} lfiflflfl 5{61:463-463. Medline DD] 13. Fergusnn 5], Bryant JT, |Gan: R, Itn K: The influence nf the acetabular labrum nu hip jnint cartilage cnnsnlidatinn: A pnrnelastic finite element mndel. J Binmeel':

lflfli};33{fl}:953—Sfifl.Medline DUI

14-. Fergusnn SJ, Bryant JT, Gan: R, Itn K: An in vitrn investigatinn nf the acetahular lahral seal in hip jnint mechanics. I Binmecb 2Ufl3:35[2}:1?1-1?fi. Medline DUI 15. Philippnn M]: Hip arthrnscnpy in the athlete. in McGinty JB, ed: Operative errbrnsenpy ,ed 3. Philadelphia, Lip-

pincntt Williams 8:: 1|Wilkins, lflfll.

16. Dumb BG, Shindle MK, McArthur B, Vnns JE, Magennis

EM, Kelly ET: [linpsnas impingement: A newly identified

cause nf lahral pathnlngy in the hip. HSS I 2131 1;?{2}:14515D. Medline

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The authnrs identified 25 patients whn underwent isnlated, primary, unilateral ilinpsnas release with either lahral dd-bridement nr repair nf a lahral tear. In this series, they identified a distinct pattern nf lahral pathnlngy that nccurs in the direct anterinr lncatinn thnught be secnndary tn

ilinpsnas impingement. Level nf evidence: IV.

1?. Fame '3], Maizlin ZV, Shrnuder J, Grant MM, Bedi A, Ayeni OR: The assnciatinn between avulsinns nf the reflected head at the rectus femnris and lahral tears: A retrnspective study. J Pediatr 011p EflldfidlfilfllT-Idl. Medline D01

The authnrs reviewed electrnnic medical recnrds nver a lfl-year perind nf patients between the ages nf 12 and 13 years and identified 9 patients with avulsinn injuries nf the rectus femnris muscle during spurts activities, with T nf the 9 demnnstrating lahral tears nn magnetic resnnance arthrngraphy. All patients were initially managed nnnsurgically, and 1 nf the 9' went nn tn arthrnscnpy secnndary

tn substantial refraetnry pain. Level nf evidence: IV.

13. Latge LA, Patel JV, Villar EN: The acetahular labral tear: An arthrnscnpic classificatinn. Artbrnscnpy 1996:13i3}:269-2?2.Medline

DUI

19. Seldes RM, Tan V, Hunt], Kat: M, Winiarsky R, Fit:geraid EH Jr: Anatomy, histnlngic features, and vascularity DI the adult acetabular labrum. Glir: Drtfinp Relet Res 2001;332:132—240.Mndline DUI

firthnpaedic Knnwledge Update: fipnrts Medicine 5

El]. Espinnsa N, Enthenfluh DA, Beck M, Gan: R, Leunig M: Treatment nf femnrn-acetabular impingement: Preliminary results nf labral refixatinn. J Barre Jul-int Surg Am lDflfi;33l5}I:915—935. Medline DUI 21. Larsnn GM, Giveans MR: Arthrnscc-pic debridement versus refiaatinn nf the acetahular labrum assnciated with femnrnacetabular impingement. Arrhrnscnpy 1Dfl9;25{4}:369-3?6.Medline DUI The authnrs cnmpared twn grnups that underwent arthrnscnpic labral ddbridement versus lahral repair for pincer-type nr cnmbined pincer- and cam-type FAI with a minimum nf 1-year fnllnw-up. The lahral repair grnup demnnstrated better mndified Harris Hip Scnres {94.3 versus 33.9} and a greater percentage nf gnnd tn excel' lent results cnmpared with the labral débridement gen-up {393% versus 563%]. Level nf evidence: IV. 22. Krych AJ, Tt-mpsnn M, Knutsnn Z, Scnnn J, |Cnleman 5H: Arthrnscnpic lahral repair versus selective labral debridement in female patients with femnrnacetabular impingement: A prnspective randnrnized study. Arthrnsenpy 1fl13;29{1]:4fi-53.Medline DUI The authnrs repnrt nutcnmes nf 36 female patients un-

dergning arthrnscnpic hip treatment fnr pincer- nr cnm-

bined-type FAI randnmi:ed tn either lahral repair versus Iabral débtidement between June Elli}? and June Iflflfl with the same rehabilitatinn prntn-cnl pnstnperatively with average fnllnw—up nf 32 mnnths. The lahral repair grnup demnnstrated super'inr imprnvement in hip functinnal nutcnmes with a greater number rating their hip functinn as

nnrmal nr nearly nnrm al. Level nf evidence: I.

23. Philippnn MJ, Briggs KK, Hay GJ, Kuppersmith DA, Dewing CB, Huang M]: Arthrnscnpic labral recnnsttunfirm .in the hip using ilintibial hand autngraft: Technique and early nutcc-mes. Artisrnscnpy lfllfl;lfi{fil:?5fl-?56. Medline LII-GI

The authnrs discuss the technique nf lahral recnnstruc— tinn fnr labral deficiency nr advanced la bral degeneratinn using an ilintibial band autngraft and nutcnmes nf 9.5 arthrnscnpic labral recnnstructinns with mean fnllnw—up nf 13 mnnths. This study shnwed gnnd nutcnmes and high patient satisfactinn, with better nutcnmes for these within 1 year Item the time nf injury. Level nf evidence: IV. 24. Shindle MK, Ranawat AS, Kelly ET: Diagnnsis and man-

agement nf traumatic and atraurnatic hip instability in the

athletic patient. Elie Spnrts Med Elli-1:25{21:309-326,

iii-I. Medline DUI

25. fihu B, Sa fran MR: Hip instability: Anatnmic and clinical cnnsideratinns nf traumatic and atraumatic instability. Bliss Sports Med lfl11;3fl{1}:349-36?. Medline DUI The authnrs reviewed the anatnmy cf the hip and bnw each structure cnntributes tn hip stability. They alsn reviewed the causes nf instability and treatment techniques. 26. Demange MK, Kakuda EMS, Pereira CAM, Sakalti MH, Albuquerque ILFM: Influence nf the femnral head

fl 211115 American Academy nf Urthnpaedic Surge-ans

Chapter in: athletic Hip Injuries ligament en hip mechanical functien. Acre Urtep Bras

capsular velume te minimise the risk ef iatregenic hip

1?. Martin RL, Palmer I, Martin HD: Ligamentum teres: A functienal descriptien and petential clinical relevance. Knee Sui-g Sperts Tranmetef Arthresc 2011;2fii6]:12i}9-

33. Eeuali T, Katthagen ED: Hip sublnxatien as a cum-

Elli—1?; 15i4]:lfl?—19l].

1214. Medline

DUI

The anthers created a string medel te examine ligamentnm teres excursien during va rieus hip pesitiens and feund the liga meutum teres te have the greatest hip excu rsien when the hip was externally retated in flexien and internally

retated in extensien. a tetal ef 35f] censecutive surgical

patients were then retrespectively reviewed te identify Eli patients with cemplete ligamentnm teres rupture. bline ef

the Eli} subjects were available fer fellew—up, and 5 ef the

9 neted feelings ef instability with squatting inte external retatien and flexien and cressing eue leg behind the ether inte internal retatien and extensien. Level ef evidence: IV. 23. Demb BU, Lareau JM, Baydenn H, Betser I, Millis ME, Yen TM: Is intraarticular pathelegy cemmen in patients with hip dysplasia undergeing periacetabulat esteetemyi Chin Urrhep Refer lies 2i] 14:4?2i2]:e?4-Eflfl. Medline DUI The anthers decumented arthrescepic incidence ef

intra-articular patbelegy cf 16 patients undergeing peri-

acetabular esteetemy fer hip dysplasia and cencemitant hip arthrescepy fer mechanical symptems censistent with

lahral pathelegy identified en MRI and feund significant

intra—articular pathelegy in all patients, te include pathelv egy ef the labrum, chendral surface, ligamentum teres, cam defermity, and pseas tenden. 2?. Krych A], Thempsen M, Larsen CM, Byrd JW, Kelly ET:

Is pesterier hip instability asseciated with cam and pincer

defermityi' Elie Urthep Refat Res lflll:4?fl{11j:339il-

3315?I T. Medline DUI

The anthers reviewed the recerds ef 22 athletes presenting with a pesterier acetabular rim fracture cenfirming a

pesterier hip instability episede and identified a peten—

tial asseciatien between the eccurrence ef pesterier hip instability and structural abnermalities asseciated with

FAI, which may centribute te a mechanism ef femereacs etabular—induced pesterier snhlnxatien.

30. Philippen M]: The rule ef arthrescepic thermal capsu-

lerrhaphy in the hip. Elie Sperts Med 2Dfl1:2fl{4}:31?—329. Medline DUI

31. Bayer JL, Eel-:iya JFC: Hip instability and capsular laxity. Uper Tech Urthep 201i};lfl{4}:13?-241. DUI

instability after hip arthrescepy.

plicatien ef arthrescepic dehridement. Arthrescepy 2fl09;35{4]:405-4i}?. Medline

DUI

The anthers reperted the case ef a 49-year-eld weman with mederate hip dysplasia whe underwent arthrescepic

lahral resectien with remeva] ef an acetabular exesteses

in whem hip instability develeped 3 menths after surgery. It was cencluded that the labrum perfermed a mere

stabilising functien in dysplastic ieints.

34. Ranawat AS, McClincy M, Seltiya JK: Anterier dislecatien ef the hip after arthrescepy in a patient with capsular laxity ef the hip. A case repert. I Beue jer'nt Surg Am Zflflfifilillfl‘E’Z-IFEMedline

DUI

The anthers reperted en a case ef anterier hip dislecatien after hip arthrescepy. 35. Frank RM, Lee S, Eush—Jeseph CA, Kelly ET, Salata M], Nhe SJ: Impreved eutcemes after hip arthrescepic surgery in patients undergeing T-capsuletemy with cemplete repair versus partial repair fer femereaceta bular impinge-

ment: a cempatative matched-pair analysis. An: I Sparta Med 2014:42illjflfi34-2642. Medline

DUI

The anthers reperted eutcemes ef as patients undergeing hip arthrescepy fer FAI that were divided inte twe treatment greups cemparing a partial T-capsnletemy repair versus cemplete repair with minimum 2—year fellew—np. Patients with cemplete capsular clesure demenstrated superier spurt-specific eutcemes and ne revisien surgery

versus 13% revisien rate in the partial repair greup.

3E. Betser IE, Martin DE, Stunt CE, Demb EU: Tears ef the ligamentum teres: Prevalence in hip arthrescepy using 2 classificatien systems. Am } Spur-ts Med 2fl11:39[5uppl}:11?S-1255.Medline DUI The anthers reviewed 5.53 primary hip arthrescepies by

the senier anther between February lflflfl and January

lflll and determined that 51% had partial er cemplete ligamentum teres tears. Patients with tears were elder and had werse preeperative functienal sceres. Magnetic resenance arth regraphy demenstrated lew accuracy and sensitivity in detectieu ef tears. Level ef evidence: IV. 37. Byrd 1W, Jeues K5: Traumatic rupmre ef the ligamentum teres as a senrce ef hip pain. Arthrescepy 2004;2fli4}:3 35391. Medline DUI

The anthers describe their surgical technique fer treatment

33. 1hl'illar RN: Hip Artbrescepy .Uxferd, Butterwerth Heineman, 1992. Medline DUI

and arthmscepy capsular plicatien.

35'. Haversath M, Hanke J, Landgraeber S, et al: The distribu-

ef hip instability including evaluatien with flnerescepy 32. Slihker w, Van Thiel (35, Uhabal JC, blhe 5]: Hip insta—

biliry and arthrescepic techniques fer cemplete capsular clesure and capsular plicatien. Uper TechI Sperts Med

1131 2;1fl:3fll-3i}9. DUI

The anthers describe twe different techniques that previde

auatemic repair ef the capsule and aim te decrease the

IE! Eillfi American Academy ef Urthepaedic Surgeens

tien ef neciceptive innervatien in the painful hip: A histe-

legical investigatien. Hesse jer'et} 2013;95-E{6}:??fl-?76.

The anthers perfermed a histelegic investigatien ef the neciceptive innervatien ef the acteabular labrum, the lig-

amentum teres. and capsule ef the hip in erder te preve

pain— and preprieceptive-asseciated marker expressien. The labrum demenstrated pain-asseciated free nerve

Urrhepaedic Knewledge Update: Sperrs Medicine 5

H

E

'U tn 3

EL '13

1 in

El-

Sectiun 2: Hip- and PHvis

ending expressinn at its base, decreasing in the periphery. The ligamentum teres was cuncentrated at its center, and

The authurs repurted results frum a new test tu detect ligamentum teres tears. The ligamentum teres test is perfur-med by placing the patient supine, flexing the hip to I'D”, abducting it 30", and rutating it intu maxitnum internal and external rutatiun. A sensitivity cf 90% and a

the capsule demunstrated almnst humugenuus marker expressiun in all investigated areas.

4f]. Kivlan ER, Richard Elemente F, Martin EL, Martin HD: Functiun cf the ligamentum teres during multi-planar mnvement cf the hip jnint. Knee Snrg Spurts Tranmatuf fifths-use: 1fl13;11{?1:1664-1653. Medline DUI

The authnrs dissected the suit tissue uf eight cadaver hips

except fur the liga mentum teres and placed the juints inter flexiun and abductiun to simulate a deep squat p-usitic-n until ligamentuus endpuint at the ligamentum teres was

specificity pf 35% were repurted.

45. Blankenbalter DG, De Smet AA, Keene J5, Del Rip fiM: Imaging appearance uf the nnrmal and partially turn ligamentum teres e-n hip MR arth mgraphy. FUR Am I Reentgene! lflll:199{5}:1093-1fl93. Medline DUI The authurs reviewed magnetic resunance arthrcgraphy images uf 116 patients who later underwent hip arthrcrs-

cupy and repurted a high level nf difficulty ef distin—

achieved. The erientatinn at the ligamentum teres was

described and fuund tu prevent the femural head from anterinrl'inferiur subluxaticn because nf its sling-like effect in suppurt uf the femural head.

guishing partially turn versus intact liga mentum teres an imaging because uf similar findings. Edema and peripheral irregularity were nut assuciated with partial tears.

41. Phillips AR, Bartlett G, Nurtnn M, Fern D: Hip stability

46. Devitt EM, Philippnn M], Gnljan P, Peixntu LP, Briggs KK, Hn CF: Prenperative diagnnsis cf pathulugic cunditinns nf the ligamentum teres: Is MRI a valuable imaging medality? Arrhrescupy 2014:30i5}:563-5?4. Medline Bill

Questiunnaires completed by 161 patients whu had undergune surgical hip dislncatiun with excisinn cf the liga-

The anthers review 3-Tesla MRI in detecting liga mentum teres tears in 141 patients whu underwent hip arthruscupy. They repur ted that MRI demunsttated sensitivity and specificity uf 50% and 34%, respectively, in identifying any pathnlugic prucess uf the ligamentum teres. MRI was repurted tu have a 91% sensitivity and ET‘i’i: pnsitive pre-

after ligamentum teres resectinn during surgical dislfl-Eatiun fur cam impingement. Hip Int lflllglljfijtdlfl-334. Medline DUI

mentum teres revealed 39% experience pain with exercise,

35% pepping and lacking, and 24% subjective feelings uf giving way. Leml of evidence: IV.

42. Yamamute Y, Villar RN, Papavasileiuu A: Supermarket hip: An unusual cause uf injury tn the hip juint. Affirmscupy lflflfl;24{4}:4fffl-49l Medline DUI .E

E a: u. 'U I: re '9

I

H

43. |[lll"DtIInnell JM, Pritchard M, Salas AP, Singh P]: The ligamentum teres—its increasing impurtance. ,f Hfp Fraser's: Sang 2014:1:3—11. The authurs reviewed the functien, mechanism nf injury, clinical assessment, imaging, arthruscupic assessment, treatment, untcumes, recnnstrncticn, and unusual cun-

ditiuns cf the ligamentum teres.

|D’Dunnell J, Ecnnnmnpnulus K, Singh P, Bates D,

Pritchard M: The ligamentum teres test: A navel and effective test in diagnusing tears cf the ligamentum teres. Am ] Sparse Med 2014:42j1]:133-143. Medline DD]

flrfltupaedie Knnwledge Update: Sparta Medicine 5

dictive value at detecting a partial ligamentum teres tear. Level ef evidence: II.

4?.

dc 5A D, Phillips M, Philippun M], Letltcnlann 5, 5i-

munnvic H, nyeni |Gilli: Ligamentum teres injuries uf the hip: A systematic review examining surgical indicatinns, treatment nptiuns, and uutcnmes. Arthrnscupy 2014:3flj12j:1634—IE41. Medline DUI

The authers perfnrmed a systematic review uf all articles frem 194E tn 2G1}!- pertaining tu surgical treatment {if the ligamentum teres, identifying nine studies meeting eligibility criteria with 39 hips undergc-ing arthrnscnpic débridemcnt er rccensttuctiun uf a turn ligamentum teres. Déhridement demunstrated gnnd nutcnmes fur partial tears, whereas recnnstructinn may be indicated

fur full-thickness tears that resulted in instability, fail—

ure uf previuus dEhridement, ur a cumbinatiun uf these cunditiuns.

El ll] 16 American AcadMy uf Drthnpaedie Surge-nus

Chapter 11

Femoroacetabular Impingement

Ljiljana Bogunovic, MD

Shane I. Who. MD, MS

increased significantly, allowing improved recognition,

Abstract

Femoroacetabular impingement can lead to pain, limited

motion, and decreased function in active adolescents and young adults. The condition arises from an osseous

deformity in the proximal femur andior acetabulum that

results in abnormal joint contact force with hip range of

motion. Damage to the labrum and articular cartilage develops with time, leading to early joint degeneration and osteoarthritis. In the symptomatic patient, early recognition and characterization of the deformity is critical to the success of surgical intervention. Keywords: femoroatetahular impingement; FAI: cam deformity; pincer deformity; dysplasia; labral' tear I n t rod u cti o n

earlier diagnosis, and the development of effective treat= ment options. Etiology

Structural deformity can occur secondary= to the sequelae of pediatric hip disease such as slipped capital femoral

epiphysis, Legg-Calve-Perthes disease, and hip dysplasia. In most cases of prim ry FAI, no prior history of disease 15 present, andItfaition is likely caused by a

combination of gen; . vironmental factors. The avity in asymptomatic adults is prevalence of estimated at in] ely 14%, with 24% .in males and

5% in fem. to have '

* s are three to five times more likely rmities than are females, and the defor-

" 1e likely to be bilateral in males.“r A 2.8

k of cam deformity in the siblings of affected * Vials suggests additional genetic contributions.a -.

. - 'eral studies suggest a link between participation in

Femoroacetabular impingement {FAI} is an increasingly -level sports at a young age and the development of recognized cause of hip pain and dysfunction. FAI has symptomatic disease 9 '3 Studies of young athletes demon-

been described as a condition resulting from a s

mismatch between the osseous anatomy of tr * femur and that of the acetabulum, leadi loading of the hip joint and subsequen

strate a lack of cam deformity III skeletally immature

e to the

individuals but a presence after physeal closure? Several studies have reported an increased prevalence of femo-

roacetabular deformities in football, soccer, and hockey

underlying labrum and articular cartilage. In the nondysplasic hip, increasing evidence suggests that FAI may

players compared with the general populationfilr‘11““5 Ace cording to the data from the National Football League

osteoarthritis.” Over the past decade, the understanding of the pathomorphology and pathomechanics of FAI has

evidence of FM, of whom 31% were symptomatic and 69% were asymptomatic. The greater the at angle the more

lead to the development of early joint degeneration and

Dr. Nho or an immediate famiiy member serves as a paid

consultant to fissur and Stiyken and has received research

or institutionai support from AiioSource, Armrest, Atniet— ico, DJ Giobai Orthopaedics, ConMed Linva tec Miomed

Orthopedics. Smith Es Nephew: and Stryker; Neither Dr.

Bogunovic nor any immediate famiiy member has received

anything of value from or has stock or stock options held in a commerciai company or institution reiated directly or .I'ndirectiyr to the subject of this chapter.

g. 2016 American Academy of Drthopaedic Surgeons

Scouting Combine, 90% of players showed radiographic

likely was the athlete to present with symptoms.16 The

repetitive stress that occurs in athletic activities is believed to influence physeal growth and potentially contribute to the development of deformity. Types of Impingement

The deformity of primary FAI can involve the proximal femur {cam}, the acetabulum {pincer}, or both {combined}. Isolated cam deformity or combined deformity appears to

be most common, and each occurs with nearly equal frequency {45%). Isolated pincer deformity is less common,

Drrhopaedic Knowledge Update: Sports Medicine 5

l‘f'

3:. 1: m 3 D. 'o

'1 5. 1n

Section 2: Hip and I'Hvis

occurring in fawer than 10% of patients with symptom-

muscle becomes pinched between the femoral head-neck

trochanteric-pelvic impingement, ischiofemoral impingement, and anterior inferior iliac spine {A115} impingement,

phologv can be developmental (types I and II] or can arise following pelvic csteotomy or secondary.r to prior

atic PALE” Extra-articular impingement, which includes is another infrequent, but increasingly.r recognized, source

of symptomatic impingement. A thorough understanding

of the pathomorpholog}r and pathomechanics of each

individual deformit}r is critical to the successful surgical

management of FAI. Cam Impingement

lElam deformity,r is characterized lav decreased offset between the femoral head and neck, most commonly occurring at the anterolateral head—neck junction. 1|With

attempted hip flexion and internal rotation, the osseous cam lesion impinges on the acetahulum, limiting motion

and causing damage at the chondrolahral junction with repetitive impingement. In cam impingement, inclusion of

the deformity.r into the acetahulum results in shear stress

and disruption of the chondrolabral junction, causing de—

lamination of the articular cartilage from the underlving suhchondral hone.” lL'Ihrer time, intrasuhstance damage to the lahrum occurs, and the chondral injury,r can progress

to a full-thickness defect. The location and severity.r of the acetahular injury can he predicted by the sire of the cam deformity, because a higher E angle is associated with increased incidence of full—thickness chondral de~

.E

E a: u. 'U I: to '9

I

oi

junction and a prominent AIIS.” Pathologic AIIS mor-

rectus femoris injur‘f.r or avulsion {type III}. Affected pa-

tients may report activitv—related groin pain, pain during prolonged sitting, limitations in motion, and a grinding sensation during deep flexion and lateral movements. Im—

pingement between the lesser trochanter and the ischium [ischiofemoral impingement} and the great trochanter

and the ilium {trochanteric—pelvic impingement} are other

potential, although uncommon, sources of extra'articular impingement that can cause pain and restricted hip extension and abduction, respectivelv. lntra—articular steroid

iniection tvpicallv provides no relief or onl].T partial relief of symptomatic extra-articular impingement.“- Bcth open and arthroscopic resection have been shown to improve

motion and alleviate painfifla

Femoral Version Femoral version can affect the severity of cam and pincer deformities and should he assessed in all patients with svmptomatic FAI. The normal adult femur has ID“ to

15" of femoral anteversion. In the setting of relative or

absolute femoral retroversion, external rotation of the hip is increased, and internal rotation is decreased. 1When

fects.lEI In most patients, decreased offset occurs at the

femoral retroversion coexists with a focal cam or pincer lesion, the osseous lesion engages earlier {with less inter-

the anterosuperior acetahulum.3 In long-standing cam im— pingement, degenerative changes can progress to involve

femoral anteversion.21 The motion restriction in patients with combined FA] and femoral retroversion is typically.F

anterolateral head—neck junction, resulting in damage to the weightuhearing spherical portion of the femoral head.

Pinrer Impingement Pincer impingement is characterized by excessive acetahu

ular coverage. The acetahular overcoverage can he global [coxa protrusio and coxa profunda] or focal {cephalad

retroversion} or can result from true acetahular retroversion.“ Pincer impingement leads to intrasubstance damage of the labrum as it is compressed between the

nal rotation} than would be seen in a hip with normal more severe than in those patients with isolated FAI. Acetohular Dysplasia

Symptomatic FA] must be differentiated from acetahular dvsplasia. In dysplasia, ahnormal joint loading occurs

seconda rv to a relative undercoverage of the femoral head

by an abnormallv deficient acetahulum. Preoperative ra-

femoral neck and the abnormal acetahular rim during

diographs are essential to the diagnosis, and common radiographic parameters should be measured to ensure

fected; less chondral delamination is present with isolated

condition varies dramaticallv from that of an isolated

extremes of hip range of motion. As in cam impingement, the anterosuperior acetahulum is most commonlyr af-

rim impingement, however. Dver time, repeated levering of the femoral head against the excessive acetahular rim can result in contrecoup chondral injurv to the postero-

inferior femoral head and acetahulum. Extra-articular Impingement

Subspine impingement is a distinct form of pincer impinge— ment, in which the anterior capsule andfor iliocapsularis

flrdtopaedic Knowledge Update: Sports Medicine 5

proper diagnosis. Although FAI mav coexist with acetahular dysplasia, the surgical treatment for the combined

PAL“ Correction of dvsplasia tvpicallv requires an open approach, most commonly performed using the Bernese periacetahnlar osteotomv.”

Given the overlap in svmptomatologv between the lumbar

spine, hip, and pelvis, it is common for patients to present

El 1016 American Academv of Drthnpaedic Surgeons

Chapter 11: Femoroaoetabular Imphigement

in a delayed fashion following previous failed treatment, or with an incorrect diagnosis. A layered approach should

he applied to assess not only the mechanics of the hip

joint but also the surrounding joints and musculature. A

primary hip disorder may be obscured by compensatory injury to the pelvic musculature, lumbar spine, pubic joint, or sacroiliac joint as the patient attempts to main-

tain a high level of activity in the setting of restricted hip motions“5 Patients may present with chronic gluteal pain, abductor irritability, trochanteric bursitis, osteitis pubis,

or trochanteric bursitis. The location, duration, and inciting factors of the pa— tient‘s pain should be elicited. Although most patients

with symptomatic impingement {30%} present with pain

in the anterior groin or lateral hip, approximately 25% of patients report pain in the lumbar spine, buttock, or even referred pain to the knee.” Patients may display the

classic “C” sign {Figure 1} when describing the location of pain. lviost report an insidious onset of symptoms

without a specific injury; however, athletes may recall a

specific event.“ Pain is often worse with activity (running,

cutting, and pivoting} and is exacerbated in positions of hip flexion, such as prolonged sitting or squatting. Physical Examination

Gait should be examined in all patients. A mild, inter-

mittent limp is common but can be extremely subtle,

occurring in up to P5 “iii of patients.” Abductor weakness on the affected side often is seen with a positive Trendelenberg sign. Range of motion should be assessed on

supine examination at full extension and at 90“ of hip

I'. -

Figure 1

I

5.:

A-‘

Photograph shows the classic "E" sign. Patients

with symptomatic impingement til-ten cup their hand around the lateral hip when describing the site of pain.

a dysplastic or unstable hip may report uneasiness or apprehension during this maneuver. The same maneuver also may re-create pain in patients with symptomatic posterior impingement. The subspiue impingement test

is performed with the patient in the supine position (Figure 4). Maximal anterior groin pain with direct hip flexion beyond 91')“ is consistent with subspiue impingement. Intra-articular anesthetic injection can be a useful adjunct to diagnosis. The injection can he performed in the

office setting via ultrasound or fluoroscopic guidance. Following injection, patients are instructed to perform

activities that would typically elicit pain. Substantial or

flexion. The contralateral limb should be examined for

complete relief with injection signifies an intra-articular source of pathology. Little to no pain relief following

75% of patients but is symptomatic in fewer than 25 Si: .3“ Restricted hip motion is a defining feature of symptomatic

should be assessed for potential extra-articular sources of impingement {subspine impingement} or other pelvic

comparison. Bilateral disease is seen in approximately

FA], and affected individuals often have less than lflfl"

of straight flexion and less than 10" of internal rotation

injection warrants further investigation. Such patients

or lumbar pathology.11

with the hip at 5‘0“ of flexion.

Several dynamic tests can be used to assess for the pres— ence of impingement and to compare with the contralater-

al limb. A positive test should re-creatc the characteristic pain that the patient experiences. The positive anterior impingement test {Figure 2} causes pain in the anterior groin with flexion, adduction, and internal rotation,

Plain Radio-graphs

Preoperative imaging is critical to the diagnosis of Phi

and in planning for potential surgical intervention. A systematic approach should be implemented and should include the following standard radiographs: standing AP

which is present in most patients (33%] with symptomatic FA]. Although sensitive for hip pathology, the anterior

pelvis, false profile, Dunn views, and frog—lateral views.” For an accurate standing AP pelvis view, the pelvis should

may be positive in any patient with a labral or chondral injury. The apprehension test {Figure 3} is performed with

coccyx is centered in the midline, the tip is within 1 to 3 cm of the pubic symphysis, and the obturator foramen is

The hip is extended and externally rotated. Patients with

dence of narrowing, sclerosis, or cystic change indicative

impingement test is not specific for impingement and the patient supine at the edge of the examination table.

IE! Elllli American Academy of flrthopaedic Surgeons

be aligned with neutral rotation and tilt such that the

symmetric.” The joint space should be assessed for evi~

Drthopeedic Knowledge Update: Sports Medichie S

H

E

'U to 3

EL '13

1 in

El-

Sectinn 2: Hip and Pelvis

a I Figure 2 -E

2

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_-

1

ttegraphs depict the anterior impingement test. This test is pertermecl with the patient in the supine pnsitinn. The affected hip is maximally flexed {A} and then adducted and internally rntated {B}. Reprnductinn nf the patient's anterinr grnin pain during this maneuver indicates clinically significant impingement andfnr intraarticular pathnlngy.

nf early nstenarthritis. Acetahular depth and cnverage shnuid be assessed. Glnbal nvercnverage is easilyr identified when the medial femnral head lies adjacent tn the ilinischial line {cnxa prnfunda} nr medial tn it {cnxa prn-

trusin}. Excessive anterinr nvercnverage, alsn referred tn

as cephalad retrnversinn, may be signaled by a crnssnver

sign. In cephalad retrnversinn, relative retrnversinn nf the

anternsuperinr acetabulum cnexists with nnrm al versinn nf the anternmedial aceca bulum. This must be differenti— ated frnm true acetahular retrnversinn, in which anterinr nvercnverage is assnciated with a deficient pnsterinr wall,

fl", and impingement: cysts nr a trnugh alnng the femnral head-neck junctinn. The false prnfile view prnvides additinnal radingraphic

infnrmatinn regarding acetahular mnrphnlngy. This im-

age is nbtained with the patient rntated at an angle nf 65“ between the pelvis and x-ray snurce and prnfiles the an—

terinr acetahulum. An anterinr center edge angle {ACEA}

greatei- than 4D“ indicates excessive anterinr nvercnver—

age.ail The mnrphnlngy nf the A115 alsn can be assessed with this view (Figure iii).

a cnnditinn that places the patient at risk fnr iatrngenic instability with isnlated anterinr wall decnmpressinn. A

The Dunn and frng-lateral views are used for assessment nf the femnral cam mnrphnlngy. The n angle is drawn tn quantify the severity nf the aspherieity. Val-

a pnsterinr wall sign {the pnsterinr wall lies medial tn the center nf the femnral head}, is indicative nf true aeetahular

The different radingraphic views help identify the lnss nf head-neck nffset at different lneatinns alnng the prnxitual

greater than 44]" indicate pincer mnrphnlngy.“ Additinnal

the superinr femnral neck is at 12 n’clnclc, and the anterinr neck is at 3 n’clnck, tn cnrrelate the pnsitinn nf the

fractures, a dnwnslnping snurcil, a Tnnnis angle less than

nhlique CT refnrmats. The 12 n’clnck pnsitinn is seen

crnssnver sign, cnmbined with an ischial spine sign and retrnversinnf'” {Figure 5}. The lateral center edge angle {LCEA} can be used tn assess lateral nvercnverage. 1Values findings cnncerning fnr rim impingement include rim

firthnpaedic Knnwledge Update: Spnrts Medicine 5

ues greater than 50“ indicate cam defnrmity [Figure T}.

femur. Nepple et all? used a clnck face technique, in which

head—neck junctinn prnfiled nn plain radingraphs tn radial

fl lflld American Academy nf Cirrhnpaedic Surge-nus

Chapter 11: Femoruaeetabular Impingement

"1.

s. -

_ a .- "If"

Figure 3

Photographs show the anterior apprehension test. which is performed with the patient supine and positioned at

the end of the examination table. A, The contralate ral hip is held in tlesio n; E, The affected hip is este nded and

externally rotated. Patients with structural instability may re port a sense of instability or appreh ension with this maneuver. Pain during this maneuver may signify posterior impingement.

l‘s'

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with the AP pelvis view, the 1 o’clock with the 45" Dunn view, the 2 o’clock with the frog-lateral view, and the 3

o’clock with the cross-table lateral view. Given the typical location of cam deformities at the anterolateral head-neck

junction {1 o'clock}, deformity is identified most readily

on the Dunn view, where the hip has abducted EU” and flexed to 45“ {45" Dunn} or 90“ {90“ Dunnlfihm The 45“ Dunn view has been shown to be more sensitive in de-

some patients, including those with ligamentous hyperlaxity, more subtle signs of dysplasia {such as an LCEA

less than 25°, uprising sourcil, ACEA less than 25"} may

give rise to symptomatic instability.” Magnetic Resonance Imaging

tecting the presence and severity of cam deformity than the 911]" Dunn viewfi‘l "When compared with the Dunn view, the frog-lateral view has improved specificity for cam morphology.“ It is crucial that all radiographs be scrutinized for evidence of acetabular dysplasia, which

MRI can be helpful in assessing labral pathology. The sensitivity is significantly enhanced with intra-articular contrast dye, making magnetic resonance arthrography {MBA} with gadolinium the preferred imaging technique. If possible, all imaging should be performed using highresolution 1.5 Tesla {or greater} MRI. True labral tears must be differentiated from naturally occurring clefts.

patient presenting with hip pain. Radiographic findings on the AP pelvis that are con-

direct signs of labral and chondral injury, respectively. Labral hypertrophy can indicate underlying dysplasia.

bility include an LCEA less than ED“ and a Tonnis angle greater than 10" (Figure 3]. Anterior coverage can be

ular gadolinium can provide additional diagnostic value. Temporary relief of symptoms verifies an intra-articular

less than EU“ is indicative of undercoverage {Figure 9}. In

with conventional MRI. Delayed gadolinium-enhanced

may coexist with FAI or be the primary pathology in a

cerning for aceta bular undercoverage and structural insta— assessed using the false profile view, on which an ACEA

IE! lfllfi American Academy of flrthopaedic Surgeons

Paralabral cysts and sub-chondral edema or cysts are in-

The addition of a long—acting anesthetic to the intra—articsource of pain. The articular cartilage is poorly visualized

Drthopoedic Knowledge Update: Sports Medicine 5

1 us

El-

Section 2: Hip and Pelvis

Figure 4

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

Figure 5

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

.5

2

to o. 'r: i: rt: EI

H

MRI of cartilage {dGEMRIC} is a newer imaging technique that can detect earl}.r chondral degeneration by

titre 30 minutes before imaging. This technique can he a useful adjunct when there is a concern for underlying

laj,rrrr:1'-"'l {Figure 10). Patients receive intravenous contrast

is a known risk factor for poor outcomes following hip

measuring the glycosaminoglycan content of the hyaline

a

firthopaedic Knowledge Update: Sports Medichte 5

osteoarthritis, because preexisting chonclral degeneration

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 11: Femoroaoetabular Impillgemetlt

.1. lg.:.- .r

n‘ i

.

Figure IE

. h. sat-.1“: '

Subspine

_

_

"

impingement If

.II "E! AIIS

I.

f

_

_. “1“”; r1.

False profile radiographic 1u'ievu' depicts a

Figure 71'

Ninety-degree Dunn view shows a cam deformity with an 1:: angle of T9“.

prominent anterior inferior iliac spine {Alli}.

type II B {arrow}.

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. Figure 3

i AP pelvic radiograph shows bilateral acetabular dysplasia- The Tennis angle measures 15‘". with an up sloping sourcil. The lateral center edge angle {LEEAII measures 9".

arthroscopy and open hip preservation surgery.“

Figure 9

False profile view shows acetabular dysplasia

with anterior undercoverage. The anterior renter edge angle measures 5‘.

chitecture, can be a helpful adjunct in planning bony resection. Although a crossover sign or ischial spine may

can be especially helpful in identifying focal rim lesions, such as cephalad retroversion, and in differentiating them from true acecabular retroversion. CT is also invaluable to the assessment of AIIS morphology, which is poorly visualized on plain radiographs. Software programs can

direct assessment of acetabular version and depth. This

ment and plan sites of resection.

Three-Dimensional CT Three-dimensional computed tomography (313! CT},

which provides detailed information about the bony ar— alert the surgeon to pincer impingement, CT allows the

IE! lfllfi American Academy of flrthopaeclic Surgeons

be applied to 313 CT images to model areas of impingeu

Drtbopoedic Knowledge Update: Sports Medicbie 5

Section 2: Hip and Pelvis

the arthroscopic management of FAI. Successful treatment requires a comprehensive approach that addresses

the osseous deformity and the resulting intra—articular

damage. Incomplete decompression of the impinging le-

sion is the leading cause of recurrent pain in patients undergoing hip arthroscopy in the absence of substantial

chondral injury.33~3"

Hip arthroscopy proceeds via the standard technique,

using a minimum of two arthroscopic portals. The procedure typically begins by addressing pathology in the central compartment, including the pincer and subspine

deformity and the chondrolahral injury. Afterward, traction is released, and the arthroscope is advanced to

the peripheral compartment for decompression of the

cam deformity. An extensive capsulotomy [interportal, H-shaped, or T-shaped} has been described to improve

access to pathology in the central and peripheral com-

partments. When performed, the capsulotomy should be made hotween the medial and lateral synovial folds

Figure 1!]

Saqittal slice of a delayed gadolinium-enhanced

MRI of the hip shows increased signal {arrow},

which signifies chondral degeneration at the superior acetahulum.

Nonsurgical Management -E

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to a. 1: I: re EI

H

The nonsurgical treatment of PM is limited to symptom.-

atic management and includes activity modification, anti-inflammatory medications, and physical therapy.“ Because impingement can result in compensatory injury

to the surrounding musculature, physical therapy directed toward improving muscular mobility and strength can provide some symptomatic relief. Common areas

of involvement include the rectus femoris, psoas muscle tendon complex, hip adductors, and hip abt:luctors.3“"3‘5

The therapy program should be customized to address

the individual needs of the patient, including mobility restriction, athletic demands, and areas of weakness. Although therapy may be helpful in the symptomatic management of FAI, no evidence suggests that it will affect the natural history of the disease andior alter the progression of degenerative changes. Surgical Management

The decision to proceed to surgery is based on a combination of factors including the patient history, physical

examination, imaging studies, failure of nonsurgical management, and temporary relief with injection. Although an open approach, such as the surgical hip dislocation

and be extended in line with the femoral neck to prevent

damage to the retinacular vessels. Capsular management

remains an area of controversy. Some surgeons argue that

anatomic closure is required to restore the stability and kinematics of the hip. Central Compartment Pincer Impingement Acetabuloplasty or rim trimming involves removal of the

pincer impingement. This can be performed with or with-

out labral takedown. The extent of the resection should

be determined preoperatively from the baseline imaging

studies. Fluoroscopy can be used to assess progress intraoperatively. I[flare must be taken to prevent overresection and iatrogenic instability.

Lahral Injuries More than 99% of labral tears occur in conjunction with

impingement deformity. The characteristics of labral in-

jury depend on the type and duration of impingement. In

early cam impingement, minimal intrasu bstance injury to the labrum is present, because the mechanism of injury occurs from shear stress between the articular cartilage

from the subchondral bone. Favorable healing rates can be achieved with labral refixation after rim trimming (Fig-

ure 1]]. In contrast, longestanding cam impingement and

combined impingement typically lead to intrasubstancc tearing and maceration of the labrum, which may present with an irreparable labrum. In the setting of an irrepara-

hle labrum, options include selective labral débridetnent and reconstruction.

described by Gan, can be used, this chapter focuses on

firthopaedic Knowledge Update: Sports Medicine 5

fl lflld American Academy of Orthopaedic Surgeons

Clmpter 11: Fempreaeetahular IatgemflnlI

l‘r' E 'U m :r

Ill

1: 1 E.

II“

Figure 11

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

IE! EDIE American .ilasadlstn3,.r pf flnhnpaedic Surgeens

Dnhepaedic Knowledge Update: Spur-ts Medichse 5

®

Secfien 2: Hip and Pelvis

Figure 12

Arth rescepic View shews the fe me ral headneclt junctien fellewing cempletien ef the esteechendreplasty.

Arthrescepic 1.I'iew shews the peripheral compartment ef the cam lesien fellewing T—ca psuletemy.

Peripheral Cempartrnent

Failure te reee—gnize and address esseeus patheiegy is a prime faeter centributing tn treatment failure.” Cemprehensiye treatment ef the cam defermity depends en the understanding ef the deferrnity, adequate yisualiaatien, the ability te access the CAM defermity in its entirety,

-E

E

e: e. 1: i: re E-

and capsular management. After the central cempartment has been addressed, the hip tractien is released, and

the hip is placed in appreximately lfl" te 30° ef flexien

I

with neutral retatien. The auther’s preference is te use a T-eapsuleteruy perpendicular frem the interpertal capsu-

H

letemy and extended re the intertrechanteric line between

Figure 111

A, Preeperatiye AP radiegraph depicts a typical cam defermity iarrew]. B, Pesteperatiye AP

radlegraph shews the restered fe rneral headneck e'ifset fellewing decempressien.

the iliecapsularis and the glutens minimus {Figure 12}. The cam defermity is reseeted using a high-speed burr while using intraeperatiye fluerescepy te cenfirm a cem—

prehensiye femeral esteechendreplasty {Figure 13]. The hip must be pesitiened frem cemplete hip extensien and

Chendral Injuries The chendral injuries asseciated with PM can range frem

delaminatien te full-thickness less. In the setting ef an intact ehendrelabral junctien, labral repair can serve re

reappreximate the delaminated cartilage back tn the sub

ehendral bene. Detached and unstable flaps pese a clinical challenge. Debridemeut, refixatieu with fibrin glue,

remeyal, and micrefracture all have been described, but

ne geld standard treatment exists. In general, significant

internal retatien te full flexien and external retatien te permit access re the entire cam defermity. After the dynamic examinatien and fluerescepie eyaluatien cen-

firm resteratien ef the head-neck effset, the capsule is cempletely clesed by shuttling numereus high-strength sutures {Figure 14}. Dutcemes

cheudral injury is a peer pregnestic faeter fer euteeme

Preper patient selectien is critical re the successful surgical treatment ef PAL Reduced pain and impreyed functien

and reduced functieu pesteperatiyely.

15% ef athletes are able te return te cempetitien at the

and is ene ef the primary predicters ef centinued pain

flrdtepaedic Knewledge Update: Sperts Medicine 5

are reperted in 63% te 96% ef patients.” Appreximately

fl lflld American Academy ef Cirrhepaedie Surge-ens

Chapter 11: Femoroaoembulsr Intpingemerlt

same level or better.“ The long-term effect of hip arthroscopy and its potential to alter the natural history of FA] and prevent early degenerative joint disease remain to be

determined. The current literature does not support pro-

phylactic cam or pincer decompression in asymptomatic

patients.” The presence of preoperative osteoarthritis {Tonnis

grade greater than or equal to E or Outerhridge grade

greater than or equal to fl} is the strongest predictor of poor outcome following hip arthroscopy. Either factors associated with a poorer outcome include older age, a

Annotated References 1.

Gen: EL, Parvisi J, Beck M, Leunig M, Hotxli H, Siebenrock PEA: Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clix! firth-op Refer Res Zflfl3;41?:112-120. Medline Beck M, Kalhor M, Leunig M, Gan: R: Hip morphol-

ogy influences the pattern of damage to the acetabular

cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone joint Sarrg Br 2fl05;3?{?}:1fl12-1013.Mcdlinc DUI

longer duration of symptoms, more severe preoperative pain, and poorer functional scored-“d” In the absence

Tannast M, lIGoriclti D, Beck M, Murphy SE, Siebenrock

is the leading cause of continued postoperative pain and

230. Medline DDI

of preexisting chondral disease, residual impingement revision surgery.3135 ‘5 um mary

Active adolescents and young adults who report hip

andIor groin pain should be assessed for FAI. The pres-

ence of a cam andr‘or pincer deformity not only restricts motion, but also leads to joint degeneration over time.

Patient history, physical examination, and radiographs

are critical tn the diagnosis of FAI and tn the planning

of surgical intervention. Hip arthroscopy is an effective treatment modality. Failure to address all the components

of osseous impingement is a prime reason for continued

pain and dysfunction following hip arthroscopy. Hey Study Points

1* FAI results from a structural mismatch between the proximal femur {cam} and the acetabulum {pincer}. 1* Extra—articular impingement is a less common but

increasingly recognized source of symptomatic

impingement. I Most patients with symptomatic impingement present with activity-related groin pain.

KA: Hip damage occurs at the zone of femoroacetabular impingement. Clin Orthop Relat Res 2903;466(2]:2?3-

Hack E, Di Primio G, Rakhta K, Beaule PE: Prevalence

of cam-type femoroacetabular impingement morpholoin asymptomatic volunteers. ,l' Horse Joint Surg Am

2010;92i14}:2436-1444.Medline not

Two hundred asymptomatic volunteers underwent MRI of both hips. The images were examined for evidence of cam deformity in angle greater than 5115“]. Cam deformity was

found in 14% of asymptomatic volunteers [1 [1.5“ii: bilateral

deformity and 3.5% unilateral deformity].

Kang AC, flooding A], floates MH, Goh TD, Armour P,

Rietveld J: Computed tomography assessment of hip joints in asymptomatic individuals in relation to femoroacetabu-

lar impingement. Am '1' Sports Med 2D10;33[6}:1 1-50-1165. Medline DID]

One hundred hips in 51'] patients with no history of hip dysfunction underwent CT for abdominal pain or trauma.

The images were assessed for evidence of impingement

pathology. At least one radiographic finding consistent with PA] was identified in 39% of hips. Ili'iosvig EH, Jacobsen S, Sonne-Holm 5, Palm H, Troelsen A: Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: A population-based survey. } Bone Joint Saar-g Am lfllflt92lfiltllfil-1 169'. Medlitte DUI

I Limited range of motion of the hip is one of the

This is a cross-sectional study of 4,151 individuals in the Copenhagen IElsteoarthritis Study. Patient radiographs

it FAI must be differentiated from dysplasia when

formity [impingement and dysplasial. The prevalence of osteoarthritis was 9.5% in men and 12.5% in women.

defining characteristics of FAI.

evaluating a patient with hip pain. The two conditions may coexist. it Both arthroscopic and open techniques are effective

in the surgical management of FAI.

1* Residual deformity is a leading cause of continued

pain after the surgical management of FAI.

1* fllder age, preexisting osteoarthritis, and a longer

duration of symptoms are risk factors for poor outcomes following surgical intervention.

IE! lfllfi American Academy of flrthopaedic Surgeons

were assessed for evidence of osteoarthritis and hip de-

Combined deformity and arthritis were found in THE

of men and 36% of women. A pistol-grip deformity was associated with an increased risk of osteoarthritis {risk ratio 2.2], as was a deep acetabular socket {risk ratio 1.4}. Laborie LE, Lehma nn TG, Engesseter IE}, Eastwood DIM, Engesseter LB, Rosendahl K: Prevalence of radiographic findings thought to be associated with femoroacetahular impingement in a population-based cohort of EDS] healthy young adults. Radiology 2011;26fli2}:494-5l}1.

Medline D01

Drthopaedic Knowledge Update: Sports Medicine 5

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Seetien 2: Hip and Pelvie

This is a prospective study ef 2,031 yeung adults {mean age, 13 years}. Radiegraphs were reviewed fm evidence ef impingement pathelegy. A pistel-grip defermity was feund in 21% cf males and 3% cf females. Piucer defermity was seen equally ameng the sexes [14% in men and 5% in wemen, p e: llflfll}.

Pella rd TC, Villar RN, Nerten MR, et al: Genetic influences in the aetielegy ef femereacetabular itnpiugcment:

A sibling study. I Beesjefut Saar-g Er 2i] 10:92l2}:2flfl-216. Medline DID]

Ninety-sis siblings cf 64 patients treated fer primary FA] were clinically and radiegraphically assessed fer ev-

2013:42ll4lflflfl4-1fl91.Medline

[ll-DI

A case-centrel cemparative analysis was perfermed eu yeung {age 9 te 22 years] elite male basketball players.

The presimal femeral physeal cstensien was measured

cam defermity had a 2.3 relative risk ef having the same defermity. Cempared with centrel patients, the siblings ef affected individuals had a 2.5 relative risk ef having Agricela ll, Heiibeer MP, llflinai AZ, et al: A cam defermity is gradually acquired during skeletal maturatien in adelescent and yeung male seccer players: A prespective study with minimum 2-year fellew-up. Am j' Sperts MerfI 2fl14;42{4}:293—3{}6.Medline DUI

13. Siebenreck HA, Kascbka I, Frauchiger L, Werlen S, Schwab Jl'vf: Prevalence ef cam—type defermity and hip pain in elite ice heckey players befere and after the end ef grewth. Am ] Sperts Med 2DlB;41{1fl}:2303-2313. Medline DUI

This is a prespective cehert study bf 63 preprefessienal

Te assess fer evidence ef FAI, 22 elite male ice heckey

impingement merphelegy.

seccer players whe were radiegraphically assessed befere skeletal maturity and then reassessed ever a 2.5-year pe-

re the grewth plate.

slewly areund the time ef physeal clesure and may be

players underwent physical examinatien and MRI. flf the athletes, 20% reperted a histery ef hip pain and had a pesitivc impingement test finding. Alpha angles were higher in athletes with clesed physes than in these with epen physes {53" versus 49"}. The e. angle was higher, and internal retatien was reduced in symptematic patients versus asymptem atic patients.

10. Carsen S, Mere: P], Rakhra K, et al: The |[titre Aufranc Award. Du the et'ielegy ef the cam defermity: A

14. Silvia ML, Mesher T], Smetana BS, et al: High prevalence ef pelvic and hip magnetic resenancc imaging findings in asymptematic cellegiate and prefessienal heckey players. Am ] Sperts Med 2011;39l4}:215-221. Medline DUI

ried. The prevalence ef a cam defermity increased frem

2.1% te 12.2% during the time ef physeal clesure, with ne additienal increase in severity fellewing physeal clnsure. The anthers hypethesiae that cam defermities develep prevented by limiting athletic activity during this peried ef skeletal grewth.

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12. Siebenreck HA, Eehning A, Mamisch TC, Schwah JI'vI: IGrewth plate alteratien precedes cam-type defermity in elite basketball players. Elie flrrbep Refer Res

using radial sequence MRI cuts and cempared with an age-matched centrel greup ef nenathletes. In athletes with clesed physes, epiphyseal entensien eccurred enly at the 3.- e'cIe-ck pesitien and cerrelated with an e angle greater than 55°. The anthers cencluded that cam defermity develeps in athletes as a censequencc ef alteratiens

idence ef hip impingement. The siblings ef patients with

cu e. 1: I: an E-

angle was feund in 22% cf hips, decreased femeral headneck effect in 64%, a cressever sign in 61%, a reduced Tennis angle in 16%, and an increased LCEA in 2%.

cress-sectienal pediatric MRI study. Cffn D-rtfrep Refer

H

Res 2014;422fllfl3fl-436. Medliue

DUI

This is a cress-sectienal cehert study ef pediatric patients. MRI was used tn evaluate 44 healthy velu nteers {33 hips} befere and after physeal clnsure. The images were assessed fer evidence ef a cam defermity in angle greater than er equal te 50.5“], and velunteer activity level was cellected. The mean at angles were 33" and 42“ in the patients with

epen and clesed physes, respectively. Altheugh ne patients

with epen physes had cam merphelegy, 3 cf 21 {14%} ef these with clesed physes had at least ene hip with cam merphelegy. These patients were all male and had a higher daily activity level. 11.

Kapreu AL, Andersen AE, Aeki 6K, et al: Radiegraphic

prevalence ef femereaceta bular impingement in cellegiate feetball players: AADS Exhibit Selectien. I Herve jefnt Snrg Am 2011;93{19}:e111, 1—10. Medline DUI

This is a prespective study ef 62 male cellegiate feetball

players {134 hips}. Plain radiegraphs were ebtained and assessed fer evidence ef FAI {cam a angle greater than er equal tn 5!)" er head-neck effset less than 3 mm, pincer

LCEA greater than 46", Tennis angle less than D“, audl'er

pesitivc cmssever sign]. At least ene sign ef cam er pincer impingement was present in 95% ef hips. An abnermal n

firthepaedic Knewledge Update: Sperts Medicine 5

This is a cress-sectienal study ef 21 prefessienal and 13 cellegiate asymptematic ice heckey players. Athletes cem— pleted the medified flswestry Disability Questiennaire and underwent MRI. Pathelegic hip changes were seen

in 64% ef athletes, and MRI findings ef cemmen adduc-

ter—abdeminal rectus dysfunctien were seen in 36% cf athletes. 15. Gerhardt MB, Remere AA, Silvers H], Harris DJ, Tatauabe D, Mandelbaum ER: The prevalence ef radiegraphic hip abnermalities in elite seccer players. Am }' Sperts Med 2012;4{l{3]:534-533. Mcdline DUI The authers retrespectively reviewed the pelvic radiugraphs ef 95 elite male and female seccer players te assess fer evidence ef FAI. Symptematic and asymptematic

athletes were included. Radiegraphic evidence ef FAI was found in 22% cf males and 5{1% ef females. A cam lesien

was feund in 63% ef males {22% bilateral} and 5D% ef females {90% bilateral}. Pincer lesiens were feund in 22%

ef males and 16% ef females.

16. Larsen CM, Sikka ES, Sardelli MC, et al: Increasing alpha angle is predictive ef athletic'related “hip” and "grein‘ pain in cellegiate Natienal Feetball League prespects. Artbrescepy 2U13;29{3}:4f}5-41fl. Medline DUI

fl 2616 American Academy ef Urthepaedic Surge-ens

Chapter 11: Femoroaeetabular Impirlgement This is a cohort study involving 125 male collegiate foot; hall players {139 hips] undergoing physical and radiographic evaluation of the hip during the National Football League Scouting Combine. Symptomatic and asymp-

of Ill patients treated with arthroscopic decompression. Arthroscopy lflllglflll oases—less. Medline

DUI

tomatic athletes were included. Ninety percent of athletes

The study is a retrospective review of 10 patients with symptomatic subspine impingement. (if all patients, Hfl'is’: had a coexisting cam lesion that also was addressed at the

deformity was found in the symptomatic group, and an

subspine decompression is presented. Postoperatively, the mean patient hip range of motion improved from 99" e

had at lea st one radiographic finding consistent with FAI {pincer or cam deformity]. An increased prevalence of cam increasing a angle was the only independent predictor of activity-related groin pain. 1?. Elohisy JC, Baca G, Beaule PE, et al; ANEHDR Study IGroup: Descriptive epidemiology of femoroacetabular impingement: A North American cohort of patients undergoing surgery. Am] Sports Med 2013;41[El:1343—1356.

Medline DUI

This a cross-sectional multicenter study assessing the epidemiology of FAI. A total of LETS consecutive pa-

tients {1,13ll hips} undergoing surgical treatment of FAI

were included. A primary cam deformity was the main pathology in 43% of hips; 4.5% had combined pincer:Ir cam pathology; and 19% had isolated pincer pathology. Surgical intervention included a hip arthroscopy in Sfl'i'v’n of patients, surgical dislocation in 34%, a reverse periacetabular osteotomy in 9.4%, a combined hip arthroscopy

and limited open osteochondroplasty in 5.3%, and an

time of hip arthroscopy. The technique for arthroscopic T” to 11?“ = 3". The modified Harris Hip Score improved from 64 to .93 at an average follow-up of 14.? months.

14. Clohisy JC, Nunley RM, Curry ME, Schoeneclter PL: Periaceta hular osteotomy for the treatment of acetahular dysplasia associated with major aspherical femoral head deformities. I Hone joint Sterg Arr: lfiflTflflfflfl‘lfl-HES. Mcdline DUI 15. Siebenroclt KA, Schiill E, Lottenbach M, Gan: R: Eernese periacetabular osteotomy. Cilia Urtlrop Relat Res 1999;363:9-29. Medline

26. Hammond S, Eedi A, 1idoes JE, Mauro CS, Kelly ET: The recognition and evaluation of patterns of compensatory injury in patients with mechanical hip pain. Sports l-l'erll'tl'sI 2014;5{2lflflfl—113. Medlinc DUI

isolated limited open osteochondroplasty in 1.5%. At the time of surgery, labral and chondral lesions were found in

The study is a literature review of the compensatory injury patterns associated with intra-articular hip pathology,

43% of hips, a labral débridement in 16%, a rim trim in SEE, and a femoral osteochondroplasty in 92%.

joint andtor lumhosacral spine.

more than RUSS of hips. A labral repair was performed in

IS. Larson CM, IL'iiveans MK: Arthroscopic management of femoroacetabular impingement: Early outcomes measures. Arthroscopy lflflR;24[S}:54fl-S45. Medline III-DI

15‘. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Gan: R: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Ellis Drthop Relet Res 2Dfl4;413:6?—?3.Medline DUI 2f}. Johnston TL, Schenlrer ML, Briggs KK, Philippon M]: Relationship between offset angle alpha and hip chondral injury in femoroacetabular impingement. Arthroscopy EDGE;E4{S}:ESH-6?5.Mcdline DUI 21. Eedi A, Kelly ET, Khanduja V: Arthroscopic hip preservation surgery: Current concepts and perspective. Bose Ins-rt] 2D13;95-E[1]:lfl-19. Medline [ll-DI

The study is a review of the epidemiology, etiology, diag-

nosis, and treatment of femoroacetabular impingement.

22. Larson CM, Kelly ET, Stone RM: Making a case for

anterior inferior iliac spinefsubspine hip impingement:

Three representative case reports and proposed concept.

Arthroscopy 2G1];2T{12J:1?32-l?31 Medline not

The study is a case report of three patients with symptomatic subspine impingement who were treated with arthroscopic decompression.

23. Hetsroni I, Larson CM, Dela Torre K, Zbeda KM, Magennis E, Kelly ET: Anterior inferior iliac spine deformity as an extra-articular source for hip impingement: A series

IR! EDIE American Academy of flrthopaedic Surgeons

including osteitis pubis and dysfunction of the sacroiliac

2?. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harrieayes M, Prather H: Clinical presentation of patients with symptomatic anterior hip impingement. Clio Grthop Relnt Res 2Gfl9:46?{31:633-S44. Medline DUI

This is a prospective cohort study that evaluated the clinical presentation of patients with symptomatic FAI. Most patients reported an insidious onset of symptoms with a time of onset to definitive diagnosis beginning at 3.1 years.

Eighty-eight patients reported pain in the anterior groin.

Hip motion was limited to an average flexion of 9?” and 9" of internal rotation at .913" of hip flexion.

2.3. Allen D, Beaule PE, Ramadan fl, Doucette 5: Prevalence of associated deformities and hip pain in patients with cam—type femoroacetabular impingement. I Horse joint Resp Br lflfl9;91{5J:539—594. Medlinc DUI This is a cohort study of 113 patients with symptomatic FAI of at least one hip without evidence of concomitant dysplasia or osteoarthritis. Bilateral cam deformity was present in FREE of patients, but only 26% had bilateral hip pain. A higher a angle was found in symptomatic hips compared with asymptomatic hips {17W versus 53",

p e flflfll}. The odds ratio of a painful hip was 2.59 in hips with an a angle greater than fill“.

29. Nepple J], Martel jM, Kim Y— , Zalta I, Clohisy JG; AN—

CHDK Study Group: Do plain radiographs correlate with CT for imaging of cam-type femoroacetabular impingement? Clio Drtlvop Relst Res 1012;4TDE12}:3313-332fl. Medline

D0]

This is a retrospective review of 41 surgical patients. Radial oblique reformats of preoperative CT scans were compared

Drthopaedic Knowledge Update: Sports Medicine 5

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Seefinn 2: Hip and Pelvis

with plain radingraphs. A standard radingraphic hip series {AP pelvis, 4.5” Dunn, and frng-lateral views} has an 36% tn 33% sensitivity in detecting an ahnnrmal a angle as seen

nu ET. The Dunn view was mnst sensitive in detecting a

cam defermity {21% tn 33%} but the frng-lateral view was the must specific {91% tn 103%}. The crnss-table lateral view did nnt imprnve sensitivity.

31. Meyer DC, Beck M, Ellis T, Gans FL, Leunig M: Cemparisnn nf six radingraphic prnjectinns tn assess femnral headfneelr asphericity. Che firshnp Reins Res 2336;445i445]:131~l35. Medline

This is a crnss-seetinnal study nf 147‘r patients in whnm prinr hip arthrnscnpy had failed. Eeasnns fnr print failure included residual femnrnacetahular impingement [25%] and residual extra-articular impingement [3.6%]. Apprnt-timately 33% cf revisinn prncedures were perfnrmed arthrnscnpically. Patients repnrted imprnved functinn fnllnwing revisinn at an average nf 15 mnnths.

32. Zilltens (I, Miese F, Kim ‘r'— , et al: Three—dimensinnal de—

3?. Clnhisy JC, 3t Jnhn LC, Schuta AL: Surgical treatment nf

layed gadnliniu m-enhanced magnetic resnnance imaging nf hip jnint cartilage at ST: A prnspective cnntrnlled study.

Eur} Rndr'ni stuns1n 1}:3426-3415. Medline m:

This is a ease—enntrnl study cf 46 patients with symptnm—

atic FAI, dysplasia, nr Legg-Calve-Perthes disease whn underwent high-resnlutinn dGEMRIC MRI fnr evaluatinn nf the hip articular cartilage. The patient imaging results were enmpared with these nf a grnup nf asymptnmatic cnntrnls. The glycnsaminnglycan cnntent was significantly higher in the cnntrnl grnup than in the patient grnup,

enrrespnnding tn underlying ehnndral damage in the pa— tients with FAI.

a: n. 1: I: rt: EI

H

reduced pain and imprnved functinn.

apprnaeh tn the plain radiographie evaluatinn cf the ynung

adult hip. j Hesse Inset Surg Am 2flflfltfiflifiuppl 4}:4?— 66. Medline DUI

E

ing, and spnrt specific prngressinu. All patients repnrted

36. Eieeiardi BF, Fields K, Kelly ET, Ranawat 6.5, Cnleman 3H, Sink EL: Causes and risk factnrs for revisinn hip preservatinn surgery. Am ] Spnrts Med 2314;42f11]:262?1633. Medline DUI

3‘3. IElnhisy JC, Carlisle JC, Eeaulé PE, et al: A systematic

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All patients underwent a three-phase physical therapy prngram prngressing frnm pain cnntrnl and trunk stabilisatinn tn muscular strengthening, sensnry mntnr train-

femnrnacetabular impingement: PL systematic review nf the literature. Ciit: Orthnp Reins Res 2010;463i2}:555~564.

Medline DD]

This is a systematic review nf 11 studies evaluating the surgical treatment nf F31. The mean fnllnw-up was 3.2 years. All studies repnrted reduced pain and imprnved funetinn in patients fnllnwing surgery. Majnr cnmplicatinns necurred in tern tn 13% nf prncedures. 33. Nhn 3], Magennis EM, Singh CK, Kelly ET: l[I'lutcnmes after the arthrnscnpic treatment nf femnrnacetahular im-

pingement in a mixed grnup nf high—level athletes. An:

33. Bngunnvie L, Gnttlieh M, Pashns G, Eaea G, Clnhisyjfl:

I Spurts Med 2311;39i3upplltl43-193. Medline

DUI

Why dn hip arthrnscnpy prncedures faili' Clive Urshnp

This is a case series cf 4? high-level athletes whn underwent arthrnscnpic treatment nf symptnmatic FAI. Fnl-

This is a prnspective cnhnrt study nf 1,224 cnnsecutive

average mndified Harris Hip Senre imprnved frnm 63 tn 33, and the mean u angle imprnved frnm 26° tn .51”. [if all patients, 29% were able tn return tn play at an average cf 9 mnnths pnstnperatively. Pit 2—year fnllnw—up, 23% cf patients cnntinued tn cnmpete.

Reins Res 2313;421i3}:2523-2529. Medline

DUI

patients whn underwent revisinn hip preservatinn surgery

fnllnwing prinr hip arth rnsenpy. Residual FAI was the reasnn fnr failure in 63% nf patients, and underlying scetabular dysplasia was the reasnn fnr failure in 24% nf patients.

Revisinn prncedures included revisinn hip arth rnsenpy {42%}. Periacetahular nstentnmy {24%}, and surgical hip dislncatinn {32%}.

34. 1iiiiall PD, Fernandez M, Griffin DR, Fnster NE: Nnnnperative treatment fnr femnrnacetahular impingement: A systematic review cf the literature. PM P. 2613:5i5JHl3-

426. Medline DUI

This is a systematic review including five studies evaluating the nnnsurgical treatment nf FAI. Despite limited data

in the included studies, the authnrs suggest that physical

therapy and activity mndificatinn may cnnfer snme henefit tn patients. Further research evaluating the nutcnme nf

nnnsurgical management, especially physical therapy, is needed, hnwever.

35. Yashelt PM, Uvanessian h", Martin RL, Fukuda TY:

Hensu rgical treatment nf aeetahular lahrum tea rs: A case series. I Drthnp Spnrts Phys TIE-er 2311;4“5 1:346-353. Medline DUI

This is a case series nf fnur patients with a symptnm-

atic lahral tear treated with nnnsurgical management.

firthnpaedic Knnwledge Update: Spnrts Medicine 6

lnw-up was nbtained in 23% nf patients at 1 year. The

39. lEnllins Jr's, Ward JP, Ynum T: Is prnphylactic surgery fnr femnrnacetahular impingement indicated? A systematic review. Am ,i Spnrts Med 2614;42i12}:3669-3i}15. Medline DUI

This is a systematic review perfnrmed tn determine the efficacy nf prnphylactic surgery fc-r FA]. Ne studies were identified tn suppnrt treatment nf an asymptnmatic hip. 43. Saad at E, Martin 5D, Thnrnhill T3, Ernwnlee SA, Lnsina E, Kat: JN: Factnrs assnciated with the failure nf surgical

treatment fnr femnrnaeetahular impingement: Review nf the literature. Am ] Sperrs Med 2013;42i6}:143?-1495. Medline Dfll

This is a systematic review nf 13 studies evaluating the

faetnrs assnciated with failure ef hip arthresenpy. Factnrs

assnciated with peer pnstnperative nutcnme and cnnversinn tn hip arthrnplasty included prenperative chnndral damage, nlder age, a pnnr prenperative mndified Harris Hip Senre, and a lnnger du ratinn nf symptnms {mere than 1.5 years}. Prenperative nstenarthritis was the strengest predictnr nf pnstnperative cnnversinn tn hip arthrnplasty. IE 2616 American Academy nf Cirrhnpaedic Surge-ens

Chapter 12

Extra-articular Hip Disorders

LWC Thomas Byrd, l'l

Guillaume D. Dumont, MD

Abstract

patient selection for various nonsurgical and surgical

Extra-articular etiologies of pain represent an import“

treatment options remain paramount for the successful treatment of these disorders. This chapter discusses the

raphy, and MRI are helpful in accurately identifying

syndrome [GTPSL piriformis syndrome, external snapping hip, and internal snapping hip.

ant subset of hip disorders. Physical examination and imaging modalities including radiographs, ultrasonog— the pathology. Most hip pathologies can be treated ini-

tially with nonsurgical measures including rest, activity modification, NSAIDs, and physical therapy. Directed

injections are helpful in the diagnosis and treatment of extra-articular pain. The surgical treatment of these disors can be successful in cases that persist despite nonsurgical measures. Keywords: greater trochanteric pain syndrome; trochanteric bursitis: hip abductor tears: piriformis syndrome: snapping hip Introduction

Extra-articular hip disorders are common and can present a diagnostic and therapeutic dilemma. Treatment algo-

rithms have evolved with the advent of modern arthroscopic and endoscopic techniques. Thorough directed history and physical examination techniques as well as

scientific advances relating to greater trochanteric pain

Greater Trochanterit Pain Syndrome GTPS is a term that encompasses various possible eti-

ologies of pain to the lateral hip, including trochanteric

bursitis, tears or enthesopathy of the gluteus medius and minimus, and occasionally, friction of the iliotihial band

over the greater trochanter. GTPS typically presents with pain or reproducible tenderness over the greater trochanter, buttock, or lateral thigh and is relatively common,

affecting 113% to 25% of the general population.I The use of the term “trochanteric bursitis” has declined in recent years, after the realization that inflammation of the bursa typically is not identified in patients with lateral hip pain. More often, pathology involving the tendinous insertions

to the greater trochanter appears to be culpable. A retrospective study of the ultrasonograms of 3?? pa-

tients with GTPS revealed that only 20.2% (1?? patients]|

had sonographic evidence of bursitis. Elf the remainder,

49.9% (433 patients) had gluteal tendinosis, [1.5% {4 patients} had gluteal tendon tears, and 23.5 '34: {250 patients}

had thickening of the iliotihial band.1

br. Byrd or an immediate famiiy member serves as an onpaid consultant to A3 Surgical; has stuck or stock options heici in A3 Surgicai; serves as a paid consuitant to or is an empioyee of Smith b Nephew; has received research or institutionai support from Smith a Nephew: and serves as a board member. owner; officer; or committee member of the American Drthopaedic Society for Sports Medicine. the Arthroscopy Association of North America, and the internationai Society for Hip Arthroscopy. Neither Dr. Damont nor any immediate famiiy member has received anything of value from or has stock or stock options heid in a commercial company or institution reiated directly or indirectiy to the subject of this chapter.

fl lflld American Academy of Drrhopaedic Surgeons

Although evidence is increasing for the importance of

tendon injury versus bursal abnormality in patients with GTPS, the importance of the bursa in GTPS should not

yet be discounted completely. h 2fl14 histologic study

found that the presence of substance P was increased, or found more frequently, in the trochanteric bursa of patients with GTPS and control subjects, but no increase

was noted within the glutens medius tendon. The study group and control group showed little evidence of positive staining for inflammatory cells in the tendon or bursa,

reinforcing the hypothesis that inflammation likely is not the main cause of GTPS. The increased presence of substance P also has been identified previously in the

subacromial space of patients with rotator tendinopathy.3

Drthnpaedic Knowledge Update: Sports Medicine 5

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Increasing evidence has shown an association between abnormal biomechanics and the development of GTPS.

A 2fl15 study of 203 hip MRIs found a significant as—

sociation between increased acetabular anteversion and

the presence of gluteal tendinosis. The mean acetabnlar version in patients with gluteal tendinosis was 13.4“ com—

pared with 15.?“ in those without gluteal pathology.‘

Gluteus

of the femur, including the gluteus medius and minimus, obturator internus, and obturator externus. The gluteus

Gluteus mirirrus ——

Several muscles insert at or near the greater trocha nter

maximns has a broad origin from the ilium and sacrum

and inserts on the iliotibial band and gluteal tuberosity of the lateral femur. The gluteus medius and minimus lie deep to the gluteus maximus, originating from the

ilium and inserting at the greater trochanter. The tensor fascia latae originates from the iliac crest and inserts on the iliotibial tract. Figure 1 shows the close relationship

of these structures. Several bursae surround the greater trochanter to protect it from the surrounding tendons. The subgluteus medius bursa lies superior to the greater

trochanter, deep to the gluteus medius. The subgluteus

maximns bursa lies between the gluteus maximus and

the gluteus medius and lateral to the greater trochanter. A division of this bursa commonly is referred to as the trochanteric bursa.” Patients typically present with hip pain. A careful his— tory can help differentiate GTPS from pain originating

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from the lumbar spine or groin pain originating from

ITIEIdLI-E _

lliotihial hand Troohanterie bursa Greater trochanter

\

Drawing shows the anatomic insertion of the

gluteus medlus and the gluteus minimus on the greater trocha nter in close proximity to the iliotihial hand. The truth anteric bu rsa lies deep

to the iliotihial hand. All of these structures have been implicated in the development

of symptoms of greater trochanteric pain syndrome.

Physical examination often shows tenderness with

intra—articular hip pathologies. Patients often report diffip culty sleeping on the affected side and pain with increased

palpation of the greater trochanter. Patients may present with an antalgic gait or the classic Trendelenburg gait if

can radiate down the lateral thigh to the knee. A dermatomal distribution of pain or pain radiation distal to

muscle testing of the gluteus medius often demonstrates weakness and reproduces pain at the greater trochanter.

periods of standing on the limb or with walking. Pain

weakness of the gluteus medius is pronounced. Manual

the knee should trigger the evaluation of lumbar spine

A new physical examination finding, the hip lag sign,

the military, and its prevalence was found to be higher

hip in 10" of extension, maximal abduction, and internal rotation. The patient’s inability to actively maintain the

largest association with the presence of GTPS, with a

sidered a positive finding associated with hip abductor

radiculopathy. The presence of GTPS was evaluated in members of in individuals older than 4!} years. Female sex had the

fivefold increase compared with males? Another prospec— tive cohort study of women treated for GTPS compared

with an asymptomatic control group found that a lower

has been described, in which the examiner places the

position, with a noted drop of 10 cm at the foot, is condamage substantiated by MRI!“ Radiographs of the hip may show surface irregularities

at the greater trochanter consistent with enthesopathy or

femoral neck-shaft angle and adiposityr were associated with GTPS.fl

calcific tendinosis. Radiographs are also useful in identifying possible coexisting disorders such as osteoarthritis

when chronic, can affect mental health, employment, and quality of life. fine study found that patients with

osseous and soft~tissue abnormalities, including peritro~ chanteric edema and tendinosis or tearing of the gluteus

pared with patients with end-stage hip osteoarthritis and asymptomatic control patients. Dtherwise, GTPS appeared to confer levels of disability and affect the quality of life similarly to end-stage hip osteoarthritis?

to aid in the diagnosis and management of gluteal tendon tears has evolved because of its low cost, availability, and

Pain from GTPS can cause substantial disability and,

GTPS were the least likely to be working full time com—

flrdiopaedic Knowledge Update: Sports Medicine 5

of the hip and fractures. MRI has the ability to depict medius and gluteus minimu s. The use of ultrasonography

ability to guide treatments such as anesthetic and cortico—

steroid injections.ll A systematic review that compared

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 12: Extra-articular Hip Disorders

the accuracy of ultrasonngraphy and MRI in diagnosing gluteal tendon pathology with surgical findings of the

most effective, eliciting a visual analog scale {VAS} score

to lflD%, a specificity of 91% to lflfl‘ifi, and a positive

tween demographic variables or ultrasound findings and pain relief."5

reduction of 3, compared with D in those given in the

same pathology found that MRI had a sensitivity of 33%

subgluteus medius bursa. No association was seen be-

predictive value of T'il'i'e to 100%, with a high rate of false—positive results. Ultrasonngraphy had a sensitivity

Extracorporeal shock wave therapy {ESWTJ has been

of ?9% to lflfl% and a positive predictive value of 95%

to 100%.” Although ultrasonography is dependent on

technician proficiency, it may be a less costly and more effective imaging modality for gluteal tendon pathology.

Nonsurgical treatment is the mainstay of care and

should begin with activity modification, NSAIDs, stretch— ing, and physical therapy. Anesthetic and corticosteroid injections to the trnchanteric bursa can be beneficial and

used tn treat varinus tendinopathies, including GTPS. A systematic review examining the effectiveness of ESWT found moderate evidence that it was more effective than

home physical therapy and corticosteroid injections at

short-term {less than 12 months] and long-term {greater than 12 months} follow—up.” Its use in conjunction with

other nonsurgical treatment methods is supported.

Surgical treatment typically is not required; however,

can be performed with or without image guidance. Ultrasonographic guidance offers the advantage of providing

in cases of recalcitrant pain with tearing of the abductor tendons, repair of the abductor tendons can be per-

and can help accurately position the injectate adjacent to

tendons to their insertion, including open transnssenus nr hone-anchored suture techniques, endoscopic techniques,

visual evidence of damage to the gluteus medius tendon

the damaged tissue tn maximize efficacy.

Fluoroscopic guidance also has been used tn direct

injections in patients with GTPS. A multicenter double-

formed.” Various techniques can be used to repair the

and tendon augmentation for repair reinforcement.19

hlind, randomized controlled study showed no improve-

Double-row fixation analogous to the repair of the rotator cuff has been described.” Either authors advocate the

jections compared with those who were administered

tension between the ilintibial band and the greater trochanter and report a technique for endoscopic bursectomy

ment in outcomes at 1—month or 3—month follow—up in patients who had received flunroscnpically guided ininjections withnut image guidance. The cost associated with flunrnscnpically guided injectinns was significantly

higher.13 Given the lack of evidence supporting the use

importance of ilintibial band release to reduce excessive and cruciate release of the ilintibial band.“

A study examining outcomes in 12 patients treated

with open repair of the gluteus medius tendon through

of flunrnscnpically guided iniectinns for the treatment of GTPS, ultrasonographic guidance can he considered in-

bone tunnels showed improvement in the mean Harris Hip Score from 53 prenperatively to 3? at 1-year

the abductor tendnns for structural damage. A randomized controlled trial of patients with GTPS

was found between tear size or pattern and outcomes, but the three patients with poor results were in the group

tions or a group that received nonsurgical care withnut injections showed clinically significant improvement at

undergo the procedure again if necessary}1

stead, because it offers the ability tn concomitantly assess

assigned tn a group that received corticosteroid injec-

follow-up and 33 at 5—year follow-up. No correlation

with larger tears. Most patients were satisfied and would

3 months in the study group compared with the control

In a series of 13 patients with GTPS who underwent endoscopic cruciate release of the ilintibial band, substan-

plete remission, although pain reduction was maximal

pain score, the modified Harris Hip Score, the Western fintario and McMaster Universities Arthritis Index, and the Hip IClutcnme Score, at 3, E, and 12 months, compared with preoperative scores. The mean VAS improved from

bursitis, versus the presence of associated gluteus medius

eratively to 36.29 at 12 months. No patients underwent

group. The difference in outcomes was no longer present at 11 months, however.” The authors of a 21314 study considered some pain relief from the first injection tn he a positive indicator of comafter the third injection tn the region of the trnchanteric bursa. The radinlngic presence of isolated trnchanteric

tial improvements were noted in the visual analog scale

3.1 prenperatively to 0.43 at 12 months, whereas the modified Harris Hip score improved from 40.2 preop-

tendinnpathy, was associated with greater pain reduction in the immediate postinjection phase and over the long term.” A study comparing the efficacy of ultrasound-guided injections directed toward the trnchanteric bursa with

found that traditional nonsurgical methods, including physical therapy with stretching, low-energy shock wave

that those administered in the trnchanteric bursa were

The efficacy of all surgical treatments studied, including

those administered in the su bgluteus medius bursa found

IE! lfllfi American Academy of flrthopaedic Surgeons

additional surgical procedures to the hip within the follow-up period.23L

A systematic review of treatment options for GTPS

therapy, and corticosteroid injectinns, help most patients.

Drthnpaedic Knowledge Update: Sports lvledichie .‘i

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bursectnmy, lnngitudinal release nf the ilintibial band, Z-plasty lengthening cf the ilintibial band, nstentnmy,

Gluteus

and gluteal tendnn repair, was superinr tn nnnsurgical

metius

management; thus, these surgical treatments are wnrthy nf cnnsideratinn in refractnry cases.M

Gluteus

ninimue

F'irifnrmis Syndrnrne Pirifnrmis synd rnme is characterized by extrapelvic cnm-

Piriinnnis

the area nf the greater sciatic nntch. Symptnms include

Eiluteus medius

pressinn nf the sciatic nerve by the pirifnrmis muscle in

pain and dysthesthesias tn the buttnck, hip, nr pnsterinr thigh and pain distally as a result nf radicnlar pain. Hy-

Gemeilue

superinr

perttnphy nf the bands nf the pirifnrmis can cnmpress the

Eemeilus inierinr

sciatic nerve nr its branches. The sciatic nerve typically exits the greater sciatic feta men, passing deep tn the belly

Quadreius iemnris

nf the pirifnrmis and superficial tn the superinr and in—

ferinr gemelli and nbturatnr internus {Figure 2}. Several anatnmic variants nf this relatinnship have been nnted and can cnntribute tn undue cnmprcssinn nf the sciatic nerve; hnwever, the nnrmal anatnmic relatinnship is fnu nd in mnst cases. Cine cadaver study identified SETS nf 294

specimens (93.6%} that had the typical anatnmic pattern, with variatinns nf the anatnmy in the nther 19 specimens

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(6.4%).” Dther lesinns such as snft-tissue masses, abscesscs, aneurysms nr aberrant veins, and mynsitis nssificans can cnntribute tn cnmprcssinn nf the sciatic nerve. Diagnnsis relies en a detailed histnry and clinical es:-

aminatinn. Pirifnrmis syndrnme shnuld be cnnsidered in cases nf sciatica nr pnsterinr gluteal nr thigh pain assnciated with nnndiagnnstic clinical evaluatinn and

Sciatic nerve

Figure '2

I

i

Dbturatnr intern us

Drawing depicts the cnurse cf the sciatic nerve. which is typically deep tn the pirifnrmis muscle and superficial tn the su peni er and inierinr gemelli, the nhturatnr internus. and the quad ratus fernnris. In patients with pirifnrmis syndrnme, the nerve is compressed by one er

mere at these structures.

H-reflex nf the pernneal divisinn nf the sciatic nerve is substantially prnlnnged in affected patients when the litnb

is placed in the prnvncative FADIR pnsitinn.“ Injectinns nf lncal anesthetic and sternid intn the pirifnrmis muscle

MRI nf the spine. Palpatinn usually reveals tenderness cf the pirifnrmis muscle, where a sausage-shaped mass

can be useful tn cnnfirm the diagnnsis.

Passive straight leg raise {the Lasegue sign} and l'lettinn,

nr leg pain made wnrse by sitting, stair climbing, andInr

Cine repnrt suggested a diagnnstic criteria fer the di-

may be nnted. Palpatinn may rcprnduce radicnlar pain.

agnnsis nf pirifnrmis syndrnme that included (1} buttnck

adductinn, and internal rntatinu [FADIR] cf the hip EIaccrbate the symptnms. Passive internal rntatinu nf the

leg crnssing; {1} pain with palpatinn cf the sciatic nntch; {3} an evidence nf artnnal lnss nf the sciatic nerve nn elec—

hip in neutral extensinn and resisted flexinn and external

rntatinn place tensinn cm the pirifnrmis muscle and can

rcprnduce symptnms. Neurnlngic enaminatinn findings

such as abnnrmal reflexes, mntnr weakness, and sensnry changes are pnssible but rare.

Diagnnstic imaging is used tn exclude nther snurces nf symptnms, including the lumbar spine and hip jnint.

trnphysinlngic testing; {4} nn nther imaging findings that

cnuld explain the presence nf sciatica; and i5} reductinn

nf symptnms by mnre than Efl% with diagnnstic injectinn under image guidance.” The treatment algnrithm nf pirifnrmis syndrnme shnuld begin with rest, anti-inflanunatnry medicatinns, muscle relaxatinn, and physical therapy directed at stretching

CT and MRI are useful fnt detecting spaceunccupying

the pirifnrmis muscle. Stretching pnsitinns shnuld include

hypertrnphied nr damaged pirifnrmis and can identify

blnclting agents have been used with success. Imaging

lesinns that cnuld prnduce symptnms nf sciatic nerve cnmprcssinn. MRI alsn can identify the presence nf a

annmalnus pirifnrmis muscle anatnmy nr variatinns in the sciatic nerve. Electrndiagnnstic testing can be useful tn lncalize an impingement nf the sciatic nerve by the pirifnrmis. The

firthnpaedic Knnwledge Update: Spnrts Medicine 5

the FADIR pnsitinn. Therapeutic injectinns tn the piri~ fnrmis muscle using sternids, bntulinum tnsin, nr painguidance using CT nr ultrasnnngraphy is acceptable. Several studies have verified the placement nf ultrasnund-

guided injectinns using MRI nr CT and fnund the

technique reliable.13~35' Caudal epidural sternid injectinns

fl lflld American Academy nf Urthnpaedic Surge-ens

Chapter 12: Extra-articular Hip Disorders

lliopsoas

A Fig u re 3

lliopaoaa

Femur internm rotated

B

Femur externally

rotated

Drawings show the iliopsoas tendon, which produces a loud and sometimes painful snapping when It moves over the anterior hip capsule and femoral head as the hip is extended, internally rotated, and odducted (ill from an externally rotated, flexed, and abducted position {3}.

also have been reported for the treatment of piriformis

inferior iliac spine and the iliopectineal eminence. The

syndrome. Anesthetic and corticosteroid injections deposited into the caudal epidural space can be expected to course along the nerve root to the sciatic nerve and can provide substantial relief.

tendon passes over the anterior hip capsule and courses

of the sciatic nerve can be performed using an open or endoscopic surgical approach. lEinly minimal functional loss occurs after release of the piriformis because of the contribution of the other external rotators of the hip. In properly selected patients in whom the piriformis is ac-

lateral position on the iliopectineal eminence and moves from lateral to medial as the hip is moved to extension,

Surgical release of the piriformis tendon and neurolysis

tually the impinging structure, immediate relief usually

can he anticipated. In a series of patients treated with endoscopic decompression of the sciatic nerve, VHS scores

for pain improved from a mean of 6.9 preoperatively to

2.4 at 12-month follow-up. Df all patients, 33% had no pain after sitting for more than 30 minutes at follow-up.“ In summary, emphasis should be placed on thorough

evaluation of patients presenting with symptoms consistent with piriformis syndrome and on the importance of exhaustive nonsurgical management, including rest, activity modification, stretching, and physical therapy. Diagnostic and therapeutic injections can help confirm the

diagnosis and provide substantial relief. Recalcitrant cases can be considered for surgical release of the piriformis and any other structures impinging on the sciatic nerve. Coxa Saltans Interns

posterior-1y in its bursa to insert at the lesser trochanter.

Patients typically report an audible, loud clunk, which they often can reproduce. With the hip in a flexed, abducted, and externally rotated position, the tendon assumes a

adduction, and internal rotation. The snapping results

from the movement of the tendon over the anterior hip capsule and femoral head {Figure 3}. Bony variants or abnormalities of the anterior acetabulum, femoral head,

or lesser trocha nter also can contribute to the pathology. Inflammation of the large iliopsoas tendon bursa also has been implicated.“

Patients may present for evaluation of medial groin pain and with history of a hyperextension injury or groin

strain. They may have noted clicking or popping of the

hip that has worsened over time. The popping sound

typically is audible to anyone near the patient, in contrast

to the external snapping hip, which clearly is visible but not usually audible. Activities of daily living may not be painful; however, sports requiring hip flexion can aggra-

vate the symptoms. Physical examination of the hip must be thorough to rule outother pathologies than can present with medi-

al groin pain, such as adductor strains, osteitis pubis,

and intra-articular disorders such as femoroacetabular impingement. In the supine position, the patient often

drome caused by the snapping of the iliopsoas tendon over

can reproduce the snapping by extending and adducting the flexed and abducted hip. The examiner can suppress

bine to form one tendon as they pass between the anterior

thereby restricting the motion of the tendon.

lL'Zoxa saltans interna, or internal snapping hip, is a synthe structures lying deep to it. The iliacus and psoas com—

IE! lfllfi American Academy of flrthopaedic Surgeons

the snapping by applying pressure over the anterior hip,

Drthopaedic Knowledge Update: Sports Medicine 5

i‘t' E 'U to :s

Ill

1: 1 E.

In“

Section 2: Hip and Pelt-fie

Plain radiographs of the hip typically are normal but may show bony morphologic variants such as hip dyspla-

Patients with increased femoral anteversion may be at risk for poorer clinical outcomes after a release of the ilio-

thickening of the tendon and fluid in its bursa.

and dynamic stabilizer of the anterior hip in this patient

sia or femoroacetabular impingement. MRI may show a certain portion of the population has a painless snapping iliopsoas tendon. Without the presence of associated

pain, the patient can be reassured, and no treatment is required. Initial treatment of the painful internal snapping hip should focus on rest, activity modification, stretching of the iliopsoas, and HSAIDs. Image-guided anesthetic injections can help to confirm the diagnosis but also can

be therapeutic with the addition of a corticosteroid. Surgical treatment involves the release or fractional

lengthening of the tendon and can be performed through

I

H

including anterior hip instability or dislocation, have been

reported after iliopsoas release in the setting of increased

femoral anteversion; therefore, caution is advised when considering the procedure in this patient population. Coxa Saltans Extorna

from an intra-articular approach. Release both from the central compartment and at the

associated with pain and can be treated with reassurance. Uccasionally, when the snapping is painful, further in-

the femur. Most cases of external snapping hip are not

lesser trochanter produced good results in a study com-

vestigation and treatment are warranted.

follow-up of 24 months}2 A series of 55 patients undergo-

maximus posteriorly, and the tensor fascia lata anteriorly.

Proximally, the iliotibial band attaches to the gluteus

ing fractional lengthening of the tendon from the central compartment reported 31.8% {45 patients} excellent or

It courses down the lateral aspect of the thigh and has insertions on the lines asp-era of the femur and on the

Resolution of the snapping was highly predictive of im— proved outcomes. The rate of persistent snapping at 2-year

band lies posterior to the greater trochanter when the hip is extended and translates anteriorly with flexion. In cases

good outcomes and 31.3% resolution of the snapping.

cu o. 1: I: re E-

when the iliopsoas is most taut.“ Serious complications,

Coxa saltans externa, or external snapping hip, is a snapping of the iliotibial band over the greater trochanter of

paring the two techniques in 2D patients with a minimum

2

population, leading to alterations in kinematics, especially with the hip in terminal extension and external rotation,

an open, endoscopic, or arthroscopic approach. The tendon can be released at its insertion at the lesser trochanter,

from the peripheral compartment, or more proximally

-E

psoas tendon. The iliopsoas may be an important passive

follow-up may be higher than previously thoughtfi'3

Gerdy tubercle on the anterolateral tibia. The iliotibial of external coxa saltans, snapping often is noted during

A 2fl14 case series described the release of the iliopsoas tendon from the central compartment for patients with

internal or external rotation of the hip, with the hip in the extended position while standing.

iliopsoas tendon. Two of the patients underwent a second procedure to release the iliopsoas at the lesser trochanter

hips with certain movements and have pain localized to the lateral hip at the greater trochanter. The pain is

had good or excellent results.“ A systematic review of reported outcomes for open

may improve if activities are modified to avoid snapping. Repetitive snapping of the hip likely causes thickening

ternal snapping hip reported a reduced failure rate, few

the greater trochanter.

undergoing arthroscopic treatment.” A cadaver study found substantial variability in the number of distinct tendons of the iliopsoas at the level of the hip joint. The psoas major tendon consistently

to stretch the iliotibial band and gluteus maximus, activity modification, and a course of NSAIDs. Pain refractory to these measures can be treated with selected anesthetic

symptomatic impingement of the anterior lahrum by the

for iliopsoas snapping. 0f the remaining 23 patients, 23

versus arthroscopic techniques for the treatment of in—

complication s, and reduced postoperative pain in patients

was found to be the most medial tendon, whereas the primary iliacus tendon was found immediately lateral to it. An accessory iliacus tendon sometimes was present

adjacent and lateral to the primary iliacus. The presence

of a single—banded, double-banded, and triple—banded iliopsoas tendon was found in 23.3%, 54.2%, and 2.5%

of specimens, respectively. The study suggests that surgeons should be mindful of this anatomic variability when performing iliopsoas tendon releases.”

firthopaedic Knowledge Update: Sports Medicine 5

Patients often report the ability to “dislocate” their

aggravated by the frequency of snapping episodes and

and inflammation of the iliotibial band at the region of

The initial treatment should focus on physical therapy

and corticosteroid injections to the trochanteric bursa. Nonsurgical treatment is the mainstay of care, and most patients will improve.

Surgical treatment occasionally is offered to patients who have exhausted nonsurgical options. An array of surgical procedures have been described to lengthen the il-

iotibial band or decompress it over the greater trochanter. One retrospective study evaluated outcomes in 15

patients with external snapping hip at a mean of 33.3

months after endoscopic transverse iliotibial band release

fl lfllfi American Academy of Orthopaedic Surgeons

Cillapter 12: Extra-articular Hip Disorders

just distal to the greater trochanter. Gf all patients, nine {69%} were pain free. Preoperative 1lli'itS pain scores improved from a mean of 5.5 to 0.53 postoperatively, and

snapping symptoms were resolved in all patients postoperatively.“ Another technique involving distal Z-plasty lenghening of the iliotibial band was presented in a series

of five patients. Although the total number of patients

was small, snapping resolved in all of them.39 Techniques

that involve release or Z-plasty lengthening of the gluteus maximus tendon also have been reported with good results.“'“~“ Each of these techniques would benefit from longer term evaluation within a larger number of study patients.

Summary

Extra-a rticular hip disorders can present a diagnostic and

therapeutic dilemma. Understanding of these disorders, including the anatomy involved, diagnostic algorithms, and treatment options, allows the physician to recommend effective treatment strategies. Directed anesthetic injec-

tions are useful in narrowing the differential diagnosis in

many cases. Endoscopic surgical techniques continue to

evolve in the treatment of extra-articular hip pathology. Hey Study Points ' Greater trochanteric pain syndrome encompasses

various etiologies of pain at the greater trochan-

ter of the femur, including trochanteric bursitis,

gluteus medius or gluteus minimus tendon tears,

and friction of the iliotibial band over the greater

trochanter.

1* Plriforrnis syndrome involves the extrapelvic com-

pression of the sciatic nerve by the pitiformis muscle or other adjacent structures. I Internal snapping hip is the result of the iliopsoas tendon moving back and forth over the internally and externally rotated femoral head.

In External snapping hip is the result of the iliotibial band snapping over the greater trochanter of the femur.

. Long SS, Surrey DE, Nasarian LN: Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis. AIR Am I Roentgenol 2013;1fl1l51fllir33-1flflti. Medline DUI

This article is a retrospective study examining the prevalence of gluteus tendon pathology, bursitis, and iliotibial band pathology on ultrasonograpby in patients with GTPS. . Fearon AM, Twin J, Dahlstrom JE, et al: Increased substance P expression in the trochanteric bursa of patients with greater trochanteric pain syndrome. Rheumerol Iat 2fl14;34{1{l}:144I-144E.Medline DUI This study examines the presence of substance P in the bursa and the abductor tendons in patients with GTPS. . Moulton KM, Aly AR, Rajasel-taran S, Shepel M, fl-baid H: Acetabular anteversion is associated with glutesl tendinopathy at MRI. Skeletal Radiol 2DlS;44(1}:4?—54.

Medline DGI

This MEI study evaluates the possible association between increased acetabnlar anteversion and gluteal tendiuopathy, trochanteric bursitis, and subgluteal bursitis. . Mallow M, Hasarian LN: Greater trochanteric pain syndrome diagnosis and treatment. Phys Med Rehehll Clin N Am 2G14;ESI2}:2?9-239. Medline DDI This review article describes the epidemiology, anatomy, diagnosis, and treatment of GTPS. . Flack NA, Nicholson HD, Woodley S]: The anatomy of the hip abductor muscles. Clix Ariel 1fl14,2?{1}:241-253. Mcdline DD] This cadaver study examines the anatomy of the hip abductors in 12. specimens.

This study examines the epidemiology of GTPS in United States military service members. . Fearon A, Stephens S, Book J, et al: The relationship of femoral neclc shaft angle and adiposity to greater trochanteric pain syndrome in women. A case control morphology and anthropometric study. Br I Sports Merl 2fl12;46l12}:333-392.Medliue DUI

increased femoral neck shaft angle and increased adiposity

1. Strauss E], Nho 5], Kelly ET: Greater trochanteric pain syndrome. Sports Med Arthrosc lfllfl;13ll}:llS—1 19.

Medline DUI

This article reviews the concepts of GTPS, including its etiologies, diagnosis, and treatment.

IE! lfllli American Academy of flrthopaecllc Surgeons

E

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Blank E, Owens ED, Burks 11., Belmont P] Jr: Incidence of greater trochanteric pain syndrome in active dutyUS military servicemembers. D-rtboped'r'cs 2011;35{?}:e1011*e101?. Mcdline DUI

This case-controlled study found an association between

Annotated References

l‘r'

and the diagnosis of GTPS.

. Fearon AM, lCook jL, Scarvell Jl'vl, Neeman T, Gormick W, Smith PH: Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: A case control study. I Arthroplusty 2fl14;29{1}:333-33IS. Medline

DUI

Drtbopaedic Knowledge Update: Sports Medicine S

Seetinn 2: Hip and Pelt-Pia

This study fnund that GTPS affects quality nf life scares and disability levels similarly tn hip nstenat'thritis. 1-3. Kaltenbern A, Enurg CM, Gutaeit A, Kalberer F: The Hip Lag Sign—prnspective blinded trial nf a new clinical sign tn predict hip abductnr damage. PLnS Utter 2fl14;5[3}:e9156l}. Medline DUI This study intreduces and validates a new physical examinatinn finding, the Hip Lag Sign, which can be used tn

predict hip abductnr damage.

11. Chnwdhu ry R, Naaseri S, Lee], Rajeswaran G: Imaging and management nf greater trnehanteric pain syndrome. Pnstgred Med] 2U14;90{1fl63}:5?fi-§31. Medline DUI

13. Byrd J‘W: Peritrnchauteric access and gluteus medius re—

tinns far greater trnehanteric pain syndrnme: l'vlulticentre randnmised cnntrnlled trial. BM] 2fl09;333:b1fl33. Medline DUI

I

H

This article is a systematic review cf the use and effectiveness of ESWT fer lewer-limb tendinnpathies, including GTP'E. The study fnund ESWT tn be mnre effective than

12. 1iiii'estacntt D], l'inns JI, auet P: The diagnnstic accuracy nf magnetic rcsnnance imaging and ultrasnnngraphy in gluteal tendnn tears—a systematic review. Hip Int 2fl11;21[6]:63?-645. Medliue DUI

flunrnscnpically guided and blind cnrticnsternid injec-

a: n. 1: l: rt: E-

17'". ivlani—Eahu 5, Mnrrissey D, Waugh {3, Screen H, Eartnn C: The effectiveness nf extracnrpnreal shnclt wave therapy in lnwer limb tendinnpathy: fl systematic review. Am I Sparts Mad 2fl15;43{31:?52-?61. Medliue DUI

hnrue training and enrtieusternid injectinns in the treat—

13. |Cnhen 5P, Strassels 5A, Fnster L, et a]: Cnmparisnn nf

E

This study investigates the effectiveness nf cnrticnsternid injectinns tn the subgluteal bursa versus thnse administered tn the trncha uteric bursa. Injectinns tn the trnehan— teric bursa resulted in greater pain relief.

This review article reviews the etinlngies and diagnnstic imaging nptinns fnr GTPS.

This systematic review cnmpa res MRI and ultrasnnngraphy as diagnnstic imaging studies fnr GTPS, using surgical findings as the reference standard.

-E

trnchanter bursa versus subgluteus medius bursa. AJR Am

I Rnetstgenni' 1013;2fllil}:W313-T. Medline DUI

This multicenter randnmiaed cnntrnllecl trial evaluates patient nutcnmes after injectinns fer the treatment cf GTPS with and witheut flunrnscepic guidance. It fnund nn benefit tn flunrnsenpic guidance. 14. Brinks A, van Rijn RM, Willemsen SP, et al: Cnrticnsternid injectinns fnr greater trnehanteric pain syndrnme: A

randomised cnntrnlled trial in primary care. Ann Fem

Med 2011;9{3}:225-234. Medline

DUI

This randnmiaecl cnntrnlled trial cnmpares nutcnmes in patients receiving injectinns fur GTPS with thnse in pa-

ment cf UTPS.

pair. Ail-thrust: Tech 2h13;2i3}:e243-e246. Medline

DUI

This study describes a technique fer gaining endescepic access tn the peritrnchanteric space and gluteus medius

tendnn repair.

15". Ebert JR, Eucher TA, Ball 5V, Janes UC: A review nf surgical repair methnds and patient nutcnmes fnr gluteal tendnn tears. Hip Int lfllfiflfi {11:15 413. Medline DUI This article reviews variens surgical repair techniques fer gluteal tendnn tears and their nutcnmes. 20. Dnmb EG, Carreira D5: Endnscnpic repair nf full-thickness gluteus medius tears. Artbrnsc Tech 1fl13;1{1}:eTT-e31. Medline DUI This article describes an endnscnpic dnuble-rew technique for the repair nf gluteus medius tendnn tears. 21. Unvaert LH, van Dijlt CH, Zeegers AV, Albers UH: Endescnpic bursectnmy and ilintibial tract release as a treatment fur refractnry greater trnehanteric pain syndrnme: A new endnscnpic apprnach with early results. Arthrnsc Tech 2012;1[2he161-e1ii4.Medline DUI

tients nut receiving injectinns. Patients receiving injectinns

This article describes a surgical technique fer endnscnpic bursectnmy and crnss incisinn nf the ilintibial band fur the treatment nf UTPS.

15. 1ilii'ilsnn 5A, Shanahan EM, Smith MD: Greater trnehanteric pain syndrnme: Dnes imaging-identified pathnlngy

22. Davies JP, Stiehl JE, Davies JA, Geiger PB: Surgical treatment nf hip abductnr tendnn tears. 1 Rune joint Snag Ant 2313;95l15'lfl42fl-1425. Medline DUI

had imprnved nutcnmes at 3 mnnths, but the imprnved nutcnmes were nn lnnger present after 12 mnnths.

influence the nutcnme nf interventinns? Int] Rheum Dis 2fl14;l?[6}:621—62?.Medlinc DUI

This article reports the clinical enrcnmes nf a series nf

This retrnspective study investigated the assnciatic-n between imaging-identified pathnlngy {gluteal tendinnpathy andl'nr trnehanteric bursitis} and nutcnmes after anesthetic and certicnsternid injectiens tn the area cf the trnehan-

augmented with acellular human dermal allngraft.

teric bursa.

Iii. McEvny JR, Lee K5, Blankenbalter DU, del Ric AM, Keene J5: Ultrasnund-guided cnt'ticnsternid injectinns fnr

treatment nf greater trnehanteric pain syndrnme: Greater

Urthnpaeclic Knnwledge Update: Spnrts Iviedich'le 5

patients with hip abductnr tears whn were treated with npen surgical repair. The repair at higher-grade tears was

2.3. Dnminguea a, Seijas E, Area U, Salient A, lI.'.'.Iusct’:l III, Cugat R: Clinical nutcnmes nf trecha uteric syndrnme endnscnpically treated. Arch Urthnp Trauma Surg 2fl15;135[1}:3994. Medline DUI

This article presents the nutcnmes cf a series nf patients with GTPS treated with endnscnpic ilintibial band release.

U lfllfi American Academy nf Urthnpaedic Surge-ens

Chapter 12: Extra-articular Hip Disorders 24. Lustenberger DP, Hg VT, Best TM, Ellis T]: Efficacy of treatment of trochanteric bursitis: A systematic review. Clix J Sport Med 3011:3115 }:44?-453. Medline DUI This article is a systematic review of treatment options for trochanteric bursitis. It found that nonsurgical modalities

helped most patients and that surgery was effective in

refractoryr eases. Surgical treatment resulted in greater improvements in VAS scores and Harris Hip Scores than did corticosteroid injections and physical therapy. 25. Natsis K, Totlis T, Konstantinidis GK, Paraslcevas G, Piagltou M, KeeblteJ: Anatomical variations between the sciatic nerve and the piriformis muscle: A contribution to surgical anatomy in piriformis syndrome. Snrg Radiof Assert 1D14;SE{3}:2?3-13fl. Medline

DUI

In this cadaver study, 294 limbs were dissected to evaluate the relationship between the piriformis muscle and the sciatic nerve. Anatomic variations were present in 19 of the limbs examined {6.4%1. 26. Jawish RM, Assoum HA, Khamis CF: Anatomical, clinical and electrical observations in piriformis syndrome. I Utthop Surg Res 1D1fl;5:3. Mcdline DUI This article presents a series of patients treated for piri— formis syndrome, including their outcomes from nonsurgical and surgical treatment. The authors identifyr new anatomic patterns of compression of the sciatic nerve and ascertain the diagnostic utility of the H—reflex of the peroneal nerve. 2?. Miller TA, White KP, Ross DC: The diagnosis and management of Piriformis Syndrome: Myths and facts. Can } Nee-ref Sci 2fl11:39[53:5??-533. Medline DUI

This article discusses various diagnostic and treatment op— tions for piriformis syndrome and proposes sta ndardiaed criteria for its diagnosis, which include presenting signs and symptoms, imaging, and the response to injections.

This article describes the presentation and evaluation of deep gluteal space syndrome and presents the surgical outcomes of endoscopic decompression of the sciatic nerve. 31. Iliaaliturri ‘v’M Jr, Camacho-Galindo J: Endoscopic treatment of snapping hips, iliotibial band, and iliopsoas tendon. Sports Med Artist-use Ifllflfl S{2}:1 2f] -1 1?. Medliue DUI This review article discusses internal and external snapping hip syndromes and their surgical treatment options. 32. Ilisaliturri UM Jr, Eugansa-Tepole M, Ulivos-Meaa A, Acuna M, Acosta-Rodriguez E: Central compartment release versus lesser trochanter release of the iliopsoas tendon for the treatment of internal snapping hip: A comparative study. Arthroscopy 2fl14:3fl{?]:?9fl-?95. Medline DUI This retrospective study examines outcomes in a series

of patients with snapping iliopsoas tendon treated with

endoscopic release of the tendon at its insertion at the lesser trochanter or release through the central compartment of the hip. Patients in both groups had favorable outcomes. 33. El Bitar YF, Stake CE, Dunne HF, Botser IE, Domb BU:

Arthroscopic Iliopsoas Fractional Lengthening for Internal

Snapping of the Hip: Clinical Outcomes 1i'il'i'ith a Minimum 2-Year Follow-up. Ant: j Sports Med Efll4;4E{T}:lfiE-'fiITUS. Medline DUI

This is a retrospective review of prospectively collected outcomes data in patients undergoing fractional lengthening of the iliopsoas tendon for painful internal snapping hip. Most patients experienced resolution of the painful

snapping. Those with persistent snapping had poorer

outcomes.

34. Nelson IR, Keene 15: Results of labral-level arthroscopic iliopsoas tenotomies for the treatment of lahral impingement. Arifvroscopy 1fl14t3fl{6}:ESS-694. Medline DUI This case series reports the outcomes of patients treated

formis muscle injection: A feasibility study. Pair: Physician 2fl14:1?[ti}:5fl?-513. Medline

compartment for the treatment of labral impingement from the iliopsoas.

This study examines the accuracy of ultrasound-guided injections to the piriformis muscle by adding iodinated contrast to the botulinum toxin injection and then perv forming CT to assess intramuscular distribution. 25". Elu nl: JA, Nowotny M, Scharf J, Benrath ]: MKI verification of ultrasound-guided infiltrations of local anesthetics into the piriformis muscle. Pair: Med 2013;14i1fi}:1593v 155' 9. Medline DUI This study uses MRI to confirm the intramuscular injection of local anesthetic to the piriformis muscle using ultrasound guidance. 3f]. Martin HD, Shears SA,Johnson JC, Smathers AM, Palmer I]: The endoscopic treatment of sciatic nerve entrapmenti deep gluteal syndrome. Arthroscopy lflllglflllflfl-IBI.

Medline DUI

IE! lfllfi American Academy of Urthopaedic Surgeons

E

'U

2-3. Fabregat U, Rosellii M, Asensio- Sampet JM, et al: Com-

puter-tomographic verification of ultrasound-guided piti-

i‘:'

with arthroscopic iliopsoas tendon release from the central

35. Khan M, Adamich J, Simunovic N, Philippon M], Ehandari M, fiyeni UR: Surgical management of inter-

nal snapping hip syndrome: A systematic review evalu-

ating open and arthroscopic approaches. Aviiiitoscom.r 2fl13;29{S}:942-943.Medlirte

DUI

This systematic review compares the outcomes of open techniques and arthroscopic techniques in the management of internal snapping hips. A reduced failure rate, fewer complications, and less postoperative pain with arthroscopic management were noted. 36. Philippon M], Devitt BM, Campbell K], et al: Anatomic variance of the iliopsoas tendon. Am ] Sports Med 2014;42{4}:Sfl?-311. Medline DUI This cadaver study explores the anatomic variants of the iliopsoas tendon at the level of the hip joint. It was

Urthopaedic Knowledge Update: Sports Medicine 5

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1 us

El-

Seeders 2: Hip and Pelvis

determined that presence nf mere than twe distinct tendnns is mere cnmmnn than preyiuusly thnught. 3?. Fahricant PD, Eedi A, De La Terre K. Kelly ET: Clinical nutcumes after arthrnscnpic psnas lengthening: The effect nf Femnral yersicrn. Arthrnsrnpy 1fl12;23{?l:965-971. Medlinc DUI This study reperts inierinr nutcc-mes in patients with increased femnral anteversinn underguing ilinpsnas lengthening fur internal snapping hip. 33. Zini R, Munegatn D, De Benedettn M, Carrarn A, Bignni M: Endnscepic ilintihial band release in snapping hip. Hip fer 2013;23i2}:125—232. Mcdlinc DUI This retrespectiye case series reperts the eutcemes after enduscnpic transverse release [if the ilintihial band fur sympt-nrnatic external snapping hip. 39. Sayed-Nnnr A5, Pedersen E, Sjijdien GD: A new surgical

methnd for treating patients with refract-a-ryr external snap-

ping hip: Pedersen—Nec-r nperatinn. 1 Surg Dreiser;- Adv

Zfllltllfllrfll-ISS.Medline DUI

This article presents a technique fer lengthening nf the ilintihial band by E—plasty under lucal anesthesia an an nutpatient basis. Snapping was resnlyed in the five patients in this series. 4D. Pnleselln GE, lQueircus MC, Dumb BIG, Cline NE, Hunda EH: Surgical technique: Endescnpic gluteus maximus tendnn release for external snapping hip syndrnme. Bliss Drrbnp Reins Res 2fl13;4?1{31:24?1-24TE. Medline DUI This article describes a technique fur the endnscnpic release ef the gluteus maximus tenden fer external snapping hip and reperts the results en a small series at patients. 41. Nani KW. "Tee J], Ken EH, Tenn K5, Kim H]: A medilied Z-plasty technique for severe tighmess nf the gluteus maximus. Scene! I Med Sci Sports 2fl11;21[1}:35-89. Medline DUI

This article describes a technique fer and presents the nutcemes fellewiug lengthening ef the ilietihial hand by Z-plasty for treatment nf external snapping hip caused by

a tight gluteus maximus.

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firthnpaedic Knnwledge Update: Sperrs Medicine 5

fl lfllfi American Academy at Urthnpaedic Surge-ens

Chapter 13

Muscle Injuries of the Proximal Thigh

James T. Beckmanu. MD. MS

Marc E. Safran. MD

Abstract

Muscle cont usions, strains, and lacerations account for lfl‘l’b to 55% of all sports-related injuries, with many

occurring around the hip. Injuries to hip muscles often result in a substantial amount of time missed Jfrom

Keywords: hip: tendon: injury: hamstring: rectus: quadriceps: contusion: strain: avulsion: treatment Introduction

competition. Muscle strains and contusions can usually

Muscle injuries most often occur during athletic par-

may require surgical reattachment. The hamstrings

account for lfl‘lt. to 55% of all sports-related injuries, with many occurring around the hip.” Up to 35% of

be managed nonsurgically, but some tendon avulsions

and quadriceps are susceptible to strain injury in spurts

requiring explosive movements andior rapid changes in

direction such as soccer, track, hockey, and football.

Return-to-sport protocols are based on the range of motion of the joint spanned by the affected muscle, pain-free use of the injured muscle in basic movements,

strength testing, and the willingness of the athlete to

risk reinjury. Supervised rehabilitation comprising trunk

stabilization, agility exercises, and eccentric strengthening is important in preventing reinjury.

Dr: Safran or an immediate family member has received royalties from EU Orthopaedics and Strylren is a member ofa speakers' bureau or has made paid presentations on behalf ofSmith 5 Nephew; serves as a paid consultant to Coaed Linvatec and Cool Systems; serves as an unpaid consultant to Cool Systems, Cradle Medical, Ferring Pharmaceuticals, Biomimedica, and Eleven Blade Solutions; has stocir or stock options held in Cool Systems, Cradle Medical, Biomimedica, and Eleven Blade Solutions; has received research or institutional support from Ferrinp Pharmaceuticals and Smith a Nephew,- and serves as a hoard member, owner: officer, or committee member of the American firthopaedic Society for Sports Medicine, the international Society for Hip Arthroscopy; and the international Society ofArthroscopg Knee Surgery; and Orthopaedic Sports Medicine. Neither Dr. Becirmann nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

fl lflln American Academy of Drrhopaedic Surgeons

ticipation. Muscle contusions, strains, and lacerations

all collegiate football injuries‘l and 1fl% to 23% of all professional soccer injuriesii involve hip muscle injuries, which can result in a substantial amount of time missed

from competition.

Muscle strains and contusions are far more common than are lacerations. lE'Jontusions result from direct

muscular trauma, which produces damage at the site of impact, and are frequently seen in contact sports. In contrast, muscle strains occur indirectly when tensile

forces shear individual muscle fibers during eccentric loading. Strains around the hip most commonly affect the hamstrings and quadriceps in sports requiring explosive

movements andlor rapid changes in direction such as

soccer, track, hockey, and football. Muscle contusions and low—grade strains share similar treatment principles

despite differing mechanistically. Most can be managed nonsurgically, but some tendon avulsions may require

surgical reattachment. Return-to-sport protocols are based on the range of motion of the joint spanned by the affected muscle, painfree use of the injured muscle in basic movements, strength

testing, and the willingness of the athlete to risk reinjury.

In some situations, MRI can help to predict the degree of

injury and the recovery time but has the same predictive value as clinical examination in terms of return to com-

petitive sports]; Patients with a previous musculotendinous

junction injury have a twofold increased risk [or greater} for recurrent strainf Supervised rehabilitation that in-

cludes trunk stabilisation, agility exercises, and eccentric

strengthening has been shown to reduce the likelihood of

Drthopaedic Knowledge Update: Sports Medicine 5

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Section 2: Hip and Pelt-do

subsequent events.” The focus of this chapter is on injuries to the quadriceps and hamstrings muscles. Evaluation of Athletic Hip Injuries Muscle injuries of the hip can occur in isolation but also

may present with other sources of hip pathology. Up

to 90% of patients with groin pain have been demonstrated to have more than one injury; therefore, consid—

eration of less obvious sources of hip pain should not be

overlooked simply because contusions and strains are

common.” l[Jonsiderable overlap exists among clinical signs and symptoms about the hip and pelvis region, ne-

cessitating a formulaic differential diagnosis addressing

both intra-articular and extra-articular sources of hip

pathology. |Common patterns of concomitant hip pathology

include the “sports hip triad” of adductor, rectus abdominis, and labral tears; the “symphysis syndrome" of abdominal, groin, and adductor pain; and associations

of muscle strains with labral tears and intra-a tticular hip

pathology.”13 In addition, femoroacetabular impingement {PHI}, hip dysplasia, and hip capsular microinsta bility in—

creasingly have been recognised as sources of hip pain in

athletes in whom only recurrent groin pulls and hip flexor

strains have been diagnosed. The duration of symptomatic athletic participation with untreated FAI is associated -E

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with worsening, irreversible joint damage and should

therefore be considered in the differential diagnosis of athletes in combination with muscular injuries."l

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H

Treatment Principles of Muscle Strain Injuries Strains are the most common injuries to the musculoten—

dinous units of the proximal thigh. Muscles most at risk

are fast-twitch muscles that span two or more joints.” including the quadriceps {particularly the rectus femo—

ris} and hamstring muscles, which cross the hip and the knee. The most common mechanism of injury is eccentric contractionfi'fi The location of injury tends to be at the musculotendinous junction. Clinically, the location of

Mild

Moderate

Severe

illustrations show the grading of

musculotendinous strains. Grade 1. stretch.

increased signal on MRI, less than 5% disrupted: grade 2, less than SUE-ii disrupted; grade 3, completely disrupted macroscopically.

the accumulated hematoma. Initial treatment is aimed at reducing the size of the hematoma and producing a conductive environment for an optimal healing response. Hematoma formation is

reduced through rest, ice, compression, and elevation

{RICE}. Compression and cryotherapy are associated with

smaller hematoma formation. Elevation reduces hydro‘

static pressure in the affected extremity and lessens the amount of interstitial fluid accumulation. Rest of the

affected muscle is recommended to allow opposition of

the muscle during early scar formation, which is allowed

to mature until it can withstand the forces applied during rehabilitation without rerupture but should not exceed 1

week.” Prolonged immobilization has been associated

with an increased risk of rerupture and large permanent

scar formation.”l After the acute phase, range of motion is initiated within the limits of pain. This phase is impor-

injury can range from mid-muscle belly to an eccentric

tant to accelerate the regeneration process and properly

Muscle strains and contusions cause myofiber damage

is controversial. NSAIDs can provide analgesia, reduce

position because some muscles have an elongated musculotendinous junction.

orient the regenerating muscle tissue.“*“ The use of NSAIDs during the acute healing phase

within the basal lamina, mysial sheaths, and associat— ed blood vessels.” Avulsion injuries are associated with

inflammation, and help prevent ectopic ossification, but concerns of delayed or weakened healing have been ex-

ent surgical recommendation and should be considered separately.” Symptoms and the clinical course following

of short-term NSAID use on the healing process; evidence of later decreased growth and healing exists, however. Rarely is NSAID use needed for longer than 3 to 7’ days following injury.

different outcomes, a different prognosis, and a differ—

grade 1 or 2 muscle strains [Figure 1) or muscle contusion

depend on the amount of muscle damage and the sise of

firthopaedic Knowledge Update: Sports Medicine 5

pressed.:"-2 Some studies have reported no adverse effects

fl lflld American Academy of Orthopaedic Surgeons

|L'ihapter 13: Muscle Injuries of the Proximal Thigh

Muscle Contusions

l[:ontusions causing significant muscle damage nearly

always occur in one of four muscles: the quadriceps, hamstrings, adductors, or calf muscles. Contracted and

stronger muscles will absorb force better and incur less

severe injuries.” Quadriceps contusions should be braced in 120" of flexion for 24 hours to limit hematoma formation. Return to play from quadriceps contusions averaged 13 days for mild, 19 days for moderate, and 21 days for

Shin

severe contusions in West Point cadets}3 Myositis ossi-

ficans occurs in 9% to 1TH: of contusions.1| lClinically, myositis ossificans should be considered if improvement is not seen in 1 week or if symptoms worsen in 2 to 3

weeks postinjury. Radiographic evidence can be present

Expected weakness fl

and!

15““

its"-

1

it

2

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it

are

I

as early as 3 weeks post injury but may take as long as

several months to become evident. NSAIDs can be used at the time of acute injury to reduce the possibility of myositis ossificans development. Rehabilitation for con-

Figure .1.

the severity of the muscle strain.

tusions should follow that of low—grade muscle strains,

and should include trunk stabilisation, agilityr exercises, and eccentric strengthening. Hamstring Strains and Avulsions Anatomy

The hamstrings are composed of three muscles: the semi-

membranosus, semitendinosus, and biceps femoris. The

biceps is formed by a short head and a long head, which are innervated by the peroneal and tibial branches of the

sciatic nerve, respectively. The long head of the biceps

and semitendinosus join proximally to form a single conjoined tendon that inserts on the medial portion of the ischial tuberosity, but they separate into distinct tendons

approximately 5 centimeters distally; the semimembra-

nosus inserts on the lateral portion of the tuberosity. The hamstrings course medially to the sciatic nerve as they

enter the thigh. This anatomic relationship is clinically

significant, because it is common to have sciatic nerve

irritation in chronic avulsions from traction injury or scarring.”l Distally, the hamstring tendons cross the knee

joint, where they serve as knee flexors. The hamstrings are

Ch art shows the grading of prone hamstring

strength testing. Weakness is expected at increasing amounts of flexion proportional to

occurred at the time of injury. 1Ii‘il'ith avulsion injuries,

patients occasionally describe feeling a “gunshot” to the area of the ischial tuberosity. Sitting can be particularly painful. Physical Examination

Inspection can show mild to severe ecchymosis over the

posterior buttocks. An examination finding of ecchymosis is associated with a prolonged return to competi-

tion {more than 4 weeks}. Palpation over the ischium or musculotendinous junction will reveal tenderness and a

possible tendinous defect in avulsion injuries. Patients

with hamstring strains will feel tenderness more in the

mid-thigh, at the elongated musculotendinous junction of the biceps femoris. Patients with more severe injuries ambulate with a stiff-legged gait to avoid hip flexion.

Range-of—motion and strength testing not only confirm

the diagnosis, but also help determine when return to sporting activities is appropriate. Strength testing at 15“,

45“, and Hi)“ can help determine the severity of the tear25

(Figure 2}. Knee extension is often limited compared with

maximally stretched with combined knee extension and hip flexion because they pass posteriorly to both the hip

the opposite extremity. The sciatic nerve, particularly the peroneal division, should be examined by testing ankle

taneous knee extension and hip flexion such as hurdling and water-skiing are common causes of hamstring strain.

for radicular pain.

and the knee. Athletic maneuvers that require this simul-

History In patients with hamstrings injuries, the history reveals posterior hip pain located deep in the buttocks. Patients will typically report that a pop, tearing, or pulling

IE! lfllii American Academy of flrthopaedic Surgeons

dorsiflexion strength and performing a straight-leg raise Imaging

Plain radiography need not be routinely performed, but

can be used to identify bony avulsion injuries. Bony ham-

string avulsions from the ischial tuberosity {Figure 3} are

common before the ischial apophysis closes during early

Drrhopaedic Knowledge Update: Sports Medicine 5

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Sectiun 2: Hip and Pelfie

adulthuod [ages 2D tn 25 years}, but can :3c as a beny ayulsiun after skeletal maturity.

l[Ilassii‘icatinn Prmrimal hamstring injuries can be divided hreadly intu

Hamstring tears have intermediate signal intensity cm Til-weighted imaging, and high signal intensity en T2

and at the three hamstrings tend-ans, the lung head at

MRI is useful in characterizing hamstring strains.

musculc-tendinnus junctiun {MTJ} er ayulsicn injuries. MT] strains ccmprise must {up re 90%} of these injuries,

imaging. MRI can reliably determine the number uf turn

the biceps femuris is must cunununly injured. Ayulsiun

shewn in a systematic review ef grade 1 and 1 injuries te

injuries and are less cc-mmnn but are assuciatetl with a

tendons and the amcunt nf tendun retracticm but was not predict reinjury'“ er the return tn spertfi"r Chrunic injuries can be delineated with MRI based cm the presence ef fatty infiltratinn, scarring, and reduced hamstring unlurne. 4s .

.

_

"3"“

injuries from the ischial tuberusity cumprise 12% cf such

wurse prugnusis and different surgical reccmmendatiuns than are MT] injuries.” A treatment algurithm fur hamstring injuries is shuwn in Figure 4.

Ayulsiun injuries can be strictly tendinclus cr ccntain an auulsed bcmy pnrticm. Subclassificatiun cf pruximal

arulsiens” is presented in Table I. 1illi'ith single—tenden

'1}.-

ayulsitms, retracticm is unlikely because the turn tendun scars tn the intact tendcns, preducing a functic-nal

III

-' .I‘ i,- .

mu sculutendinuus unit; therefure, single—tendun a‘rulsiuns

rarely require surgery.15 The putential fer tendcm retractinn and impaired functiunal healing increases prupertic-nally tn the number at ayulsed tenduns. Retractiun

greater than 2 cm requires twn fit more cempletely turn tendcns, and retracticm greater than 5 cm is indicative

crf a three—tendtm atrulsienn25 {Figure 5}. Strength deficits with ncmsurgical treatment are clinically detectable when all three tendens are ayulsed. Treatment MT] injuries and single-tendun ayulsicns cf the ham-

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Figure 3

AP radiugreph demnnstrates an apuphyseal erulsien injury at the ischial tuhe resity.

(Cuurtesy crf Marc E. Sefren, MD, Pale Alto. CA.}

I

strings can be treated successfully withuut surgical interventiun. The initial 3 re 5 days fulluwing injury are

devoted tn rest, ice, relative immubilisatiun, cempressiun,

H

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

In i .1 ry M L] scul nten{J i n en :3. ju n-:::ti c-n If M T. .| ]

eyulsien

Rehabilitatien

1. tr Ter'itinns inuclued :-_. Arne-unt uf r'etrnctiun

1. Strength :- sure ' . Hamstnngtfluad ratie =_= sue-i: ' Tends-n

E Tendon

'. Full knee estensinn - .Ml'nimal pain

Fiet rsctinn T

Hehabiiitaticn cflcm

Fieturn tn spurt 4-6 weeks

Eu r-g-e r y

Fietu rn tu- spe rt e :5: ts Ie reted

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

firthupaedic Knuwledge Update: Sperts Medicine 5

fl lfllei American Academy cit Orthupaedic Surge-ens

|Ellapter 13: Muscle Injuries of the Proximal Thigh

and analgesics. 1illii'eight hearing as tolerated with crutches is permitted until pain-free ambulation without a limp is

Corticosteroid and platelet-rich plasma {PEP} injections have been reported to expedite a return to play

1 day after injury is associated with a shorter recovery time than is an inability to do so. lClinical findings such

junction. Corticosteroid injections were reported to be

achieved. The ability to ambulate unassisted without pain

as bruisingl'hcmatoma, tenderness to palpation, a lack of

complete range of motion, and pain with isometric limb

lengthening 3 to 5 days following injury are predictors

of a prolonged recovery (more than 4 weeks}? Rehabilitation following the acute phase should focus on agility training and eccentric exercises, which have been shown

in randomized trials to return athletes to competitive sport more quickly than traditional hamstring strengthening protocolsdd"

-— Wood Classification of Hamstring Injuries Characteristic MhWH-l

Type

Bone avulsion

Musculotendinous junction avulsion Incomplete avulsion

Complete avulsion {no retraction} Complete avulsion {retraction}

following hamstring injuries of the musculotcndinous

safe in 53 National Football League {NFL} players with focal hamstring musculotendinous injuries. These players

all had a significant hamstring injury evidenced by a palpable defect on physical examination, but over Slidi- were ablc to return to play within a week of injury.“ Despite

the beneficial effects found in this case series, concerns raised by experimental studies question the practice of corticosteroid injection for acute hamstring injuries. De-

layed hematoma evacuation, skeletal muscle necrosis, and

reduced biomechanical strength all have been found as a

result of glucocorticoid injection. PRP injection for grade 2 MT] injuries was compared with isolated rehabilitation

in a recent nonblindcd randomised trial. Patients receiving

the PRP injection were able to return to sport an average

of 6 days faster.32 Additional studies have found better

pain relief with PEP injection measured by visual analog

scale. This contrasts with the findings of a EDI-4 study of El} recreational athletes that showed no difference in return to play or reinjury in a double— blinded study com— paring PRP with normal saline.” Strength, range of motion, and pain are the typical

criteria used to determine the timing of a return to sport. l‘t' E 'U to :i

Ill

1: 1 E.

II“

A Figure 5

coronal {A} and axial {Ell Mill views depict the appearance of a hamstrlng avulslon injury wlth retraction. {courtesy of Marc E. Safran, MD, Palo Alto, CA.)

El lfllfi American Academy of flrthopaedic Surgeons

Drthopaedic Knowledge Update: Sports lvledichie .‘i

Section 2: Hip and Pubic

Hamstring strength should be at least 30% of the contralateral side, and the hamstringfquadriceps ratio should

protects the repair. Hip or knee braces can be used to

flexion, and minimal tenderness over the proximal ham—

erally better tolerated. The brace is discontinued IS weeks

strings have been shown to be important predictors in

preventing reinjury when returning to sport. The pres-

ence of pain at the time of the return to sport has been found to portend a fourfold increased risk of reinjury on return.” Reinjury is common following proximal hamstring musculotendinous strains. Rates of reinjury have been reported in up to 43% of patients. Prior injury, reduced

hamstring flexibility, strength asymmetry, and age have

been reported as independent predictors of reinjuryfi“ Reduced eccentric hamstring strength was found to

increase the relative risk of hamstring injury FLT-fold in a prospective study of Australian football players.“

3 months postoperatively, with the goal of returning to sport at S to 9 months postoperatively. Quadriceps Strains and Avulsions

Anatomy

The four quadriceps muscles are the rectus femoris, vastus

medialis, vastus lateralis, and vastus intermedius. The bipennate rectus femoris is the most susceptible to strain

or avulsion, because it is the only quadriceps muscle that crosses the hip joint and serves as a hip flexor, in addiincreased risk for strain compared with the vastus mus-

strated that warmer muscles have muscle length to failure ratios.” Trunk stability and agility exercises have been

I

tion exercises are initiated. Strengthening is introduced

exercises in both the affected and unaffected limb“ and predispose to re-strain. Previous studies have demon-

H

postoperatively. At 6 weeks, stretching and range-of-mo-

tion to being a knee extensor.” As with the hamstrings,

may require more intense training to reduce the risk of reinjury. Inadequate warm-up or stretching also could

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prevent stress on the repair.“ A knee brace locked in flexion may suffice to limit active knee flexion and is gen-

Athletes with prior hamstring injury have been shown

to have smaller improvements with eccentric hamstring

2

Preventing simultaneous hip flexion and knee extension

exceed 5fl% but can vary significantly by sport and po—

sition played.“ Clinical parameters including full knee extension, symmetric leg-extension strength at 15° of

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Postoperative Care

shown to prevent reinjury compared with stretching and

strengthening for grade 1 and 2 hamstring strains and should be included in rehabilitation protocols.”

Surgical Indications Complete hamstring avulsions involving all three tendons

or two tendons with significant retraction may benefit

from early surgical repair.” Ischial apophyseal avulsions

are treated with surgical repair only if they are displaced

more than 1 to 31 centimeters. A systematic review of

proximal hamstring avulsions found superior results in

patients treated with acute repair compared with those

treated with chronic repair or nonsurgical management. Acute surgical repair performed within 4 weeks of injury

was found to have a higher return to preinjury levels of sport {96%} than chronic repair {T5941} or nonsurgi-

cal management {14%}. Acute surgery was associated

with better patient satisfaction, subjective outcomes,

pain relief, and strength and less chance of rerupture.3E| Selection bias inherent in the retrospective series design

was present in all studies included in this review. Poor

description of the number of avulsed tendons between groups also could bias these results and explain the differences found.

firthopaedic Knowledge Update: Sports Medicine 5

this anatomic relationship places the rectus femoris at cles, which are purely knee extensors. In fact, only two cases of vastus lateralis avulsions have ever been reported. The direct head of the rectus femoris originates from the

anterior inferior iliac spine {A115}, whereas the indirect

head originates more laterally from the supra-acetabular ridge adjacent to the acetabular labrum [Figure 6}. The

indirect head is more commonly injured. Distally, the indirect head extends nearly two-thirds the length of the

entire muscle as a central intramuscular tendon, whereas

fibers from the direct head blend anteriorly on the periphery of the muscle belly. This anatomy is important to

appreciate because central tendon injuries of the indirect

head are associated with a longer return to play than are peripheral injuries.”

Patient Evaluation Quadriceps injuries occur during kicking or sudden deceleration from a sprint. Soccer players and football kickers typically are affected. Injury mechanisms include

a sudden forcible block to a kicking motion, or kicking the air instead of the intended object. Risk factors in-

clude insufficient warm-up, poor muscle conditioning, and previous tears. Physical examination demonstrates tenderness to palpation around the A115. Ecchymosis and palpable defects can be seen in more severe injuries. Rarely, in chronic cas-

es, the avulsed proximal tendon can be palpated distally as a mass that can sometimes mimic a tumor, but a history of trauma helps to differentiate the two pathologies.“

Radiographs are not obtained routinely for isolated

fl lflld American Academy of Orthopaedic Surgeons

Chapter 13: Muscle Injuries {if the Prnitima] Thigh

Anterinr

inierinr

iliac spine Grnnve

supannr

tn anatahulum

l-ig u m 6

Drawing depicts the anatnmy nf direct and indirect rectus femnris insertinn.

injuries that fnllnw the expected clinical cnurse. A ra-

dingraphic wnrk—up shnuld he cnnsidered fnr palpable defects near the A115, recurrent injuries, and ynung patients with risk Enr avulsinns. MRI helps tn characterize MT] injuries and prnzcimal avulsinns. Increased signal nn

Figure 3'

Axial Til-weighted MRI shnvvs a bulls-eye lesinn

asantiated with injury tn the indirect head cf

the rectus femnris muscle. {Cnurtesy nf Mart Fl. Safran. MD, Pain Ann, CA.)

fluid-sensitive imaging within the indirect head is the mnst cnmmnn MRI finding. Injuries nf the indirect head can

invnlve a lnng segment nf the rectus muscle centrally that can result in a bulls-eye sign nn axial imaging (Figure 7'}, lnngitudinal scarring, nr pseudncystihematnma.

l‘r'

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PI'flIlIflfll rectus femnris injuries are classified as either

1

MT] nr avulsinn injuries, similarly tn prnstimal ham—

in

El-

string injuries. Musculntendinnus injuries can invnlve the indirect head, the direct head, nr the cnnjnined pnrtinn

nf the tendnn. Avulsinns nccur with nr withnut a hnny pnrtinn nf the A113. In slteletallj.r immature patients, ALIS

avulsinns accnu nt fnr 2U% tn 25% nf all avulsinn injuries

and nearly 50% nf all pelvic apnphyseal avulsinns.“ PUSH-i-

imal avulsinn alsn can nccur less cnmmnnly in skeletally mature individuals {Figure 3}.

Treatment Musculntendinnus injuries are treated nnnsurgically with a graduated rehabilitatinn prngram aimed at returning

Figure 3

AP radingraph shnvvs an avulsinn injury nf the

right anterinr inferinr ilisc spine in a skeletally mature patient. [Cnurtesy nf Marc E. Safran. MD, Fain Altn, EA.)

ble 2}. Return tn participatinn was shnvvn tn he prnpnrw tinnal tn the length nf the central apnneurnsis tear in

AIIS avulsinns with less than 2 centimeters nf tendnn retractinn can he treated nnnsurgically. Retractinns nf mnre than 2 centimeters are mere likely tn develnp

greater than 4 cm resulted in an average 5-day increase in return tn spnrt. Prnnimal injuries nf the rectus femnris

undergn internal finatinn. Subspinnus impingement can cause pain and reduced hip range nf mntinn, because the

an average nf apprmtitnately 1 1|.veelit.‘u

ing A115.“ Suhspinnus impingement is mnst cnmmnn

athletes tn cnmpetitinn 6 tn 1E! weeks after injury {Ta-

Spanish snccer players. Every 1-cm increase in tear length require a lnnger recnvery perind than dn distal tears by

IE! Eillii American Academy ni' flrthnpaedic Surgenns

nnnuninns nr cause subspinnus impingement and shnuld

femnral neck nr greater trnchanter impinges cm a lnw—ly-

Drthnpaedic Knnwledge Update: Spnrts Medicine 5

Section 2: Hip and Pelvis

-— Suggested Nonsnrgical Rehabilitation for Rectus Femoris Injuries Week 1:

Protected weight bearing with crutches Ice Anti-inflammatory medications Modalities Passive range of motion

Weeks 2-4:

Gait training Active range of motion lsometrics

Weeks 4-6:

Resisted strength training Running

Functional drills Weeks s-m:

Return to play

Chronic injuries that fail to improve may require surgical management. A pain-free remrn to sport has been reported in a soccer player treated with surgical

repair of a chronic musculotendinous junction injury.”

Surgical debridement of the symptomatic tendon stump also can enable a return to high—level sport. Authors of

a 2011 study reported on five collegiate athletes who

underwent debridement of chronically painful retracted

indirect heads.” Although all five improved, only one pa~

tient returned to sport without recurrent pain or reduced athletic ability. Symptomatic pseudoeyst formation, which can occur around the central tendon of the indirect head,

can be surgically excised with good results.5L1 Sum m ary

Muscle injuries are common in sports and frequently

involve areas around the hip. MT] injuries can be treated nonsurgically, initially with RICE followed by rehabilitation focusing on agility training, trunk stabilization,

and eccentric strengthening. The return to sport should be determined by physical examination criteria including

minimal pain, full range of motion, and near—symmet—

ric strength to prevent reinjury; full recovery may take

several weeks in some cases. Avulsion injuries should be

when the AIIS extends to the level of the acetabular rim -E

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[type 2] or past the rim, which is seen most frequently as

a sequelae of healed avulsion injuries [type 3}. Surgical in—

dications for chronic AIIS avulsions include reduction and

internal fixation of symptomatic nonunited fragments,

resection of exostoses that cause functional impairment, and painful subspinous impingement.“

Acute surgical reattachment of purely tendinous avul-

sions has been reported in several case series with good

results; other studies have shown good results with nonsurgical management alone, however, even in high-level

kicking athletes.“ In a series of four soccer players and

one hurdler treated with acute repair {at less than 102

days], all were able to return to their previous activity level between 5 and 1i] months after surgical repair.“ Authors of a 2012 study reported on If) professional soccer players who underwent repair of an av ulsed rectus injury with direct suture repair or bone anchors.” At a

recognised and treated differently than low—grade strains or contusions according to specific guidelines for the affecred muscle. key Study Points

1- Hip muscle strains are commonly encountered in sports, treatment is largely nonsurgical with RICE

acutely followed by rehabilitation focusing on agility training, trunk stabilization, and eccentric

strengthening.

'- Complete hamstring avulsions involving all three

tendons or two tendons with significant retraction may benefit from early surgical repair. I Rectus femoris strains and avulsions can both be managed successfully even in high-level kicking athletes with 6 to 10 weeks of rehabilitation. The length of the central aponeurosis tear in MT] strains predicts return to play.

mean followup of 35 months, they found fewer reinjuries

in the surgical repair group. In contrast, another study reported on 11 HF L players, including two punters who were treated nonsurgically.“ The NFL players were able

to return to professional football at a mean of W) days. Studies between surgical repair and nonsurgical management are needed to compare the two treatment options.

firthopaedic Knowledge Update: Sports Medicine 5

Annotated References

1. Eeiner JM, Joltl P: Muscle contusion injuries: Current treatment options. I Am Acad Drtbop Sing lflfl1;9{4}:22713?. Medline

fl Ellie. American Academy of Orthopaedic Surgeons

|l:.'.l1:.:lj:ite1' 13: Muscle Injuries at the Prairimal Thigh

. Eltstrand J, Higglund M, Walden M: Epidemialagy

at muscle injuries in praEessianal Faatball {sacccr't Am

rehabilitatian pratacala. IlrJI Sparta Med 1fl13:4'?{15j:953955'. Mcdlinc DUI

Fifty-ane saccer teams, camprising 2,299 players, were fallawed praspectively far 3 years, registering 2,9133 mus-

Prafessianal saccer players were randamited ta twa rehabilitatian pratacala. Canventianal rehabilitatian was faund ta have a langer return ta play {mean af 51 days}

,1 Sparta Med 2fl11;39{6}:1226-1232. Medline DUI

cle injuries. Un average, a player sustained [1.6 muscle

injuries per aeaaan. DI the injuries, 92% were sustained by the majar muscles af the lawer leg. Level af evidence: II.

Uarrert WE Jr, Rich FR, Niltalaau PK, Vaglet JB III: Camputed tamagraphy af hamstring muscle strains. Med Sci Sparta Exerc 1939;21i5}:5fl6-514. Medline DUI . Wands C, Hawkins RD, Malthy S, Hulse M, Thamaa A, Hadsnn A; Fnatball Assaciatian Medical Research Pragramme: The Faerball Assaciatian Medical Research Pragramme: An audit af injuries in prafessianal fact-

ball—analysis af hamstring injuries. Br I Sparta Med

20M:33{I}:35~41.Medline DUI

. Fauseltis K, Tscpis E, Paulmedis P, Atbanasapaulas 5, Vagenas G: Intrinsic risk factars cf nan-cantact quadriceps and hamstring strains in saccer: A praspective study af IUD prafessianal players. Br ,1 Sparta Med 2fl11545[9}l:?fl9T14. Mcdlitlc DUI This cahart study c-f Iflfl prafessianal saccer players fauud that players with eccentric hamstring-strength asymme-

tries and functianal legalength asymmetries were at greater

risl: far hamstring strain. Quadriceps strains were seen in players with eccentric strength and flexibility asymmetries.

. Malliarapaulas N, Isinkaye T, Tsitas K, Ma ffulli N: Reinjury after acute pasteriar thigh muscle injuries in elite traclt and field athletes. Arr: jl Sparta Med 2fl11;39{2j:3i}4-31D. Mcdline DUI

Return ta apart in track and field athletes was lawer far law-grade injuries: 14 days far grade I, 12.9 days far grade 2, 29.5 days far grade 3, and Sill days for grade 4

injuries. Uhjective clinical findings accurately predicted the risk cf reinjury.

. Warren P, Gabbc E], Schneider-Kalslry M, Benncll KL: Clinical predictcrs cf time ta return ta campetitian and af recurrence fallawing hamstring strain in elite Australian faatballers. Br ,1 Sparta Med 201D;44{E}:415—419.

campared with a pratacal emphasising lengthening at the muscle graup {mean at 2.3 days}.

19. Marelli V, Weaver V: Grain injuries and grain pain in athletes: Part 1. Print Cars 2005;32{1):163-133. Medline DUI 11. Feeley ET, Pawell jW, Muller M5, Barnes RP, Warren RF, Kelly ET: Hip injuries and labral tears in the natianal Iaatball league. Am ,1 Sparta Med 2UD3;36{11}:213?-2195.

Medline DUI

12. Galla RA, Silvis ML, Smetana B, et a1: Asymptomatic hiplf grain pathalagy identified an magnetic resanance imaging af prafessianal hackey players: Uutcames and playing status at 4 yes rs‘ Iallaw—up. Arthrascapy 2014;30{1fll:12221233. Medline

DUI

Twenty-cue asymptamatic hackey players underwent MRI and were fallawed far 4 years. Despite a high prevalence c-I muscle strains {11“.} cf 21} and labral tests {15 at 11}, anly ane player missed campetitian because cf a hipy’pelvis injury. Level af evidence: IV. 13. Faete E], Maislin EV, Shrauder J, lI'Srrant MM, Eedi A, Ayeni UR: The assaciatian between avulsians af the reflected head at the rectus femaris and labral tears: A retraspective study. } Pedistr Urtirap 2013:33i3}:22?—231. Medline DUI Seven af nine pediatric patients with sparts-related rectus femaris avulsians alsa were faund ta have labral tears an magnetic resanance arthragraphy. The ages ranged ftam ii ta 1? years, with twa patients requiring surgery. Level af evidence: IV. 14. Philippan M], Weiss DR, Kuppersmith DA, Briggs KK, Hay CI: Arthraacapic labral repair and treatment af femaraacetabular impingement in prefessianal hackey players. Arr: J Sparta Med lfl'lil;33j1l:99-Ifl4. Medline DUI

Medline DUI

Treatment cf femaraacetabular impingement and labral lesians in prafessianal hncltey players resulted in successful

Australian factballers were 4 times mare likely ta have a pralanged recavery if they were unable ta wallc pain-free

return ta apart within a mean cf 3.4 manths. Level cf evidence: IV.

the day after injury. A lflafald increased risk far recurrence

was seen if the previaus hamstring injury had accurred in

the last 12 manths.

. Arnasan A, Andersen TE, Halme I, Engebretsen L, Baht Ii: Preventian af hamstring strains in elite saccer: An interventian study. Scared I Med Sci Sparta 2Gflfl;13{1j:4fl-43. Mcdline DUI . Askiing CM, Tengvar M, Tharatenasan A: Acute hamstring injuries in Swedish elite Iaatball: A praspective randamiaed cantralled clinical trial camparing twa

IE! Eillfi American Academy ai' Urthapaedic Surgeans

autccmcs, with high patient satisfactian and a prampt

15. Safran MR, Garrett WE Jr, Seaber AV, lIErlissan RR, Ribbeclc EM: The tale af warmup in muscular injury

preventian. Am } Sparts Med 1933:16j2}:123-119. Mcdline DUI

16. Hughes C IV, Hasselman CT, Best TM, Martinez 5, Earrett 1i‘iFEJr: Incamplete, intrasubatance strain injuries cf the rectus femaris muscle. Am I Sparta Med 1995;13j4ltiflil5116. Medline DUI

Urthapaedic Knawledge Update: Sparta Medicine 5

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Section 2: Hip and Pelvic

1?. Jiirvinen TA, Jiirvinen M, Kalimo H: Regeneration of injured skeletal muscle after the injury. Mnscles Ligcments

Tendons I1013;3[4j:33?-34S. Medline

This review focused on fire basic biologic principles of filial-

eta] muscle regeneration and healing pmcesses. Clinical

and animal studies were discussed, with recommendations provided to promote healing and return athletes safely to competition.

13. Wood DE, Packham I, Trikha SP, Linklater J: Avulsion

of the proximal hamstring origin. j Bonejoini Surg Am

2UflS:90l11j:2365-23?4.Medline

DUI

19. Jiirvincn M: immobilization effect on the tensile properties of striated muscle: An experimental study in the rat. Arcl: Phys Merl Reliabil 19?7;SS{3j:113-12?. Medline

ll]. Afirimaa V, Rantanen ], Best T, Schultz E, Corr D, KaIirno H: Mild eccentric stretch injury in skeletal muscle causes transient effects on tensile load and cell proliferation. Sccerl ] Merl Sci Sports lflfl4:14{6}:36?-3?2. Medline DUI 21. Kannus P, Parkltari J, Jiirvinen TL, JS rvinen TA, Jiirvinen M: Basic science and clinical studies coincide: Active treatment approach is needed after a sports injury. Scared I Med Sci Sports lflflS;lS[3}:15fl-154. Medline DUI 22. Almekinders LC, ISilhert JA: Healing of experimental muscle strains and the effects of nonsteroidal antiinflammatory medication. Am J Sports Med 1935;14l4jr3 [13 -3-flfl. Medline DID] -E

E

a: o. 1: l: rt: EI

H

13. Ryan JB, WheelerJH, Hopkinson W], Arciero ILA, Ko-

la kowslci KR: Quadriceps contusions. West Point update. Am J Sports Med 1991;19l3}:299-304. Medline DUI

2.4. li'iross M], Vandersluis R, 1|Wood D, Banff M: Surgical repair of chronic complete hamstring tendon rupture in the adult patient. Am I Sports Merl 1993;26ffij:TSS-TSS. Medline 25. Cohen 5, Bradley]: Acute proximal hamstring rupture. I Am Acerl Urilrop Siirg 2G0?;15{E}:330-355. Mcdlinc

16-. De 1|li'os R], Reurinl: G, Goudswaard G], Moen Mi-I, Weir A, To] JL: Clinical findings just after return to play predict hamstring re-injury, but baseline MRI findings do not. Br I Sports Med lfll4:4fl{1flj:13??—13il4. Modline DUI

This cohort study found no association bepeecn baseline

MRI findings and hamstrings reinjury within iii months; previous hamstring injuries and clinical signs {knee extension or isometric-force deficits and tenderness with palpation] were significant independent predictors of reinjury, however.

2?. Moen MH, Reurink G, 1|Illicit A, Tol JL, Mass ivi, |lii'roudswaard G]: Predicting return to play after hamstring injuries. Br 1 Sports Merl lfll4;4S{1fi}:lSSS-1363. Medline DUI

firthopaedic Knowledge Update: Sports Medicirie S

In 3’4 nonprofessional athletes, MRI findings were unable to predict return to play. |[illnly a self-predicted time to remrn to play by the athlete and a passive straight leg raise

deficit remained significantly associated with the time to return to sport.

ES. Koulouris ('3, Council D: Evaluation of the hamstring muscle complex following acute injury. Skeletal Radiol

lflfl3;31{1flj:SSE-SSS. Medline DUI

19'. Guillodo ‘1", Bouttier R, Sarat A: Value of sonography combined with clinical assessment to evaluate muscle injury severity in athletes. } Arlil Train .101 1:4Sl3}:.'ifl D-SEH.

Medline

Ninety-three consecutive sports-related muscle injuries were analyzed. Physical examination findings (bruising,

tcnderuess to palpation, limited range of motion, and

pain with isometric contraction} and ultrasound findings including hematoma volume were found to predict the return to play following muscle strain. 3f]. Sherry MA, Best TM: A comparison of 2 rehabilita-

tion programs in the treatment of acute hamstring

strains. J Grrhop Sports Phys Ther lflfl4;34{3}:i 16-125. Medline DD]

31. Lewne WN, Bergfeld jA, Tessendorf W, Moorman CT LII: Intramuscular corticosteroid injection for hamstring

injuries. A 13—year experience in the National Football

League. An: _l Sports Med EDDG;ES{3}I:29?FSDG. Medline

32.. A Hamid MS, Mohamed Ali MR, Yusof A, George J,

Lee LP: Platelet-rich plasma injections for the treatment of hamstring injuries: A randomised controlled trial. Am

y Sports Med 1014:41llfljfl4lfl-1413.Medline not

This randomised trial compared rehabilitation programs

with and without a single platelet—rich plasma {PR P} injection on return to play following hamstring strain. Return to play was, on average, 15 days longer in the rehabilitation-only group. The study was not placebo controlled.

Leml of evidence: II.

33. Rcurink G, lGoudswaard G], Moen MH, er a]: Dutch Hamstring Injection Therapy {HIT} Study Investigators: Platelet-rich plasma injections in acute muscle injury. N Eirgljr Merl lfli4;3?fl{26j:2546-254?. Medline DDI In a three—center randomized, placebo—controlled trial comparing PEP to isomnic saline, the investigators found an equal return-to-play time {mean of 42 days} for both

groups. Two injections were given: one S days after injury,

and the second at it! to 12 days after injury.

34. Clanron TC}, Coupe K]: Hamstring strains in athletes:

Diagnosis and treatment. _.l Arr: Acarl Drtlrop Sarg 1993;5l4}:23?-24S. Medline

35. Engehretsen AH, Mylrlehusr G, Holme I, Engebrersen L, Bahr Ii: Intrinsic risk factors for hamstring injuries among male soccer players: A prospective cohort study. Am I Sports Merl lfllflfifllfijtll‘lT-IISS. Medlitle

DUI

Q lfllfi American Academy of Orthopaedic Surgeons

Chapter 13: Muscle Injuries cf the Praarimal Thigh

In a cahart af SHE prafessianal saccer players, TE ham;

string injuries were identified. In multivariate analysis, previaus hamstring injury was the mast predictive factar far reinjury, mare than daubling the risk af a new injury. Level af evidence: II.

36. Upar DA, Williams MD, Timmins RG, Hickey J, Duhig 5], Shield A]: Eccentric hamstring strength and hamstring injury risk in Australian faatballers. Med Sci Sparta Exarc 2D15;4?{4}:SS?—SES.Medline DCiI Australian faathallers with reduced preseasan eccentric

43. Hetsrani I, Paultsides L, Bedi A, Larsau CM, Kelly ET: Anteriar inferiar iliac spine marphalagy carrelates with hip range af matian: A classificatian system and dynamic madel. Ciir: Drtbap Raint Rea 2fl13;4?1{3}:149?-25fl3. Medline DUI

The authars reparted a carrelatian between AIIS marphal-

agy and hip range af matian. A lawer-hanging AIIS {at at belnw the level af the acetabular rim] carrelated with decreased hip flexian and internal ratatian an clinical

eaaminatian. Level af evidence: III.

hamstring strength belaw a threshald value had a l.?—fald

Hetsrani I, Larsau CM, Dela Tarre K, Zbeda RM, Magennis E, Kelly BT: Anteriar inferiar iliac spine defarmity as an extra-articular saurce far hip impingement: A series nf lfl patients treated with arthrascnpic decampressinn. Arthraarapy lflllglfljl 1}:lfi44-ISSS. Medline DCII

3?. Clpar DA, Williams MD, Timmins RG, Hickey J, Duhig

The authars describe the arth rascapic technique and autcamll af AIIS decampressian. At a mean cf 14 manths pastaperatively, hip range af matian and madified Harris

increased risk af hamstring injury that seasan. Canversely, increased eccentric strength mitigated ather risk factars, including increased age at previnus injury.

5], Shield AJ: The effect af previaus hamstring strain

injuries an the change in eccentric hamstring strength during preseasan training in elite Australian faatbaIlers. Ant J Sparta Mad 1fl15;43{2}:3??-334. Medliue DUI

Hip scares impraved significantly. Level af evidence: IV.

Athletes with previaus hamstring iniuries shawed a relatively reduced capacity far eccentric strengthening with exercise campared with these withaut previaus injury. This finding was true far the affected and the nnnaffected

45. Gamradt SC, Ernphy RH, Barnes R, Warren RF, Thnmas Byrd JW, Kelly ET: Hanaperative treatment far prairimal avulsian cf the rectus femaris in prafessianal American fantball. Arr: J Sparta Meal lDflS’;3T{TJ:13Tfl-1374. Medliue DUI

33. Harris JD, Griesser MJ, Best TM, Ellis TJ: Treatment af prairimal hamstring ruptures - A systematic review. Int

46. Irmala T, Heikkilii JT, Drava S, Sarimn J: Tatal praatimal tendan avulsian at the rectus femaris muscle. Stand} Med Sci Sparta EGUTHTHJfiTS-SSE. Medline

limb. Level af evidence: II.

J Sparta Mad 2fl11;32{?]:49fl-495. Medline DUI

This systematic review campared surgical treatment with nansnrgical treatment and acute repair timing af prmtimal

hamstring avulsians with that af chranic repair. Han-

surgical and chranic repairs were faund ta have inferiar autcames in terms af patient satisfactian and return tn the previaus level af campetitian.

35'. Crass TM, Gibbs N, Hauaug MT, Gameran M: Acute

quadriceps muscle strains: Magnetic resanance imaging

features and pragnasis. Am I Sparta Med lflil4;32{3}:?lil7’19. Medline DCII

413'. Hasselman CT, Best TM, Hughes C IV, Martinez S, Garrett WE Jr: Au explanatian for varinns rectus femaris strain injuries using previnusly undescribed muscle architecture. Am I Sparta Med 1995;23{4}:433—499.

Medline DCiI

41. Schuett D], Eamar JD, Pennack AT: Pelvic apaphyseal avulsian fractures: A retraspective review af 113 cases. J Pediatr Drthap 2fl14. Medline DUI

The authars identified 123 apaphyseal avulsians. The

mean age was 14, and TESS af injuries accurred in males. Mast injuries accurred during sprinting at kicking. AIIS avulsians were mast camman {49%}, fallawed by avulsians at the anteriar superiar iliac spine {30%}, ischial tuberasity [11%], and iliac crest {'lfl‘i'al. Level af evidence: IV.

42. Balius R, Maestra A, Pcdret C, et al: Central apaneurasis tears cf the rectus femaris: Practical sanagraphic pregnasis. Br J Sparta Med 2Ufl9;43[11}:313-324. Medline DDI

IE! Eillii American Academy af Clrthnpaedic Surgeans

4?. Garcia VV, Duh rkap IJC, Seiias FL, Area 0, Cugat R: Surgical treatment af pranimal ruptures af the rectus femaris in prafessianal saccer players. Arch Grthap Trauma Satrg

1012:132E3}:329—333.Medline an:

This study included ten praaimal rectus avulsians in high-level athletes wha underwent surgical repair. Sis: were repaired directly, whereas suture anchnrs were used in faur cases. Na recurrences accurred, and all athletes returned ta the same level af campetitian. 4E. Straw It, Calclaugh III, Geutjens G: Surgical repair af :1 chranic rupture cf the rectus femaris muscle at the PIC!!imal musculatendinnus junctian in a saccer player. Br J Sparta Med 1003,3?[2}:131—1fl4. Medline DDI 49. Wittstein J, Klein S, Garrett WE: Chranic tears nf the reflected head cf the rectus femaris: Results af apera— tive treatment. Ant I Sparta Mad 2011:39t9}:1942-194?.

Medline

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Five patients with chranic tears af the rectus femaris that

failed nansnrgical therapy were treated with encisiau af

the reflected head. All reparted a reductian in pain severity, but four af five had mild residual symptams with athletic participatinn. Level af evidence: IV. Si}. Gicvarid T, Lucin K, Rath S, Ivancii‘.‘ A, Marinavifi M,

Santic V: Giant pseudacyst af the rectus femaris muscle—

repetitive strain injury in recreatianal saccer player. Call Antrapai lfllfl;34{Suppl 21:53-55. Medline

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Chapter 14

Athletic Pubalgia/Core Muscle Injury and Groin Pathology

Ch ristophcr M. Larson. MD

David M. Rowley. MD

challenges can lead to time lost from athletic participa-

Hip and groin-related symptoms and disorders are in-

creasingly recognised as a cause of significant disability

in athletes. Hip and groin symptoms can be the result of extra-a rticular disorders [sports herniaiathlctic pubalgiaicore muscle injury, proximal adductor pathology, osteitis pubis} and or intra-articular disorders (labral tears, chondral pathology, femoroacctabular impinge-

ment}. It is now recognized that there is a compensatory relationship between intra-articular and extra-articular hip and groin disorders, and a high index of suspicion

is required to accurately diagnose these conditions. A thorough history and physical examination combined

with appropriate imaging studies can lead to an accurate

diagnosis and effective treatment recommendations. Ultimately, this can help to minimize disability duration and maximize return to athletic participation in this potentially challenging patient population. Keywords: athletic puhalgia: groin injuries: hip Injuries Introduction

Hip and groin injuries are common problems that can lead to disability in athletes. The clinical and diagnostic presentations of the various potential entities can overlap, making diagnosis and treatment difficult. These Di: Larson or an immediate family member serves as a paid consultant to A3 Surgicai and Smith S- Nephew: has stock or stock options held in A3 Suryicai; and has received research or institutionaisupport from Smith 5 Nephew Neither fir. Rowiey nor any immediate family member has received anything of vaiue from or has stock or stock options heid in a commerciai company or institution reiated direci‘iyr or indirectly to the subject of this chapter:

fl lflld American Academy of Drrhopaedic Surgeons

tion and subsequent frustration for athletes with these

conditions.1 The differential diagnosis for activity-related

groin pain has been described in broad categories as core

muscle injury {athletic pubalgia or sports hernia}, hiplf

joint pathology {intra-articular pathology), and other etiologies.2 This chapter discusses extra-articular hip pathology with a focus on athletic pubalgia, proximal

adductor injuries, and osteitis pubis.

The anatomic structures of the hip and pelvis have

been described based on layers. Layer 1 consists of the osseous morphology, including the pelvic bones, acetabulum, and proximal fcmu r. Layer 2. consists of soft tissue in and around the hip including the labrum, capsule, and ligaments, which add substantial stability to the hip.

Layer 3 consists of the contractile layer around the hip including the adductors, abductors, flexorsiextensors, and

internal and external rotators of the hip. Layer 4 consists

of the neurovascular structures that surround the hip.

The main components of this layer are the lateral femoral cutaneous nerve, obturator nerve, inguinal nerve, sciatic

nerve, and genitofemoral nerve.J It should be noted that

all of these structures can be sources of pain when evaluating patients with lower abdominalihipigroin pain. In

addition, patients with extra—articular hip pathology can

have concomitant femoroacetabular impingement {Frill} or intro-articular hip pathology. Athletic F'ubalgia Pathoanatomy

The anterior bony pelvis, with its many muscle attach-

ments and the pubic symphysis, forms the center of core

injuries and sports hernia.1 The abdominal wall musculature also has been described in layers. The layers, from superficial to deep, are the fascia, external oblique fascia and muscle, internal oblique fascia and muscle,

transversus abdominis muscle, and transversalis fascia.‘ The rectus abdominis muscle, conjoint tendon (internal oblique and transversus abdominis fascia}, and external

Drthopaedic Knowledge Update: Sports Medicine 5

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Section 2: Hip and Pelvis

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

2

to a. 1: I: rt: EI

H

oblique muscle merge to form the pubic aponeurosis,

athletic pubalgia were athletes.‘5 Patients typically present

which inserts onto the pubic tubercle. The medial thigh compartment consists of the pectineus, the gracilis, and

with exertional pain during activity without a specific injury or event causing the pain. They report anterior groin

ure 1). The ligamentous complex at the pubic symphysis

activity and is usually relieved with rest.‘r The lower abdominal or groin pain often resumes with activity after a

the adductor brevis, longus, and magnus muscles {Fig-

or lower abdominal pain that is brought on by physical

consists of the anterior, superior, posterior, and arcuate ligaments. The superior and arcuate ligaments are the

period of rest from vigorous activity. Coughing, sit-ups,

generated at the anterior pelvis. Athletic pubalgia is de—

ture or distally into the thigh, groin region, or scrotum.1

main stabilizers of the pubic symphysis.‘ The pubic symphysis is the center of the various forces

fined as an injury to one of the previously described struc-

tures, as it inserts into the pubis, without the presence of a clinically recognizable hernia, so the term spurts

and kicking can reproduce the symptoms. l[itccasionallyg pain can radiate proximally into the abdominal musculaPhysical Examination

hernia is a misnomer.5 Injury to or deconditioning of one

The physical examination should begin with palpation of the pubic symphysis, the rectus ahdominis muscle, the

to complete disruption of one of the musculotendinous

tor muscles, the pectineus and gracilis muscles, and the inguinal ring for areas of tenderness. Lower abdominal

of the anterior pelvic structures can result in increased stress and strain on the adjacent structures. This can lead

internali'eaternal oblique muscles, the origin of the adduc-

originsfinsertions or ligaments about the pelvis.

pain or groin pain, pain that is worse with sport-specific

Clinical Presentation Rapid lateral motion, acceleration, deceleration, hyperezc—

the pubic ramus, pain with resisted hip adduction, and

tension, or hyperabduction can lead to increased tension

activities including kicking, cutting, sit—ups, and sprinting and that is relieved with rest, tenderness to palpation over

in the pubic region.‘ Athletic pubalgia is seen primarily

pain with resisted abdominal sit-ups are the five most common complaints or findings in patients with athletic

tivities. In one study, 31% of patients who presented with

thology using the FADIR {fleecion, adduction, internal

in athletes who are involved in cutting and pivoting ac—

firthopaedic Knowledge Update: Sports Medicine 5

pubalgia.E Evaluation of potential intra—articular hip pa—

fl lfllfi American Academy of Orthopaedic Surgeons

lli'lllapter 14: Athletic Pubalgiail'Core Muscle Injury and |l'3toin Pathology

rotation] test should be performed, because concomitant

hip-joint pathology is not uncommon, and intra-articular and extra—articular hip and pelvis disorders often are

related and compensatory in nature. Imaging

Initial imaging begins with a well-centered AP pelvis and

lateral hip radiograph.9 These images are usually negative

in patients with isolated athletic pubalgia but are used to rule out avulsion injuries about the pelvis, radiographic signs of bony impingement, stress fractures, osteitis pubis, sacralised lumbar vertebrae, and other potential sources of pain. MRI is the current standard for evaluation of activity—

related pelvic pain.” A dedicated athletic pubalgia MRI protocol, including large field-of-view and small field-o f-

view images focusing on the pubic symphysis, is useful for

accurate diagnosis and location of the pathology.1 MRI is 68% sensitive and lflfl'ii: specific for rectus abdomi-

nis pathology compared with findings at surgery and is

36% sensitive and 39% specific for adductor pathology.

It also is lflfl% sensitive for osteitis pubis.” MRI should be reviewed closely for osteitis pubis, rectus abdominis

strain, adductor tendon injury, rectus abdominis or ad-

ductor apoueurotic injury or plate disruption, inguinal hernias, femoral stress fractures, and hip—joint—related

pathology.” The most frequent finding on MRI is fluid

signal extending from the anterior-inferior insertion of

the rectus abdominis into the adductor origin, with cor responding fluid signal in the pubis"!11 {Figure 2.]. Diagnostic Injections As described previously, sewral potential pain genera-

tors are present about the pelvis and groin. Diagnostic

injections can help determine the etiology of pain when conflicting results appear on clinical examination. Administering an intra—articular injection of local anes—

thetic into the hip joint can be useful before having the

athlete perform activities that typically provoke pain or

re—examining the patient in the office. Persistent pain in the groin or lower abdominal regions after intra-ar-

Figure 1

MRI of the hip and pelvis of a 22-year-old

football player with left-side lower abdominal and proximal adductor—related pain reveals a disruption of the distal rectus ahdominislr

atltl uctor aponeurosis on the left (arrow).

{Reproduced with permission from Larson EM. Sports hernial'athletic pubalgia: Evaluation and

management. Sports Health 2D14;E[2]:135-1d4.]

focus on resolving imbalances between the pelvic and hip stabilizers.Gr NSAIDs and ice can he used to minimise swelling and pain during the rehabilitation period. Patients generally are treated for at least 3 months with activity modification and physical therapy. If substantial improvement is achieved, nonsurgical treatment is con-

tinued with a gradual sport-specific activity progression.

If no improvement is seen by 3'.- months, surgery might

be considered? Ultimately, the duration of nonsurgical treatment and the timing of potential surgery are variable,

depending on the level of the athlete and the schedule of

the sport season.

Surgical Treatment

isolated athletic pubalgia. Anesthetic injection into the pubic symphysis, adductor cleft, or psoas bursa also can

Various surgical procedures have been described for the treatment of athletic pubalgia. Plication of the transversalis fascia, reapproximation of the conjoint tendon to the inguinal ligament, and approximation of the exter-

Treatment

had a return—to—sport rate of 95% at 12 weeks. An open approach for the treatment of athletic pubalgia has been

ticular injection can be consistent with concomitant or aid in diagnosis.

Nonsurgical Treatment

Relative rest and avoidance of activities that provoke pain comprise the initial treatment. Physical therapy should focus on core strengthening as well as identifying areas

of weakness or reduced range of motion. Therapy should

IE! lflli‘i American Academy of flrthopaedic Surgeons

nal oblique apoueurosis has been described.” Patients

described, with reattachment of the anterior—inferior rectus abdominis with an adductor releasef' 152 of 15'?

patients with athletic pubalgia who underwent primary

pelvic floor repair were able to return to their preinjury

level of competition. In a study examining results over

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Sectiun 2: Hip and Pub-fie

20 years, 95% nf athletes were able tn return tn spurts participatiun at 3 mnnths pnstnperatively.” An npen re-

pair technique using mesh has been studied; all patients

underwent bilateral mesh repairs with the mesh bridging

frnm the pubis tn the anterinr superinr iliac spine.15 The

perituneum was clused uvcr the mesh, and it was rcpurted that all patients were able tn return tn full spurts pa rtic-

ipatinn pnstnperatively. Multiple authnrs have published

their experience with laparuscupic repain'fid'" A. recent randnmized cuntrnlled trial cumpared patients with ath-

letic pubalgia treated with a laparnscnpic mesh technique

with thuse whn underwent nunsurgical treatment. At 3.- munths, Elfl'ii: nf the laparnscupic gruup retunted tn

spurt cumpared with 2?"?4: nf the nuusurgical gruup. At

12 munths, STEP—ii uf the surgical gruup had returned tn spurt cnmpared with sex. nf the nunsurgical gruup.”

increased stress placed un the pubic symphysis, which

I

abduminal grnin nr hip pain. Recently, using a cadaver made], it has been shnwn that patients with FAI have may predispuse tn cumbined FA] and athletic pubalgia.“

It is imperative tn determine the snurce nf the pain an that pmper expectatiuns and treatment nptiuns can be present-

The must cummun pnstnperative cnmplicatiun is edema

ed. A subset nf patients will present with cumbined FAI

infectiun is rcpurted at {1.4%, and hematuma requiring renperatiun has a rate nf fl.3%. Herve dysesthesia has a less than 1% nccurreuce rate and usually affects the

imaging can help tn determine the cumbined diagnusis

in the abdnmeu, thighs, genitals, and perineum. Wnuud

H

|IZabined Athletic Pubalgia and Fill

tn suggest that une repair technique is superiur tu anuther, Enmplicatinns

cu n. 1: I: an E-

frurn a 23-year-uld man shuw cumbined iernnrnacetabular impingement (FM) and athletic pubalgia.

It is recummended that patients with suspected athletic

based nn the current published literature.

2

AF pelvis {A} and Dunn lateral {B} radiugraphs

llEil'verlap between intra-articular and extra-articular pathulugy uften uccurs in patients presenting with luwer

pubalgia be referred tn an experienced general surgeun with an interest in grain pathnlngy. There is little evidence

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Figure 3

anteriurirlateral femnral cutaneuus nerve distributinn, the

and athletic pubalgia. Clinical examinatinu and detailed

{Figure 3}. ten, it is difficult tu determine huw much pain nr disability results frnm each entity. In these cases, anesthetic intra—articular and extrararticular injectiuns

ilininguinal nerve, nr the genitufemnral nerve.” Penile

can aid in the diagnusis. When it is determined thrnugh

resnlved. The must cummun reasnn fur renperatiun is the develnpment nf athletic pubalgia nu the cuntralateral

can he tailnred fur bnth entities. Treatment nf nnly nne nf

vein thrnmbusis is rcpurted in the literature but all cases side. The sncund must cummun reasnn fur renperatiun

is inadequate adductur release nr repair at the time nf the athletic pubalgia repair.” Failure tn address intraarticular pathulugy {Phil is anuther reasnn fur cuntinued

disability after repair.”

Rehabilitatinn Must recent studies have repurtecl a return tn full activity 1 tn 6 mnnths after surgery, depending nu the type nf repair."=“' Patients may bear weight as tulerated pustupcratively, with physical therapy starting at 1 tn 14 days pustuperatively. Physical therapy initially fucuses un ab”

duminal and adductur flexibility and targeted abduminal strengthening. A stepwise running prngram begins at 4

weeks after surgery, with spurt—specific exercises starting

at week 533'" Activity as tulerated is alluwed aruund 6 weeks pnstnperatively.“

a detailed examinatinu, imaging, and pussibly diagnustic injectiuns that a cumbined prucess is uccurring, treatment

the pathulugies can lead tn a subuptimal result. In a study

nf patients with cumbined FA] and athletic pubalgia, patients whn had athletic pubalgia surgery alnne returned tn their previuus level uf spurt participatiun 25% uf the

time. Df patients whn underwent arthrnscnpy for PA] unly, 50% returned tn their previuus level. Di patients

whn had bnth athletic pubalgia surgery and hip arthrus— cnpy, 35% tn 91% returned tn spurt. Nu difference was

seen, whether surgery was perfnrmed in a staged fashinn ur if huth treatments were perfurmed at the same time.” adductur Strain

Pathnanatnmy

Myutendinuus injuries and strains are mure cummun

when the muscle crnsses twu juints, and they usually result frnm eccentric cuntractinn.11 The injury usually uccurs at the myntendinuus junctiun. Adductnr injures

nften nccur at the urigin nntn the pelvis, hnwever, and

firthupaedic Knnwledge Update: Spurts Medichie 5

fl lflld American Academy nf Cirrhnpaedic Surge-nus

cluster 14: Athletic Pubalgial'Cc-re Muscle Injury and Grain Patbelngy may be caused by a different mechanism than typical muscle strainll {Figure 4}. Adductnr attains are cnmmnn in athletes whn participate in pivnting and cutting activities

and in kicking in snccer. The adductnr grnup wnrlcs in

cnnjunctinn with the abdnminal musculature tn stabilise the pelvis during walking and running.” The adductnr

lnngus nrigin en the pelvis may be predispnsed tn injury because nf its small crnss-sectinnal area cnmpared with

the size cf the muscle belly.21 Annther etinlngy fnr adductnr strain is a muscle imbalance between the abductnrs and the adductnrs. It has been reperted that prnfessinnal

hnclcey players are 1? times mnre likely tn incur an ad— ductnr strain if their adductnr strength was less than Efl'lfi nf their abductnr strength?-1 In a fnllnw—up study,

the authnrs shnwed a significant reductinn in adductnr

Hentus

abduminls

Inguinal ligament Superficid ring Ilinpsnas Sent-nus

FEGllI'IEUE Adductnr

Inngue

strains in a similar pnpulatinn when a preventive adductnr

strengthening prngram was institu

3“?”

Clinical Presentatinn

Adductnr strains are cnmmnu in athletes participating in fnntball, snccer, hnckey, and dance.“ These athletes

nften present with acute medial grnin nr prnximal thigh pain. Adductnr strains are usually self—limiting, requir— ing minimal treatment with very high rates nf return tn play. Chrnnic prnximal adductnr pain related tn spnrts

participatinn can be assnciated with athletic pubalgia nr hip impingement, such as FAI. Cine study nf athletes with prnximal adductnr pain repnrted underlying FAI in 94% nf athletes, based nn radingraphs.” Du examinatinn, ten—

Figure 4

Illustration shnws Injury tn the ahdnminal wall at the fascial attachments cf the rectus and add uctnrs nntn the pubis, which is implicated in athletic pubalgia. The two arrews shnw the nppnsing fnrces that are placed an the pubis secnndary tn the rectus and adductnrs.

tears with a palpable defect usually shnw a 3—cm nr great—

er retractinn nf the tendnn nn MRI“? {Figure 5}.

Treatment Activity mndificatinn, ice, cnmpressinn, NSAIDs, and gentle range-nf-mntinn exercises are the mainstay nf ini-

derness tc- palpatinn is present ever the adductnr lnngus

tial treatment after adductnr injury. When pain decreases, formal physical therapy can begin using a variety of

and a palpable defect snmetimes will be present. Patients alsn have pain with resisted adductinn. When evaluating

mnbiliaatinns, and prnprinceptive neurnmuscular facilitatinn. Cryntherapy may be helpful fer the reductinn nf

tendnn.“ Patients experience pain with passive abductinn,

mndalities, including static stretching, massage, tissue

patients with adductnr injury, it is impnrtaut tn assess fnr

swelling and pain relief.15 Electrical stimulatinn may be

Imaging

prnvide cnmfnrt in the acute setting.

athletic pubalgia and PAL

Imaging fnr adductnr strains is usually nnt indicated,

used tn prevent muscle atrnphy. External wraps can litnit the amnunt nf active and passive hip abductinn and can 1'Ii'lil'hen pain is manageable, gentle range-nf-mntinn

because many at these injuries are self-limiting. Fnr

exercises can begin, including exercise-bike riding and

may be warranted. A well-centered AP pelvis radingtaph

a strengthening prngram is instituted fncusing nn cnre strengthening, plynrnetrics, and gentle running straight

avulsinns, nsteitis pubis, pelvic stress fractures, nr intraarticular findings that may explain cnntinued disability.

play after full strength and painufree mntinn are achieved,

patients experiencing chrnnic disability secnndary tn a grnin injury nr in patients with a palpable defect, imaging

shnuld be nbtained, with initial evaluatinn fnr apnphyseal

MRI is the next study fnr evaluatinn nf musculntendinnus injury, injury at the insertinn site, and intra-articular hip

pathnlngy. MRI sequences that have been described fer

the evaluatinn nf athletic pubalgia are indicated? Muscle strains with a cress-sectinnal area invnlvement greater than Sfl‘li- nu MRI, fluid cnllectinns, and muscle tears are

assnciated with lnnger recnvery times. Adductnr lnngus

IE! lfllti American Academy nf flrthnpaeclic Surgenns

pen] exercises. After full range nf mntinn is achieved,

ahead.21 The patients‘ activities are gradually advanced with spnrt-specific drills. Patients are able tn return tn

with a mean return tn play nf 6 weeks.“ Fnr patients in whnm nnnsurgical treatment has failed, injectinns may be warranted. Platelet—rich plasma {PEP},

cnrticnsternid, and simple anesthetic injectinns have been described fnr adductnr strains. Injectinns intn the adductnr enthesis have shnwn snme success in cnmpetitive and recreatinnal athletelI

Drthnpaedic Knnwledge Update: Spnrts Medichie 5

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Figure 5

MRI depicts an anterior adductor avulsion in a professional football defensive back presenting with severe leftside groin pain. Flight-side defensive backs often injure their left rectus abdominisradductor aponeurosis when transitioning during pass coverage. A, Large field-of—view coronal short tau inve rsion —recovery {STIR} image of the bony pelvis shows detachment of the left adductor origin from the aponeurosis {arrow} with the retracted tendon

fibers {arrowhead}. The distance of retraction often is measured best on the coronal STIR images. B. Small field-

of-view coronal oblique Tit-weighted fat—saturated fast spin—echo image using a pubalgia protocol demonstrates the detachment of the left anterior adductor origin from the aponeurotic plate {a now). te n, the pectineus and adductor longus muscles detach together. This condition is referred to as an anterior adductor avulsion because these muscles are the two most anterior muscles at the pubic attachment. [He produced with permission from Pallsch A, logo A, lvleyers w: Imaging of athletic puhalgia and tore muscle injuries: Clinical and therapeutic correlations. Clio Sports Med 2D13:32[3]:42?-44?.} -E

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If nonsurgical treatment of 3 to 6 months has failed,

surgical treatment may be considered. In a case series of

16 competitive athletes with chronic isolated addnctor pathology, nonsurgical measures including rest, physical

therapy, NSfiIDs, and corticosteroid injections failed in

all patients.23 Surgical treatment consisted of open tenotorny 1 cm from the adductor longns origin. All patients

Complications

Injury to the spermatic cord can occur during surgical

lengthening of the addnctor longus if dissection is carried medial to the gracilis origin on the pubisfii’d”

improved and were able to return to sports activities.

Rehabilitation Postoperatively, patients can bear weight as tolerated with crutches until a nonantalgic gait is achieved. Gentle range—

duction strength was weaker after full recovery. One of

exercises may begin at 6 to 3 weeks, with a mean return

At final follow-up, ll] of It? patients were pain free. Ad-

the authors of this chapter {CML} prefers a fractional lengthening 3 cm distal to the origin to minimize post-

of-motion exercises may begin as tolerated. Strengthening to play of 12 weeks.

operative weakness. Caution should be exercised when

considering a release in soccer strikers, because this procedure might lead to detrimental adductor weakness.2T In a 2013? study of 19 National Football League {NFL}

Pathoanatomy

|liii'steitis pubis is thought to be a stress injury of the para“

players who sustained a rupture of the addnctor longns, 14 were treated nonsurgically, and 9 underwent surgical

symphyseal pubic bones secondary to increased strain on the anterior pelvis.“ It is described secondary to chronic

weeks, compared with 12 weeks in the surgical group. No strength deficits were present in either group. {if the

symphysis and later leads to symphyseal pathology.“ This was demonstratcd in a study of pubic rami hone biopsies

fact that favors nonsurgical treatment in these instances.

The specimens showed formation of new woven bone,

repair.2T The nonsurgical group returned to play at 6 surgical group, 2fl% experienced wound complications, a

firthopaedic Knowledge Update: Sports Medicine 5

overuse, resulting in a stress reaction adjacent to the pubic

of athletes in whom osteitis pubis had been diagnosed.”

fl lfllfi American Academy of Orthopaedic Surgeons

|ililtapter 14: Athletic Pubalgiai'flore Muscle Injury and Gram Pathology

Figure E

AP hip radiographs from a collegiate soccer player show bilateral FAI and athletic pubalgia. The preoperative

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

inflammatory cells and no signs of osteonecrosis. Osteitis

of motion. Patients with reduced hip range of motion are also more likely to have osteitis pubis, because it is thought

American football, and distance running.“

Imaging

osteoblasts, and neovasculariaation, with an absence of pubis is seen most commonly in athletes participating in soccer, Australian—rules football, rugby, ice hockey,

to cause compensatory stress at the pubic symphysis.“

Patients often present with lower abdominal pain,

The initial imaging study for the evaluation of osteitis pubis is plain radiography. A wellrcentered AP pelvis radiograph will be normal in acute cases. |Chronic cases

patients who present with athletic pubalgia or adductor

present with cystic changes, sclerosis, or widening of the symphysis. A single-leg stance AP flamingo view of

pubic symphysis and adjacent rami.Em Pain also can be es:-

Widening greater than 7' mm or vertical shift greater

Clinical Presentation

bilateral or unilateral groin pain, andfor pain over the anterior pelvis. Initial symptoms are similar to those in strains. Patients also have tenderness to palpation over the

perienced in the perineal, inguinal, and scrotal regions.“ Patients may report a clicking sensation over the anterior

pelvis with activity. Pain is usually aggravated by running

or cutting activities, loading of the rectus abdominis,

and resisted hip flexion and adduction. Dsteitis pubis is often a chronic condition that can result in an inability to compete in athletics secondary to pain and discomfort.33

{those lasting more than 5 months} of osteitis pubis can

the pelvis can be used to evaluate for pubic instability.

than 2 mm indicates instability at the pubic symphysis.Jij Radiographs also should be evaluated for the presence of FAI, stress fractures, and avulsion injuries” {Figure 6}. MRI will show subchondral bone marrow edema similar to that seen in osteoarthritis of other joints. The edema

is usually bilateral but often will be asymmetric, with increased signal intensity on the more symptomatic side

This presentation is distinctly different from the osteitis pubis presenting with disability during daily activities and

[Figure '5’}. The bone marrow edema will encompass the entire subchondral region of the symphysis from anterior

Physical Examination

related to an avulsion injury. Subchondral cysts and resorption of the subchondral bone also can be present on

a waddling gait, which is seen more typically in females.

Examination findings commonly overlap with athletic

pubalgia and adductor strains and include tenderness to palpation over the pubic symphysis and pubic tubercle, ad-

ductor origin tenderness, and pain during resisted adduc—

don.“ Patients may have apprehension during hip range

IE! lfllfi American Academy of flrthopaedic Surgeons

to posterior, thus differentiating it from isolated edema

l'irIRI.1“I A severe episode of osteitis pubis can show articular erosion in addition to subchondral edema similar

to that seen in patients with osteolysis at the acromioclavicular joint. Healing can be protracted in these more advanced cases.“

Drthopoedic Knowledge Update: Sports Medichie 5

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Treatment

Nonsurgical Treatment Nonsurgical management consists of rest, ice, NSAIDs,

activity modification, corticosteroid or PEP injections,

instituted once pain allows. Patients progress through a

graduated strengthening program with return to activity as tolerated at 45 weeks.

and physical therapy focusing on core strengthening. Cur-

rently, the evidence for nonsurgical treatment of osteitis pubis was diagnosed by physical examination and MRI in 2? professional Australian-rules football players. Treat-

The understanding of athletic pubalgia and groin pathology is constantly expanding. Previously, they were seen as several isolated pathologies, but substantial evidence now

tolerated. Core strengthening and cycling were started at 3 weeks in patients who were relatively pain free. Stair

hip and pelvis disorders as well as other compensatory disorders up and down the kinetic chain in patients pre-

pubis is level IV. In a prospective cohort study, osteitits ment consisted of swimming and upper-body activities as

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stepping was started at 6 weeks, with a graduated running

supports the overlap of intra-articular and extra-articular senting with groin pain. As the ability to diagnose specific

program instituted at 12 weeks. Using this protocol, 39% of the athletes returned to their sport at 1 year, and 100%

groin—related pathology improves, precise treatment of these disorders will help to optimise results and minimise

authors’ practice for osteitis symptoms subside after 1 to 2 years regardless of treatment.

population. Based on the evidence supporting an overlap between athletic pubalgia and PM, athletes presenting

Surgical Treatment

tities. A critical aspect of treating patients with combined

failure of prolonged nonsurgical management. Techniques that are described in the literature for the treatment of osteitis pubis include curettage of the symphysis, wedge resection, mesh reinforcement of the symphysis, arthrode-

require treatment for both entities. This is a challenging

returned at 2. years.“ It is not uncommon in the chapter

The surgical treatment of osteitis pubis is indicated primarily for demonstrable instability on radiographs or

sis of the symphysis using compression plating, and broad

disability times in this challenging and demanding patient

with groin or pelvic pain should be evaluated for both en—

intra-articular hip pathology and athletic pubalgia, adductor strain, or osteitis pubis is deciding whether patients

scenario, because a point likely exists at which treating

FA] alone is inadequate secondary to advanced injury to the anterior pelvic musculature andi'or structures.

pelvic—floor core-muscle proceduresfi‘biii‘”

Key Study Points

Complications

it The key anatomic structures involved in extra”

Complications after surgical treatment of osteitis pubis include hemospermia, scrotal swelling, continued symphyseal instability, and chronic anteflor groin pain?1

Rehabilitation Postoperatively, patients are initially kept nonweight hear— ing. Gentle range-of-motion exercises and stretching are

firthnpaedic Knowledge Update: Sports Medicine 5

articular hip pain should be identified.

1' An understanding of the diagnosis and treatment

of the various causes of extra-articular hip pain is

imperative.

i Key physical examination findings differentiate intra-articular and extra-articular hip pain.

fl lflld American Academy of Orthopaedic Surgeons

Chapter 14: Athletic Pubalgiat'flure Muscle Injury and |Grain Pathulugy

Nufsinger C, Kelly ET: Methudical appruach tn the histury and physical exam af athletic grain pain. Uper Teal:I Sparta Med 2Ufl?;15{4l:152~156. DUI

Annatated References 1. Palisch A, Zuga AC, Meyers WC: Imaging uf athletic puhalgia and cure muscle injuries: Clinical and therapeutic carrelatians. Elia Sparta Med 2013;32{3J:41?—44?.

Medline DUI

This article highlights several camman causes af grain pain in the athlete. The article describes the clinical pre-

10. Mullens FE, Zaga AC, Marrisan WE, Meyers 1WC: Review uf MRI technique and imaging findings in athletic puhalgia and the “spurts hernia“. Eur J Radfuf 1011;S1{121:37’3931'92. Mcdliue DUI This article presents a cumpreheusive, current review uf

sentatiun and MRI findings uf these cummun causes uf

cummuu and uncummun MRI findings in patients with

grain pain. It alsa highlights the averlap af symptams and presentations that these cunditiuns share.

Meyers W, Zuga A,]useph T, et al: lCurrent understanding af care muscle injuries {athletic puhalgia, “spurts hernia”), in Thamas Byrd JW, ed: Dperetiee Hip drthraseapy. New Turk, Springer, 2013, pp EFT-T71 DUI This chapter aims tu clarify suft-tissue injuries in the

pelvis. It explains why spurts hernia is a misnumer and

athletic puhalgia. It alsu evplains an MRI pratacul specifically devised fur the diagnusis af athletic puhalgia.

Level af evidence: V.

11. Zaga AC, Kavanagh EC, |[l'mar IM, et a1: Athletic puhalgia and the “spurts hernia“: MR. imaging findings. Rudialugy lflfifl;24?{3}:?9?—Sfl?. Medline DUI

12. Larsun CM: Sparta herniatathletic puhalgia: Evaluatiun and management. Sparta Health aa14,a{a}:139—144.

describes the camplea anatamy af the pelvis. The chapter alsu stresses the impurtance uf currectly identifying the injured area as intra—articular ur extra—articular.

Medline

This article pravides up-ta-date infarmatian an the averlap af athletic puhalgia and PM. It highlights that patients with cumhined intra-articular and extra-articular pathulugy have impruved uutcumes when buth are addressed. Level uf evidence: 1.".

Draavitch P, Edelstein J, Kelly ET: The layer cancept: Utilizatiun in determining the pain generaturs, pathulugy and huw structure determines treatment. Cu rr Rea Matseulaaltelet Med 1011;5{1}:1-S. Medline

DUI

This article discusses the cumpletr anatamy uf the pelvis in layers. Layer 1 is the asseaus layer, layer 2 is the tissue layer, layer 3 is the cuntractile layer, and layer 4 is the

neurumechanical layer. Level uf evidence: V.

Birmingham PM, La rsun CM: Medial saft tissue injuries uf the hip: Adductur strains and athletic puhalgia, in Kelly ET, Larsun CM, Eedi A, eds: Sparta Hfp Injuries: Diagnaar'a and Managemertt. New Jersey. SLAEK Inc. 2013. This review highlights camman extra-attic ular causes af grain pain, facusing an athletic puhalgia and adductar injuries. Farher A], 1iu'.'i£"ilcltens JH: Sparta hernia: Diagnasis and ther— apeutic appraach. J Am Aeed Grtbap Snrg 20D?:15{S]:50T— .514. Medliue Taylur DC, Meyers WC, Muylau JA, Luhues J, Bassett FH, Garrett WE Jr: Ahdamina] musculature ahnannalities as a cause uf gruin pain in athletes. Inguinal hernias and puhalgia. Arr: ,I Sparta Med 1991:19{3}:139-241. Medline DUI

Meyers WE, Fuley DP, Garrett WE, Lahnes JH, Ma ndle— haum ER: PAIN {Perfarming Athletes with Ahdaminal ur Inguinal Neurumuscular Pain Study Gruup}: Manage-

D01

13. Gilmure UJA: Gilmure‘s grain: Ten years experience uf grain disruptiun—a previuusly unsulved prublem in spurtsmen. Sparta Med Saft Tissue Treasure 1991;1{3}:12-14. Medline

14. Meyers WC, McKechnie A, Philippun M], Hurner MA, Zuga AC, Devun UN: Experience with “spurts hernia” spanning twu decades. Ann Surg 1Dfifl;143{4J:BSS-SSS. 15.

Genitsaris M, Guulimaris l, Silcas N: Laparascapic

repair uf gruin pain in athletes. Arr: j Sparta Med

2Ufl4:32{5}:1233-1242. Medline DUI

16. Kluin J, den Hued PT, van Linschuten R, IJaerman JC, van Steensel C]: Enduscupic evaluatiun and treatment uf gruin pain in the athlete. Am I Sparta Med lfifl4;31{4}:944-949. Medliue DUI 1?. Inguldhy C]: Laparascapic and cunventiunal repair af grain disruptian in spartsmen. Br] Starg 199?:34{2}:213215. Medline [ll-DI 13. Paajanen H, Erinclt T, Hermunen H, Airu I: Laparuseupic surgery fur chruuic gruin pain in athletes is mure

effective than nuuaperative treatment: A randumiaed clinical trial with magnetic resanance imaging at {it} pa-

ment at severe luwer ahdaminal ur inguinal pain in high-

tients with apartsman’s hernia {athletic puhalgia]. Surgery 2fl11:15fl{1}:99-1D1Medline DUI

Litwin DE, Sneider EE, McEnaney PM, Euscuni ED:

This praspective randamiaed trial campared nansurgical treatment with surgical treatment uf athletic puhalgia. Thirty patients were randumizecl intu each gruup after nunsurgical treatment at at least 3 munths duratiun

perfarmance athletes. Am 1 Sparta Med lflflfl:28{1l:2—S. Medline

Athletic puhalgia {spurts hernia}. Clint Sparta Med ZflllafiflilltdrIT-drddr.Medline DUI This article pravides an appraach far the diagnusis and treatment uf athletic pubalgia. It alsu instructs clinicians

haw re use the current infurmatiun and understanding

af grain pathalagy ta accurately diagnase the cause at lawer ahduminal pain syndrame in the athlete. Level af evidence: V.

IE! lfllfi American Academy af flrrhapaedic Surgeans

failed. Uf surgical patients, Slfl‘lrh returned tu spurts at 3 munths, cumpared with 2?% uf the nunsurgical patients at 3 munths. Level af evidence: II.

15'. Larsun CM, Pierce ER, Giveans MR: Treatment uf ath-

letes with symptamatic intra-artieular hip parhalagy and

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Seeders 3.: Hip and Pelvic

athletic pubalgiaisparts hernia: A case series. Artbrascapy

2fl11:2?{6}:?63-??5.Medline DUI

This case series presents 37'" patients wha had camhined femaraacetabnlar impingement {FAI} and athletic pubala

gia. {If patients wha underwent hip arthrascapy far FAI

and athletic pubalgia surgery, 39% were able ta return ta apart, campared with 2.5% wha had isalated athletic

pubalgia surgery and 513% wha had isalated hip arthrascapy. Level af evidence: IV.

ll]. Birmingham PM, Kelly ET, Jacabs R, McGrady L, Wang

M: The effect af dynamic femaraacetabular impinge-

ment an pubic sy mpbysis matian: A cadaveric study. Am

] Sparta Med 1312;40'115 1:1113-1113. Medline DUI

This cadaveric study leaked at pubic symphysis matian in

specimens with FAI. Cam lesians led ta increased matian at the pubic symphysis and were prepased ta cantribute ta athletic pubalgia in patients with FAI. Centralled labaratary study.

21. Andersan K, Strickland SM, Warren E: Hip and grain injuries in athletes. Am I Sparta Med 2001;29l4}:521v533.

Medline

Larsan GM, Birmingham PM, Uliver SM: Athletic pubalgia, in Deiee tit Drea's Drtirapcedic Sparta Medicine: Principles and Practice, dtb Editian. Philadelphia, PA, Elsevier, 1315, pp SSS-STA. This baalc chapter is dedicated tn the anatamy, diagna-

sis and treatment af athletic pubalgia. It discusses key

imaging findings af athletic pubalgia. It alsa discusses nansurgical and surgical treatment af athletic pubalgia. -E

2

cu a. 'a I: rt: EI

H

This case series presents 19 Natianal Faatball League [NFL] players with dacnmented praacimal adductar langus teadan ruptures. Nansu tgical treatment led ta a faster

return ta play with fewer camplicatians than did surgical repair. All players were able ta return ta play in the NFL. Level af evidence: IV.

13. Alrermarlr C, Jahanssan C: Tenatarny cf the adductar langus tendan in the treatment af chranic grain pain in athletes. Am I Sparta Med I??2;20{fi}:64fl-S43. Medline DUI

29. Riaia L III, Salva jP, Schiirhaff MR, Uribe JW: Addue-

tar langus rupture in prafessianal faatball players: Acute repair with suture anchars: A repart af twa cases. Arr:

i Sparta Med assassinate—145. Medline ear

3'3. Rabertsan I], Curran C, McCaffrey N, Shields C], McEntee GP: Adductar tenatamy in the management af grain pain in athletes. fat I Sparta Med lflll;32{1]:45a43. Medline DUI In this case series, IIEIiEI male athletes underwent unilateral tenatamy far the treatment af chranic adductar pain. {If all patients, 91% repartcd impravement after tenatamy.

The pracedure was mast successful far patients wha pre—

sented with severe preaperative pain and disability. Level af evidence: IV.

31. Hiti G], Stevens K], Jamati MK, Garza D, llvlathesan GU: Athletic asteitis pubis. Sparta Med 3011;41i5}:361v3?e. Medline DUI

13. Mann RA, Maran GT, Daugherty SE: |Camparative elec-

This article presents the current understanding af and variaus treatment aptians far asteitis pubis. The authars emphasise the need far future research ta determine the apu'mal treatment af this pathalagy. Invel af evidence: IV.

and sprinting. An: I Sparta Med 1936:14i6}:5fl1-51fl.

32. Gamble JG, Simmans SC, Freedman M: The symphysis

tramyagraphy af the lawer extremity in jagging, running,

Medline DUI

14. Tyler TF, Nichalas S], Campbell R], McHugh MP: The assaciatian af hip strength and flexibility with the incidence af adductar muscle strains in prafessianal ice hacltey players. Am ] Sparta Med lflfl1;39{2}:124-123. Medline 35. Strauss E], Campbell K, Easca JA: Analysis at the crass— sectianal area cf the adductar langus tendan: A descriptive anatamic study. Am I Sparta Med lflfl?;3S[SJ:SSS-999. Medline DUI 25. Weir A, de Vas R], Maen M, Hiilmich P, Tal: Prevalence af radialagical signs af femaraacetabular impingement in patients presenting with lung-standing adductar-related grain pain. Br 1 Sparta Med 201 l:45[l}:6-5. Medline DUI This case series leaked at 34 patients with Iang-standing adductar-related grain pain. Pelvisihip radiagraphs were talren af each patient. Uf all patients, 94% had radiagraphic signs af FAI. Level af evidence: IV. 2'3". Schlegel TP, Bushnell BD, Gadfrey J, Eaublilt M: Success af nanaperative management af adductar langus tendan

ruptures in Hatianal Faetball League athletes. Am ] Sparta Med 2D09;3?{7}:1394-1399. Medline

DUI

Urthnpaedic Knawledge Update: Sparta Medicine 3

pubis. Anatamic and pathalagic cansideratians. Ciir: Ur— tiJap Reict Res 1936;203:261—Efl. Medline

33. Verrall GM, Henry L, Faaaalari NL, Slavatinek jP, Ualteshatt RD: Bane biapsy af the parasymphyseal

pubic bane regian in athletes with chrnnic grain injury demanstrates new waven bane farmatian cansistent with

a diagnasis af pubic bane stress injury. Am I Sparta Med lDflS;35{IE}:2415-2431.Medline DUI 34. Eadie R, Annear P: Use af pubic symphysis curettage far treatment-resistant asteitis pubis in athletes. Am I Sparta Med lflflS;3S{1j:121—IZS. Medline DUI 35. Williams PR, Tbamas DP, Dawnes EM: |EII'steitis pubis and instability cf the pubic symphysis. When nanaperative measures fail. Arr: ] Sparta Med lflflfl;13{3j:35[ll-35.5. Medline 36. Cunningham PM, Brennan D, |D’Eannell M, MacMaban P, U’Neill P, Eustace S: Patterns af bane and saft-tissue injury at the symphysis pubis in saccer players: Ubservatians at MRI. AjH An: I Raeritgeitaf 200?;133i3}:W291-256.

Medline DUI

3?. Grace JN, Sim FH, Shives TC, Gaventry ME: Wedge resectian cf the symphysis pubis far the treatment af asteitis pubis. ] Banejaint Snrg Am 1939;?1l3}:33 3-364. Medline

D 21315 American Academy af Cirrhapaedic Surge-ans

ctio '

Knee and Leg

Chapter 15

Cruciate Ligament Injuries

Lucas 5. McDonald. MD, MPHStTM

Nathan Coleman, MD

Abstract

Andrew [1 Pearle. MD

Anterior Eruciate Ligament Injury

Anterior cruciate ligament iACL} injuries and their

The rate of anterior cruciate ligament [ACL] reconstruc-

injury to the posterior cruciate liagcment {PCL} is rare. A low-grade injury can be successfully managed non-

per lflflflflfl' person—years from 1994 to lflflfi because of

treatment continue to bc intensively studied. Isolated

surgically. The discussion includes the anatomy and function of the ACL and PCL, the evaluation of injuries, surgical techniques for ACL reconstruction and revision including tunnel placement and graft choice, surgical management of the PCL including surgical techniques,

and the association of the PCL with multiligamentous knee injury.

tions in the United States increased from 32.9 to 43.5

an increased number of reconstructions in patients who were women, were younger than 10 years, or were older than 443 years.1 High rates of radiographic osteoarthritis

have been reported after ACL reconstruction, with recent long-term outcomes data demonstrating a threefold in-

crease in prevalence} Predictors for the development of

radiographic knee osteoarthritis after ACL reconstruction include a prior medial or lateral meniscectomy, medial

meniscectomy at the time of reconstruction, elevated body

Keywords: anterior cruciate ligament reconstruction: posterior cruciate ligament reconstruction; revision anterior cruciate ligament

reconstruction Introduction

lCruciate ligament injuries of the knee are common, and

their incidence continues to increase. Current research

focuses on anatomic evaluation, the biomechanics of injury, and reconstruction techniques. Clutcome studies can

guide treatment, but ideal graft locations and surgical techniques have not yet been identified.

mass index, and a relatively long time from injury to surgery}!3 Nonsurgical management of ACL—deficient knees

in active patients does not lead to a satisfactory result,

and a delay of more than 12 months before reconstruction is associated with meniscal and chondral injuries."1 The

cost-effectiveness of early ACL reconstruction is an addi-

tional argument for surgical treatment. The cost to society is $1,5{li} lower, and there is an increase in the patient’s qualityuadjusted lifeuyears when surgical stabilization was

performed within 1 year rather than 2 years after injury.5 Anatomy and Biomechanics

The anatomy of the ACL footprint and the ideal surgical graft position remain areas of active research. Macroscopically, the ACL consists of anteromedial and posterolateral functional bundles (Figure 1}. The anteromedial bundle

is tighter in knee flexion, but the posterolateral bundle is

tighter in extension. Both bundles are under tension during

loading with anterior translation or combined anterior

Dr. Pearle or an immediate family member has received royalties from Biomet; serves as a paid consultant to Biomet and Makofiurgical: has stoclr or stock options held in Bluebelt Technologies; and serves as a board member, owner, officer; or committee member of Bluebelt Technologies. Neither of the following authors nor any immediate family member has received anything of value from or has steel: or stock options held in a commercial company or institution related directiy or indirectly to the subject of this chapter: Dc McDonald and Di: Coleman.

@ lflld American Academy of Drthopaedic Surgeons

translation and internal rotation, with the anteromedial bundle maintaining tension throughout knee flexion. The native ACL inserts on the tibia just anterior to the

posterior part of the anterior horn of the lateral meniscus.

Tibial tunnel placement should include a portion of the

anteromedial bundle footprint to provide optimal graft obliquity. lGraft placement anterior to the footprint notch

can cause impingement in extension or posteriorly can cause impingement on the posterior cruciate ligament (PCLJI.

Orthopaedic Knowledge Update: Sports Medicine 5

to F. :5

re re tn 3

El.

s

Sectibn 3:1iinee andLeg

AM buncla F'L bundle

Figure 1

Schematic drawings shbwing the anterbmedial {AM} and pesterblateral {PL} macrbscbpic

bundles bf the anteribr cruciate ligament (AELIr.

A. The pesterblateral bundle {in blue) is tighter than the anterbmedial bundle in extensibn.

althbugh it is less isbmetric than in flexibn. I. The anterbmedial bundle {in red} is tighter than the pbsterblaterai bundle in flexibn.

A systematic review based bn all studies published since 2030 repbrted radibgraphic findings and arthrbscbpic

landmarks related tb ACL fembral anatbmy.I5 The center

bf the ACL fernbral fbbtprint is 43% bf the distance frbm

the presimal tb distal articular cartilage margin. The cen-

ter bf the anterbmedial bundle is 29.5% bf the prbrcimal tb

distal distance bf the lateral fembral intercbndylar nbtch, and the center bf the pbsterblateral bundle is 50% bf the same distance. The pbsteribr edge bf the ACL is 2.5 mm

frbm the pbsteribr articular cartilage bbrder‘5 {Figure 2}. Histblbgic evaluatibu bf ACL fembral fbbtprint anatbmy is defined by direct and indirect insertibn fibers.

Direct insertibn fibers are rubre critical than indirect insertibn fibers in the prbcess bf linking ligaments tb bbne, and the placement bf recbustructibn tunnels may prbduce a mbre anatbmic ACL recbustructibn. A we

relatibn bf histblbgic and macrbscbpic findings bf ACL DI

cu

._I

T:

l: n: cu Iii-1 I: a:

H

fembral insertibn anatbmy fbund that the ACL inserts

rubre anteribrly bu a macrbscbpic than bu a histblbgic level.T The direct insertibn is in a narrbvv area extending

Figure 2

Schematic drawings representing the anteribr cruciate ligament {AEL} fern bral fbbtprint. The pbsteribr edge bf the ACL is 2.5 mm frbm the pesteribr articular cartilage ipu rple lines]. A. The center bf the AEL fem bral fbbtprint iblaclt dbt albng the red line). is 43% bf the

distance frbni the presimal tn the distal articular cartilage margin. B, The center bf the anterb medial {AM} bundle {bla cit dbt albng

the blue line] is 29-5% bf the distance hen:

the prbirimal tb the distal articular margin. The center bf the pesterblateral {PL} bundle {blade

dbt along the red line) is sess bf the distance

frbm the prbnimal tb the distal articular margin.

frbm the intercbndylar ridge tb a secbnd bssebus ridge 4

Diagnbsis The diagnbsis bf an ACL rupture is made frbrn patient

re the articular cartilage are indirect fibers with a fanlike

sensitive in-bffice examinatibn fbr diagnbsing an acute.

mm pbsteribr. The direct fibers db nbt cbntinue tb the pbsteribr articular cartilage. Pbsteribr fibers that extend attachment? {Figure 3}. Further research is necessary tb determine the best lbcatibn fbr graft placement based bn macrbscbpically visible bundles br histblbgic principles.

flrrhbpaedie Knbwledge Update: Sperm Medicine 5

histbry, physical examinatibn findings, and imaging studies. The Laehman test remains the mbst clinically

cbrnplete ACL rupture. The sensitivity bf the in-bffice pivbt shift test is nbt as high. During an examinatibn

under anesthesia. the Laehman test remains mbre sen-

sitive but the sensitivity bf the pivbt shift test imprbves, and it is the mbst specific physical examinatibn finding

El ll] 16 American Acadeimr bf Cirrhbpaedie Surge-ems

Chapter ’15: lEruciate Ligament Injuries

as determined on physical examination or by patient-re-

ported outcomes.”

Cigarette smoking negatively affects the outcome of ACL reconstruction. Patients who smoked had an increased risk of postoperative anterior translation and knee

instability after ACL reconstruction with bone-patellar

tendon-bone {EPTB} autograft.“ Patients who stopped smoking at least 1 month before ACL reconstruction had

no difference in outcome from patients who had never smoked. Surgeons should consider delaying reconstruc-

tion until patients have stopped smoking tobacco. AEL direct fiber insertion AGL indirect fiber insertion

Schematic drawing depicting the narrow oval-

shaped direct fibers {hash marksl in the anterior

aspect of the anterior cruciate ligament MEL} insertion and the fa n-shaped indirect fibers {dots} in the posterior aspect.

for ACL tears.El MRI can be useful for the diagnosis of ACL disruption or associated meniscal, osteochondral,

Tunnel Placement Multiple techniques exist for drilling ACL tunnels. 1'Iilii'ith

the traditional transtibial endoscopic single-bundle technique from the early 199fls, in some knees the tibial bone

tunnel was placed in the posterior portion of the native

ACL footprint at the posterolateral bundle insertion. This placement can result in a malpositioned femoral tunnel,

with vertical graft placement and femoral insertion su-

perior to and outside of the native footprint. A cadaver comparison of transtibial and independent femoral drilling techniques found that a smaller portion of the

or collateral ligament injury.

tunnel aperture was contained within the anatomic tibial footprint during transtibial drilling.”

increased likelihood of meniscal injury or chondral damageiMedial collateral ligament {MEL} injuries are com-

stibial and anteromedial drilling techniques found that anteromedial techniques created a more anatomic femoral

A delay in AC1. reconstruction is correlated with an

Evaluations of femoral tunnel placement with tran-

monly associated with ACL disruptions. Grade I and II

tunnel position and improved postreconstruction stability

reconstruction. Missed or untreated fibular collateral

and clinical studies rotational stability was superior when

{MEL} injuries are treated nonsurgically, but distal grade III injuries may be best treated with surgical repair or

on the anterior drawer, Lachman, and pivot shift tcsts.1'5*1"' A systematic review found mixed results; in some cadaver

ligament or posterolateral corner knee injuries, which increase the stress on the ACL graft, are common reasons

the anteromedial technique was used, but in other studies there was no difference based on the use of a transtibial

Surgical Treatment

demonstrated slightly higher failure rates 4 years followr ing ACL reconstruction with transtibial techniques than

AC1. reconstruction is unsuccessful.m

or anteromedial technique.” flue registryubased study

IIllutcomes

with anteromedial techniques, hypothesizing a greater

to a competitive level.“ Factors having a positive asso-

femoral tunnel, the goal is to be in the correct position.

1.4,:

femoral tunnels to the anatomic ACL femoral footprint.”

re re tn 3

(July 65% of patients return to their preinjury level of sports after ACL reconstruction, and only 55% return ciation with return to a preiujury level of participation include relatively young age, symmetric hopping ability, male sex, and sports participation at an elite level.11 The desire to return to sports soon after ACL reconstruction

is not always realistic. A 33% rate of successful return

to competitive sports was reported 12 months after ACL

reconstruction with hamstring autograft.ll Although women are at a greater risk than men for

primary ACL disruption, a recent systematic review found

no greater risk among women than men for graft failure, contralateral ACL rupture, or postoperative knee laxity

El Ifllii American Academy of Urthopaedic Surgeons

force placed on this anatomically placed graft.” Although debate exists as to the ideal method for creation of the

The use of flexible guide pins and reamers can be advantageous because they permit transtibial drilling of Although anatomic tunnel placement is possible using anteromedial techniques with rigid instruments, the use of flexible instruments results in longer femoral tunnels

that exit further from the posterior femoral cortex.” Biomechanical evidence supports the importance of an anatomic ACL reconstruction. ACL reconstruction in the center-center position {anatomic} was compared

with reconstruction in the posterolateral-to-anteromedial

Drthopaedic Knowledge Update: Sports Medicine .5

FT. :5

El.

E

Section 3:1l'inee andLeg

[nonanatomicl position}1 With an instrumented Lachman examination, the use of the center-center position

reduced anterior tibial translation from 4.? mm to 2.0

mm following ACL reconstruction. Q.

placement, or failure to treat concomitant pathology.m

Technical challenges during revision ACL reconstruc-

tion include the management of tunnel expansion, need for bone grafting, graft choice, and hardware removal. Weight—bearing plain radiographs, alignment radio-

Video 15.1: Arthroscopic Double-Bundle ACL Reconstruction Using Quadriceps

graphs, MRI, and CT are useful in decision making. Tunnel dimensions that absolutely necessitate bone graft-

nae-Young Lee. lD; ln-Ree Jo. MD; and

although a tunnel diameter exceeding 16 mm typically requires bone grafting."J Removal of the initial implant is

Tendon Autograft. Sung-Jae Kim, IVID; Sui-Gee Rim. MD; Sung-Hwan Kim. MD; Yong-Min Chun, MB {10 min]

Double-Bundle Reconstruction A meta—analysis of randomized controlled studies com—

paring clinical outcomes of ACL reconstruction using

single-bundle or double-bundle techniques found that

double—bundle techniques may improve rotational sta—

bility without adding a substantial clinical benefit.12 Any benefit of an anatomic double-bundle ACL reconstruction is limited to biomechanical findings rather than clinical

ing and staged procedures have not been determined,

not always required during tunnel drilling; it is possible to

avoid a metallic implant located outside the new footprint or to drill through a biocomposite implant. The use of autograft for revision ACL reconstruction leads to better

outcome and activity scores than the use of allograft, and the rate of subsequent graft rupture is almost three times lower when autograft is used?-5

@'

Video 15.4: Pitfalls in AEL Reconstruction. Darren L. Johnson, MD [12 minutes}

outcomes, and it is not known which patients will benefit from this reconstruction technique. Q.

Video 15.2: Revision Single Bundle ACL Reconstruction Using BPTB Autograf't

@'

part 1. Bernard R. Bach. Jr. MD (21 minutes}

Q.

Video 15.3: Revision Single Bundle ACL Reconstruction Using BPTB Autograft

part 2. Bernard R. Bach. Jr. MD {13 min)

@ .

Video 15.6: Anatomical Rectangular Tunnel AEL Reconstruction Using BTB Graft. Ronsei Shino, MD, PhD {1? min}

@'

Video 15.1: ACL Reconstruction Using a Free-Tendon Quadriceps Autograft. John

Revision Surgery

Causes of failure following ACL reconstruction include

recurrent instability, postoperative complications includ

ing infection, or loss of motion and comorbidity from concomitant pathology such as a meniscus deficiency. A

graft rupture rate of 4.5% and a contralateral ACL injury

rate of 15% were reported at 3—year follow-up?-3 There was an increased risk for injury to either knee in patients UI

to

._I

T:

I: m to III-1 I: S:

H

@'

who were younger than 20 years or who had returned

to sports requiring cutting and pivoting. A longer term srucly reported a 23% rate of graft rupture or contralat-

Video 15.5: Anatomic AEL Reconstruction-All Corners. Marl: D. Miller, MD; Joseph Hart, PhD, ATE; and Gregory Hurltis. Medical Student {20 min}

@'

P. Fulkerson, ll (21 min}

Video 15.5: Technique for Harvesting

Hamstring Tendons for ACL Reconstruction. Stephen M. Howell, lv'lD {B min]

Video 15.9: Tips for Harvesting BTB Autograft. K. Donald Shelbourne. ll {13 min)

eral ACL rupture at a minimum 15-year follow-up?1 The

93% rate of expected graft survival at 5 years decreased to 39% at 15 years.

The reasons an ACL reconstruction was unsuccessful must be determined before a revision reconstruction is attempted. Early recurrent instability results from poor surgical technique, failure of graft incorporation, or premature return to high—demand activities. Late recurrent instability usually is the result of trauma, poor graft

flrrhopaedic Knowledge Update: Sports Medicine 5

Graft Selection Several studies have compared hamstring to BPTB auto-

grafts and compared the use of autografts or allografts. The graft choice should be individual to the patient,

with consideration of the research literature. At 15-year

follow-up of ACL reconstruction, hamstring autografts

had an overall survival rate of 33%, and BPTB autografts

El 1016 American AcadMy of Urrhopaedic Surgeons

Chapter ’15: lEruciate Ligament Injuries

had a similar survival rate?“ The size of the hamstring

Rehabilitation and Return to Sport

graft may play a role in the outcome; grafts smaller than

A wide variety of criteria are used to determine readiness

overall risk of revision after ACL surgery was less than

construction, and no consensus criteria exist. However, many surgeons require full motion and normal Lach-

tionsmdg A comparison of outcomes after BPTB or ham—

criteria.” flbjective data on testing and return—to—play

10—year follow-up, although hamstring autografts were

recommend at least 6 months of rehabilitation, an absence of knee effusion, full knee motion, symmetry greater than

3 mm in diameter have a relatively high risk of failure.“ Large Scandinavian and Danish studies found that the .5“ but was significantly higher after hamstring autograft reconstruction than after BPTB autograft reconstrucstring autograft reconstruction in young athletes found no difference in return to preinjury activity levels at 2- to

associated with more complete restoration of knee extension, less radiographic osteoarthritis, and better patient outcomes scores}D Hamstring autograft reconstruction

is more likely to lead to deep surgical site infection than BPTE autograft or allograft reconstruction.3| @'

Video 15.10: ACL Reconstruction Us-

ing Achilles Allograft and Interference Screws. IZolin G. Looney, MD, and William I. Ste-rett, MD [1' min)

a'

Video 15.11: Anatomic Single Bundle ACL

Fteconstruction without Roof and PCL Impingement - Tibialis Allograft. Stephen M. Howell, MD, and fiscar Andres, MD {20 min}

Randomized controlled studies comparing hamstring

autograft and soft—tissue allograft reported no differences for any outcome measures, although one study found

increased laxity with irradiated allograft than with an-

tograft.32 These results were in patients with an average age older than 31] years and may not he applicable in

younger patients. In skeletally mature patients younger

for return to unrestricted sports activities after ACL re-

man, pivot shift, anterior drawer, and proprioception tests without using specific clinical scores as retum-to-play

criteria are not yet available, although most researchers 90% with single-leg hop, and quadriceps strength of 35%

compared with the contralateral side.”

Posterior |Eruciate Ligament Injury No recent studies have defined the incidence of isolated PCL injury, but it is less common than ACL injury.

Emergency department studies report PCL injury in 3Tb”:-

to 44% of knees affected by trauma and in 1% to 3%

of all injured kneesfimr41 PCL injury is often associated with other pathology, with concomitant ligament inju-

ry in up to 95% of high-energy PCL injuries. The most

common causes of FCL injury are motor vehicle crashes involving a motorcycle or dashboard impact, followed by sports—related injuries such as falls onto a flexed knee

with a plantar flexed foot.” Prospective data collected an average 3 years after injury indicated that 40% of patients

had an excellent result with nonsurgical management of an isolated PCL—deficient kneeflar‘” Functional knee scores

had not deteriorated at an average 14-year follow-up, but 11% of patients had moderate to severe radiographic osteoarthritis.

Anatomy and Biomechanics

than 13 years, EPTB allogra fts failed 15 times more often than BPTB autografts; all failures occurred within the

The PCL is stronger than the ACL, has a broader femoral

reconstruction led to less anterior knee pain and better

PCL is to resist posterior displacement of the tibia in all knee flexion angles. The PCL is also a secondary varus,

first year after ACL reconstruction.33 EPTB autograft

attachment, and because of its extrasynovial location, it has better healing potential. The primary function of the

overall International Knee Documentation |Eommittee scores, pivot shift test results, and return to preinjury

valgus, and rotational stabilizer, and it facilitates inter-

to

and posteromedial bundles l[Figure 4}. The anterolateral

m at tn 3

activityr levels than BPTB allograft?I The rates of graft rupture and knee laxity were higher and overall patient satisfaction was lower with BPTB allograft, however. Systematic reviews comparing the outcomes of ACL re—

construction with autograft, nonirradiated allograft tis-

sue, and nonirradiated, nonchemically treated allograft tissue found no difference on any outcome measurefi'lm5

Finally, a comparison of Achilles tendon with anterior tibial tendon allograft found no differences in clinical or laxity testing after ACL reconstruction.”

Eb Ifllti American Academy of Urthopaedic Surgeons

nal rotation of the tibia at higher flexion anglesfii‘Hi The FCL has two functional components, the anterolateral bundle carries more load in flexion, and the posteromedial

bundle carries more load in extension {Figure 5}. The PCL is associated with the meniscofemoral ligaments of Humphrey {anterior} and Wrisberg {posterior}. The femoral insertion of the PCL extends more than 20 mm from anterior to posterior. The antemlateral bun-

dle is more vertical than the posteromedial bundle and inserts on the anterior roof of the intercondylar notch.

Drthopaedic Knowledge Update: Sports Medicine .5

FT. :5

El.

S

Sectien 3:1Cnee andLeg

AL

fibers

leeee

PM fibers light

A Figure 5

Schematic drawings depicting tensiening patterns ef the anterelateral {AL} and

peste remedial {PM} bundles ef the pesterier

cruciate Iiga ment th re ugh a range of metien.

A, The PM bundle with a greater lead than the AL bundle with knee estensien is shewn. B.

The AL bundle with a greater lead than the PM bundle with lrnee flexien is shewn.

Figure 4

Schematic drawings depict the insertien sites ef the antereiateral {AL} and pesteremedial

{PM} bundles ef the pesterier cruciate ligament

iFCLi. A. The PEL insertien en the antereiateral

aspect ef the medial femeral cendyle in the intercendyiar netch is shewn. I. The PEL insertien en the pesterier tibia. 1 cm distal tn the jeint line, is shewn.

The pesteremedial bundle is mere ebliqne, inserting pes-

terierl'f en the lateral wall ef the medial femeral cendjrle.

The PCL and meniscefemeral ligaments cever almest all ef the medial aspect ef the intercendylar netch anterier re DI

a:

._I

T:

r: in re Iii-1 i: s:

H

the medial intercendylar ridge. The anterier margin ei the

PCL is 2 mm frem the articular cartilage.| and the bundle centers are an average ef 11 mm apart”*‘” [Figure 15}.

The tibial insertien ef the PCL is narrewer than the femeral insertien and is in the pesterier intercendylar fessa ef the prestimal tibia. The PCL feetprinr extends

anterierl}F and prea'imall}.r frem the medial meniscus met

and the edge ef the lateral plateau articular cartilage re a peint 1 re 1.5 cm belew the jeint line and distal re the

pesterier esseeus ridge ef the tibial plateau?“ The meat

pesterier distal fibers censist ef the thicker pesteremedial bundle, and the}.F blend with the periestenm and pesterier

flrdtepaedie Knewledge Update: Sperts Medicine 5

Figure 5

Schematic drawing shewing an arth rescepic view at the temeral attachment ef the pesterier cruciate ligament {MEL} in a right

knee. ALE = the antereiateral bundle. aMFL

= the anterier menisce'iemeral ligament.

PM E = the pesteremedial bundle. pMFL = the pesterier meniscefemerai ligament. The PCL and meniscefemeral ligaments ceuer must ef the inte rce ndylar netch anterier tn the medial interce ndyiar ridge.

capsule te insert distal re the esseeus ridge cradling the

anterier prescimal fibers ef the antereiateral bundle. The centers ef these bundles en average are 9 mm apart."3

El ll] 16 American Academe ef Cirthepaedie Surge-ens

Chapter ’15: lEruciate Ligament Injuries

Diagnnsis A I’CL injury can be diagnnsed frnm the patient histnry

and physical examinatinn. Examinatinn maneuvers specific tn the PCL include the pnsterinr drawer and quad-

riceps active tests. The pnsterinr sag sign indicates a PCL

injury. The accuracy, sensitivity, and specificity nf the clinical examinatinn findings fnr PCL injury are greater than 90% .5“ Assessment nf tibial statinn is useful fnr de— termining the severity nf a PCL injury. In the intact state, the medial tibial plateau is apprnximately 1 cm anterinr tn the medial femnral cnndyle. In a grade I injury there

is {1.5 cm nf pnsterinr tibial translatinn, a grade II injury is flush with the femnra] cnndyles, and a grade III injuryr causes tibial translatinn pnsterinr tn the femnral cnn—

dyles. Determining the amnunt nf pnsterinr translatinn is challenging, hnwever, and a simplified grading system has been develnped fnr PCL injuries?1 With the knee in

9D“ nf flexinn, a pnsterinr fnrce is applied tn the tibia. The result is nn tibial nffset in a nnrmal knee, a slight lnss nf anterinr tibial nffset in a grade A injury, a tibia

flush with the femnral cnndyles in a grade Ii- injury, and tibial displacement pnsterinr tn the femnral cnndyles in a

The treatment nf isnlated grade III PCL injuries is cnntrnversial. Snme experts recnmmend acute recnnstructinn nf grade III injuries in ynung athletes nr if nnrmal tibial statinn cannnt be maintained in the presence nf a sncalled peel—nff lesinn. Surgical treatment is recnmmended

fnr a chrnnic grade III lesinn if the patient is symptnmatic.‘9!“~54 There is nn cnnsensus nn graft chnice nr technique fnr repair nr recnnstructinn nf the PCL.“

Avulsinn nf the PCL usually nccurs at the femnral attachment and can be repaired using suture anchnrs nr

femnral bnne tunnels. Large nssenus avulsinn fragments

frnm the tibial attachment can be repaired with np-en

reductinn and screw-and-washer fixatinn.

1|y'arinus surgical techniques permit recnnstructinn nf

the PCL. The tibial inlay technique is usually perfnrmed thrnugh an npen pnsterinr apprnach. The bnne blnclt is recessed and fixed with an interference screw at the pnsterinr tibia, ensuring tn avnid graft prntrusinn. The advantages cf the tibial inlay technique include nssenus

graft healing, avnidance nf sn—called killer turn stresses,

grades I, II and III injuries when cnnsidering treatment nptinns and nutcnmes.

decreased graft wear, and imprnved graft binmechanics. An arthrnscnpie inlay technique using suture buttnn fixatinn nver the tibial-side bnne blnck has been described as cnmbining the advantages nf arthrnscnpie and inlay techniquesfifl In the transtibial technique, the tibial tun-

tained if knee ligament injury is suspected. Radingraphs can reveal PCL tibial avulsinn injury, capsular avulsinn,

under direct arthrnscnpic and flunrnscnpic visualizatinn. The tibial fnntprint is apprnxitnately 7' mm anterinr tn

pnsterinr subluxatinn nf the tibia. Stress radingraphs alsn

imagefif Cadaver binmechanical data revealed nn differ— ence between transtibial and tibial inlay techniques when

grade C injury. Grades A, B, and C injuries cnrrelate with

A cnmplete series nf plain radingraphs shnuld be nb-

nr assnciated fracture as well as resting pnsitinn and any

can be used tn assess PCL disruptinnfil-SJ MRI is used tn

nel is reamed frnm anterinr tn pnsterinr th rnugh the tibia

the pnsterinr tibial cnrtex as seen cm a perfect lateral

determine the ln-catinn and severity nf PCL disruptinn and shnws cnncnmitant meniscal, nstenchnndral, chnndral,

grafts were apprnpriately pretensinned befnre insertinn.“

is present and radingraphs shnw mnre than II] mm nf

tibial inlay techniques nr between arthrnscnpie and npen

and ligament injuries. If grade III pnsterinr tibial laxity pnsterinr subluxatinn, a cnmbined PCL and pnsternlateral cnrner injury shnuld be suspectedfi‘bfi

Treatment and nutcnmes Nnns urgical treatment is recnmmended for a patient with an isnlated grade I nr II injury. The prngram includes

extensinn bracing, prntected weight bearing, and quad riceps strengthening rehabilitatinn. Return tn sp-nrt can

be cnnsidered as early as 2 tn 4 weeks after injury. Twn

natural histnry studies nf nnnsurgically treated isnlated grade I nr II PCL injuries fn und gnu-d subjective and nbjective nutcnmes with nn functinnal deterintatinn and 9Tb“: quadriceps and 93% hamstring strength.“3="“l A T—year fnllnw—up study repnrted that based nn Tegner Activity Level Scale and Lyshnlrn-II Knee Questinnnaire scnres,

92% nf patients with grade I nr II injuries had a gnnd tn excellent result after nnnsurgieal management.”

Eb Ifllti American Academy nf Urthnpaedjc Surgenns

Multiple studies repnrt nn difference in functinnal, radingraphic, nr clinical nutcnmes between transtibial and techniqucsfg'fl'm'fi“

Binmechanical cnmparisnn studies nf dnuble-bundle

and single-bundle PCL recnnstructinn techniques cnn-

cluded that clnuble—bundle recnnstructinn is preferable fnr decreasing pnsterinr tibial translatinn and imprnving rntatinnal restraint?“ Binmechanical advantages were nnt cnrrelated with superinr clinical nutcnmes, hnwever,

and isnlated single-bundle recnnstructinn yields gnnd

lnng-terrn results withnut functinnal differences in cnm-

parisnn with dnuble—bundle recnnstructinn."“‘~""i Summary

Althnugh ACL injury is amnng the must cnmmnnly studied nrthnpaedic injuries, many questinns remain

unanswered. Irrespective nf technique, the gnals nf ACL recnnstructinn include an anatnmic tunnel pnsitinn fnr

Drthnpaedic Knnwledge Update: Spurts Medicine 5

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re re tn 3

El.

E

Sectinn 3:1Cnee andLeg

nptimal binmechanical and clinical nutcnmcs. Return-tn-

3. Li RT, Lnrens 5, Eu Y, Harner CD, Fu FH, Irrgang J]:

hamstring nr BPTB autngraft, althnugh lnwer rates nf

rinr cruciate ligament recnnstructinn. Am I Sparta Med 2fl11:39(12}:1595-26l}3.Medline DUI

play prnfiles are similar after ACL recnnstructinn with

revisinn surgery and Inwer infecticn rates were nbserved with the use nf BPTB autngraft. Allngraft use is an np—

tic-n but requires cautinn in ynung athletes. Further study cf [nag-term entcnmes is needed tn determine the anti-

mal patient age ranges and activity levels fnr each graft

chnice. Mnst PCL injuries can be managed nnnsu rgically, altbnugh surgical recnnstructinn is preferable fer snme higher grade injuries. Differences exist between the bin-

mechanical advantages and patient nutcnmes nf specific surgical techniques.

Key Study Pnints

1* ACL anatnm].r has bnth macrnscnpic and micrnscnpic definiticns, and the chnice cf the best lecaticn

fnr recnnstructinn after injury shnuld cnnsider the native anatnmy.

I: The specifics nf ACL recnnstructinn, including the methnd nf tunnel drilling and the graft chnice, remain debatable. It is impnrtant that the tunnels

be placed cnrrectly. The use nf autngraft may be

preferable tn allngraft in ynung athletes.

1' Mnst isnlated PCL injuries can be nnnsurgically

managed, thnugh sntne higher grade injuries benefit from surgical recnnstructicn. Optimal graft chnice and methncls nf tibial graft attachment remain debatable.

Predictnrs nf radingraphic ltnee nstenarthritis after ante-

Despite decreased instability and imprnved activity levels, patients undergning ACL recnnstructinn were at increased risk fnr ltnee nstenarthritis. Level nf evidence: III. . Fnlc AW, Tau 1WP: Delay in ACL recnnstrnctinn is assnci-

ated with mere severe and painful meniscal and chnn—

dral injuries. Katee Snag Spcrts Ttaametci Artbrnsc

2013:21i4}:928-933.Medline DUI

Delay befnre flCL recnnstructinn was assnciated with an increased incidence nf articular cartilage and meniscus

pathnlngy. Level cf evidence: III.

. Mather RC III, Hettrich CM, Dunn WE, et a1: Cnst-effectiveness analysis nf earlyr recnnstructinn versus reha— bilitaticn and delayed recnnstructinn fnr anterinr cruciate ligament tears. Art: I Spnrts Med 2fl14;42{?]:1533-1591. Medline

DUI

in ecnnnmic and decisinn analysis studyr fnund that early MIL recnnstructinn imprnved quality-adjusted life—years at a lnwer ccst than delayed ACL recnnstructinn after rehabilitatinn and frnm a health system perspective was

the preferred treatment. Level nf evidence: II.

. Piefer JW, Pflugner TR, Hwang MD, Lubnwitz JH: An-

teflnr cruciate ligament fcmnral fn-ntprint anatnmy: Sys—

tematic review cf the 21st century literature. Aflbrcsccpy 2012:23i6}:3?2-831.Medline DUI A systematic review nf basic science studies cnncluded

that the center nf the ACL fnntprint is 43% nf the prmt-

imal—tn—distal length cf the mmnral intercnndylar nnteh

wall and the radius cf the femnral sncltet is 2.5 mm anterinr tn the pnsterinr articular margin.

Annntated References 1. Mall NA, Chalmers PH, Mnric M, et al: Incidence and treflds nf anterinr cruciate ligament recnnstrnctinn in the United States. Am ] Spnrts Med 2U]4;42I[lfl}:2363 -23?0.

Medline DUI

An epideminlcgic study described an increase in the number nf ACL recnnstructinns in the United States between DI

a:

._I

T:

I: as a: III-1 I: a:

H

1994 and lC-‘flfi, particularly in wnmen and in patients

ynunger than 2i] years nr nlder than 43 years.

. Sasaki N, Ishibashi Y, Tsnda E, et al: The femnral insertinn nf the anterinr cruciate ligament: Discrepancy between macrnscnpic and histnlngical nbservatinns. Artbrnscnpy lflllglflifllfllSS-IHE. Medline DCII a basic science study defined the direct and indirect fem. nral insertinns nf the ACL as they cnrt'esp-nnd tn macrnscnpic appearance.

. van Eclt CF, van den Bel-:ernm MP, Fu PH, Pnnlman 11W, Kerkhnffs GM: Methn-ds tn diagnnse acute ante-

rinr cruciate ligament rupture: A. meta—analysis nf phys— ical eaaminatinns with and withnut anaesthesia. Katee

2. Barenius E, Pnnaer 5, Shalabi A, Eujalt R, Nerlén L,

3mg Spnrts Tranmetnf Artbrnsc 2013;21i8]:1395-19i}3. Medline DUI

cruciate ligament recnnstructinn: A 14-year fnllnw-up study nf a re ndnmiaed cnntrnlled trial. Am ,i' Spurts Med 2fl14;42{5 1:1049-1051 Medline DDI

A meta-analysis nf diagnnstic test accuracy cnncluded that the Lachman test is mnst sensitive fnr diagnnsing acute aCL disruptinn in an nffice setting. With the patient under anesthesia, the Lachman test remained the mnst

Erikssnn K: Increased risk nf netenarthritis after anterinr

A threefnld increased incidence cf nstenarthritis was fnund after ACL reccnstructinn ccmpared with the cnntralateral ltnee. Level nf evidence: I.

sensitive, but the pivnt—shift test was mnst specific. Level nf evidence: II.

Sri—Ram K, Salmnn L], Pincaewski LA, Fine JP: The incidence cf secnndary pathnlngy after anterinr

Drdtnpaedic Knnwledge Update: Spnrts Medicine 5

ID ll] 16 American Academy nf Drtbnpaedic Surge-ens

Chapter 15: Cruciate Ligament Injuries

cruciate ligament rupture in .5036 patients requiring lig-

percentage af placements cf the tibial tunnel in an anatamic pasitian.

A retraspective review ta determine the incidence af sec-

16. Hedi a, Musahl V, Steuber V, et al: Transtibial versus anteramedial partal reaming in auteriar cruciate ligament recanstructian: An anatamic and biamechanical evalua-

ament recanstructian. Barre jafnt I 2D13;95-E{1]:59-64. Medline DUI

andary patltalagy with respect ta time between injury and recanstructian faund an increased incidence af medial meniscal tears and chandral damage. Level af evidence: III.

ID. Kamath CV, Redfern JC, Creis PE, Eurlts ET: Revisian auteriar cruciate ligament recanstructian. Am I Sparta Med 1fl11;39{1}:199—21?. Medline DUI

A clinical update an revisian ACL recanstructian reviewed diagnastic and surgical challenges as well as causes af failure ta pravide decisian-malting guidance. 11. Ardern CL, Taylar NF, Feller 13:, Webster HE: Fifty-five per cent return ta campetitive spurt fallawing auteriar cruciate ligament recanstructian surgery: An updated

systematic review and meta—analysis including aspects af

physical functianing and cantextual factars. Br J Sparta Med 2014;4S{21}:1543-1552. Medline DUI A systematic review reparted varied return-ta-sparts rates

after ACL recanstructian; 31% af patients returned tn

tian af surgical technique. Artbraacapy lfl]1:2?l3}:33fl390. Medline

DUI

a cadaver study faund that, campared with transtibial techniques, anteramedial partaI drilling allawed place-

ment af the femaral sachet central in the native faatprint, thus impraving time-aera tibial translatian and pivat shift testing.

1?. Tampkins M, Milewski MD, Brackmeier SF, Gaskin CM, Hart jM, Miller MD: Anatamic femaral tunnel drilling in auteriar cruciate ligament recanstructian: Use af an acces-

sary medial partal versus traditianal transtibial drilling.

Am ] Sparta Med 2012:4flifii:1313~1321. Medline DUI

A cadaver study faund that anteramedial drilling placed the femaral tunnel in the native femaral faatprint mare aften than transtibial drilling.

same apart, but anly 55% returned ta a campetitive-level apart.

13. Chalmers PN, Mall NA, Cale E], Verma NH, Bush-Jaseph CA, Each ER Jr: Anteramedial versus transtibial tunnel

12. Ardern CL, 1Webster BEE, Taylar HF, Feller JA: Return

systematic review. Arrhraacapy 2fl13t29{?}:1235-1242. Medline DUI

tn the preinjnry level af camp-etitive apart after anteriar cruciate ligament recanstructian surgery: Twa-thirds af patients have nat returned by 12 manths after surgery. Ant ] Sparta Med 2011:39f3]:333-543. Medline DUI A case study faund that patients may require [anger than the typically reparted ill-manth return ta spurts after ACL recanstructian. Level af evidence: IV.

13. Ryan J, Magnussen RA, Cax CL, Hurbanelt JG, Planigan DC, Kaeding CC: ACL recanstructian: Da autcames

differ by sex? A systematic review. 1 Base faint Surg Am

2fl14t95{fi}:5fl?-512.Medline DUI

drilling in anteriar cruciate ligament recanatructians: A

A systematic review with a review af cadaver studies campared anteramedial and transtibial drilling techniques far ACL recanstructian. Same studies faund superiarity af anteramedial techniques, and athers faund na differences. Level af evidence: III. 19. Baht-Wagner L, Thillemann TM, Pedersen AB, Lind MC: Increased risk af revisian after anteramedial campared

with transtibial drilling cf the femaral tunnel during pri-

mary auteriar cruciate ligament recanstructian: Results fram the Danish Knee Ligament Recanstructian Register.

Arthrascap'y 2fl13;29{1}:93-1fl5. Medline

DUI

A systematic review and meta-analysis faund na difference in graft failure risk, cantralateral ACL rupture rislt, ar pastaperative ltnee laxity based an the sex af the patient.

A registry—based study camparing revisian rates fallawing

14. Him 5-], Lee 5-K, Kim 5-H, Kim 5-H, Ryu S-W, Jung M: Effect cf cigarette smelting an the clinical autcames af ACL

2.0. Steiner ME, Smart LR: Flexible instruments antperfarm rigid instruments ta place anatamic auteriar cruciate liga-

Level af evidence: II.

recanstructian. 1 Hana faint Sarg rim 2fl14:96{12}:iflfl?-

1fl13. Medline

DUI

A pragnastic study faund that cigarette smalting had a

negative effect an the autcame af ACL recanstructian. Level af evidence: III.

1.5. Keller TC, Tampltins M, Ecanamapaulas K, et al: Tibial

tunnel placement accuracy during anteriar cruciate ligament recanstructian: Independent femaral versus trans-

tihial femaral tunnel drilling techniques. Artbraacapy

satasutsinna—nss. Medline DUI

A cadaver study suggested that transtibial drilling had

ACL recanstructian with femaral tunnels drilled thraugh

transtibial and anteramedial appraaches that demanstrated higher revisian rates with the anteramedial appraach.

ment femaral tunnels withaut hyperflexian. Arthraacapy

2013;23i6}:335-S43.Medline

DUI

A cadaver study faund that the ability ta abtain an anatamic femaral tunnel with transtibial drilling was im-

praved by the use af flexible instruments and langer tunnel length when campated with use cf the same instruments in an anteramedial drilling technique.

31. Hedi a, Maalt T, Musa hl V, et al: Effect af tunnel pasitian and graft site in single-bundle auteriar cruciate ligament recanstructian: An evaluatian af tirne-aera l-tnee stability. AflflfflScflpj} lil]1:2?(11}:1543-1551. Medline DUI

deleterians effects an tibial tunnel pasitian and aperture. Independent femaral drilling was assaciated with a higher

4D Ifllii American Academy af Urtltapaedic Surgenns

Unhapaedic Knawledge Update: Sparta Medicine 5

1-9 FT. :5

rs rs tn 3

CI.

E

Section 3:1Cnee andLeg

A cadaver study found that increased graft size does not compensate for nonanatomic tunnel position or improve time-zero stability of the knee after ACIL reconstruction. Li 'f—L, Hing G—Z, Wu Q, et al: Single-bundle or doua Isle-bundle for anterior cruciate ligament reconstruction: A meta-analysis. Knee 2fl14;11{1}:lS-3?. Medline DD] A meta-analysis comparing single- and double-handle ACL reconstruction techniques found better outcomes

for rotational laxity with double-bundle techniques, but

there were no functional between-group differences. Level of evidence: II.

23. 1|I'ili'ehster RE, Feller JA, Leigh ”WE, Richmond AK: Tfounger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. An: }' Sports Menr 20145433,}:641—641

Medliue DDI

A case-control study determined that patients younger than 2‘3 years are at higher risk for graft rupture and

contralateral ACL injury than older patients after ACL reconstruction. Level of evidence: III.

14. Bourke HE, Salmon L], Waller A, Patterson V, Pincaewski LA: Survival of the anterior cruciate ligament graft and the connalateral AEL at a minimum of 1.5 years. Arr: J Sports Med 1012;4fl{9}:1935-1992. Medliue

DflI

A case study reported an 39% survival rate of ACL grafts

15 years after surgery. The expected survival rate for the contralateral ACL was S?%. Level of evidence: IV.

MARS Group: Effect of graft choice on the outcome of

revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study {MARS} Cohort. Am ] Sports Med 2014;4lllfl}:1301-131l}. Medline DUI A cohort study reported improved sports function and patient—reported outcomes with decreased graft rerupture rates when autograft rather than allograft was used for revision ACL reconstruction. Level of evidence: II.

26. Bourke HE, Gordon D], Salmon L], Waller A, Linklater ], Pinczewski LA: The outcome at 15 years of endoscop-

ic anterior cruciate ligament reconstruction using ham-

string tendon autograft for ‘isolated' anterior cruciate ligament rupture. ] Bone Joint Sarg Br 2011;94l5]:63063?. Medline D-Dl

DI

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I: n: w III-1 I: S:

H

At 15 -year follow-up after ACL reconstruction using hamstring tendon autograft, graft survival was 33%, and Fit of patients had osteoarthritic changes. Level of evidence: IV. 2?. Conte E], Hyatt AE, Gatt E] Jr, Dhawan A: Hamstring autograft size can he predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy 1014;30{?J:SSE-SSD. Medline DUI A systematic review found decreased failure rates in quadrupled hamstring autogra ft with a diameter of more than 3 mm. Level of evidence: IV.

ES. Gifstad T, Foss CIA, Engehretsen L, et al: Lower risk of revision with patellar tendon autografts compared with hamstring autografts: A registry study based on 45,593 primary ACL reconstructions in Scandinavia. Am. I Sports Med 1U14;42{1l}}:1319-2313. Medline

DUI

In a cohort study of Scandinavian patients, ACL reconstruction with patellar tendon autograft led to a lower rate of revision than ACL reconstruction with hamstring autogra ft. Level of evidence: II. 29. Rahr—Wagner L, Thillemann TM, Pedersen AB, Lind M: Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a

nationwide population-based cohort study: Results from

the Danish registry of knee ligament reconstruction. An: I Sports Med 2014;41{2}:2?S-234. Medline DUI A population-based cohort study reported an increased percentage of ACL reconstruction using hamstring autograft and overall good outcomes with both patellar tendon and hamstring autogra ft. There was an increased relative risk of revision ACL reconstruction surgery with ham-

string autograft. Level of evidence: II.

Si}. Mascarenhas R, Tranovich M], Kropf E], Fu FH, Harner CD: Bone-patellar tendon-hone autograft versus ham— string autograft anterior cruciate ligament reconstruction in the young athlete: A retrospective matched analysis with I-lfl year follow-up. Knee Burg Sports Tronmator' Arthrose 1012;Zfl{3_]:1520—152?. Medline DE}!

A casemontrolled therapeutic study comparing hamstring

and BPTS autograft AC1. reconstruction techniques fou ad that TUSS of patients returned to sports. Duly SUSS returned to their preinjury activity level. Hamstring graft reconstruction yielded better motion and outcomes scores, and it led to less radiographic osteoarthritis than EPTE graft reconstruction. Level of evidence: III.

31. Maletis GB, Inacio MC, Reynolds S, Desmond JL, Maletis MM, Funahashi TT: Incidence of postoperative anterior cruciate ligament reconstruction infections: Graft choice makes a difference. An: I Sports Med 2fl13;41{Sl:1?SflITSS. Medline DUI A cohort study reported a DASSS rate of surgical site infection after ACL reconstruction. The risk was 3.1 times

higher after hamstring tendon autograft than after EPTB autograft reconstruction. Level of evidence: II.

32. Cvetanovich GL, Mascarenhas R, Saccomanno MF, et al:

Hamstring autograft versus soft-tissue allografr in anterior cruciate ligament reconstruction: A systematic review and meta—analysis of randomised controlled trials. Arthrosco-

py lflldgdflflfiirldlS—ldld. Medline no:

A systematic review and meta-an alysis reported no signif—

icant difference between ACL reconstruction with ham-

string autograft or soft-tissue allograft in patients with an average age older than 342} years. Level of evidence: II. 33. Ellis HE, I'vIatheny LI'vI, Briggs KK, Pennock AT, Stead-

man JR: Outcomes and revision rate after hone—patellar

tendon-hone allograft versus autograft anterior cruciate

Drrhopaedie Knowledge Update: Sports Medicine 5

El 1016 American AeadMy of Drrhopaedie Surgeons

Chapter IS: lEruciate Ligament Injuries ligament reconstruction in patients aged 13 years or younger with closed physes. Arthroscopy 2013;33j12]:13191325. Medline DUI A retrospective comparative study found no differences in function, activity, or satisfaction between EPTE allograft and autograft for AEL reconstruction in young patients, although allograft reconstruction had a 15 times

39. Mueller LM, Bloomer EA, Durall C]: Which outcome measures should be utilized to determine readiness to play after ACL reconstruction? I Sport Refrain? 2014;23l2}:153154. Modline DUI Uutcome measures to determine readiness for return to play after ACL reconstruction were discussed.

higher failure rate than autograft reconstruction. Level of evidence: III.

40. Fanelli GEE: Posterior cruciate ligament injuries in trauma patients. Arthroscopy 1993;9{3):291-294. Medline DUI

34. Kraeutler M], Bravman IT, McCarty EC: Bone-patellar

41. Fanclli (3C, Edson C]: Posterior cruciate ligament injuries

wndon-hone autograft versus allograft in outcomes of anterior cruciate ligament reconstruction: A meta-a nalysis of .5132 patients. Am I Sports Med 2fl13:41{1flj:2439-244S. Medline

DUI

A meta—analysis concluded that patients who underwent

ACL reconstruction with BPTB autografts had lower rates of graft rupture or knee laxity and better satisfaction than those who underwent ACL reconstruction with BPTE

allograft.

3.5. Mariscalco MW, Magnussen RA, Mehta D, Hewett TE, Flanigan DC, Kaeding EC: Autograft versus nonirradiated allograft tissue for anterior cruciate ligament reconstruction: A systematic review. Am I Sports Med lfll4,42{1j:491-499.Medline DUI

in trauma patients: Part II. Arthroscopy 1995:11j5 1:526529. Medline DUI

4E. Schulz MS, Russe K, Weiler A, Eichhorn H], Strobe] M]: Epidemiology of posterior cruciate ligament injuries. .IlirctilI Urtbop Trunnm Snrg 2003:123l4jflf16-1 91. Medline 43. Shelbourne KD, Muthulcaruppan Y: Subjective results of

nonoperatively treated, acute, isolated posterior cruci-

ate ligament injuries. Arthroscopy lflflS:21{4}:4S?—461. Medline

44.

DUI

Shelbourne K1), Clark M, Gray T: Minimum lfl-year follow-up of patients after an acute, isolated posterior cruciate ligament injury treated nonoperatively. Am I Sports

Med 2G13:41{?j:1SES-1533. Medline DUI

A systematic review compared autografts with nonirradi— ated allografts for AUL reconstruction in patients in their late 20s to early 30s. No differences were reported in graft failure rate, postoperative knee laxity, or outcome scores.

Sixty—eight patients treated nonsurgically for isolated PCL injury were followed prospectively with subjective and objective outcome measures. At an average 14-year fol-

35. Lamblin CI, Waterman ER, Lubowitz IH: Anterior cru-

and had full knee motion. The rate of osteoarthritis was 11%. Lewl of evidence: W.

Level of evidence: III.

ciate ligament reconstruction with autografts compared with nonwirradiated, nonmchemically treated allografts. Arthroscop'y 2fl13;19{6]:1113-1122. Medline

DUI

A systematic review compared outcomes after autograft or non—chemically treated, nonirradiated allograft tissue was used for ACL reconstruction. No statistically significant

differences were found. Level of evidence: III.

37. Kim 5—], Eae J-H, Lim H-fl: Comparison of Achilles and

tibialis anterior tendon allografts after anterior cruciate ligament reconstruction. Knee Snrg Sports Tranmutol Arthrosc ll] 14:11j1}:135 -141. Medline DUI

An outcome study found no significant differences be—

tween outcomes of ACL reconstruction using Achilles tendon or anterior tibial allograft. Level of evidence: III. SS. Petersen W, Zantop T: Return to play following ACL reconstruction: Survey among experienced arthroscopic surgeons [AUA instructors}. Arch Urthop Trauma Surg 2013;133l?):969-9T1Medline DUI Surgeons were surveyed on the outcome measures they used to determine readiness for return tn play after ACL reconstruction. Most surgeons relied primarily on physical examination and motion while considering other factors to a lesser degree.

D 11116 American Academy of Urthopaedic Surgeons

low-up, 44 patients had good strength, remained active,

45. Li G, Papa nnagari R, Li M, et al: Effect of posterior cruciate ligament deficiency on in vivo translation and rotation of the lcnee during weighthearing flexion. Am I Sports Med 19H3;36{3}:4T4-4?S'. Medline DUI 4S. Kennedy HI, Wijdiclcs CA, Goldsmith MT, et al: Kinematic analysis of the posterior cruciate ligament: Part

1. The individual and collective function of the antero-

lateral and posteromedial bundles. Am I Sports Med 1D13j41j11]:1323—1f133.Medline DUI A controlled cadaver biomechanics laboratory study evaluated knees at different flexion angles in the intact, PULdeficient, and PCL-reconstructed state after a single-hundle graft fitted in the anterolateral position. A single-hun-

dle graft was found to reduce ltnee laxity at all angles but not to the intact state.

4?. Amis AA, Gupta: CM, Bull AM, Edwards A: Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Sterg Sports Tranrnntof Arthrosc 1Dfl6;14{3}:25?d263.Medline DUI 4S. Anderson C], Ziegler CG, Wijdiclcs CA, Engebretsen L, LaPrade RF: Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the posterior cruciate ligament. I Bone Joint Surg Am 2012;94{21}:19361945. Modline DUI

Urthopaedic Knowledge Update: Sports Medicine S

P! FT. :15

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A cadaver dissectian study described the anatamy af the PCL in relatian ta relevant anatamic landmarks.

5G. Rubinstein RA Jr. Shelbaurne RD. McCarrallJR. 1ivl'anMeter CD. Rettig AC: The accuracy af the clinical examina-

5D. McAlliater DR. Markalf KL. |Dishes DA. ‘r'aang CR. McWilliams J: A biamechanical camparisc-n af tibial inlay

DDI

51. Marx RC}. Shindle MR. Warren RF: Management af pasteriar cruciate ligament injuries. |Dper Tech Sparta Med 20 09;l?:1t52-1ti ti. DDI Institutianal preferences far treatment af PCL injury ta include patient selectian. surgical timing. preferred surgical technique. graft selectian. rehabilitatian and return ta apart were reviewed. Additianally. previaualy published literature an autcames was reviewed. 52. Jackrnan T. La Prade RF. Panrinen T. Lender PA: Intraabserver and interabserver reliability af the kneeling tech-

nique af stress radiagraphy far the evaluatian af pasteriar

61. Sang E-K. Park H—W. Ahn Y—S. Sean J—R: Transtibial ver— sus tibial inlay techniques far pasteriar cruciate ligament recanstructian: Lang-term fallaw-up study. Am I Sparta

Med amassnsjasaassvi. Medline am

A cahart study faund that the autcames af the tranatibial

63. May JH. Gillette EP. Margan JA. Krycb AJ. Stuart M]. Levy BA: Tra natibial versus inlay pasteriar cruciate ligament recanstructian: An evidence-based systematic review. J Knee Sarg lfl]fl;23{2}:?3-?9. Medline DDI

.54. Harner CD. Hfiher J: Evaluatian and treatment af pasteriar cruciate ligament injuries. Am J Sparta Med 1993;26{3J:4?1-432. Medline

structian were reviewed. Ha differences were faund in clinical results.

DUI

PEL as well as its diagnasis and treatment was reviewed.

.56. Patel D‘v". Allen AA. Warren RF. Wickiewica TL. Simu—

H

61. Zehms CT. Wbiddan DR. Miller MD. et al: Camparisan af a dauble bundle arthrascapic inlay and apEn inlay pasteriar cruciate ligament recanstructian using clinically relevant ta-als: A cadaveric study. Arthraacapy Eflflfigl4i4}:4T2-43fl.Medline Dfll

53. Schulz M5. Steenlage ES. Russe K. Strabel MJ: Distributian af pasteriar tibial displacement in knees with pasteriar cruciate ligament tears. I Barre faint Snrg Arr: EDDTfifi'tljfifl—flfl.Medline DDI

The literature an the anatarny and biamecbanics af the

I: as a: Iii-1 I: a:

tian techniques: Graft pretensian and knee laxity. Am J Sparta Med lflfllflfllfljflll-Lill Medline

and tibial inlay techniques far PCL recanatructian were camparable. Level af evidence: III.

Medline

._I

and tibial tunnel pasteriar cruciate ligament recanstruc-

knee laxity. Am I Sparta Med 2Ufl3;36{3l:15?1—15?6. Medline DDI

55. ‘v’aas JE. Maura C5. Wente T. Warren RF. Wickiewics TL: Pasteriar cruciate ligament: Anatamy. biamechanics. and au'tcames. Am J Sparta Med 2fl12;4fl{1}:212-131.

T:

al inlay dauble-bundle technique. Sparta Med Arthraae 200?;15H]:1?6-133.Medline DD] 59. Campbell RB. Jardan 55. Schiya JR: Arthrascapic tibial inlay far pasteriar cruciate ligament recanstructian. Arthraacapy 2i]U?;23[12]e1356.e1-1356.e4. Medline DDI

tian in the setting af pasteriar cruciate ligament injuries.

cu

ligament recanstructian using a new arthrascapic tibi-

45". MacGillivray JD. Stein BE. Park M. Allen AA. Wickiewicr. TL. Warren RF: lCamparisan af tibial inlay versus transtibial techniques far isalated pasteriar cruciate ligament recanstructian: Minimum 3-year fallaw-up. Arrhraacapy 2Dfl6;22l3}:32fl-323.Medline DUI

Am J Sparta Med 1994:22{4}:550-551 Medline

DI

.53. Jardan 55. Campbell RE. Seltiya JK: Pasteriar cruciate

nian PT: The nanaperative treatment af acute. isalated {partial ar camplete} pasteriar cruciate ligament-deficient knees: An intermediate-term fallaw—up study. H33

__I meanness—14a Medline aai

5?. Hammaud S. Reinhardt KR. Marat RE: Uutcames af pasteriar cruciate ligament treatment: A review af the evidence. Sparta Med Artbraae 2D1Il;13{4l:23{i-291. Medline DUI A systematic review af databases evaluating treatment autcames af isalated PCL injury and multiligament injury knee injury faund na cansensua an treatment af isalated PCL injury ar recanatructian technique. The results af nunsurgical and surgical treatment generally are gaad.

Drrhapaedie Knawledge Update: Sparta Medicine 5

Studies camparing tibial inlay ta tranatibial PCL recan-

64. Panchal HE. Seltiya JR: Dpen tibial inlay versus arthraacapic tranatibial pasteriar cruciate ligament recanstructians. A-rthraacapy 1011;2T{9]:1239—1195. Medline DUI A systematic review af biamechanical and clinical studies camp-ared apen tibial inlay and arthrascapic tranatibial techniques far PCL recanstructian. Level af evidence: IV. 65. Markalf KL. Feeley ET. Jacksan 5R. McAlliater DR: Biamechanical studies af dauble-bundle pasteriar cruciate ligament recanstructians. ] Bane faint Surg Am

2Uflfi;33{3l:1?33-1?94.Medline nai

66. l'vlarkalf KL. Jacksan 5R. McAlliater DR: Single- versus dauble—bundle pasteriar cruciate ligament recanstructian: Effects af femaral tunnel separatian. Am J” Sparta Med 2010;33tfilfll41-1146.Medline DDI A cantralled labaratary cadaver study evaluated the binmechanics af dauble-bundle femaral recanstructian af the PCL. The pasteramedial bundle carries a high laad

in full eatensian.

6?. Markalf KL. Feeley BT. Jacksan 5R. McAlliater DR: Where shauld the femaral tunnel af a pasteriar cruciate

El 1016 American Aeadenty af Drrhapaedie Surge-ans

Chapter 15: lErueiate Ligament Injuries

ligament recnnstrnctinn he placed tn hest restate anternpnsterinr laxity and ligament fnrcesiI Am I Spnrts Med

15.4: Jnhnsnn DH: Pitfalls in ACL Recenstrnctinn [viden excerpt]. Rnsetnnnt, IL, American l'tcademlir nf lCirthnpaedic Snrgenns, 213111}.

I53. Hermans S, Cnrten K, Bellemans J: Lung-term results nf isnlated anternlateral hnndle recnnstrnctinns nF the peeterinr cruciate ligament: A 5- tn 12-year fellnw-up studs. Ant I Spnrts Merl lflfl9;5?{3]:1499-15{11 Medline DUI

15.5: Miller MD, Hart J, Knrlcis G: Anatnntic ACL Recenstrnctinn—-All Centers [viden excerpt]. ll'_."harlnttes'r.rille, VA, 2013.

lflfl6;34{4]:fifl4-511.Medline nnl

15.6: Shine K: Anatomical Rectangnlar Tunnel ACL Recen-

The medium- tn lnng-tetm nutcnmes nf 25 patients with isnlated single-bundle PCL recnnstructinn were evaluated. Level nf evidence: IV.

strnctinn Using BTB Graft [viden excerpt]. |Lil'salta, Japan, 11] ll].

59'. Knhen RE, Selciva JK: Single-bundle versus dnnhle-hnndle

Qnaciricsps Antngrafl [viden excerpt]. Farmingtnn, CT, 5101!].

pnstericu' cruciate ligament recnnstruetinn. ArilerevsttcijzijI 2009;25lllltl4TD-14TT.Medline DUI

A systematic review nf studies cnmparing single- and dnnhle-hnndle PCL recnnstructinn did nnt find either tn be superinr. Level nf evidence: IV.

tilden References 15.1: Kim S], Kim 5G, Kim SH, Lee DY, Jn Iii: Artlrrnscnpis Daniele-Handle AEL Recnnstrnctinn Using Quadriceps Tencic-n Antngraft [viden excerpt]. Easement, IL, American Academy nf Drthnpaedic Snrgenns, 20111}. 15.2: Bach Jc ER: Reeisinn Single Handle ACL Recnnstrnctinn Using HPTE Antngraft, part 1 [viden excerpt]. River Fncest,

15.5“: Fulltersnn JP: AUL Recenstra ctinn Using a Free-Tension

15.5: Harwell 5M: Technique fer Harvesting Hamstring Ten:inns fer ACL Resnnstrnctinn [viden excerpt]. Sacramentn, CA, Hill]. 15.9: Shelhnurne KD: Tips for Harvesting BTB Antngraft [viden excerpt]. hdianapnlis, IN, Zillll. 15.10: Lianne}: CG, Sterett WI: ACL Reennstrnctinn Using .Aelrilles Allngraft and interference Screws [viden excerpt]. Franklin, TN, lfllfl.

15.11: avell SM, Andres O: Anatnrnic Single Bundle ACL Reconstructinn witnnat Rnnfanci PCL l-nipingentent — Tibialis

Allegraft [viden excerpt]. Sacramentn, CA, lfllfl.

IL, lfllfl.

15.3: Each Jr ER: Renisinn Single Bundle ACL Reennstrnetinn

Using EPTB Aatngrnft. part 2 [viden excerpt]. River Fncest,

IL, Ifllfl.

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4D Ifllii American Academy nf flctlinpaedie Snrgenns

Drthnpaedic Knnwledge Update: Spnrts Medicine 5

Chapter 15

Collateral Ligament Injuries

Eduard Alentorn-Geli. MD. MSc. PhD. FEEDT

Joseph I. Stuart. MD

Abstract

The most important research related to the medial

collateral ligament, posteromedial corner, lateral collateral ligament, and posterolateral corner during the

past 5 years includes more than 5'] studies related to the basic science, anatomy, biomechanics, diagnosis,

and treatment of these structures. Most of the studies

involved anatomy or biomechanics {25 studies} or injury

treatment {19 studies}. The most important advances in research into collateral ligament injuries of the knee have involved anatomic identification, biomechanical

testing, and clinical outcomes of anatomic reconstruction of ligament injuries. Keywords: lateral collateral llgament; mecllal collateral ligament: posterolateral corner: posteromeclial corner Introduction

Collateral ligament injuries of the knee are common and challenging to treat. Medial collateral ligament {MEL} and lateral collateral ligament (LCL) injuries often occur

with cruciate ligament injury, and the combined injury Dr. Moorman serves as a paid consultant to or is an em— ployee of HeadTrainer; has stoclr or stock options held in

HeadTrainec Privii: and Hegado; has received research

or institutional support from Torniec Moxlmed. Eetroz. HeadTrainei; and Histogenics; and serves as a board memhec ownec offices or committee member of the Atlantic Coast Conference Team Physicians Society and the Amer— ican Orthopaedic Society for Sports Medicine. None of

the following authors or any immediate family member

has received anything of value from or has stocir or stoclr options held in a commercial company or institution re

lated directly or indirectly to the subject of this article: Dr. Alentorn-Geii. Dr. Stuart and Dr Choi.

@ lfllfi American Academy of Drthnpaedic Surgeons

].H. Iames Choi. MD

Claude T. Moorman III. MD

is even more complex to treat. The number of original

investigations related to collateral ligament injuries has increased in recent years. This chapter reviews the most

important recent research related to the MCL, posteromedial corner (PMC), LCL, and posterolateral corner {PLC} and provides clinical recommendations for treatment of these injuries. The Medial Collateral Ligament

Basic Science The healing potential of the MCL is greater than that of the anterior cruciate ligament {ACL}. An in vitro inves-

tigation found differences in the stem cell characteristics of the MCL and ACL} Specifically, the size and number of ACL—derived stem cell colonies were smaller, and they

grew at a slower rate than MEL—derived stem cell colonies. The MEL-derived stem cells expressed lower levels

of stem cell marker genes than the MCL—derived stem

cells. MIL-derived cells had less potential for adipogen— esis, chondrogenesis, and osteogenesis. Another recent investigation found that gene expression of lysyl oxidases

was higher in MEL fibroblasts than in ACL fibroblasts.2 These enzymes are important for cross-linking between collagen and elastin during injury healing. In response to

transforming growth factor—I31, which is an important mediator of ligament healing, MCL fibroblasts had a higher expression of lysyl oxidases; ACL fibroblasts had

a higher expression of matrix metalloproteinases, which increase the degradation of extracellular matrix?| The same results were observed when the expression of lysyl

1-‘r'

ical mediator of acute inflammatory response in injured

re re tn 3

oxidases and matrix metalloproteinases was compared in response to interleukin-1H, which is an important chemligaments.4 Together, these results show that the MCL has good healing potential because of the growth rate and functioning of its stem cells and the expression of impor-

tant enzymes for ligament healing. These results may explain why isolated MCL injuries have a better response

to nonsurgical treatment than isolated ACL injuries.

Orthopaedic Knowledge Update: Sports Medicine 5

FT. :5

El.

:5

Section 3:1Inee andLeg

Anatomy and Biomechanics

failure and stiffness, followed by the PDL and the deep

The perpendicular mean distance from the saphenous nerve to the adductor tubercle or the medial epicondyle

after all medial knee structures were sectioned for valgus

Three studies recently were published on MEL anatomy.” was found to be 5 cm or 6.1 cm, respectively.j The per—

pendicular mean distance of the sartorial branch of the saphenous nerve to the anterior aspect of the superficial

the meniscus in a healthy MEL and an MEL detached

Minor variations of the insertion sites were found to sig-

the displacement did not significantly differ between the

healthy and the detached MEL.‘ The femoral insertion site of the superficial MEL was found to be a mean 1.6 mm posterior and 4.9 mm proximal to the intersection

between a line paralleling the posterior femoral cortex and a line drawn perpendicular to the posterior femoral cortex, where it intersects the Blumensaat line? Thus,

and posterior tibial translation” [Figure 1}. A subsequent

cadaver study compared superficial MEL anatomic repair

augmented using ipsilateral semitendinosus graft with anatomic reconstruction using bovine digital extensor tendon gra ft.” Both techniques significantly reduced me—

was able to reproduce the behavior of the native intact MEL. Nonanatomic MEL reconstruction using a shorter

in cadavers?” Isolated grade III superficial MEL injury

in a cadaver model resulted in a mean increase of 3.2 mm in medial joint line opening; in the intact state, the

differences based on surgical technique. Neither technique

graft technique produced greater tibial external rotation

during active knee extension and passive stability testing conditions, in comparison with anatomic superficial MEL reconstruction, which restored normal knee kinematics

and stability.15

opening increased to 3.3 mm when the deep MEL and

Treatment of Injuries

3.2. mm of medial joint line opening was established as

was 23 days."5 This time did not significantly differ be-

posterior oblique ligament {PEI'L} were injured and to 13.3 mm when AEL injury was added.'5 A cutoff distance of the basis for suspecting an isolated grade III superficial MEL injury. In another biomechanical study, the MEL and LEL showed no significant difference in stiffness, but

the ultimate tensile strength of the MEL was twice that of the LELf' The MEL was most commonly torn at the

H

reconstruction {superficial MEL and PEIL, Figure 1] completely restored stability for valgus angulation as well as external and internal rotation but did not restore anterior

Several MEL biomechanical studies have investigat~ ed aspects of MEL injury diagnosis, tensile properties,

individual components of the medial complex, and bio~ mechanical characteristics of several surgical procedures

I: ro ru III-1 I: a:

nificantly modify the graft excursion. The anatomic MEL

dial joint space gapping and valgus rotation compared with the sectioned state of the MEL, with no significant

length patterns during gait, structural properties of the

._I

superficial MEL attachment {the most isometric point1.”

intraoperative fluoroscopy can be valuable in treating a chronic tear with an absence of ligament footprint or bony attrition.

T:

only).11 The optimal position for MEL reconstruction

to reproduce native knee kinematics was found at the center of the femoral attachment and the center of the

from the femoral insertion found that only a few fibers of the ligament radiated to the medial meniscus and that

as

angulation, external rotation, internal rotation (from O“ to 60" only], anterior tibial translation {from EC!" to 90" only), and posterior tibial translation {from I)“ to 30“

MEL was 4.3 cm at a point 2 cm distal to the joint line, 4.1 cm at 4 cm distal to the joint line, and 3.3 cm at 6 cm

distal to the joint line. A comparison of displacement of

DI

MEL. A significant increase in displacement was observed

femoral insertion site, and the LEL failed at the fibular attachment {60%} or midsubstance {41] ‘ifsl. In a healthy knee

A recent large epidemiologic study of 346 MEL injuries in soccer players found that the mean return-to-play time tween players with an index injury {13 days} or a reinjury {13 days}. Whether patients underwent nonsurgical or

surgical treatment was not specified, but it can be assumed

that almost all patients received nonsurgical treatment. The outcomes of nonsurgical treatment of recalcitrant

MEL injuries recently were published.” The therapy

the anterior bundles of both the superficial and deep MEL

consisted of an image—guided injection of anesthetic and hydrocortisone beneath the periosteal attachment of the

bundles were distended with knee flexion angles.m The elongation of the posterior bundles peaked at midstance

was observed at a mean 9—month follow—up, and 66% of athletes returned to the previous level of sports competi-

The structural properties of the individual compo— nents of the medial knee ligaments (superficial MEL,

Recent studies related to the surgical treatment of isolated MEL injuries were based on modifications of the

were elongated in flexion during gait, and the posterior and the terminal extension-preswing stance phase.

deep MEL, and POL} were investigated in a controlled

laboratory study.“ The superficial MEL with intact fem— oral and distal tibial attachments had the highest load to

Erdtopaerlic Knowledge Update: Sports Medicine 5

MEL. A significant improvement in pain and function

tion, including professional sports.

surgical techniquem‘i-1 {Table 1}. In the MEL recession

technique for treating symptomatic chronic MEL laxity, a bone block of the medial epicondyle containing

El ll] 16 American AcadMy of Eirrbopaedic Surgeons

Chapter 15: Collateral Ligament Injuries

in the proximal insertion of the deep MCL. None of the

patients had improvement with nonsurgical treatment.

Surgery revealed lack of healing as well as retraction. The surgical repair elicited good results; all patients returned

to spurts and remained asymptomatic at a mean 43—week

follow-up.”

Pasteremedial Corner and Either Combined Injuries Anatomic and Biomechanical Studies

An MRI-based retrospective study found that 31% of patients with a confirmed knee dislocation or a knee dislocatable under anesthesia had an injury to the PMC,

and 63% had a superficial MCL tear alone.“ All patients

with injury to the posterior horn of the medial meniscus

had concomitant meniscotibial ligament injury, and sass had a tear of the PCIL. All patients with grade III [unity of

the MCL had a complete tear of the POL and meniscotibSchematic drawing showing an anatomic medial knee reconstruction. PDL = postetior ohliq ue ligament. sMEL - superficlal medial collateral ligament

the ligament insertion was obtained.“I The bone was removed from the bone window to a depth that would create sufficient tension on the MCL. The bone block was fixed with a cancellous screw and spiked washer.1E|

The results of using this technique were not reported.

Another nonanatomic MCL reconstruction procedure

ial ligament. The researchers concluded that high-grade

medial instability or an MCL tear with an associated

tear of the posterior horn of the medial meniscus should

raise suspicion for I’MC instability.11 A biomechanical study compared injured and intact knees for PCL or PflL injury alone or in combination, before and after reconstruction.“ Reconstruction of the PUL was found

to significantly contribute to a decrease in the posterior

tibial translation of knees with associated PCL injury

and applied valgus and internal rotation moments. The addition of MCL reconstruction did not improve knee kinematics. A nonanatomic reconstruction of the PMC

used a triangular double—bundle allograft. The anterior bundle was placed 4.5 cm distal to the joint line, and the

was done using a double—strand semitendinosus graft.”

the same femoral fixation site in anatomic position“ [Figure 2}. The medial joint line opening and anteromedial

Although most MEL injuries do not require surgical treatment because of the great healing potential of the MCL,

posterior bundle was placed 2 cm below the joint line with

Surgical Treatment

rotatory stability improved after the reconstruction. The

some injuries need to be surgically fixed, particularly if

International Knee Documentation Committee {IKDC}

Subjective Knee Evaluation Form scores {grade A in 59%

and grade B in 36%} represented a significant improve-

ment over scores from the preoperative period. These parameters did not significantly differ between patients who underwent isolated MCL reconstruction and those who underwent MEL plus ACL reconstruction.11 Another study reported the outcomes of the surgical treatment of MCL injuries.HI Anatomic medial knee reconstruction led

to a significant increase in subjective IKDC scores and a significant decrease in medial compartment gapping on valgus stress radiographs."*‘-~'m The natural history and out-

comes of surgical repair of proximal deep MEL injuries have been described.” This subgroup of injuries did not respond well to nonsurgical treatment. Most injuries were

caused by a combined valgus stress and external tibial rotation during sports participation. MRI revealed edema

Eb Ifllti American Academy of flrdmpaedic Surgeons

other ligaments also are injured. The outcomes of surgical treatment of the PMC, with or without injury to the MCL and cruciate ligaments, generally are good {Table 1}. In

a study of a minimally invasive reconstruction of medial

structures with ACL reconstruction, MEL and POL repair was done through advancement and retensioning

pg

well as stability in valgus stress and external rotation was

m rs in 3

of both ligaments proximal to the medial epicondylefM Improvement in subjective and functional outcomes as reported in the postoperative period compared with the preoperative period. A similar surgical technique was used

in patients with acute or chronic grade III ACL or medial knee injury}:T Medial knee injuries were treated with prox-

imal advancement of the superficial and deep MC L, PDL,

and joint capsule {Figure 3). 0f the 13 patients, I” needed

double semitendinosus tendon augmentation to achieve adequate medial-side knee stability.15 The researchers

Drrhopaedic Knowledge Update: Sports Medicine .5

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Sectiun 3:1Cnee audLeg

Chapter 16: Culleternl ligament Injuries

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Dnhnpaedie Knnwledge Update: Sparta Medicine .5

fit Ifllfi American Academy nf flrflmpaedje Surgeens

Sectien 3:1Cnec andLeg

Interference screw

Ailegraft I tibial Phaterier tunnel

4.5 e ' _Anterier tibial tunnel

-

II " .5 an em

Peeterier

Anterier

tibial tunnel

lihial tunnel

A

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

recenstructlen ef the medial cellateral ligament.

Veetue

madialis

Adducter

matinee

F'CI'L Superficial MEL EemirneIriJraneaus

Deep MEL Gracilia Eerritendinesus Sarierius

B

DI

cu

._I

T:

I: in ca Iii-1 I: a:

Figure 3

Schematic medial-view drawings showing the preximal advancement precedure fer peemremedial cerner repair alene {A} and with deuhle semltentlinesus tenden augmentatien {I}. MEL - medlal cellateral Ilga ment, PDL pesterier ehligue ligament.

H

repetted significant imprevenient in radiegraphically as-

scssed valgus larcitjr as well as adequate functien, sperts perferrnance, and satisfactien with surgery. Beth studies fennel geecl results after surgical treatment ef medial knee ininry in patients with a cencemitant ACL tear.

Twe studies reperted the eutcernes ef surgical

flrdiepaedic Knewledge Update: Sparta Medicine 5

treatment ef MCL injnr].r nsing Achilles tenden allegraft in the cement ef cemhined ligament iniuryz'i'” {Table 1}.

The MC L was recenstrncted by fixing the hene hleck ef the Achilles tenden allegraft inte anaternic pesitien in

the femur and fixing the tenden part inte the tibia with a certical screw and spiked washer.16 The MEL was fixed

El ll] 16 American Academe ef Cirthepaedic Serge-ens

Ehapter 15: Enllateral Ligament Injuries

at 10“ nf fleainn and slight varus after recnnstructinn nf

the ACL. The 14 patients had gned functienality, sta-

bility, and return tn preinjnry activity level. A similar technique was used tn cnrrect subacute and chrenic valgus instability in multiliga ment—injured knees thrnugh super—

ficial MEL recnnstructinn.“ 1'llalgus lat-city and functinnal nutcnmes significantlyr impreved after surgeryr en the su-

perficial MEL with the ether injured ligaments. Because

nf cnncerns related tn the difficulty nf the surgical technique, the risk nf infectinn, and the less nf mntinn, seme

surgenns prefer tn use Achilles tendnn allngraft nnly if

multiple ligaments are invnlved and net fnr isnlated MEL injury. The surgical nutcnmes ef MEL recnnstructinn

were repnrted when a nnvel hybrid technique was used

in multiligament-injured knees.IE The MEL was recnnstructed using bnth semitendinnsus tendnn autngraft and

a pnlyester tape (Henligamentsl. The tibial tape pnrtien

nf the graft was reflected tn the anternmedial tibia under

the subcutaneeus tissue after being passed theugh the tibial tunnel {Figure 4]. This recnnstructinn has binme-

chanical prnperties cnmparable tn thnse nf a hens-patellar tendnn-bnne graft fixed with an interference screw, allnws anatnmic tunnel placement, and has gnnd length

and thickness adaptability. Functinn and stability were satisfactnry at an average 1-year fellnw-up.

A study nf the surgical treatment nf PME injuries in—

cluded a cnmparisnn nf repair and recnnstructinn nf beth

the MEL and PUL.” The repair was dnne with suture Viden 15.1: Medial Enllateral Ligament

@I {MEL} Acute Meniscntibial Repair. David Gnrden, MB, EhE, MD; Len Pincaewski, FRACS [9.fl4 min}

anchnrs in injuries less than 4 weeks nld. Repairs ef PME

injury had a higher failure rate than recnnstructinn with autngraft nr allngraft. Therefere, recnnstructinn may be

preferable tn repair ef PME injury.

The rccnmmended surgical technique for PME injuries is the medified Eeswnrth technique, with plicature nf the pnsterinr capsule tn treat injury tn the FEIL. The Lateral Enllateral Ligament .lllinatnmyr and Binmechanics In an anatnmic study, the LEL femnral insertinn site was

identified after anatnmic dissectien and cnrrelated with the radingraphic lncatinn.“ The LEL was feund tn be lncated at 53% nf the width nf the cnndyle frem the anterinr aspect and at 2.3 mm distal tn the file mensaat line,

and there was less than 5 mm variance frem mean values. Annther study determined the relatinnship between the

El Ifllti American Academy nf flrflmpaedic Surgeens

Schematic drawing shewlng an anatnmic

medial cnllateral ligament recnnstructinn using a hybrid technique with semitendinnsus tenden autngraft and a pnlyester tape. The arrnws de me nstrate the directinn ef the cnnstruct,

which is anchnred in the lateral aspect ef the

distal humerus (dashed lines].

LEL femnral insertinn site and the physis nf skeletally

immature cadaver knees.31 The midpeint nf the femnral

nrigin ef the LEL in infants and children was 6.3 mm nr

5.9 mm distal tn the physis. respectively. LEL recnnstruc— tinn is uncnmmnn in patients with npen physes, but this

study allnws preventinn nf iatrngenic injury by imprnving

the understanding nf the spatial relatinnship between the LEL femnral nrigin and the distal femnral physis.

A binmechanical study using a finite element analysis

determined the stress changes ef the LEL at several knee

flexinn angles (0“, 3D“, 60“, 90", and 120“} and translatinn fnrces {anterier-pnsterinr, varus rntatinn, and internalesternal rntatinn]? The LEL was fnund tn shnrten with

increasing knee flexinn and tn be mest vulnerable with

varus mntinn in almnst all evaluated knee flexinn angles.

pg

flexien. A binmechanical cadaver study cnmpared the

re re tn 3

The stress en the LEL increased with anterinr-pnsterinr translatinn and internal-external rntatinn at 3C!“ nf knee varus stability nf isnlated LEL tears after figure—nf—fl recnnstructinn er biceps femeris tenndesis}3 Nine knees

were leaded at 10 him {0" and 30" nf knee fleainn] in three states: with an intact LEL, with a sectinned LEL,

and after recnnstructinn. Beth techniques restnred varus stability at least tn baseline values. The nnrmaliaed varus

displacement was significantly lewer after tenndesis than after figure-ef-E recnnstructinn. The advantage nf this

Eirrhnpaedic Knnwledge Update: Spnrts Medicine 5

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flrflmpafidic Knnwledge Updatc: Sparta Medicine 5

Chapter 16: Cellaternl ligament Injuries

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Dnhnpaedie Knnwledge Update: Sparta Medicine .5

fit Ifllfi American Academy nf flrflmpaedje Surgeens

Sectinn 3:1Cnee andLeg

nnnanatnmic recnnstructinn technique is that it is simple and dnes nnt require allngraft nr autngraft.

related tn tunnel cnllisinn. This study determined that the LCL femnral insertinu site was 1.4 mm prnximal and 3.1

injuries evaluated return tn play in prnfessinnal American fnntball players after nnusurgical nr surgical treatment

PLC recnnstructinn.39"'3 The LCL and pnplitenfibular

surgically treated patients missed an average 14.5 weeks nf play and did net return tn play until the next seasnn.

was mnre impnrtant than the LCL fnr limiting external

nnly an average 2 weeks nf play. Fnur patients returned tn play at an average nf 11'] days, and the remaining patient

suggest that PLC knee injuries nccurring at a high knee flexinn angle may have mnre invnlvement nf the PFL

sample size was limited, the data warrant further research.

ical studies cnmpared recnnstructinn techniques. Varus and external rntatnry laxity were cnmpared in PT and

nf an isnlated grade III LCL injuryM {Table l}. The fnur In cnntrast, the five nnnsurgically treated patients missed

returned tn play the next seasnn. Althnugh the study’s Posters-lateral Corner and Either Ccmhinecl Injuries Anatnmic and Binmechanical Studies

Anatnmic studies have been based en identificatinn nf ligaments invnlved in the PLC and the intertunnel relatinn— ships in multiligament-injnred knees.35'” A recent study detailed the anatnmy nf all structures cf the PLC.“ The LCL was fnund tn be mnre prnximal tn the lateral femnral

epicnndyle (mean, 3.5 mm) than the pnplitens tendnn {PT} insertinn, which was mnre anterinr tn the LCL fnntprint

(mean, 5.? mm] than previnu sly repnrted. The study alsn

specified the length and diameter nf the fabellnfibular, arcuate, nblique pnpliteal, pnsterinr meniscnfemnral, and

pnplitenmeniscal ligaments. The intertunnel relatinnship

in multiligament knee surgery was investigated in three studies. The mnst adequate tunnel angles fnr anatnmic

._I

I: [I'll cu Iii-1 I: a:

H

ligament {PFL} were fnund tn equally limit tibial external rntatinn at lnw flexinn angles {13“ and 30"), and the PFL

rntatinn at fill“ and 90" nf knee flexinn.“I These results {and prnbably the PT} than the LCL. Fnur binmechan‘

LCL recnnstructinn using the pnsterinr tibial tendnn, PT

and PFL recnnstructinn using patellar tendnn and hnne, and PFL and LCL recnnstructinn using the semitendinnsus tendnn.” Nn significant differences were fnund in varns and tibial external rntatinn at fl”, 3D“, 6D“, and

fill“ nf knee flexinn. Nnne nf the three techniques cnuld

achieve the strength nf the native knee. Tibial external rntatinn depended nn whether the PT, PFL, nr bnth were recnnstructed {in an intact LCL mndel}.“3 Sectinning bnth structures significantly increased external rntatinn. The PFL recnnstructinn restnred external rntatinn tn that nf the intact knee at 3!)“ and 90” nf knee flexinn. Hnwever, the PT and PT plus PFL recnnstructinn techniques nvercnnstrained external rntatinn at El“, 311]“, 45”, 60“, 9!)“, and

11!?“ cf knee flexinn. Varus and tibial external rntatinn at

IT, 30", and 60" nf knee flexinn were cnmpared in several

angles fnr anatnmic PLC recnnstructinn were fnu nd tn he

and fibular attachment with an anterinrupnsterinr nr

plane and fl" angulatinn in the cnrnnal plane. A study

ligament-deficient state, but the dnuble femnral tunnel (nne tunnel fnr the PT and annther fnr the LCL} with an

PT drilling at 3i)“ nf angulatinn in bnth axial and cnrnnal planes and LCL drilling at 3D“ angulatinn in the axial

T:

mm pnsterinr tn the lateral epicnndyle.“ Several recent binmechanical studies were related tn

PLC recnnstructinn were determined in CTuassessed, muln

tiligament—injured cadaver kneesfi‘5 Tn avnid cnllisinn with ACL and PCL tunnels, the safest femnral tunnel drilling

as

LCL femnral nrigin may explain differences in angles

Treatment cf Injuries

The nnly recent study nf the treatment nf isnlated LCL

DI

tunnel cnllisinn. It is likely that small variatinns in the

fibularhased recnnstructinn techniques: femnral attachment with a single-tunnel nr dnuble-tunnel technique

nblique tunnel technique.“ All recnnstructinn techniques restnred varns and external rntatinn cnmpared with the

nf the vinlatinn nf the intercnndylar nntch and pntential tunnel cnllisinn in single-bundle nr dnuble-bundle ACL

nblique fibular tunnel was the best technique fnr restnr-

and PT tunnels were 2U“ anterinr and 1C!” prnximal tn the transepicnndylar axis}T Detailed data were prnvided cm

techniques nvercnnstraincd the knee at the evaluated knee flexinn angles. Hnwever, drilling mnre than nne tunnel

nn single—bundle nr dnuble-bundle recnnstructinn and anternmedial nr transtihial femnral tunnel drilling. In a

surgery, especially if tunnel cnmmunicatinn develnps,

tinn nf LCL and ACL tunnels were 4-3“ anterinr angu— latinn in the axial plane and CI” prnximal angulatinn in

were cnmpared in a fibula—based figure—nf—S technique alnne and a cnmbined PT and fibula-based figure-nf-S

specimens fnr the axial plane and twn nf five specimens fnr the cnrnnal plane had a trnchlea vinlatinn withnut a

and tibial external rntatinn stability at 3'3" and 90“ cnmpared with the intact state. Varus stability at 31]" in the

recnnstructinn fnund that the safest angles fnr the LCL

distances and angulatinns in ACL recnnstructinn based similar study, the safest angulatinns tn prevent intersecthe cnrnnal planefi'fl Hnwever, at these angles twn nf six

flrdmpaedic Knnwledge Update: Spnrts Medicine 5

ing native knee kinematics. Nnne nf the recnnstructinn

in the femur may increase the cnmplexity nf a revisinn

and can increase the risk nf tunnel cnllisinn if there is assnciated ACL inju ry.“ Varus and tibial external rntatinn

technique.“ These techniques similarly restnred varus

El 1016 American AcadMy nf Drthnpaedic Surgenns

Chapter 15: Collateral Ligament Injuries

fibula-based reconstruction technique was significantly

lower than in the combined procedure, although it was

not significantly different from that of the intact knee. Diagnostic Studies

An MRI-based study determined the location of bone

bruises in PLC injuries.“ In 23 patients with an isolated

grade III I’LC injury and T4 with a combined ligament

injury, the most common bone bruise location was in the medial compartment. Specifically, bone bruises were

located in the anteromedial femoral condyle in 60% of

patients with an isolated injury and 52% of patients with a combined injury. Bone bruise of the posteromedial tibial plateau also was found in 29% of patients with PLC

and ACL injury. Another diagnostic study classified the peel-off type of acute grade III PLC injury using both MRI and intraoperative arthroscopy in 43 patients.“ A

peel-off injury was found in 19 patients {413%}, of whom 4 (21%} had a type I isolated PT injury, 3 {41%} had a type II combined PT and LCL tear, and Ti [3?%] had a

type III complex tear involving intra substance-based antbr or fibula-based injury. Peel-off injury led to tibial external rotation of more than ID” in 34% of patients and to pos—

itive varus instability in 93% of patients. These injuries could be diagnosed with visualization of the lateral gutter during arthroscopy in 94% of patients.“

Surgical Treatment Two recent studies evaluated the results of surgical treat— ment of isolated PLC injuries‘liv‘ii [Table 2]. In a study of

1? patients with this injury who were treated with ana-

Schematic lateral-view drawing showing the modified biceps femoris rerouting technique fer posterolate ral corner insufficiency. After confirming the isometric point, a 3.2-mm hole was created proximally from the isometric point as long as the radius of a so'ew and washer {9 mm] used for fixation.

combined procedure had excellent return to work and

sporting activity outcomes. Three studies reported the outcomes of surgical treatment of PLC injuries associ-

ry stability, and 19 {91%) had a normal or near-normal IKDC score.” Five of six pediatric patients {mean age,

ated with PULP“fl The outcomes of patients who underwent PCL reconstruction in combination with anatomic PLC reconstruction {LCL and PT} were compared with those of patients who underwent posterior tibial tendon

after an acute avulsion fracture of the femoral attachment of the LCL and PT.“fl At a mean 5-year follow-up, the

to significantly better results in terms of rotatory stability,

Score {KGB 5} quality of life score of SD, and normal knee

patients with PLC and PCL injuries surgically treated with

9."

excellent results in terms of absence of complications,

re re or 3

tomic reconstruction of the PLC {LCL, PT, and PFL] with

hamstring autogra ft, 26 {95 ‘34:.) achieved adequate rotato-

13.3 years) were surgically treated with fragment fixation

patients had a mean Lysholm Knee Questionnaire score of 93, a mean Knee Injury and Dsteoarthritis Dutcome

stability and range of motion. A study of PLC injuries associated with other ligament

injuries compared the surgical outcomes of ACL and PLC reconstruction with those of ACL reconstruction alone‘lif {Table 2}. All PLC injuries were treated with the split biceps tenodesis technique. At a mean 35-month follow-up,

allograft or the split biceps tenodesis technique51 [Figure 3}. The anatomic PLC reconstruction technique led varus stability, Lysholm score, IKDC score, and range of motion than the biceps tenodesis technique. A study of 19 a single-bundle reconstruction of the PCL and a modified Larsson technique for LCL and PFL reconstruction found dial test and varus stress stability, range of motion, and function.5”A comparison of the results of single-bundle

PCL reconstruction with Achilles tendon allograft com-

all patients had a negative dial test, and the Lysholrn, fliDC, and K005 scores had significantly improved com-

bined with a miniopen PFL reconstruction using anterior tibial tendon allograft found significant improvement in

lower after a combination of procedures than after ACL reconstruction alone, but the patients who underwent a

1-year follow-up?“1

pared with preoperative values. Several parameters were

Eb Ifllii American Academy of Urthopaedic Surgeons

posterior tibial translation, tibial external rotation, and

function (as measured using IKDC scores] at a minimum

Drthopaedio Knowledge Update: Sports Medicine .5

5'": :5

El.

s

Sectinn 3:1I'inee andLeg

The recnmmended Surgical technique fnr treating PLE

injuries is the fibula—based, single-bundle, figure-nf-S sem-

itendinnsus autngraft recnnstructinn. @I

Video 15.2: Pnsternlateral Enrner Primary Repair and Recnnstructinn. Ease Based. Marl: D. Miller, MD; Brian E. Werner,

Its-y Study Pnints t’rnntr'rmedj * lsnlated PLE recnnstructinn and PLE recnnstruc-

tinn assnciated with cruciate ligament recnnstruc— tinn lead tn gnnd nutcnmes in terms nf stability and functinn at shnrt-term and midterm fnllnw-up.

MD; Sean Higgins [17345 mini Surnrrlaryr

ments cf the knee are related tn the basic science, anatnmy, and binmechanics nf the MEL and LEL. Many nf

1. Ehaug J, Pan T, Im HJ, Fu Fl-I, Wang JH: Differential prnperties nf human AEL and MEL stem cells may be respnnsible fnr their differential healing capacity. BME Med Efl11;9:63. Medliue DUI

warrant surgical treatment. In general, auatnmic recnn—

flu in vittn study fnund differences in the stem cell characteristics nf the human AEL and MEL, which are related tn differences in healing pntential.

The mnst recent findings nn injury tn the cnllateral liga'

the studies cnrrespnnd tn studies cm the PME nr PLE. These injuries clearly impair knee stability and may

structinn is recnmmended tn achieve knee stability and functinn. Hnwever, clinical studies are needed tn cnmpare anatnmic and unnanatnmic PME nr PLE recnnstructinn befnre definitive cnnclusinns can be drawn. Hey Study Pnints

1* The MEL has gnnd healing pntential thanks tn greater grnwth and functinn nf stem cells and expressinn nf impnrta nt enzymes fnr ligament healing,

as cnmpared with the AEL.

1' Mnst MEL injuries can be treated nnnsurgically,

especially if they are incnmplete nr isnlated jnnt assnciated with PME nr multiligament knee injury}. * Mnre than 3.2 mm nf medial jnint line npem'ng shnuld raise suspicinn fnr a grade III cnmplete tear

in a superficial MEL injury. 1! The MEL and LEL have similar stiffness, but the ultimate tensile strength nf the MEL is twice that

nf the LEL.

as

._I

T:

I: as as III-1 I: M

H

nf lysyl nxidase family in AEL and MEL fibrnblasts after mechanical injury. Injury 2013;44{?j:393-9flfl. Medliue DUI

in in vitrn study fnund higher expressinn nf lysyl nxidase

in the human MEL than in the REL, which is related tn greater healing pntential in the MEL.

. Hie J, Wa ng E, Huang DY, et a1: TGF—betal induces the different expressinns nf lysyl nxidases and matrix metallnprnteinases in anterinr cruciate ligament and medial

cnllateral ligament fibrnblasts after mechanical injury.

J Bins-tech 2fl13;45[5}:390—393. Medline

DEII

An in vitrn study fnund that transfnrming grnwth factnr—Bl induces higher expressinn nf lysyl nxidase in the human MEL than in the PLEL. There is higher expressinn

nf matrix metallnptnteinases in the human AEL than in

the MEL. These findings are related tn a lnwer healing pntential in the AEL than in the MEL. . Elie J, Wang E, Yin L, En E, Zhang Y, Sung KL: Interleultiu-l beta influences nn lysyl nxidases and matrix metal-

lnprnteinases prnfile nf injured anterinr cruciate ligament

results in terms nf knee stability I[valgus angulatinn and external and internal rntatinnj and functinn. 1' The drilling angles in an anatnmic PLE recnnstruc-

em in vitrn study fnu ad that interleukin-1 induces higher expressinn nf lysyl nxidase in the human MEL and higher

tinn tn avnid tunnel cnllisinn with cruciate ligament recnnstructinn are the PT drilled at 311]“ nf angula-

tinn in bnth axial and cnrnnal planes and the LEI.

drilled at 30“ angulatinn in the axial plane and fl” angulatinn in the cnrnnal plane. *I The fibularbased and cnmbined fibular and tibial PLE recnnstructinn techniques allnw adequate res-

tnratinn nf ltnee varus and tibial external rntatinn.

Elrdtnpaedie Knnwledge Update: Spurts Medicine 5 @ ,

. Iie J, Huang W, Jiang J. ct al: Differential expressinus

1' lsnlated anatnmic MEL recnnstructinn, PME recnnstructinn, and MEL recnnstructinn assnciated

with cruciate ligament recnnstructinn have gnnd

DI

Annotated References

and medial cnllatetal ligament fibrnblasts. Int Drrhnp

Efl13;3?[3]:495-505. Medline

DUI

expressinn nf matrix metallnprnteinases in the human

nEL, which are related tn a lnwer healing pntential in the AEL than in the MEL.

. 1i'lii'ijdiclts EA, Westerhaus ED, Brand EJ,Jnhansen 5, Engebretsen L, Laf'rade RF: Sartnrial branch cf the saphennus nerve in relatinn tn a medial knee ligament repair

nr recnnstructinn. Knee Snrg .Epnrts Tmametnl Artbrnsc Efllflflfljflhllflfi-llfliMedline DID] a human cadaver study repnrted the anatnmic relatinnships between the surgical apprnach fnr MEL injuries and

the saphennus nerve with its sartnrial branch.

El 1016 American AcadMy nf Drthnpaedie Surge-ens

Chapter 16: Uellateral Ligament Injuries Stein G, Keebke J, Faymenville U, Dargel J, Miiller LP, Schiffer U: The relatienship between the medial cellateral ligament and the medial meniscus: A tepegraphical and biemechanical study. Surg Eadie! Ana: 1011:33l9]:?63-

166. Medline DUI

A human cadaver study feund that the deep MUL had ne relevant influence en the stability ef the medial meniscus. Hartshern T, Utaredifard K, 1|White EA, Hatch GP III: Radiegraphic landmarks fer lc-cating the femeral erigin

ef the superficial medial cellateral ligament. Am } Sperts

Med sels,41{11}:sssv—ssss. Medline DUI

A human cadaver anatemic and radiegraphic study reperted the exact le-catien ef the femeral attachment ef the superficial MEL using true lateral radiegraphs. LaPrade RF, Bernhardsen A5, Griffith C], Macalena JA, Wijdicks CA: Cerrelatien ef valgus stress radiugraphs

with medial knee ligament injuries: An in vitre bieme—

chanical study. Am I Sperts Med lfllfl:33{2}:33fl-333. Medline DUI

A human cadaver anatemic and radiegraphic study quantified medial cempartment gapping with valgus stress tests based en types ef medial knee injuries. Wilsen ”WT, Deakin AH, Payne AP, Picard F, Wearing 5C: Cemparative analysis ef the structural preperties ef the cellateral ligaments ef the human knee. } Urrbep Spears Phys Ther 2611;42j43:345-351. Medline DUI A human cadaver study cempared the structural preperties

ef the LEL and MEL. Differences were feund in geemetry

and strength but net stiffness.

ll]. Liu F, lUadiketa HR, Keadnek M, et al: In vive length patterns ef the medial cellateral ligament during the stance phase ef gait. Knee Surg Sperts Traumetei Arch-resc2Il11;1 91:5 }:?1 951?. Medline DUI

A human biemecha nical study feund differences in the elengatien ef anterier and pesterier bundles ef the super— ficial and deep MCL du ring gait. 11. Wijdicks CA, Ewart DT, Huckley D], Jehansen 5, Engebretsen L, LaPrade RF: Structural preperties ef the primary medial knee ligaments. Am I Sperts Med 2D1fl;33jflj:1633—1646.Medline DUI

A human biemechanical cadaver study investigated lead

te failure and stiffness ef the superficial and deep MEL and the PUL.

12. Ueebs ER, Wijdicks {3A, Armitage BM, et al: An in vitre analysis ef an anatemical medial knee recenstrucn'en. Am I Spur-ts Med lfllfl;33{2]:339-34T. Medline DUI A human biemechanical cadaver study feund that anaremic medial knee recenstructien cempletely restered valgus and internal-external retatien instability. 13. Feeley ET, Muller M5, Allen AA, Graechi CC, Pearle AD: Isemetry ef medial cellateral ligament recenstructien.

4D 1616 American Academy ef Urthepaedie Surgeens

Knee Surg Sperts Traumarei Arthresc Eflflfiflflfljflfli’fl1032. Medline DUI A human cadaver biemechanical study investigated the isemetry ef anatemic MCL recenstructien. The lewest

graft excursien was feund when the graft was fixed in the center ef the MCL femeral attachment and the center ef the superficial MCL attachment.

14. Wijdicks CA, Michalski MP, Rasmussen MT, et al: Superficial medial cellateral ligament anatc-mic augmented repair versus anatemic recenstructien: An in vitre biemechanical analysis. Am ] Sperrs Med lfl]3;41[12}:23532366. Medline DUI A human cadaver study cempared superficial MCL anaternic repair and anatumic recenstructie-n. Beth tech-

niques significantly reduced medial jeint space gapping

and valgus retatien cempared with intact knees.

15. 1iIi'an den Begaerde JM, Shin E, Neu GP, Marder RA: The superficial medial cellateral ligament recenstructien ef the knee: Effect ef altering graft length en knee kinematics and stability. Knee 3mg Sperts Traumatel' Arthresc lfl11;19{5uppl 11:560-563. Medline DUI

A human biemechanical cadaver study feund that nenanatemic superficial MEL recenstructien led re higher values ef tibial external retatien than anatemic recenstructien. 16. Lundhlad M, 1iLil'aldIE-n M, Magnussen H, Earlssen J, Ekstrand]: The LlEFA injury study: 11-year data cencerning 346 MEL injuries and time tn return te play. Br} Sperts Med 2fl13;4?{12}:?59-T62. Medline DUI A prespective cehert study ef 346 MCL injuries in Eurep-ean seccer players feund that the mean time te return tn play was 23 days. Level ef evidence: II. Drumm U, Chan U, Malliaras P, Merrissey D, Maffulli N: High-velume image-guided injectien fer recalcitrant

medial cellateral ligament injuries ef the knee. Elie Rediei

2fl14;69j5}:e211-e215.Medline DUI

A retrespective case study reperted geed results after image-guided anesthetic and hydrecertisene injectien fer recalcitrant MEL injuries. Level ef evidence: IV. 13. Backes JR, Wiltfeng RE, fiteensen RN: Medial cellateral ligament recessien fer chrenic medial knee laxity. Jlr Knee Surg 2313:26f3}:1?3—133. Medline A surgical technique fer chrenic iselated MEL laxity censisted ef MEL recessien. Eerie black was ebtained frem the femeral erigin ef the superficial MCL, bene was

remeved frem the depth ef the windew, and bene bleck

fixatien was clene in a mere lateral pesitien te increase

tensien.

15'. Narvani A, Mahmud T, Lavelle J, Williams A: Injury te the preximal deep medial cellateral ligament: A preblematical subgreup ef injuries. ] Harte jeint Sarg Br lfllfl;92{?j:94fi953. Medline DUI In a retrespective case study, injury te the preximal deep MCL was identified as having a peer pregnesis. This

Urrhepaedie Knewledge Update: Sperrs Medicine 5

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Sectien 3:1Cnee andLeg

injury may nnt heal easily and may be best treated surgi-

cally. Level nf evidence: IV.

213'. LaPrade RF, Wijdicks EA: Surgical technique: Develnpment nf an anatnmic medial knee recnnstructinu. EH1: Urrliep Eels: Res 2fl12;4?fl{3j:3fl6-314. Medline DO] A prnspective case study ef patients with anatnmic MEL recenstructien {superficial MEL and PDL} fennd geed nutcnmes related tn stability and functinn. Level nf evidence: IV. 21. Dnng JT, |Ehen BC, Men HQ, et al: Applicatinn nf trian-

gular vecter tn functienally recenstruct the medial cnl-

lateral ligament with deuhle~bundle allegraft technique. Artbrnsenpy 2012;23l10]:1445-1453. Medline DUI

A retrespective case study cempared patients with isnlated MEL injury tn these with MEL and ACL injury. Triangular vectnr recenstructien ef the MEL led tn geed stability

and functien. Level ef evidence: IV.

22. Ehahal J, AI—Taki M, Pearce D, Leibenberg A, 1i'i'ihelan DB: Injury patterns re the pesteremedial cerner ef the knee in high-grade multiligament knee injuries: A MRI study. Knee 3mg Spnrts Trenmetnl Artbrnsc 2GID:13{3}:1093IIIH. Medline DUI A retrespective diagnestic study cerrelated MRI—assessed injury patterns in the PME in multiligament knee injuries with examinatinn under anesthesia. Level nf evidence: IV. 23. Weimann A, Schatka I, Herbert M, et al: Recnnstructinn nf the pnsterinr nhlique ligament and lite pnsterinr

cruciate ligament in knees with pnsternmedial instability.

I: re a: III-1 I: :e

H

injured knees with superficial medial cnllateral ligament

recenstructien using Achilles allegrafts: A quantitative analysis with a minimum 2-year fnllnw-up. Am I Spert-s Med 2fl13;41{5j:1fl44-Ifl50. Medline DUI A retrespective case study nf patients with a multiligament

knee injury treated with Achilles tenden allngraft recen—

structien ef the superficial MEL reperted gen-d functienal and valgus stability. Level nf evidence: IV.

2E. Kitamura H, Ugawa M, Kende E. Kitayama S. Tehyama H, Yasuda K: A nnvel medial cnllateral ligament recnnstructinn prncedure using semitendinesus tenden aute-

graft in patients with multiligamenteus knee injuries:

Clinical eutcemes. An: I Sperss Med 2013:41lfijfl2241231. Medline DUI

A retrespective case study nf patients with a multiligament

knee injury treated with a nevel superficial MEL recen—

structien technique cembining semitendinesus tenden autngraft and synthetic tape reperted gnnd functinnal and stability eutcemes. Level nf evidence: IV.

29. Stannard JP, Black ES, Achell E, agas DA: Pnsternmedial cerner injury in knee dislncatiens. I Knee Snrg A retrespective case study nf patients with a knee disln— catien cempared repair and recenstructien ef the PME. Recnnstructinn led tn better stability than repair. Level nf evidence: IV.

DUI

cnnsisting nf minimally invasive MEL and PUL repair in

tu

2?. Liu X, Feng H, Zhang H, et al: Surgical treatment ef suhacute and chrenic valgus instability in multiligament-

A human biemechanical cadaver study reperted gned stability after recenstructien nf the PUL in knees with injury tn the PME and PEL.

A pruspective case study fnund that a nnvel technique

T:

and cembined knee ligament injuries were treated with Achilles tenden allegraft reperted gend medial stability at 2- tn 5-year fnllnw-up. Level nf evidence: IV.

2fl12525{5}:429-434.Medline en:

2fl12;4?fl{3}:?91-292.Medline

DI

A retrespective case study in which patients with MEL

Arthrnscepy 2312;2fllflj:1233-I239. Medline DUI

24. lCanata GL, Ehiey A, Lenni T: Surgical technique: Dnes mini—invasive medial cnllateral ligament and pnsterinr ehlique ligament repair restnre knee stability in cnmbined chrenic medial and AEL injuries? Elie Urrhep Eels: Res

._I

cnmhined knee ligament injury. Eli's: Urthnp Field! Res 2012;4?fl{3}:293-SDS.Medline DUI

Si}. Kamath UV, Redfern JE, Burks RT: Femnral radingraphic landmarks fer lateral cnllateral ligament recenstructien and repair: A new methed ef reference. An: I Sperrs Med 2010;33l3}:5?fl-5?4.Medline DUI A human anatnmic and radingraphic cadaver study identified the femnral nrigin nf the LEL. Intranperative flunrns-

patients with chrenic medial laxity led tn geed stability and functinn. Level nf evidence: IV.

cepy can be used In determine femeral tunnel placement

25. Kega H. Munera T. Yagishita Ii"... Ju Y]. Sekiya 1: Surgical management nf grade 3 media] knee injuries cnmhined wid1 cruciate ligament injuries. Knee Snrg Spnrts Trestmetel Arthrese 2012;20i1j:SS—94. Medline DEII

31. Shea KG, Peleusky JD, Jacebs JE Jr, Ganley T]: Anatem— ical dissectien and ET imaging ef the pesterier cruciate and lateral cnllateral ligaments in skeletally immature cadaver knees. ] Eerie feint Sang Am 2014.;96(9J:253-?59. Medline DUI

A retrespective case study ef presimal advancement ef heth the superficial MEL and the PEL with the underlying deep MEL and jnint capsule in patients with cnmhined cruciate ligament injuries reperted reasnnahle restnratinn ef medial knee stability. Level ef evidence: IV.

2S. Mars: RE, Hetsreni I: Surgical technique: Medial cellat— eral ligament recenstructien using Achilles allegraft Int

Elrrltepaedie Knewledge Update: Sperts Medicine 5

during pesterelateral er LEL recenstructien.

A human anatnmic and radingraphic cadaver study in skeletally immature knees described the relatienship ef the PEL and LEL tn the physeal structures. S2. 2".heng TL. 1Wang Y. 1ilii'ang HP, Reng K. Xie L: Stress

changes nf lateral cnllateral ligament at different knee flexinn with er witheut displaced mevements: A S-dimensienal

El 2016 American AcadMy ef Urthepaedie Surge-ens

Chapter 16: Unilateral Ligament Injuries angulatinn tn avnid tunnel cnllisinn fnr the LEL was 40" anterinr angulatinn in the axial plane and 0" pruximal angulatinn in the cnrnnal plane.

finite element analysis. (Shir: I Tremearnl 2011;14i2]:?933. Medline A binmechanical study investigated stress changes nf the LCL at different knee flexinn angles, with nr withuut dis-

placement mnvements. The LCL was vulnerable tn varus

39. Feeley ET, Muller M5, Sherman 5, Allen AA, Pearle AD: Cnmparisnn nf pnsternlateral cnrner recnnstructinns using cnmputer—assisted navigatinn. Arthrnscnpy Zfllfltlfijfllflflflfltlflfi'fi.Medline DUI

33. Eeitn C, Parks 13G. Tsai M, Hintnn RY: Biceps tenndesis versus allngraft recnnstructinn fnr varus instability. ] Knee

A human binmechanical cadaver study cnmpa red several fibula-based techniques fur PLC injuries. The dnuhle femural tunnel with an nblique fibular tunnel was the best

fnrce and susceptible tn anterinr-pnsterinr translatinn and internal-external rutatinn at 313° nf knee flexinn.

Surg2014:2?{1j:133—13?.Medline but

technique fnr restnri ng native knee kinematics.

A human binmechanical cadaver study fnund that buth

biceps tenndesis and allngraft recnnstt uctinn restnted var. us stability tn baseline values. 34. Bushnell ED. flitting 55. l{Stain JM, Enublik M, Schlegel TF: Treatment nf magnetic resnnance imaging-dncumented isnlated grade III lateral cnllateral ligament injuries

4D. Kim S], Kim HS, Mnnn HK, l[lbs-mg Iilllli'I-I, Kim 5G, Uhun 1t'l'vi: A binmechanical cnmparisnn nf 3 recnnstructinn techniques fnr pnsternlateral instability nf the knee in a cadaveric mndel. Arthrnscnpy ZDID;25{3}:335-341. Medline DUI

A human binmechanical cadaver study cnmpared varus

in Natinnal atball League athletes. Am I Spnrts Med lfllfl;33{l}:SE-91.Medline

DUI

and external rntatinn laxity in PT—LCL. PT-PFL, and PFL— LCL recnnstructinn techniques. There were nu differences in varus and external rntatinn laxity.

A crnss-sectinnal study nf grade III LEI. injuries fnund that nunsurgical treatment led tn mnre rapid return tn

play than surgical treatment.I with an equal likelihnud uf returning tn prnfessinnal-level play. Level nf evidence: III.

35. Usti M, Tschann P, Kiinxel KH, Eenedettu KP: Pusterulateral cnrner nf the knee: Micrnsurgical analysis nf anatnmy and mnrphnmetry. Urthnpedies 2013:36i91m1114-e112fl. Medline DUI

41. Rauh PB, Clancy WU Jr, Jasper LE, lCurl LA, Eelknff S, Mnnrman CT III: Einmechanical evaluatinn nf twn recnnstructinn techniques fnr pnsternlateral instability cf the knee. ,7 Bnne fnirrt Snrg Br 2010:92f1fl}:146{i-1465. Medline DUI A human binmecha nical cadaver study cnmpared fibulabased and cnmhined tibial and fibular tunnel recnnstructinn techniques. Bnth techniques restnrcd varus and tibial external rntatinn stability at 3E!" and 9D" nf knee flexinn.

A human cadaver study detailed the anatnmy nf structures

cf the PMC. with emphasis en the LCL.

36. Gelb-er PE, Erquicia JI, Susa G, et al: Femnral tunnel drill-

ing angles fur the pnsternlateral cnrner in multiligamentary

knee recnnstructinns: IEnmputed tnmngraphy evaluatinn in a cadaveric mndel. Arthrnscn‘py 2fl13;29{2}:15?-265. Medline

43. Lim HC. Bae JI-l. Bae TS, Mnnn BC, Shyam AK, Wang JH: Relative rnle changing of lateral cnllateral ligament en the pnsternlateral rntatnry instability accnrding tn the

knee flexinn angles: A binmechanical cnmparative study

D'UI

nf rnle nf lateral cnllateral ligament and pnplitenfibular ligament. Arch Urtfrup Trauma 3mg 2fl12;132{11}:16311635. Medline DUI

A human anatnmic cadaver study nf intertunnel relatinna

ships in FLC and cruciate ligament recnnstructinn fnund

that the safest angulatinn fnr avniding tunnel cnllisinn was 3D” axial and fl” cnrnnal angulatinn fur the LCL and 3D” angulatinn fnr buth axial and cnrnnal planes fur the PT. 3?. Kim 5], Chang CB, Chni CH, et al: Intertunnel relatinnships in cnmhined anterinr cruciate ligament and pnsternlateral cnrner recnnstructinn: An in vivn 3-dimensinnal anatnmic study. Am J Spnrts Med lfl13;41[4}:349-351 Medline DUI

A human binmechanical cadaver study fnund that the PFL and LCL equally restnred tibial external rntatinn at lnw knee flexinn angles but that the PFL was mnre impnrtant than the LCL at limiting this mnvement at ED” and 9'0". 43. Ehang H. Zhang J. Liu K. et al: In vitrn cnmparisnn nf pnpliteus tendnn and pnplitenfibular ligament recnnstruc-

tinn in an external tntatinn injury mndel cf the knee: A

cadaveric study evaluated by a navigatinn system. Arr:

] Spurts Med 2013:41f9}:1135-2142. Medline

A human anatnmic cadaver study repnrted intertunnel

relatinnships in cnmhined PLC and cruciate ligament

A human binmechanical cadaver study cnmpared PT, PFL, and PT-PFL surgical recnnstructinn techniques fnr PLC

recnnstructinn. The safest angulatinns tn avnid tunnel cnllisinn nf the LCL and PT tunnels were I'll“ anterinr and Ill“ prnximal tn the transepicnndylar axis.

33. Narvy 5]., Hall MP, Kvitne RS, Tibnne JE: Tunnel intersectiun in cnmhined anatnmic recnnstructinn nf the ACL and

pnsternlateral cnrner. Urrhnpedics lfll3:3fi[?l:529—532. Medline DUI

A human anatnmic cadaver study nf intertunnel relatinnships in LCL and ACL recnnstructinn found that the safest

Eb Ifllti American Academy nf Urthnpaedie Surgenns

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injuries. All techniques restnred external rntatinn, but PT and PT-PFL techniques nvercnnstrained the external rntatinn.

44.

Shuler M5. Jasper LE, Rauh PB. Mulligan ME. Mnnrman CT III: Tunnel cnnvergence in cnmhined anterinr cruciate ligament and pnsternlateral cnrner recnnstructinn. Arthrnscnpy lflflfi:21{1}:153-193. Medline

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s

Sectitm 3:1Cnee andLeg

A human cadaver anatnmic study nf tunnel cnliisiun in cnmbined PLC and flCL recnnstructinn feund that tunnel cullisinn is cemmun and that the surgeun shnuld keep a neutral alignment in the cc-rnnal plane, avcid leng tunnels. and direct the lateral tunnel anterinrly in the axial plane nn mnre than 4U“.

A crnss-sectinnal study uf surgical treatment nf PLC injuries fnund that the split biceps tenndcsis technique plus ACL rcccnstructicn impreved functinnal and stability

c-utcemes. Laval af evidence: III.

50. Zcrei {3, Alan: M, Iac-anc- V, Madenna V, Rcsa D, Maffulli

4.5. |Geeslin AG, LaPrade RF: aatinn nf bunne bruises and nther nssenus injuries assnciated with acute grade III isclated and ccmbincd pasteralateral knee injuries. Are ,1 Sparta Med lfllflfifltlllfljfll-ESDE. Medline DD] A retrnspective case study described the lncatinn nf bnne bruises in PLC injuries. Must bnne bruises were lncated

in the medial cumpartmcnt in bath isulated and cumbined PLC cnrner injuries. Lewl cf evidence: IV.

Feng H, Ehang H, Hung L, 1|Wang XS, '3t KB, Zhang

N: Cnmbined PCL and PLC reccnstructicn in chrcnic

pnsternlateral instability. Knee 3mg Sparta Traumatic! Arthrnsc 2fl13521{5}:1fl36-1041. Medline DUI

A retruspcctive case study cf patients treated using the

medified Larsscn technique fer PLC reccnstructic-n and PCL recnnstructinn reperted gnnd results in firms c-f stability and range of mntinn. Level nf evidence: IV.

51. Kim 5], Kim TW, Kim SIG, Kim HP, Chun TM: Clinical cnmparisnns cf the anatnmical recnnstructinn and mud-

ified biceps reruuting technique for chrcnic pusterulateral

J: Femcral peel-eff lesicns in acute pcsterclateral ccrner injuries: Incidence, classificatinn, and clinical characteristics. Arthrnscnpy 2fl11;2?{?}:951-953. Medline DUI

instability ccmbined with pcsteriar cruciate ligament recnnstructic-n. I Bnae Inimt Strrg Am 2D11;93{9}:3fl9 «313. Medline DUI

A retrnspective diagnnstic study described the peel-eff

A crnss-sectinnal study cnmpared the results nf anatnmic and biceps tencdesis techniques fer PLE injuries asscciated

type cf injury, which represents 40% cf PLC injuries.

Level cf evidence: IV.

4?. Jakcbsen B'iV, Lund E, Christianscn 5E, Lind MC: Anatemic tecnnstructinn ef the pesterclateral cerner cf the knee: A case series with isnlated recnnstructinns in 1? patients. drtbruscepy 201 fl:26{?}:913-925. Medline DUI

A retmspective case study cf patients with an isulatcd

PLC injury treated with anatcmic reccnstructic-n with hamstring autngraft fuund gend functinn and stability nutcnmes. Level nf evidence: IV.

43. vnn Heidelten J, Mikkelssnn C, Eustrfim Windhamre H, Janarv PM: Acute injuries tn the pnsternlateral cnrner

cf the knee in children: A case series cf 6 patients. Am

with PCL reccnstrucn'en. Anatcmic reccnstructien had

better functinna] and stability nutcnmes than the biceps tenndesis technique. Level nf evidence: Ill. 52. Ehang H, Hnng L, Wang KS, et al: Single-bundle pers-

terinr cruciate ligament tecuuatructinn and mini-upen

pc-plitecfibular ligament reccnstructicu in knees with severe pnsterinr and pnsternlateral rntatinn instability: Clinical results nf minimum 2-year fnllnw-up. Arthrne-

copy lfllfl:16[4}:503—514. Medline DEII

.6. crass-sectiunal study repc-rtcd the results cf PCL and

minicpen PFL reccnstructic-n. This technique prc-vided gnnd pnsterinr and p-nsternlateral rntatury stability. Level nf evidence: III.

I Sparta Med 2011;39i1fl}:2199-2105. Medline DUI

A retrespective case study cf acute PLE injuries {acute Iemnral avulsinns} in children fnund gnnd functic-nal and

Stability nutcnmes after fragment rcattachrnent. Level nf evidence: IV. 43'. Cartwright—Terry M, Yates J, Tan CH, Pengas IP, Banks

IV, McNichelas M]: Medium—tenn {Svyear} ccmpa risen cf the functinnal nutcnmes nf cnmbined anterinr cruciate ligament and pesternlateral cnrner recnnstructinn cnmpared

with isulatcd antcric-r cruciate ligament recunstructicn.

DI

tu

Arthrnscepy 2014;3{i{?]:311-31?. Medline

Videe References 16.1: Gnrdnn D, Pincaewslti L: Viden. Mediai Unilateral Lig-

ament (MEL) Acute Meeiscutibiai Repair. Sydney, Austalia, 2.012.

16.1: Miller MD, 1Werner ED, Higgins 5: Videc. Pustereiater-

a! Career Primary Repair and Receastrectine. Case Based. Charlnttesville, VA, 2fl14.

DUI

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flrfltepaedic Knnwledge Update: Sparta Medicine 5

El 1016 American Academy at Drthnpaedic Surge-ans

Chapter 17

Patellofemoral Joint Disorders iviiho ].Tanalta.I'vID

John I. Elias, PhD

Andrew I. Cosgarea. MD

Abstract

The evaluation and treatment of patellofemoral disorders

requires a thorough understanding of the multiple factors that can contribute to these conditions. Treatments

should be individualized to address the specific anatomic

or functional deficits of a patient, while taking care to avoid the commonly reported complications that can

. occur with these procedures.

often is exacerbated by mechanical or structural variations that contribute to kinematic alterations within

the joint. In contrast, patellar instability is a partial or

complete displacement of the patella. from the trochlear

groove. The stability of the patellofemoral joint is influenced. by the interaction of multiple anatomic factors that

generally are categorized as static soft-tissue restraints, osteochondral constraints, dynamic restraints, and lower extremity alignment. Anatomy and Biomechanics

Keywords: patellofemoral Instability: medial patellofemoral ligament; tibial tuberoslty osteotomy

The medial patellofemoral ligament {MFFIJ is the pri-

ma ry static restraint to lateral patellar translation within the first 30“ of knee flexion. A cadaver dissection study

described the femoral origin of the MPFL as 9.5 mm

Introduction

The patellofemoral joint is a complex structure in which

distal and 9.5 mm anterior to the adductor tubercle.1 The femoral origin was radiographically described as

a point 1 mm anterior to a line that extends along the

the patella articulates with the femoral trochlea. The patella serves as a fulcrum for the extensor mechanism,

posterior cortex, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the posterior

patellofemoral joint. Disorders of the patellofemoral joint typically arise from joint overload or instability. Joint

the MPFL typically merges with the attachment of the

and as a result, high loads are transmitted across the

overload can he caused by overuse or excessive force and Dr. Eiias or an immediate famiiy member has received

research or institutional support from Meddhape and

has received nonincome support [such as equipment or services}, commerciaiiy derived honoraria, or other non-

research-reiated funding {such as paid travel) from Miteir

and Synthes. Dr. Cosyarea or an immediate family member has received research support from Toshiba and serves as a hoard member. owner: officer: or committee member of the American Academy of Orthopaedic Surgeons. the American Orthopaedic Society for Sports Medicine, and

the Pateiiofemorai Foundation. Neither Dr. Tanaira nor any

immediate family member has received anything of value from or has stock or stock options held in a commercial

company or institution reiated directly or indirectiy to the

subject of this chapter.

@ lfllfi American Academy of Drthopaedic Surgeons

aspect of the Elumensaat line.‘1 On its patellar insertion,

vastus medialis obliquus {VMD} and vastus intermedius tendons and extends to the medial border of the patella.”|

The average width of the MPFL is 1'? mm at its insertion on the proximal two-thirds of the medial border of the

patella. The MPFL remains relatively isometric between

fl“ and T0“ of knee flexion and tension decreases with greater knee flexion.‘

At a flexion angle greater than 3d“, the osteochondral

pg

tients with normal anatomy found that the mean depth

m m in 3

constraint of the trochlea provides primary stability to the patellofemoral joint {Figure 1}. Au MRI study of pa-

of the trochlea was 4.0 mm. This value differed significantly by sex {3.4 mm in women and 4.2 mm in men}.5 The media] facet contributed to 314% of the width of the cartilage covering the trochlea, and the lateral facet contributed to 52.6%. Decreased trochlear depth can

reduce the cffecrivencss of the osteochondral restraint of the patella and contribute to patellar instability. A recent Study using a created cadaver model found that elevating

Orthopaedic Knowledge Update: Sports Medicine 5

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Sectien 3: Knee and Leg

that measurements ef lateral patellar translatien and tilt were cerrelated with a delay in the activatien ef the VMU

in patients with pain and that an increase in the activatien ratie ef the vastus lateralis re the tastes medialis was

asseciated with increased lateral patellar tilt.“

Abnermalities in lewer extremity alignment can influence the kinematics ef the patellefemeral jeint. An MRI—based study feund that measurements of femeral

anteversien and gene valgum were greater in knees with patellar instability than in healthy centre] knees.” In-

creased lateralixatic-n ef the tibial tuberesity relative tn

the trechlear greeve is a cemmen type {if lewer extremity malalignment. Recent studies have decumented the rela-

tienship ef radiegraphic measurements ef malalignment

with patellar pesitien. A study ef patellar kinematics based en MRI at multiple knee fiexien angles feund that

a radiegraphic measurement ef malalignmeut was sig‘

nificantly cerrelated with increased lateral shift and tilt ef the patella in patients with patellar instability]; An in

Figure 1

axial three-dimensienal ET recenstructien

at the knee demenstrates the esteeehendral restraint ef the trechlea previding stability

te the patellefemeral jelnt at flexlen angles greater than 3D“.

the fleer ef the trechlea simulated trechlear dysplasia.‘

Bic-mechanical studies feund that measurements ef trech—

using dynamic cine phase—centrast MRI feund that ad— ministering a meter branch black tn the VMU increased lateral patellar shift during knee extensien.“ The mer-

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greeve. A. study evaluating tepegraphic differences en

instability.“r An earlier biemechanical study alse found a relatienship between patellar height and abnermal pa-

shift at multiple flexicm angles?” Ililienversely, a study

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patellefemeral kinematics by increasing the extent ef knee fiexien befere the patella can engage within the trechlear

knee flexien angles.“3 The Vivifl presides a dynamic restraint te lateral

force applied by the VHS decreases the maximum lateral patellefemeral centact pressure and lateral patellar

T:

The patellar height type ef malalignment influences

lear dysplasia are significantly cerrelated with increased

trauslatieu. In vitre studies feund that increasing the

as

with a tibial tuberesity esteetemy {TTDJ decreased the lateral shift and tilt ef the patella.”

MRI between patients with er witheut patellar insta~ bility feund that radiegraphic measurements ef patellar

lateral patellar displacement and tilt acress a range ef

DI

vitre study feund that reducing tuberesity lateralisatien

phelegy ef the VMD was feund te be cerrelated with its functien. A senegraphy-based study feund a significant difference in the characteristics ef the VMU based en whether a patient had patellefemeral pain.11 The 'msertien level ef the Vhdfl {measured as distance re the preximal

pele ef the patella}, the medial erientatien ef the VMO muscle fibers, and VIVID muscle velume were lewer in

these with parellefemeral pain. The rele ef the Vhdfl in

patellar stability can be assessed in terms ef its relatien-

ship tn the vastus lateralis. A prespective study ef men undergeing military training feund a significant delay in

activatien ef the VMU with respect re the vastus lateralis

in these whe later experienced patellefemeral pain.” A hiemechanical study using weight-bearing MRI feund

flrrhepaedic Knewledge Update: Sparta Medicine 5

height were significantly greater in these with patellar

tellar tracking, with greater lateral shift and tilt ef the

patella in subjects with an increased patellar height index {patella alta}.1’-‘

Clinical Evaluatien

History and Physical Examinatien The primary ebjective in evaluating patellefemeral dys— functien is te differentiate between pain and instability. A clear descriptien ef the patient’s symptems can be helpful

when distinguishing patellar subluxatien frem symptems such as giving way ef the knee because ef pain er weak-r

uess. The mechanism ef injury and the chrenicity, num-

ber, and type ef episedes (dislecatien versus subluxatien] are impertant elements ef the patient’s histery. Knewledge

ef earlier treatments and surgical precedures can aid in determining treatment eptiens.

A systematic examinatien that extends beyend the pateliefemeral jeint can identify multiple facters centributiug te a patient’s symptems. General ligamenteus laxity has been asseciated with an increased risk ef patellar

El 1016 American AcadMy ef Unbepaetlic Surge-ens

Chapter 1?: Patellnfemnral Jnint Disurders

instability” and can be identified using criteria such as

the Beightnn hypermnbility scnre. The assessment nf

alignment begins with the patient in a standing pnsitinn. Alignment cf the lnwer extremity traditinnally has been

quantified with the Q angle, but this measurement shnuld

be used with cautinn because its reliability and validity

have nnt been established. The lateralizatinn cf the tibial

tubernsity is assessed relative tn the axis nf the femur.

Abnnrmalities in alignment such as external tibial tnrsinn and a greater than nnrmal valgus angle at the knee, as

well as the presence nf increased femnral anteversinn,

can effectively increase lateraliaing fnrces nn the extensnr mechanism. Rntatinnal malalignment in particular was fnund tn be a risk factnr in patellar instability.” Excessive

fcmnral anteversinn nften can be detected in hip range nf mntinn, and nften sn-called squinting patellae are present

when the patient stands in neutral pnsitinn {Figure 2}.

Dynamic assessment nf the lnwer extremity includes quadriceps strength. Quadriceps weakness is assnciated

with the presence nf patellnfemnral pain. In unilateral

limb-lnading tests such as single-leg squatting and landing frnm a single-leg hnp, greater dynamic knee valgus

was fnund tn be present in patients with patellnfemnral

pain than in cnntrnl subjects.” Patients with unilateral symptnms had increased dynamic knee valgus angles in the symptnmatic knee cnmpa red with the nnrmal cnntra—

lateral knee. Deficits in hip strength, particularly in hip abductinn and external rntatinn, alsn were assnciated

with the presence nf symptnms.?-1 "aen with patellnfem-

nral pain had less activatinn nf the gluteus medius than cnntrnl subjects during single-leg squat testing. Lack nf flexibility nf the hamstring musculature and tightness nf the ilintibial band {detected using the I.Il'ber test} alsn are

assn-ciated with the presence nf symptnms. Ilintibial band tightness can lead tn excessive lateral retinacular tightness

and decreased medial patellar mnbility. Patellar mnbility is assessed using the glide test. A fnrce is applied in bnth medial and lateral directinns,

and the translatinn is quantified based nn patellar quadr

rants {15% cf the width nf the patella] {Figure 3}. The presence nf twn quadrants nf patellar mntinn is nnrmal,

with variatinn in snme individuals. Cnmparisnn tn the cnntralateral side is useful fnr gauging nnrmal patellar

mntinn in patients with unilateral symptnms. The patellar

tilt test is used tn assess lateral retinacular tightness. A recent study fnund that patients with unilateral patellar

'

Figure 2

gifl'

-__' I"

.u' -

Phctn-graph shnwing squinting patellae.

which are assntiated with excessive fern nral anteversinn and tibial tnrsinn.

actively extends the knee frnm a flexed pnsitinn. Increased

lateraliaatinn during terminal extensinn, called the] sign,

may indicate lnss cf the medial snft—tissue checkreins. A pnsitive apprehensinn test and] sign in the setting nf increased lateral glide can represent a lnss nf patellar

stability. Nut all patients with these clinical signs have in— stability episndes, hnwever. Findings shnuld be cnrrelated

with the patient‘s descriptinn nf symptnms tn determine whether the patellnfemnral jnint is functinnally unsta blc.

instability had increased lateral patellar translatinn and

tilt in bnth knees, and they had greater lateral patellar translatinn and tilt than patients with nnrmal knees.“ In

patients with patellar instability, the apprehensinn sign

can be elicited using a manually directed lateral fnrce cm the patella. Patellar tracking is nbserved as the patient

Eb Ifllii American Academy nf Urthnpaedie Surgenns

Hedingraphy

The radingraphic assessment cf the patellnfemnral jnint includes AP, lateral, and axial views. Patellar height is

assessed nn lateral radingraphs using several different

Drthnpaedic Knnwledge Update: Spnrts Medicine .5

1.4.} FT. 3

m m a: 3

El.

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Secticm 3:1i'2nee andLeg

radingraphie measurements {Figure 4}. The Insall-Salvati

index describes the ratic cf the length {if the patellar

tendnn tn the length cf the patella; an ahnnrrnal value is greater than 1.1L The mndiiied Insall-Saivati index

adjusts fer differences in patellar muirphulugsr by mea-

suring the length {if the articular surface cf the patella

relative to the length nf the patellar tendcin {frcnn the inferier articular surface tn the tuberesitvi; an abnermal

value is greater than 2. The Catnu—Deschamps index al—

lews assessment cif patellar height regardless nf patellar

tendnn length and can be helpful if the patient has had

a TTCI. The l|f.‘.atci~n—]3'eschamps index is calculated by

dividing the distance farm the inferinr articular surface uf the patella tn the anteresuperinr margin nf the tibial plateau b}? the length of the patellar articular surface.

Nnrmal values are less than 1.3. In a lateral radingraph used fer determining patellar height, the knee shnuld be

pcsiticmed in 3i)” c-f flexinu tn allnvv apprc-priate tensicm

an the patellar tendnn. Trnehlear dvsplasia is assessed en lateral radiegraphs

using the Dejc-ur classificatinu {Figure 5 i. The severity,r cf

trcichlear dvsplasia is classified as mild (type A] re severe ltvpe D}, based en the appearance ef the anterier femnral cendvles. Tvpe A dvsplasia is described as a crcssing sign

at the superinr margin nf the truchlea, which cnrrespnnds

re the presence ef a shall-aw trnchlea. Type E is described

as a crnssing sign with a supratrcchlear spur, indicating

Figure 3

Fhetegraph shewing the glide test, in which

fcirce is applied in bath medial and lateral directicns tci assess patellar mchility.

a flat trcchlea. Type C is characterized by the presence at a dnuble-centeur sign in additien tn the cressing sign;

the dnuble ccutnur indicates medial cnndvlar hvpcplasia.

Tvpe D dvsplasia has all three cnmpcnents {the crnssing

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Figure 4

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

flrdinpaedic Knnwledge Update: Sparta Medicine 5

El 1016 American Academir cif Cirrhnpaedie Surgenns

Chapter 1?: Patcllofemoral Joint Disorders

Dream-Trifle B

wallow! Shallow trochlear :- ma” j

, {ire-smug slgn

Eupre li'eehlear spin

Baseball Tire- I: Double

contour

Flat

Drapleah'l'rlfl D

Lateral

Double contour

onnvauily

Glifl Supra

trochlear

spur

l-ig u re 5

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

sign, supratrocblear spur, and doubleucontour sign} and is

years} than those with patellar-based ruptures after a

correlated with a sorcalled cliff pattern, which is a promr inence at the junction of the medial and lateral margins

patellar dislocation event?” Axial CT or MRI studies are used to measure the sul-

LT and MRI

(Figure 6}. The sulcus angle is measured by determining the angle formed by the two lines that connect the ante-

femoral morphology and in particular allows measure ment of patellar tilt and the patellar height index.” MRI

to the deepest point of the trochlear groove. An angle greater than 144“ is considered pathologic. Trochlear

carries on radiation risk. After an acute patellar disloca-

the line through the posterior condylar axis and a second line along the lateral trochlear wall. An angle of less than

and medial patella may be seen on MRI, as is typical with a relocation event. The presence of a large chondral

determined by measuring the angle between the posterior condylar axis and the midpatellar line. An angle greater

repair. MPFL injuryr is identified in most patients who have had a patellar dislocation event. Skeletally immature

ular tightness. The distance between the tibial tuberosity and troch-

of the trochlea.

MRI is comparable to CT in its ability to show patellohas two advantages over CT: it allows chondral lesions and the location of MPFL injury to be identified, and it tion episode, bony edema on the lateral femoral condyle fragment may suggest the necessity of an early surgical

patients are most likely to sustain a patellar-side injury.

Those with femoral—based ruptures of the MPFL have been found to he older (25.? +l'- 9.1 versus 19.? +!- 6.1

El Ifllli American Academy of flrflinpaedie Surgeons

cus angle and trochlear inclination in trochlear dysplasia

rionnost points of the medial and lateral femoral condyles inclination is determined by measu ring the angle between

to

11" indicates trochlear dysplasia. Lateral patella: tilt is

re re a: 3

than Zfl" is pathologic and may indicate lateral retinac-

lear groove {the TTTG dista ncel is measured as the lateral

distance between the deepest portion of the trochlear groove and the apes: of the tibial tuberosity, on a line

Drrhopaedic Knowledge Update: Sports Medicine 5

F. :5

El.

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Sectic-n 3:1Enee and Leg

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

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

traditiunally is used far this measurement, but MRI alsn has been used. Hewever, MRI may underestimate the TTTG distance by 2.3 mm, and this pussibility shuuld be

cunsidered when determining surgical treatment}5 Vari— ability in the TTTG distance has been identified based cm differences in measurement techniques. An MRI study

cif patients withuut patellar instability fuund that the T'TTG distance decreased as patients flexed the knee.it Patients-specific facturs alsu have an influence. A currela—

tiun was repurted between TTTG distance and the age and height pf the patient.“ TTTG distance increased as

a functiun cif height regardless [if whether the patient had

patellar instability. The TTTG distance was fuund tp decrease with increasing age in patients with instability. Because c-f the variability in TTTG distances, the distance

from the tibial tuberusity tn the medial border pf the pustericir cruciate ligament has been prnpused as an alterDI

cu

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native measurement fur determining malalignment.“ This

technique uses nvu landmarks en the tibia and thereby eliminates the influence {if the knee flexibn angle as well

as the difficulty uf measuring TTTG distance in patients

with severe truchlear dysplasia. Further study is needed tn validate the applicability cif the tibial tuberusity—pnsterinr

cruciate liga ment distance in determining indicatinns fer

tuberusity usteutumy {TTU}. Dynamic CT and MRI recently have been used In allnw nbjective evaluatinn nf patellnfemnral mntinn and tracking. Dynamic kinematic MRI was used in a study uf patients with at withuut patellar instability, in which

flrdtnpaedic Knnwledge Update: Sparta Medicine 5

Figure 7

CT axial image shuwing measurement at the tibial tuberusity and truchlear gruuve distance tin mm. dencited in red {ill between the deepest partinn at the trnchlear grnnve {2} tn the apex at the tibial tu berusity (3], cm a line parallel tn

the pestericir cendylar axis {1}.

these with unilateral patellar instability were fuund tn have abnnrmal patellar subluicatinn and tilt in bath the

affected and the asymptumatic knee.“- Anuther study used

preeperative and pestciperative dynamic CT tn create a camputatinnal recnnstructinn at in viva knee functinn

and applied this technique tn the assessment pf patellar kinematics.“5 Surgical patellar stabilizatien with tuberusity

El ll] 16 American AcadMy cit Cirtbnpaedie Surge-ens

Chapter 1?: Pateflnfemnral Jnint Disnrders

medialixatinn was fnund tn decrease lateral patellar shift and tilt, particularly at lnw knee flexinn angles. Patellnfemnrel Pain Syndrnme

Patellnfemnral pain syndrnmc is a nnnspecific diagnnsis

traditinnally used tn describe anterinr knee pain withnut nvert instability. Patients nften describe pain with run—

Patellar taping was fnund tn alter patellnfemnral hin-

mechanics, specifically by cnrrecting lateralixatinn and

increasing the pnsterndistal pnsitinn nf the patella.“I Earlier and increased muscle activity in the vastus medialis

was repnrted when Mcnnell taping was used during

squatting activities.“ at nrthnses are used as an adjunct treatment because altered mechanics in the fnnt affect tibial rntatinn; nrthnses can be used tn cnrrect fnrefnnt

ning, jumping, climbing stairs, nr prnlnngcd sitting with the knee in a flexed pnsitinn. Althnugh many thenries

valgus, rearfnnt cversinn, and prnnatinnf'1 In a study nf

mnst nften is multifactnrial. An assnciatinn between jnint nverlnad and pain in the

12 weeks nf use. In cnmparisnn with all patients in the study, thnse whn had a favnrable respnnse wnre relatively

fnnt nrthnsis use in patients with patellniemnral pain,

have been prnpnsed, the cause nf patellnfemnral pain

nnly 25% repnrted a marked imprnvement in pain after

patellnfemnral jnint has been suppnrted by finite element

unsuppnrtive fnntwear, repnrtecl a lnw initial level nf

repnrted greater peak and average strain levels within

while wearing fnnt nrthnses.”

Increased jnint stresses and altered cnntact fnrces within

nr lengthening can be used tn treat isnlated lateral pa-

analysis studies that used cnmputatinnal mndeling tn predict stress distributinns within the jnint. One study

the jnint during squatting maneuvers in wnmcn with patellnfemnral pain, cnmpared with cnntrnl subjects.“

pain, had decreased ankle dnrsiflcxinn, and repnrted an immediate reductinn in pain during single-leg squatting Surgical treatment rarely is indicated fnr patellnfemnral pain syndrnme. nlthnugh lateral retinacular release

the patellnfemnral jnint alsn may be the result nf patellar maltracking. A kinematic study using a three-dimensinnal

tcllnfcmnral cnmpressinn syndrnmc, the indicatinns are limited, and it is critical that patellar instability be ruled

kinematics during squatting maneuvers in patients with nr withnut patellnfemnral pain.“ The patients with symptnms had mnre lateral rntatinn and lateral translatinn nf the patella at 9‘3“ nf knee flexinn. Chnndral damage in the patellnfemnral jnint has been

lar release shnuld nnt be used as an isnlated treatment nf instability because it can lead tn disastrnus medial and

thnugh this finding nften is nnnspecific. A cnmparisnn nf wnmen with patellnfemnral pain and cnntrnl subjects

Mnst patients whn have had a first patellar instability episnde can he successfully treated withnut surgery. Re-

nptical mntinn capture system cnmpared patellnfemnral

implicated in the develnpment nf anterinr knee pain, al— identified a negative relatinnship between cartilage thick

ness and cnmputatinnally determined strain magnitude within the patcllnfemnral jnint. This relatinnship was cnn-

stant in bnth grnups. Thnse in the grnup with symptnms

nut befnre the prncedure is cnnsidered. Lateral retinaculateral patellar instability.

F'ntellnfemnral Instability

current episndes nf instability nccur in fewer than half nf

these patients.“ Small lnnse bndies are cnmmnnly fnund but nften are asymptnmatic.

had significant reductinn in patellar cartilage thickness in cnmparisnn with thnse in the cnntrnl grnup.”

First Dislncatinn The initial gnals after an acute patellar dislncatinn are

exercise prngram emphasising strengthening nf the quad— riceps, cure, and hip muscles. A multicenter randnmiaed

while the symptnms and functinn gradually imprnve. Pain and swelling can he treated using a cnmbinatinn nf

The mainstay treatment nf patellnfemnral pain is an

study fnund that adding hip- and cure-strengthening ex-

ercises tn an exercise prngram fncused cm the knee led tn an earlier resnlutinn nf pain and increased gains in

strength.31 A systematic review fnund several factnrs that

significantly predicted successful management nf patellar pain with exercise treatment, including negative patellar apprehensinn, lack nf patellar chnndral defects, and tibial

tubernsity deviatinn nf less than 14.6 mm; in cnmparisnn with nther patients, these patients alsn had symptoms less nften and nf shnrter duratinn, were ynunger, had a

faster VMD respnnse time, and had a larger quadriceps crnss-sectinnal area nn MRI}2

Eb Ifllti American Academy nf flcthnpaedic Surgenna

tn cnntrnl pain, manage swelling, and prntect the knee

cryntherapy, nver-tbe-cnunter analgesic medicatinns, and

1.4,:

uncnmfnt‘table shnuld use a knee immnbilixer, fnllnwed

m m tn 3

cnmpressinn. Must patients benefit frnm using crutches tn limit weight bearing. Thnse whnse knee is unstable nr by a functinnal hinged brace as they gradually return tn recreatinnal and nccupatinnal activities. Knee aspiratinn

helps tn relieve pain in patients with a tense hema rthrnsis.

Heel slide and quadriceps activatinn exercises are initiated within a few days nf the injury and are fnllnwed by a super-

vised rehabilitatinn prngram. Physical therapy allnws the

patient tn prngress tn light activities withm days tn weeks and tn athletic activities within weeks tn a few mnnths.

Drrhnpaedic Knnwledge Update: Spnrts Medicine 5

FT. :5

El.

:5

Sectinn 3:1Cnee andLeg

Radingraph5 5hnuld be nbtained tn a55e55 for the pre5-

ence nf a fracture nr large n5tenchnndral lnn5e bndie5.

current in5tability fnund that 3 nf 29 kneE5 {23%} had a

ticuIar pathnlngy. Lnn5e bndie5 are cnmmnnly fnund

graft 5nurce5 and fixatinn methnd5, but nn nne technique

5urgery after a fir5t—time di5lncatinn are the pm5ence nf

may nnt be ennugh tn 5tabiliae the patellnfemnral inint

MRI can be 5eIective u5ed tn a55e55 the 5tatu5 nf the exten5nr mechani5m and rule nut cnncnmitant intra-ar— after di5lncatinn but u5ually are 5mall, a5ymptnmatic, and net amenable tn fixatinn. The primary indicatinn5 fnr repairable n5tenchnndral Inn5e bndie5 nr large chnndral lnn5e bndie5 that are nr are likely tn becnme 5ymptnm-

atic. Other indicatinn5 include a cnncnmitant injury 5uch

nf 313% tn 96%, with few nccurrence5 nf recurrent in-

daily living. MPFL recnn5tructinn had a gnnd nutcnme

in 31 knee5 with recurrent patellar in5tahility.“ Range nf mntinn, Kuiala Anterinr Knee Pain Scale 5cnre5, and

Recurrent Instability The repnrted incidence nf recurrent in5tahility after a

nne patient 5hnwed 5ign5 nf apprehen5inn at fnllnw-up. Studie5 repnrting the re5ult5 nf MPFL recnn5tructinn

tinn i5 indicated if the patient ha5 recurrent in5tahility and nnn5urgical treatment ha5 nnt been 5ucce55ful. A

fnllnw~up, and the u5e nf cnncnmitant prncedure5 55 well 55 limited infnrmatinn nn rehabilitatinn and return tn

if the patient i5 willing tn mndify athletic activitie5. A patient with 5ub5tantial malalignment i5 relatively likely tn have nngning in5tahility epi5nde5. hnwever. I’hy5ical

radingraphic indexe5 imprnved after 5urgery, and nnly

generally are limited by 5mall 5ample 5iae5, 5hnrt-term 5pnrt5. The large5t 5tudy tn date included 240 cnn5ecu-

tive MPFL recnn5tructinn5 at a 5ingle clinic. The mean Kujala 5cnre imprnved frnm 62.5 tn 30.4 at a minimum 1-year fnllnw—up. A cnncnmitant TTO wa5 dnne in 23%

examinatinn and imaging 5tudie5 are u5ed tn identify the anatnmic and binmechanical factnr5 that created a pre-

nf patient5.“I The mn5t cnmmnn cnmplicatinn5 cf MPFL recnn-

5urgical treatment plan. The three main 5tabiIiaer5 cf the patellnfemnral jnint are the muscle5 that prnvide dynamic

ful hardware, and patellar fracture. The large5t 5tudy tn date repnrted a 4.6% rate nf recurrent di5Incatinn.”

di5pn5itinn tn in5tahility and tn develnp a patientu5pecific 5tabi1ity {the V1510, hip external rntatnr5, and cure}, the medial 5nft—ti55ue re5traint5 {MPFL and medial retinacu— Inm} and the n5tenchnndral cnn5traint5. 1‘-}"'Il"'ealcne55 nf the dynamic 5tabiliaer5 i5 treated thrnugh rehabilitatinn. If

H

by recngnitinn nf the difficulty nf the 5urgica1 technique

in treating patellar in5tahility.

rehabilitatinn prngram nften can be cnn5idered 5ucce55ful

I: m :5 III-1 I: :5:

enthu5ia5m fer MPFL recnn5tructinn ha5 been mnderated

5tabiIity.“ In general, excellent nutcnme5 were repnrted, with a high likelihcnd nf re5umptinn nf activitie5 nf

fir5t di5lncatinn i5 15% tn 44%_35.35 Surgical 5tabiliaa-

._I

in a patient with 5ub5tantial malalignment. The initial

5urgery i5 nece55ary fnr annther rea5nn. In the ab5ence nf annther indicatinn, MPFL repair ha5 nnt been 5hnwn

tn be beneficial fnr re5tnring functinn nr avniding recur— rence. I5nlated lateral retinacular relea5e i5 nnt effective

T:

i5 clearly 5uperinr. Althnugh the graft ti55ue i5 much 5trnnger than the native ti55ue, MPFL recnn5tructinn alnne

per5i5tent 5ublunatinn. I'viany clinician5 cnn5ider primary

repair nf the turn MPFL after a fir5t—time di5lncatinn if

55

later recurrence.3H Numernu5 technique5 fnr IvIPFL recnn.5tructinn have been de5cribed, u5ing a variety nf different

and the frequency nf cnmplicatinn5???” Studie5 nf MPFL recnn5tructinn repnrted 5ucce55 rate5

a5 a meni5cal tear, anterinr cruciate ligament tear, nr

BI

in5tahility. A ca5e 5tudy nf i5nlated MPFL repair fnr re-

5tructinn are recurrent in5tability, ln55 nf mntinn, painIn additinn, 14% nf patient5 had a pn5itive apprehen-

5inn 5ign, and 12% had a Her-Linn deficit nf 1G“ nr mnre. A meta-analy5i5 cf 25 5tndie5 repnrting cm a tntal nf 625' knee5 fnund that a cnmplicatinn nccurred in 154 knem (26.1%).“ The mn5t cnmmnn nf the5e cnmplicav

medial 5nft—ti55ue in5ufficiency i5 identified, a prncedure such 55 MPFL recnn5tructinn can 5tabiliae the patella by

tinn5 were recurrent apprehen5inn {521’164 l-tnee5}, ln55

If the primary deficiency invnlve5 the n5tenchnndral re— 5traint5, a 5nft-ti55ue prncedure alnne nften i5 in5nfficient

fracture {4] (Figure 3]. The ri5k nf patellar fracture frnm vinlatinn nf the anterinr patellar cnrteit nr large-diameter

ree5tabli5hing the deficient medial 5nft-ti55ue checkrein.

tn cnrrect the underlying pathnanatnmy, and a TTfl may

be nece55ary.

Medial Patellnfemnral Ligament Hernn5tructinn

The MPFL prnvide5 the primary m5traint tn pathnlngic lateral tran5latinn. Repair cf the IvIPFL i5 5 gnnd np-

tinn after an acute fir5t-time di5lncatinn if the lncatinn nf the tear can be identified. The re5ult5 are inferinr tn

thn5e nf MPFL recnn5tructinn in a patient with rec nrrent

flrfltnpae-dic Knnwledge Update: Sparta Medicine 5

nf knee fleainn {22], painful hardware {19} and patellar

tran5ver5e patellar tunnel5 ha5 led tn the develnpment nf

numernu5 alternative graft fixatinn technique5. Apprn~ priate pn5itinning cf the bnny turmel5 and ten5innir1g

cf the graft are thnught tn be crucial tn the 5ucce55 nf

MPFL recnn5tructinn. Malpn5itinning nf the femnraI tunnel and 5ecuring nf the graft with exce55ive ten5inn

are a55nciatecl with medial patellnfemnral articular nverlnad. iatrngenic medial 5ublurtatinn, and recurrent lateral

in5tahility.35'~‘5 Prnper pn5itinning cf the femnral tunnel

El 1016 American AcadMy nf Drthnpaedic Surge-um

Chapter 1?: Pacellofcmoral Joint Disorders

a study of 34 athletes found that excellent overall results

were achieved by anteromedialiaation combined with lateral retinacular release. Distalixation also was used

in the patients with patella alta.“'E There is no consensus as to when distaliaing osteotomies should be included.

IGood to excellent outcomes were reported in 63%

to 95% of patients, with modest deterioration of results

caused by patellofemoral pain and arthritis.” The overall

rate of recurrent patellar instability after TTD ranged from 0% to 15%. Male sex, predominant instability

symptoms, and low-grade cartilage lesions were generally

positive prognostic factors." The location of chondral lesions was found to be correlated with clinical results

after anteromedialiaation.“ Patients with distal or lat-

eral lesions had improvement after surgery, but patients

with medial, proximal, or diffuse lesions had little to no improvement. Postoperative decrease in lateral patellar

CT sagittal image showing a patellar fracture after MPFL reconstruction. Such fractures are most common with surgical violation of the anterior cortex or creation of large patellar

tunneh.

shift and tilt was reported in a small group of patients who underwent successful TTU.”

The most common complications of TTiZ‘.I include painful screws, loss of motion, proximal tibial fracture,

shingle fracture, delayed union, nonunion, neurovascu-

lar injury, thromboembolic events, and overcorrection.

can be difficult, even for experienced surgeons. In a study of MPFL reconstructions, ll] of the 29 femoral tunnels

In one study, 49% of patients required screw removal.“ Painful hardware after TTC} is more common with the

for achieving optimal tunnel positioning. Confirmation of normal patellar translation and full knee range of motion

Postoperative fracture of the proximal tibia and tibial tuberosity shingle can be prevented by optimal screw

overtensioning of the graft.

bearing {Figure 9}. Patients with proximal patellar lesions may be adversely affected by anterioriaation. flvermedial-

were malpositioned.” Intraoperative fluoroscopy is useful

is recommended before final graft fixation to prevent

Tibial Tuherosity Dsteotomy

use of 6.5— or 4.5—mm screws than with 3.5—mm screws.

fixation and 5 weeks of postoperative protected weight iaation of the tuberosity increases patellofemoral contact

TTD procedures correct malalignment by permanently realigning the abnormal bony anatomy. Modification of

pressures in the medial patellofemoral compartment and may lead to patellofemoral osteoarthritis.” Anterome-

changes the forces applied to the patellofemoral joint. A variety of T'TIICII| procedures have been described for

tibiofemoral compartment loading, with unknown long-

term consequences?

osteotomy such as the Elmslie-Trillat osteotomy is used to correct maltracking caused by a lateraliaed tuberosity

Trochleoplasty Trochlear dyspiasia is found in 35% of patients with re-

is used to treat patella alta. An anterioriaing {Magnet} or anteromedializing {Pulkerson} osteotomy is used to

procedure is to correct the shape of the deficient distal femoral articular constraint. A sulcus-deepening trochleo-

the position of the patellar tendon attachment on the tibia

use with different types of malalignment. A medialiaing {an increased TTTG distance]. A distaliaing osteotomy unload specific areas of articular cartilage wear. lElomplex

distaliaing osteotomies incorporate medial or anteromedi— al displacement of the tuberosity shingle. Medialiaing os-

dialiaation also can cause postoperative changes in the

current patellar instability.” The goal of a trochleoplasty

1.4.}

plasty is prefmable to elevation of the lateral condyle to

m m tn 3

avoid the risk of increasing the lateral patellofemoral joint forces. Trochleoplasty is contraindicated in patients with

teotomy is indicated if the TTTG distance is greater than

patellofemoral arthritis, open physes, or isolated anterior

distaliration, and the slope of the osteotomy to achieve

lenging, and carries a significant risk of cartilage damage,

15 to 2G mm. The TTD is modified to the patient’s needs by adjusting the amount of medialiaation, the amount of the desired degree of correction. Surgeons often combine a TTD with soft-tissue release, repair, or reconstruction.

El Ifllii American Academy of Urthopaedic Surgeons

knee pain without instability. The procedure generally is performed through an arthrotomy, is technically chal-

osteoarthritis, and arthrofibrosis. Trochleoplasty almost always is done with a concomitant soft-tissue procedure

Eirthopaedic Knowledge Update: Sports Medicine .5

FT. :5

El.

:5

Sectien 3: Knee and Leg

Nene ef the analyzed studies directly cempared the twe

precedures, and there was ne streng evidence ef superier

clinical eutcemes after a trechleeplasty precedure. The patients treated with trechleeplasty had a lewer redislecatien rate {0.9% vs 16.2%} but a higher rate ef deficits

in range ef metien than these treated with a nentrechleeplasty precedure. The meat cemmen cemplicatiens ef

trechleeplasty were arthrefibresis, persistent pain, and esteearthritis. Pesteperative centinueus passive metien

eften is recemmended te reduce the risk ef stiffness. Summary

lvlultiple facters centribute te the stability ef the pa— tellefemeral jeint, including static restraints, dynamic restraints, esteechendral censtraints, and lewer extremity alignment. Patellefemeral diserders appear as pain er

A Figure El

AP {A} and lateral {a} radiegraphs sh ewing a tibial fracture that eccurred as a cemplicatien cf tibial tu beresity esteetemy. {Re preducecl with permissien frem Luhmarin Sl, Fuhrhep 5, D'Dennell JE, Gerden JE: Tibial fractures

after tibial tubercle esteetcimies fer patellar instability: A cum parisen at three esteeten'iy ce nfiguratiens. J Child Ctrthep 2011;5[1]:19-25.]

{especially lateral release and MPFL recenstructien] and eften with TTD with anteremedialiaatien er distaliea-

tien. As a result, it is difficult te determine the efficacy ef

trechleeplasty as an iselated precedure. Recemmenda— tiens fer eptimal surgical treatment are elusive because ef the variable pathelegy as well as the variety ef precedures

described in the literature. Trechleeplasty usually is net necessary te achieve patellar stability, even in the presence ef a dysplastic trechlea.’i1 Because ef the relatively rare

indicatiens and the technical difficulty ef trechleeplasty, it sheuld be reucineiy perfermed enly by surgeens with extensive experience in the precedure.

Studies ef trechleeplasty cemhined with MPFL recen— atrnctien feund excellent results at a minimum 1-year

DI

cu

._I

T:

I: in cu Ill-1 i: s:

H

instability. Identifying and treating the anatemic er functinnal deficits specific te the individual patient are crucial

fer directing nensu rgical and surgical treatments. Surgery

may be indicated in patients with recurrent instability after unsuccessful nensurgical treatment. The surgical

precedure sheuld be tailered te the specific dynamic and

anatemic variatiens centributing re the patient’s instabil— ity. Future directiens in patellefemeral research include

quantificatien and standardizatien ef the measurements

ef centributing facters te determine the apprepriate in~ dicatiens fer surgical cerrectien. Hey Study Peints

1* The clinician sheuld differentiate between patellefemeral pain and instability based en the patient’s histery and physical examinatien.

i The etielegy ef patellar instability is multifacterial, and successful surgical management requires iden-

tifying and censidering the centributing facters.

' The cemplicatiens ef patellefemeral instability

surgery eften can be aveided by using apprepriate

surgical techniques.

fellew-up.fl+” The incidence ef pesteperative pain and

radiegraphic arthresis was lew, especially in these with minimal degenerative changes at the time ef the index

surgery. Patients with substantial preeperative pain,

unsuccessful earlier patellar stabilizatien, and chendral degenerative changes had the peerest results. Very geed

results can be ebtained even in patients whe had under-

gene unsuccessful patellar stabilisatien surgeryflM A systematic review ef studies ef patients with severe trechlear dysplasia found a cemplicatieu rate ef 13.4% in

these whe underwent trechleeplasty cempared with 19.1% ef these whe underwent a nentrecheeplasty precedure.”

flrfltepaedic Knewiedge Update: Sparta Medicine 5

Annotated References

1. Placella G, Tei MM, Sebastiani E, et a1: Shape and size ef the medial patellefemeral ligament fer the best surgical recenstructien: A. human cadaveric study. Knee Sur'g Sperts Traumatef Arthresc 2fl14;21l10}:231?-2333. Medline [101

Analysis ef ll} cadaver knees revealed that the MPFL at—

taches en the preximal third ef the patella. (in the femur,

El 1016 American AcadMy ef Drthnpaedic Surge-ens

Chapter 1?: Paoellofemoral Joint Disorders the attachment was on average 9.5 mm distal and anterior to the adductor tubercle.

and that patellar height was the best predictor of patellar tilt at El". Level of evidence: III.

. Schiittle PB, Sch meling A, Rosenstiel H, 1lili'eiler A: Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Arn ] Sports Med

Elias J]. Kilambi S, Goerke DR, Cosgarea A]: Improv-

2flfl?;35{5}:301-3fl4. Medline

DUI

. Mochiauki T, Nimura A, Tateishi T, Yamaguchi K, Mu-

neta T, Akita K: Anatomic study of the attachment of the medial patellofemoral ligament and its characteristic relationships to the vastus intermedius. Knee Snrrg Sports Trnnrnnioi Arthrosc 2013;21i2}:3l]5-31l]. Medline DUI Analysis of 16 cadaver knees revealed that the proximal

fibers of the MPPL are attached to the vastus intermedius

tendon and that the distal fibers are interdigitated with the medial retinaculum attached to the medial margin of

the patellar tendon.

. Smirk C, Morris H: The anatomy and reconstruction of the medial patellofemoral ligament. Knee 2003;1lli3}:22l22?. Medline DDI . Hasler RM, Gal I, Eiedert RM: Land marks of the normal adult human trochlea based on axial MRI measurements:

A cross-sectional study. Knee Snrg Sports Tronrnntof Arthrose 2614;22i1fl}:23?2-23?6. Medline DUI

In an MRI study of 53 patients without trochlear dysplasia, the mean trochlear depth was 4.6 mm {3.4 mm in women, 4.2 mm in men}. The lateml facet contributed 62.6% of the width of the cartilage, and the medial facet

contributed 32.4%. Level of evidence: II.

. Latt LD, Christopher M, Nicolini A, et al: A validat-

ed cadaveric model of trochlear dysplasia. Knee Snrg Sports Trnnrnatol Arthrosc 2DI4:22{16}:235?—2363. Medline DO]

A model of trochlear dysplasia was created in a cadaver Study by elevating the floor of the trochlear groove and

comparing radiographic markers of dysplasia before and

after modification. Decreased trochlear depth, increased sulcus angle, and positive cmssing signs were noted.

. Biyani R, Elias J]. Saranathan A, et al: Anatomical fac-

tors influencing patellar tracking in the unstable patellofemoral ioint. Knee Snrg Sports Trnnntntoi Ambrose 2fl14522flflltl334-234I.Medline DUI Computational models were created using MRI to repre— sent knees with patellar instability when flexed and loaded to multiple flexion angles. The patellar bisect offset index

and lateral tilt were significantly correlated with the lateral trochlear inclination and the distance between the tibial tuberosity and trochlear groove. Level of evidence: II.

. Teng HL, |Chen ‘1’], Powers CM: Predictors of patellar alignment during weight bearing: An examination of patellar height and trochlear geometry. Knee 2fl14;21{1}:142-

146. Medline DUI

MRI of the patellofemoral joint at multiple flexion angles in 36 participants indicated that lateral trochlear inclination was the best predictor of lateral patellar displacement

4D 2616 American Academy of Drthopaedic Surgeons

ing vastus medialis obliquus function reduces pressure applied to lateral patellofemoral cartilage. I Cirthop Res

2UUS:2?{S]:5?S-533.Medline nor

A blomechanical study assessed changes in patellofemoral cartilage pressures with VMD loading. Increasing the VMD force significantly decreased the maximum lateral pressure and increased the maximum medial pressure at

different knee flexion angles.

ll]. Shaihoub S, Maletsky LP: Variation in patellofemoral kinematics due to changes in quadriceps loading configuration during in vitro testing. ] Biomeeh 2014:4?{1}:13fl136. Mediine DUI In vitro kinematic simulation of 14 knees indicated that

a weak vastus medialis increased patellar lateral shift

and abduction rotation and that a weak vastus lateralis increased patellar medial shift and adduction rotation. 11. Sheehan FT, Borotikar BS, Eehnam A], Alter KE: Alterations in in vivo knee joint kinematics following a femoral nerve branch block of the vastus medialis: Implications for patellofemoral pain syndrome. Elie Biomecb (Bristol, Avon} 2D12;2?[6}:525-531. Medline DD] In kinematic analysis of asymptomatic knees of women using dynamic cine phase-contrast MRI, administering a

motor branch block to the HMO increased patellar lateral

shift, tibiofemoral lateral shift, and tibiofemoral external rotation. 12. Jan MH, Lin DH, Lin J], Lin CH, Cheng CK, Lin ‘i'F: Differences in sonographic characteristics of the vastus medialis obliquus between patients with patellofemoral

pain syndrome and healthy adults. An: 1 Sports Med 2Dfl9;3?l9}:1?43-1T49.Medline DUI

Sonographic analysis of the VMD in 54 patients revealed that insertion level, fiber angle, and muscle volume were

significantly smaller in those with patellofemoral pain than in control subiects. Level of evidence: III.

13. Van Tiggelen D, Cowan S, lfloorevits P, Duvigneaud N, Witvrouw E: Delayed vastus medialis obliquus to vastus lateralis onsfl timing contributes to the development of patellofemoral pain in previously healthy men: A prospective study. Am } Sports Med 2609;32i6}:1099-11l}5. Medline DD] Surface electromyographic analysis of the VMD and vastus lateralis in '29 healthy men before 6 weeks of military basic training found a significant delay in VMD activi-

ry in those who later had patellofemoral pain. Level of evidence: II. 14. Pal S, Draper CE, Fredericson M, et al: Patellar maltracking correlates with vastus medialis activation delay in patellofemoral pain patients. An: ] Sports l’vllenlI 1fl11;39{3]:59fl-593.Medline

DUI

Drthopaedic Knowledge Update: Sports Medicine 5

pg FT. :5

to n: to 3

El.

2

Sectien 3:1I'inee audLeg

Based an weight-bearing MRI, patellar lateral tilt was cerrelated with an increase in the ratia ef vastus lateralis

ta vastus medialia activatien. Lateral translatian and tilt

were carrelated with vastus medialis delay in patients with pain arising frem maltrackiug. Level ef evidence: III. 1.5. Diederichs U, Kahlita T, Karnarepaulas E, Heller MU, 1infallnberg E, Scheffler 5: Magnetic reaeuance imaging analysis af ratatianal alignment in patients with patellar dislecatiens. elm ] Sparta Med 2013:41i1}:51-5?.

instability and centre] subjects. A significant difference

16. Elias J], Carrina JA, Saranathan A, Uuseila LM, Tanaka M], Cesgarea A]: Variatians in kinematics and functieu

knees in patients, and healthy knees in central subjects. Level af evidence: II.

fellawing patellar stabilizatien including tibial tuheras2fl14tllj1lljtl35fl-235fi.Medline DUI

|I'Semputatianal medels af six knees based en dynamic CT were used ta quantify lateral shift and tilt ef the patella

at varying flexian angles. Cemparisan af CT befere and

after atabilisatian surgery shawed decreased shift and tilt at law flexien angles. Lavel af evidence: II.

1?. Charles MD, Halaman S, Chen L, Ward 5R, Fithian D, Afra E: Magnetic resana nce imaging-based tepegraphical differences between central and recurrent patellafemeral instability patients. Am J' Sparta Med 2013;41{2}:3?4—3 34.

Medline DUI

A retraspective review af MRI ef 40 patients with recu rrent patellar instability and 31 central subjects shawed that the symptematic knees had mare patellar tilt, patellar height, and trachlear dysplasia. Level af evidence: III. 13. Ward SR, Terk MR, Pewera CM: Patella alta: Asseciatien with patellafen'iaral alignment and changes in cantact area during weight-hearing. 1 Hana JItznt'act Sarg Arr: 2Dfl?;39[3]:1?49-1?55.Medline DUI 19. Arubjernasen A, Egund H, Rydling Ct, Stackerup R, Ryd L: The natural histary ef recurrent dislecatian af

the patella. Lang-term results af canaervative and apera— tive treatment. I Barre jairit Sarg Br 1992;?4{1}:14D-I42.

._I

I: n: a: III-1 I: a:

H

a study ef Si} patients faund that patients with patellar pain had greater trunk lean and centralateral pelvic drep and knee ahductian as well as 1'?% less hip adductian and 1?% less hip external retatien strength an single—leg squat testing than these withaut pain.

tian than knees af central subjects and almast three times mare mechanical axis deviatian. Level af evidence: III.

ity realignment. Knee Sarg Sparta Traamutai Artbraac

T:

DUI

MRI ef 30 patients with patellar instability and 3!] central subjects revealed that symptamatic knees had apprexi-

mately 1.6 times mere femeral antetarsian and knee reta-

tu

Medline

21. Regalada G, Lintula H, Eskelinen M, et al: Dynamic HIRE—MRI in patellafemaral instability in adalescents. Krtee Strrg Sparta Truflmutaf Artbraac 2914;22i11}:2?95 23112. Medliue DUI

Medline DUI

U'I

and females with and withaut patellefemaral pain syndrame. I Urtbap Sparta Phys Tiber 2012:41j6}:491-501.

Medline

20. Herringtan L: Knee valgus angle during single leg squat and landing in patellefemaral pain patients and cantrels. Knee 2014;EI{2}:514—511 Medline DUI Twelve wemen with unilateral patellafemaral pain and 3D asymptamatic central subjects were assessed far frantal plane prejectian angle during single-leg squatting and single-leg happing. Patients in the symptematic graup had significantly greater frantal plane angles in bath tests. 21. Hakagawa TH, Mariya ET, Maciel CD, Serrae FV: Trunk,

pelvis, hip, and knee kinematics, hip strength, and glu-

teal muscle activatian during a single-leg squat in males

UrrItapae-die Knawledge Update: Sparta Medicine 5

Kinematic MRI was used te campare patients with patellar was nated in bisect affset, lateral patellar displacement and patellar tilt angles between the affected knees, unaffected

23. Felus ], Kewalcsyk E: Age—related differences in medial patellafemaral ligament injury patterns in traumatic patellar dislecatian: Case series af 5U surgically treated children and adaleacenta. Arr: I Sparta Med 2012;4fli10}:235?—

2364. Medline DUI

The lecatiens af MPFL injuries in first-time traumatic patellar dislecatiens were campared using sanagraphy. Ferry-six percent ef patients had injury in mere than ane lacatian. Skeletally immature patients had a greater

incidence af patellar—aide injury than akeletally mature patients {Wiri- versus 54%}. Level af evidence: IV.

24. Petri M, van Falck C, Eraese M, et al: Influence af rupture patterns ef the medial patellefemaral ligament [MPFL] an the autceme after aperative treatment ef traumatic patellar dialecatian. Knee Surg Sparta Trunruutai Artbraar: 2fl13;11{3]:633-639.Medline DUI

.6. retraspective study af 4!] patients wha underwent MRI after first-time traumatic patellar dislecatien faund that patients with patellar-based MPFL rupture were camparatively yaung {mean age, 19.5 years} and that elder patients were mere likely ta sustain femaral-side ruptures {mean age, 25.4 years}. Lavel af evidence: IV. 2.5. Camp UL, Stuart M], Krych A], et al: UT and MRI measurements ef tibial tubercle-trachlear graeve distances are net equivalent in patients with patellar instability. Ana

1 Sparta Med 1013:41t3}:1335—1340. Medline ear

a randamised, blinded study used CT and MRI af patients

with patellar instability ta determine TTTU dista nces. The mean TTTG distance was 15.9 mm an CT and 14.? m an

l'lI. Interrater reliability was excellent far each madality but anly fair when the eve madalities were campa red.

Level ef evidence: II.

2.6. Dietrich T], Bets M, Pfirrmann CW, Kach PP, Fucentese 5F: End-stage extensien af the knee and its influence en tibial tuheresity-trachlear graeve distance {TTTG} in

asymptamatic valunteers. Knee Sarg Sparta Traametal' Arthraac 2fl14;22{1}:214—213. Medline DUI

U ll] 16 American AeadMy af Urrhapaedic Surge-ans

Chapter 1?: Peuellefemeral Jeint Diserders Thirty asymptematic individuals underwent MRI at ‘3'", 15", and 3D“ ef knee flexinn. Mean TTTG distances were feund te significantly decrease with increasing knee flexien. 1?. Penneck AT, Alam M, Bastrenl T: Variatien in tibial tubercle—trechlear greeve measurement as a functien ef age, sex, size, and patellar instability. Am I Sperts Med ED14;42{1]:339-393.Medline

DUI

'TTTG distance was measured cm MRI, and nermal values were reperted. TTTG distance increased with everall height in patients with patellar instability and centre] subjects, and it decreased with age in these with instability. Level nf evidence: III. 23. Seitlinger G, Scheurecker G, Hegler E, Labw L, Innecenti E, amann 5: Tibial tubercle-pesterier cruciate ligament

distance: A new measurement te define the pesitien ef the tibial tubercle in patients with patellar dislecatien. Am

I Sperts Med 2fl12;4-fl{5}:1119-1125. Medline

DUI

A new tibial tubercle-pnsterier cruciate ligament distance measurement was described as an alternative tn TTTG distance. Mean values were 13.4 mm in centrel subjects and 21.9 mm in patients with patellar dislecatien. A value greater than 24 mm was censidered abnermal. Level ef evidence: II. 29. He KY, Keyak JH, Pewers CM: Cnmparisen nf patella bnne strain between females with and with-nut patellefemeral pain: A finite element analysis study. J Biemecb 2014:4Ti1jildfl-336.Medline DUI Finite element analysis ef 1!] patients with symptems and 1f] centre] subjects shnwed that the patients had greater

peak and average principal strain in the patella. Patellar cartilage thickness was negatively asseciated with peak minimum and maximum principal patellar strain.

3D. Wilsen NA, Press JM, Keh JL, Hendrix KW, Zhang LQ: In vive neninvasive evaluatien nf abnnrmal patellar tracking during squatting in patients with patellefemeral pain. j’ Beeejeiet eg Aer 2009:91j3}:553-566. Medline DUI An epteelectrenic metien capture system was used te recerd three-dimensienal patellar kinematics in 9 patients with patellefemeral pain syndreme and ill] centre] sub-

management: A systematic review and meta—analysis. Sperts Med 2014;44i12}:1?fl3-1?16. Medliue [II-DI A systematic review ef eutcnme predicters in nensurgical management nf patellefemeral pain fennd that several facters were asseciated with successful exercise interventien: absence ef chendremalacia patella and TTTG distance ef less than 14.6 mm, as well as a relatively shnrt symptnm

duratinn, lnw frequency nf pain, ynung age, fast VMG

reflex respense time, and large cress-sectienal area ef the quadriceps en MRI.

33. Snug CY, Huang HY, Chen 5C, Lin JJ, Chang AH: Effects ef femeral retatienal taping en pain, lewer extremity kinematics, and muscle activatien in female patients with

patellefemeral pain. } Sci Med Spent ll] 14. Medline DUI

Electremyelegraphy was perfermed in 16 patients with pa—

tellefemeral pain and S centre] subjects during single—leg squatting after tandem assignment tn kinesietaping, sham taping, er ne taping. In the patients with symptems, ki-

nesietaping shifted the patella pesterierly and distally.

34. Lee SE, Che SH: The effect ef Mcnnell taping en vastus medialis and lateralis activity during squatting in adults with patellefemeral pain syndreme. j Exerc Hebe-fad 1fl13;9{1}:325-330. Mcdline

DUI

Sixteen patients with patellefemeral pain received an taping, placehn taping, er McCennell taping. Vastus medialis activity and its ratie te vastus lateralis activity were greater after McCennell taping than ne taping. 35. Barten I3], Men: HE, IL'Iresslcy KM: Clinical predicters ef feet ertheses efficacy in individuals with patellefemeral pain. Med Sci Sperts Exerc 1011:43{9j:1603-151fi. Medline DC}!

Twenty—five percent ef patients reperted imprevement

in patellefemeral pain after 12 weeks ef wearing feet nrthnses. The percentage increased te Tfl‘ib if three nf these criteria were met: use ef relatively unsuppertive feetwear, visual analeg pain scale scere lewer than 21, weight-bearing ankle dersiflexien ef less than 41", and reduced pain during single-leg squatting while wearing the ertheses.

jects. At 91'1“ nf knee flexien, the patients had increased

36. Cefield EH, Bryan RS: Acute dislecatien ef the patella: Results ef censervative treatment. I Trauma 19T?;1?{?}:525-

31. Ferher R, Belgla L, Earl-Eeehm JE, Emery I3, Hams-

3?. Pithian DC, Paxten EW, Stene ML, et a]: Epidemielegy

lateral spin and lateral translatien.

trar‘iliiright K: Strengthening ef the hip and cere versus knee muscles fer the treatment ef patellefemeral pain: A multicenter, randemiaed cnntrnlled trial. I AIM Train [Published enline ahead ef print bievember 3, 1014].

Medliue Ell-DI

Patients with patellefemeral pain were assigned te a 6-week knee- er hip-exercise pretecnl. 1Visual analeg scale scnres imprnved in patients in hnth grnups but irnpreved 1 week earlier in these in the hip pretecel, whe else had greater everall gains in strength.

32. Lack 5, Batten E, Vicenzine B, Merrissey D: But-

ceme predicters fer censervative patellefemeral pain

Eb Ifllfi American Academy ef Urthepaedjc Surgeens

.531. Medlinc

DUI

and natural histery ef acute patellar dislecatien. Am I Seer-rs Med 2004:31i511:1 114-1121. Medline DGI

33. lCamp CL, Krych AJ, Da hm DL, Levy BA, Stuart M]: Medial patellefemeral ligament repair fer recurrent patellar dislecatien. Am I Sparta Med lfllflflflj‘lljfll-‘I-fl-llfid. Medline DUI

Retrespective review a minimum ef 2 years after 2? pa-

tients [29 knees] underwent MPFL repair fer recurrent dislecatien fnund that 23% nf patients had a recurrent

dislecatien. The nnly significant risk factnr was nnnana-

temic MPFL repair at the medial femeral cendyle. Level ef evidence: IV.

Drthepaedic Knewledge Update: Sperts Medicine 5

1.4,: FT. :5

re re e: 3

1:1.

E

Sectinn 3:1Inee andLeg

39. Ballier M, Fulkersnn J, Cnsgarea A, Tanaka M: Technical

failure nf medial patellnfemnral ligament recnnstructinn.

Artiste-seep}! 101 1,2?{31fl 153-1 159. Medline DUI

Five patients with malpnsitiuned femural tunnels and disabling symptnms required revisinn MPFL reconstructinn. The effects nf a malpnsitinne-d femnral graft were described, with strategies to identify the femnral insertinn during surgery. Level at evidence: IV.

40. Servien E, Fritsch B, Lustig S, et al: In vivu pusitinning analysis at medial patellnfemnral ligament recnnstructinn.

Am J Spares Med 2011:39i1}:134-139. Medline DD]

A prnspective study bf 29 patients undergc-ing MPFL recnnstructinn faund that that 19 femnral tunnels were

in the pruper lncatinn and 10 were in an anteriur and!

er high pnsitic-n. This study highlighted the difficulty nf reptnducible anatnmic femnral tunnel p-nsitinning. Level nf evidence: IV. 41. Buckens CF, Saris DE: Recnnstructinn cf the medial

patellnfemnral ligament fur treattnent cif patellufemnral

instability: A systematic review. Am _I Sports Med 2U]fl:33{1]t131-133. Medline

DUI

A systematic review {if 14 studies fnund generally excellent functinnal nutcnmes after MPFL recnnstrnctinn. Mast studies were small, had limited fellnw-up, and encum— passed additinnal prucedu res. As a result, it was difficult tn distinguish the determining factnrs in the nutcnmes. Level c-f evidence: IV. 42. Deie M, Uchi M, Adachi N, Shibuya H, Nakamae A: Medial patellnfemnral ligament recnnstructinn fixed with

a cylindrical bane plug and a grafted semitendiuusus

tendnn at the nriginal femnral site fur recurrent patellar dislncatinn. Am I Sparta Med 2911;39illtl4fi-145. Medline DUI Thirty—cine knees in 19 patients with recurrent patellar

dislncatie-n were treated with MPFL recnnstructinn. At

a minimum 2-year fnllnw-up, the mean Kujala Anterinr Knee Pain Scale scare had imprnved frnm 64 tn 94.5 paints. Une patient had residual apprehensinn, but there

were an redislncatinns. Level nf evidence: IV.

DI

tu

43. Enderlein D, Nielsen T, Christiansen SE, Fauna P, Lind M: Clinical nutcnme after recnnstructinn at the medial patellnfemural ligament in patients with recurrent patella instability. Knee Stetg Spain‘s Treamntal' Artistes-s 2fl14;22{1{l}:2453-2464.Medline DUI A prospective study ed 114 patients undergning MPFL recnnstructinn with a gracilis tende-n autngraft faund imprnvement in mean Kujala scare frum 51.5 tn 30.4 at 1-year fnllnw—up. The revisinn rate was 2.3%. MPFL tecnnstructinn cnnsistcntly nnrmalixed patella stability and imprnved knee functinn. Age greater than 30 years, nbesity, cartilage injury, and female sex were predictnrs nf a peer subjective nutcnme. Level nf evidence: IV.

._I

T:

I: as ea 4-1 I: as

H

44.

Shah JN, Hnward JS, Flanigan DC, Brnphy RH, Carey JL,

Lattermann C: A sysmmatic review at cumplicatinns and

failures assnciated with medial patellnfemnral ligament

Urdtnpaedic Knnwledge Update: Spares Medicine 5

recc-nstructinn far recurrent patellar dislncatic-n. Am ] Spar-rs Med 1fl12;4fl{3]:1916-1923. Medline DUI A systematic review {if 15 articles an MPFL recnnstructinn fnund a tntal at 164 cnmplicatiuns in 629 knees {26.1%}. The rate at recurrent subluxatinn was 4.3%, and 13’96 {if patients had cantinued apprehensinn withnut subluxatinn. 45. Elias J], Cusgarea A]: Technical errnrs during medial patellnfemnral ligament recnnstructinn ccrnld nverlnad

medial patellufemural cartilage: A cumputatinnal analysis. rim I Sparse Med 2U flfi;34{9}:14?S—I4SS. Medline DUI

46. Tjuumakaris FP, Fnrsythe B, Bradley JP: Patellnfemural instability in athletes: Treatment via mndified Fulkersnn nstentnmy and lateral release. Am I Sparts Med

2010;33t5}:992-999.Medline nnI

Fatty—cine knees in 34 athletes underwent Fulkersnn asteutnmy and lateral retinacular release fur patellnfemnral instability. Une patient had recurrent instability at a minimum 22-mnnth fallnw-up. Seventeen patients had symptnmatic hardware remnved. Level {if evidence: IV. 4?. Naveed MA, Ackrnyd CE, Partenus A]: Lang-term {ten- tn 15—year} nutcnme nf arthrnscnpically assisted Elmslie-Trillat tibial tubercle usteute-my. Bane fairer I 2013:95Bl4]:4TS-435.Medline DUI In a study nf patients whn underwent an Elmslie-Trillat TTU, 19 knees {?9.1%} had a guard err excellent nutcnme

at 4-year fullnw-up, and 15 knees (62.5%] had a gund

nr excellent uutcnme at a minimum III-year fulluw-up. Intranperative chandral damage created a predispnsitinn tn the develnpment nf patellnfemnral nstenardtritis. Level of evidence: IV.

4B. Pidnriann A], 1|ill-"Einstein RN, Euuck DA, Fulkersc-n JP: Currelatinn at patellar articular lesinns with results frnm anternmedial tibial tubercle transfer. Ans I Spur-ts Med 199T:25{4}:533-53?.Medline LII-DI 49. Eurnda R, Kambic H, Valdevit A, Andrish jT: Articular cartilage cantact pressure after tibial tubernsity transfer:

A cadaveric study. An: I Spurts Med1001;19(4}:4fl3-4fl9. Medline

50. Deiuur H, 1|IIIir'alnth G, Heve-Jusserand L, Guier C: Factnrs at patellar instability: An anatnmic radingraphic study. Knee Satrg Sparts Traumntnl Artbrnse 1994;2{1}:19-26. Medline DUI

51. Thaunat M, Bessiere C, Pujnl N, Enisrennult P, Eeaufils P:

Recessinn wedge trnchlenplasty as an additinnal pracedure

in the surgical treatment at patellar instability with majnr truchlear dysplasia: Early results. Urtbnp Treamatnl Sarg Res 2011:9?{Sl:333-345. Medline DUI Seventeen patients {19 knees) with severe truchlear dysplasia and patellnfemnral instability underwent recessinn wedge trnchlenplasty. At a minimum 1—year fullnw—up, the trnchlear prnminence was reduced frnm a mean 4.8 mm tn 41.3 mm. Twn patients had instability, and three

required further surgery. Level nf evidence: IV.

El 1016 American AcadMy nf Urrhnpaedic Surge-ans

Chapter 1?: Panellufemural Juint Disurders

52. Nelitr M. Dreyhaupt J. Lippacher 5: Eumbined truchleu-

plasty and medial patellufemnral ligament recnnstructinn fur recurrent patellar dislncatinns in severe trnchlear dys-

plasia: A minimum 2-year fulluw-up study. Am } Spurts Med 2013;4“5 }:lflflfi-IDIE. Medliue

DUI

Twenty-three cunsecutive patients (26 knees} with patellafemnral instability and severe trnchlear dysplasia underwent cnmhined trnchlenplasty and MPFL recnnstructinn.

At a minimum 2-year fulluw—up. there was significant impruvement in Kujala. Internatiunal Knee Ducumentatic-n Cnmmittee Subjective Knee Evaluatinn Farm, and visual analng scale scnres. Nu dislncatinns nccurred, and 22 patients (95.??9] were satisfied ur very satisfied. Level

cf evidence: III.

.53. Ntagiupuulus PG. Byu P. Dejuur D: Midterm results uf cumprehensive surgical recunstructiun including sulcus- deepening trnchleuplasty in recurrent patellar dis-

at a minimum 2-year fulluw-up. The mean Kujala scure imprnved item .59 tn 3'3". The apprehensinn sign remained

pnsitive in 19.3% cf patients. Level nf evidence: IV.

54. Dejnur D, Eyn P, Ntaginpnulns PG: The Lynn's sulcus-deepening truchlenplasty in previnus unsuccessful patellefemural surgery. int Ortbup 2D13:3?{3]I:433-439.

Medliue [II-DI

Twenty-twp patients {24 knees} whc- had undergnne unsuccessful patelln-femn-ral surgery underwent sulcusdeepening trnchlenplasty cnmbined with additinna]

suit—tissue and huuy surgery. At a minimum 2-year ful-

luw-up. Kujala scures had imprmared.r and nu patient had p-nstnperative instability nr patellnfemnral arthritis. Level

c-f evidence: IV.

.55. Sung GT, Hung L, Zhang H, et a]: Trnchlenplasty versus

neutruchleuplasty precedures in treating patellar insta-

lucatiuus with high-grade truchlear dysplasia. Am I Sperts Med 2013:41i5}:993-10fl4. Medline DUI

2fl14;3i}{4}:523-532.Medline

Twenty-seven patients {31 knees] with recurrent patellar dislncatiun and high-grade truchlear dysplasia withnut previnus surgery underwent sulcus-deepening trnchlenu plasty cnmhined with additiunal hnne ur suft-tissue surgery. There were nu pnstuperative dislncatinns er radingraphic evidence of patellnfemnral nstenarthritis

A systematic review {if 1? studies {if patients with patellar instability and severe trnchlear dysplasia treated with trnchlenplasty {329 patients} ur a nuntruchleuplasty prucedure {130 patients] fuund luwer redislucatiuu and nstenarthritis rates but pnnrer range nf mntinn after trnchlenplasty. Level nf evidence: IV.

bility caused by severe truchlear dysplasia. Artbruscupy DUI

1.4.} F. :F

m n: e: 3

El.

E

Eb Ifllfi American Academy cf flrfltnpaedic fiurgenus

Drrhupaedic Knewledge Update: fipurrs Medicine 5

Chapter 13

Articular Cartilage of the Knee Andreas H. IL’Iiomoll. MD

Brian I. Chilelli, MD

Abstract

Injuries to articular cartilage of the knee are increasingly common. Chondral lesions may involve only the

superficial layer of articular cartilage or may extend

more deeply to affect the underlying subchondral bone, leading to an injury to the entire osteochond ral unit. Symptomatic defects are often associated with injury to

be given and articular cartilage and suhchonclral hone

should be viewed as a closely related osteochondral unit.

Any disturbance of this osteochondral unit can lead to altered biomechanics and abnormal joint contact pressures, leading to an inflammatory response. This response

may result in pain and dysfunction with the theoretical risk of widespread joint degeneration. An initial trial of nonsurgical management is usually warranted in the

ether structures of the knee and can lead to significant pain and dysfunction. Management of these conditions

form of rest, activity modification, anti-inflammmatory medications, physical therapy, bracing, or injections. Pa-

surgical technique and cartilage repair technology. It is

benefit from surgical intervention. Surgical management should focus on removing inflammatory mediators and

continues to be challenging despite recent advances in crucial for the surgeon to evaluate the articular cartilage and subchoudral bone as an intimately related unit. Sev-

eral procedures are available to treat both the chondral and suhchondral components of the osteochondral unit.

tients who do not respond to conservative measures may restoring the osteochondral unit. Surgical options include arthroscopic de'bridement, bone marrow stimulation, os-

teochondral autograft transfer, osteochondral allograft transplantation, autologous choudrocyte implantation, as

well as various newer, emerging techniques. This chapter Keywords: articular cartilage: cartilage

repair: cartilage restoration; chondral defect: osteochondral defect Introduction

Articular cartilage injuries are common and may be

will concentrate on the evaluation, diagnosis, and management of injuries to the interrelated osteochondral unit

of articular cartilage and subchoudral bone in the knee. Basic Science

Articular cartilage is a complex and highly organized structure. The primary component of articula r cartilage

idiopathic, associated with repetitive microtrauma, or traumatic in etiology. Defects that extend beyond the

is type II hyaline cartilage, which decreases force through the joint by dissipating stress to the suhchondral hone

the underlying subchondral bone. Careful attention to ar— tic ular cartilage and subchondral bone pathology should

is aneural, alymphatic, and lacks a blood supply. These characteristics contribute to the poor healing potential

superficial chondral surface have the potential to affect

Dr. Gomoll or an immediate family member serves as a paid consultant to Aesculapifl. E‘raun, CartiheaL Geistlich,

Genzyme, Novartis. and Science for Eioivla teriais and serves

as a hoard memhec owner; offices or committee member of the American Orthopaedic Society for Sports Medicine

and the international Cartilage Repair Society: Neither Dr.

Chilelli nor any immediate family member has received anything of value from or has stock or stock options held

in a commercial company or institution related directly or indirectly to the subject of this chapter.

@ lflld American Academy of Drthopaedic Surgeons

and facilitating low-friction motion. Articular cartilage

of articular cartilage and its inability to restore its struc-

ture after injury. Chondral defects have little potential for self-repair or spontaneous healing.” A full-thickness

defect that penetrates the subchondral bone may release bone marrow content, mesenchymal cells, and growth

factors. An intralesional clot may then form, followed

by a fibrocartilaginous scar primarily composed of type

I collagen.”I The biomechanical properties and wear characteristics of this fibrocartilage were found to be inferior

to those of hyaline cartilage, which is primarily composed

of type II collagen.5=lj

Orthopaedic Knowledge Update: Sports Medicine 5

1.4.} FT. :5

re re cu 3

El.

:5

Section 3: Knee and Leg

Epidemiology and Natural Historyr Chondrai or osteochond ral lesions were found in 61% to

66% of patients undergoing knee arth roscopyf'i’ A recent

many defects are asymptomatic. A cartilage defect can be

anatomic detail of subchondral bone if a bone injury is

microtrauma. Cartilage damage is often associated with

sometimes occurs in conjunction with malalignment. Acute anterior cruciate ligament tears and meniscal de-

lent visualization of the articular cartilage. The distance from the tibial tubercle to the trochlear groove or from

rangement are highly correlated with chondral defects.“+12 A chondral or osteochondral lesion was found in more

than 9fl‘ib of patients with a patellar dislocation.” The

natural history of articular cartilage defects is not com—

pletely understand, but any disruption of the osteochondral unit can alter its biomechanics and increase the joint contact forces to the surrounding chondral surfaces and

subchondral bone. The resulting mechanical wear and loose body formation can lead to an inflammatory re-

sponse, and subsequent release of cartilage-degrading

enzymes potentially causing joint degeneration. If left untreated, chondral defects can lead to osteoarthritis.”~” Clinical Evaluation

Patients with a symptomatic chondral defect typically

have knee pain and swelling. Instability and mechanical symptoms such as catching and locking may be present.

A traumatic etiology is often associated with a specific

event such as a fall or a twisting injury while playing sports. The patient may not recall a specific event preceding the insidious onset of an idiopathic lesion or a

lesion associated with repetitive microtrauma. A detailed history as to the onset of symptoms should be followed by

a comprehensive physical examination, although neither

the history nor examination is sensitive or specific for a cartilage defect compared with another type of intracu

I: m or III-1 I: at

H

however.” Ligamentous and meniscal structures should be assessed for any evidence of injury. CT can provide line

suspected, as after subchondral drilling, bone grafting, or osteochondral allograft transplantation, for example. The

injury to another anatomic structure of the knee and

._I

lesion on imaging is helpful for prognostic purposes and can help guide surgical decision making. The size of a le-

sion is often underestimated by more than fifl‘ib on MRI,

idiopathic, traumatic, andfor associated with repetitive

T:

tecting subchondral edema. Determining the size of the

systematic review estimated a 36% prevalence of focal chondral defects of the knee in athletesd" The true inci-

deuce and prevalence are difficult to determine because

DI

is effective for evaluating the articular cartilage and de-

articular derangement. The physical examination begins

with a gait analysis and continues with an assessment for

effusion, deformity, contracture, malalignment, range of motion, ligament stability, and patella: maltracking, with

close attention to the possible presence of a mechanical blockage or crepitus.

The routine radiographic studies include the standiug AP, lateral, Merchant, and 45" flexion PA views. The

radiographs are scrutinized for fractures, loose bodies,

osteophytes, and joint space narrowing. Full—limb length

radiographs may be helpful to determine mechanical align— ment in a patient with a known chondral defect. MRI

flrrltopaodic Knowledge Update: Sports Medicine 5

addition of intra—articular gadolinium to CT allows excelthe tibial tubercle to the posterior cruciate ligament can be

determined from axial MRI or CT in patients with patellofemoral instability or a patellofemoral chondral defect. Nonsurgital Treatment

Most articular cartilage lesions are initially managed with rest, activity modification, anti-inflammatory

medications, and physical therapy. Steroid or viscosup-

plementation {hyaluronic acid} injection may decrease

inflammation and improve symptoms, especially in a patient who is sedentary or older than 55 years. However,

physiologic age is often more important than chronologic

age when determining treatment options. The use of an unloader brace can be effective in a patient with unilat-

eral compartment overload, in which a chondral defect

is exposed to excessive forces as a result of malalignment or meniscal deficiency. Q.

Video 13.1: Combined Cartilage Resto-

ration and Distal Realignment for Patellar

and Trochlear Chondral Lesions. Peter Chalmers. MD; Adam Yanks. MD; Seth Sherman, MD; ‘v'asili icaras. ES; Brian J. Cole, MD, MBA [24 min}

Surgical Treatment

Patients whose symptoms are not relieved by nonsurgical

measures should be considered for surgical intervention.

The patient’s age, activity level, expectations, defect size, and associated injuries are important factors in deter-

mining whether surgery is appropriate. A patient who is

considered to be a candidate for surgery must understand

that many cartilage-restoring procedures require extensive rehabilitation, a return to activity will not be possible

for an extended period, and high-impact activity such as running or basketball is discouraged.

El 1016 American AcadMy of Drtbopaedic Surgeons

lChapter 13: Articular Cartilage cf the Knee

B Fig u re 1

Schematic drawings shnwing steps in micrnfracture. A. The chnndral defect is prepared with a ring curette tn create stable herders. I. The sub-chnndral plate is penetrated muttiple times 2 tn 3 mm apart tn a depth cf 2 tn It ITIITI.

Arthrnscnpic déhridemeut is cnmmnnly dnne as a first-line

defect; penetratinn is dnne 2 tn 3 mm apart and 2 tn 4 mm deep perpendicular tn the surface.” a micrnfractute awl

meniscal flaps. Arthrnscnpic debridemeut can be useful

but recent investigatinns fnund that drilling prnvides a superinr result?“ Enne marrnw stimulatinu causes

restnratinn {nlcler than 55 years, advanced degenerative changes, high BMI}, nr a patient whn is unwilling tn

fnrm fibrncartilage repair tissue {type I cartilage}. Fncal lesinus smaller than 4 cm‘I in patients ynunger than 3!]

Arth rnscnpic Débridement

prncedure. The gnal nf the surgery is tn remnve inflammatnry mediatnrs, lnnse hndies, and unstable chnndral nr fnr a patient whn is nnt a gnnd candidate fnr cartilage

adhere tn a strict pnstnperative rehabilitatinn ptntncnl.

Data are lacking tn suppnrt the lnngrterm efficacy nf arthrnscnpic déhridement, hnwever. Bnne Marrnw Stimulatinn

Bnne marrnw stimulatinn using micrnfractute, intralesinnal drilling, nr ahrasinn arthrnplasty is cnmmnnly

dnne tn treat a full—thickness chnndral defect. A review nf mnre than 153,flflfl cartilage prnceclures in the knee nver a 6-year perind fnund that 93% cnnsisted nf micrn-

fracture nr chnndrnplasty.” Bnne matrnw stimulatinn can he dnne arthrnscnpically, thtnugh a mininpen apprnach, nr thtnugh an npen medial nr lateral parapatellar ap-

is traditinnally used tn penetrate the suhchnndral plate, fnrmatinn nf an intralesinnal clnt with the pntential tn

years were fnund tn he must amenable tn this tech nitlueffl Micrnfracture shnuld he avnided if sub-chnndral h-nne

deficiency is present.

Pnstnp-erative rehabilitatinn generally invnlves a prn-

lnnged perind nf nnn—weight bearing nr partial weight hearing. The use nf passive mntinn is recnmmended be-

ginning immediately after surgery, generally by using a cnntinunus passive mntinn (CPM) machine fnr a perind

nf 6 weeks. The gas] is tn return the patient tn spurts activity 6 tn 9 mnnths after surgery.

Dstenchnndral Autograft Transfer

flstenchnnd ta] autngraft transfer {HAT}, alsn called mn-

prnach. The arthrnscnpic and mininpen rnethnds mnsc frequently are used.

saicplasty, invnlves harvesting nne nr mnre nsten-chnndral cylinders frnm a minimally weight-hearing area

lesinn with an arthrnscnpic shaver nr curette tn remnve lnnse chnndral flaps and create a cnntained lesinn with

weight—bearing area {Figures 3 and 4}. DAT can he dnne as an arthrnscnpic, npen, nr mininpen prncedute. The

suhchnndral plate is penetrated multiple times tn recruit mesenchymal stem cells frnm the bane marrnw intn the

cnmprnmise nffering minimal mnrbidity and maximal

The micrnfracture technique invnlves preparing the

stable hnrders nf healthy cartilage {Figures 1 and 2}. The

Eb Ifllti American Academy nf Urthnpaedic Surgenus

cf the femur fnr transfer tn a defect in a mnre heavily

mininpen prncedure is increasingly recngnized as a useful

precisinn.

Drrhnpaedic Knnwledge Update: Spnrts Medicine 5

pg F. :i

re re tn 3

El.

E

Section 3:1Enee and Leg

DI

as

._I

T:

I: m as III-1 I: a:

H

Figure 2

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

Figure 3

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

Most commonly, diagnostic arthroscopv is followed bv

to the articular cartilage.” The graft is inserted into the

of the defect are determined, and the defect is prepared with the use of proprietaryr equipment. The femoral donor site is selected based on the size and contour of the recipient defect. The reconunended donor sites include the intercondylar notch region or the peripheral trochlea

gressive impaction of the chondral surface of the graft should he avoided to minimize chondrocyte death.15'“

UAT through a miniopen approach. The size and shape

{medial or lateral} above the level of the sulcus terminalis.

The lateral trochlea is larger than the medial trochlea, but the medial trochlea has lower contact pressures.“

The osteochondral cvlinder is obtained using a harvesting

chisel. To obtain an even chondral surface, it is important to ensure that the harvesting chisel remains perpendicular

flrdtopaedic Knowledge Update: Sports Medicine 5

prepared recipient tnn nel using a press-fit technique. AgContact pressures and forces are normal when grafts

are placed flush with the surrounding articular cartilage. Small incongruities, especially if the graft is proud, can increase contact pressures}?

Dne of the main advantages of this procedure is that it provides hvaline cartilage at the defect site?“ In addition, OAT can be successfnlhr used in the setting of subchondral bone loss or abnormality. The drawbacks of DAT include possible donor site morbidity and the

El 1016 American Academv of Cirrhopaedic Surgeons

Chapter 13: firticular Cartilage cf the Knee

|"'

a

1..

I-

I" 4'"- H ‘1';

Figure 4

.

I

u

Ill-L-

?

.

ILL

‘

II.'

I'I ' :|_. " 'llrhtmflli _I

-|.J.|;:':“""

d-rl" fiakilII-H'Lt'l'

-

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-|-

.

fill-5- _'_I."-

[:1-

'-

I*’E'-—1. 11.1151;t

.-|_

I-

IL. l' I—qjl

—.II:- I

| _L

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

limited amnunt nf graft material that can be harvested. As a result, DAT is ideal fnr chnndral nr nstenchnndral

is larger than can he nhtained in an autngraft {Figures

Pnstnperative rehabilitatinn includes tnedtnuch weight

placed in the center nf the defect fnr sizing. When the

defects smaller than 2 cm1.

bearing fnr 4 tn 3 weeks, depending cm the size nf the

lesinn and the number nf nstenchnndral cylinders used. Early prngressive mntinn is encnuraged with use nf a

(3PM machine. A return tn athletic activity is delayed far 4 tn 6 mnnths.

5 and 6}. A medial nr lateral parapatcllar arthrntnmy is perfnrmed, and the lesinn is identified. A guidewire is size has been determined, the defect is prepared using prnprietary equipment. The defect is reamed tn remcve

the abnnrmal cartilage and apprnzimately E tn lfl mm

nf sub-chnndral bnne. The recipient tunnel is created, and the dnnnr nstecchnndral cylinder is taken frnm the fresh allngraft specimen. An attempt is made tn harvest frnm a

|Illistenchnndral Allngraft Transplantatinn flStEflCl'tDflElI'fll allngraft transplantatinn is an excellent np-

matching area nf the allngraft specimen an that the cnn— tnur will match the recipient area. The dnnnr cylindrical

4 cm1. This prncedure alsn can he used as a salvage nptinn after an unsuccessful cartilage repair surgery. The defects

As in DAT, the use nf a mallet shnuld he avnidcd during insertinn tn minimize chnndrncyte death.

tinn fnr chnndral nr nstenchnndral defects larger than 2 tn mnst cnm mnnly treated are in the weight-hearing medial

plug is inserted intn the recipient tunnel with a press fit.

Pnstnpcrative reh abilitatinn includes tne-tnuch weight

nr lateral femnral cnndyle. Tibial and patellnfemnral deF facts can he treated with this prncedure, but tihial access

bearing fnr 6 tn 12 weeks. Early prngressive mntinn is encnuraged with use nf a CPM machine. Snme surgenns

tellar and trnchlear surface genmetry presents challenges fnr graft matching and preparatinn. Fresh refrigerated

6 weeks in patients treated fnr a patellnfemnral lesinn. High-lnading activities such as running and jumping

requires extensive surgical dissectinn. The cnmplez pa-

recnmmend limiting fleainn tn 45" during the first 4 tn

1.4,:

specimens tn ensure the highest level nf chnndrncyte vi— ahilityfi'1 The recnmmended time frnm graft harvest tn

shnuld he avnidcd fnr 6 tn 12 mnnths after surgery.

re re tn 3

Autnlngnus Chnndrncyte Implantatinn

s

time at least THEE nf chnndrncytes are viable}1 Ideally the graft is frnm the same side and cnmpartment as the

ticular cartilage—restnring prncedure used tn treat 2 tn 4 cm1 nr larger full-thickness chnndral defects cf the

The technique is similar tn that fnr BAT except that the cylinder nhtained frnm the dnnnr cadaver hemicnndyle

which an initial arthrnscnpic cartilage binpsy is fnllnwed by 4 tn 6 weeks nf in vitrn chnndrncyte expansinn and

allngrafts are used rather than frnzen nr freeze-dried

transplantatinn is an mare than 23 days because at that recipient defect and is size matched.

Eb Iflli‘i American Academy nf Urthnpaedjc Surgenns

nutclngcus chnndrncyte implantatinn {AC1} is an ar-

knee {Figures T and 8]. AC] is a twp-stage prncedure in

Drthnpaedic Knnwledge Update: Spnrts Medicine 5

FT. :5

El.

Sectien 3:Ilinee audLeg

G Figure 5

Schematic drawings shew steps in esteechend ral alleg raft tra nsplantatien. A, The size and shape at the chendral

defect are determined. I. The defect is reamed te remeve abnennal cartilage and E tn 1e mm at subchendral bene. C. The dener esteechendral cylinder is ebtained frem the fresh alleg raft specimen. D. The dener cylindrical plug is inserted inte the recipient tunnel using a press fit.

re

I." _.-:. _ ‘—

Figure 5

|

I 'i.

-

'I.

'

'

_.

' :-

Phetegraphs shew.r steps in esteechendral allngrait transplantation. A. Unhealthy cartilage and underlying subchendral bene have been remeved in preparatien fer insertien ef the esteechendral allegraft cylinder. E, The fresh fe meral hemicendyle is prepared fer ebtaining the dener esteechen dral cylinder. I2. The esteeche ndral

aliegraf't cylinder has been placed inte the recipient tunnel using a press 'iit.

reimplantatien. The first-generatien technique required harvesting ef prescimal tibia periesteum fer use as a patch

added that allews implantatien te be delayed as much as 2 years. The reimplantatien precedure requires a medial

Secend—geueratien techniques use a synthetic type Ir'III cellagen membrane. The advantages ef using the type LI"

fied and eutlined using a scalpel te centain the defect by establishing a stable rim ef surreunding cartilage. Ring

te centain the chendrecyte suspensieu within the defect.

III cellagen membrane include sherter surgical time, less

merbidity, and fewer pestsurgical cemplicatieus such as graft patch hypertrephy.“ A third-generatien technique DI

cu

._I

T:

I: us ca Iii-1 I: a:

H

is being used in Eurepe but has net yet been appreved

fer use in the United States. The purpeses ef the initial arthrescepy are te evaluate the size and lecatien ef the defect and determine whether the lesien has a stable ritn ef surrenudiug healthy carti— lage. If the defect is determined te be amenable te ACI, a full-thick ness Zflfl- te Slim-mg cartilage biepsy is ta ken

er lateral parapatellar arthretemy. The defect is identicurettes are used te remeve all remaining unhealthy ea :-

tilage in the centained defect while aveiding penetratien ef fl'lE subchendral plate. The defect is traced ente sterile

gleve paper er feil te create a template fer the type Ir'III

cellagen membrane. The membrane is trimmed te the desired size and shape and sutured te the stable rim ef cartilage using a Iii-{l pelyglycelic acid suture in a simple

interrupted fashieu. A small epening is left se that an iii-gauge plastic angiecatheter can be inserted beneath the

membrane. Befere inserting the cells, fibrin glue is applied

frem the superelateral intercendylar netch er the periph— ery ef the trechlea. The biepsy material is transperted in

te the perimeter ef the membrane except fer the area te be used for cell insertien. After cell injectien, this small

tn 6 weeks, the cells usually are ready te be reimplanted.

glue te create a watertight seal. Due ef the advantages ef this technique is that there is an limit te the size er shape

special medium fer espansien in the iaberatery. After 4

Fer mest patients, hewever, a cryepreservatien stage is

flrdtepaedie Knewiedge Update: Sparta Medicine 5

epening is ciesed using an additienal suture and fibrin

El 1016 American Aeadem1r ef Cirtbepaedic Surge-ens

lChapter 13: Articular Cartilage ef the Knee

a, Figu re Ir'

Schematic drawings shew steps in autelegeus chendrecyte implantatien. A. Cartilage biepsy tissue is ebtained frem the intercendylar regien ef the lateral trechlea. B, The chendral defect is prepared with a ring curette te

create stable berders. C. Type lrlll cellagen membrane has been secured in place. and chendrecytes are injected beneath the membrane.

A

K,

Figure 5

-.

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

ef the lesien treated as lung as the defect is centained.

AC1 and decreases the surgical time, but it has net been

US FDA dees net censider patellar er tibial lesiens te be appreved indicatiens.

te be cemparable te these ef standard MIL“ Rehabilitatien after AC1 begins with immediate me-

Any lecatien in the knee can be treated, altheugh the

The meet current technique is cell-seeded AG], in which

the cellagen patch is sized and cut tn shape while dry and subsequently seeded with the chendrecyte suspensien in

the eperating teem. 1Within 5 te 10 minutes, the cells

attach themselves re the membrane, which is placed inte the defect and secured circumferentially with a running

6-D reserbahle suture. The suture line is waterpreefed with fibrin glue, but ne additional injectien ef cells is

required. This technique is less invasive than standard

El Ifllli American Academy ef Urthepaedic Surgeeus

appreved fer use in the United States. The results appear

pg

tien. A CPM machine is used 6 te 3 hears a day fer the

re re er 3

first Ii weeks with pregressien reward 90° ef knee fleicien. After treatment ef a defect in the femeral cendyle, tee-

teuch weight bearing is used fer 6 weeks, after which the

patient pregresses reward weight hearing as telerated. After treatment ef a patellefemeral defect, the patient

can bear weight frem the beginning as telerated in full

extensien. Running is net allewed fer 12 menths, and ether strenueus sperts activity is restricted fer 13 menths.

Drrhepaedic Knewledge Update: Sperrs Medicine 5

FT. :5

El.

E

Sectinn 3:1Cnee and Leg

Outcn mes

Until recently, little high—quality evidence was available nn articular cartilage surgery. In 11113, a review nf cartilage

surgery studies fnund the methndnlngic quality tn be

generally pnnr hut tn have imprnved within the preceding 10 years.” Several recent high-quality studies were nnt included in the reviewdifl

Micrnfracture

At 11-year fnllnw—up nf 9'2 patients whn underwent mi— crnfracture fnr a full-thickness defect nf the knee, sub-

stantial imprnvement in Lyshnlm Knee Questinnnaire

repnrted that patients had imprnved clinical scnres after

than 413' years {59%}, female sex {61%}, and a defect larger

than 3 cm1 {59%}. Patients ynunger than 40' years with a

defect smaller than 3 cm: had a failure rate nf nnly 12.5% and a favnrable mean Lyshnlm scnre nf SZ.

nstenchnndral Allegraft Transplantatinn

fnr 4t] tn 50 years. Several studies fnund satisfactnry nntcnmes.”"*5' A recent lung-term nutcnme study repnrted the

in 53 patients at a mean 22-year fnllnw-up.” At the time nf surgery, the patients were ynunger than 5|] years and

had a unipnlar nstenchnndral nr nstenchnnd ritis dissecans

defect nf the distal femur larger than 3 cm in diameter and 1 cm in depth. Graft survival at It}, 15, 1f), nr 25

years was 91%, 34%, 69%, nr 59% respectively. Patients

with surviving grafts had a mean mndified Hnspital fnr Special Surgery scnre cf 36. A systematic review nf 19 studies evaluated the nut-

micrnfracture surgery.35f Hnwever, the results nf micrnf~ racture may deterinrate with time. A systematic review cf

cnmes nf nstenchnndral allngraft tra nsplantatinn in 644 knees at a mean 5B -mnnth fnllnw-upfi1 The mean patient

imprnved knee functinn at 24-mnnth fnllnw—up, but data were insufficient fnr evaluating lnnger term nutcnmes.”

The defects were idinpathic nr related tn trauma, nstenchnndritis dissecans, nr nstennecrnsis. The nverall patient

23 studies invnlving Innre than 3,900 patients repnrted A systematic review repnrted that micrnfracture fnr a

small lesinn in patients with lnw physical demands had gnnd nutcnrnes at shnrt-term fnllnw-up but that treatment

age was 3? years, and the mean defect size was 6.3 emf.

satisfactinn rate was 36%, and 65% nf patients had little

nr nn nstenarthritis. The shnrt-term cnmplicatinn rate was

failure cnuld he expected after 5 years, regardless nf lesinn

2.4%, and the nverall failure rate was 18%. Despite the cnmplexity nf nstenchnndral allngraft

fnund tn he expected 2 tn 5 years after surgery.42 Even

nf 14 fresh patellnfemnral allngraft transplantatinns in

size.“ Similarly, micrnfracture fnr small lesinns imprnved symptnms, hut deterinratinn nf clinical nutcnmes was with prnper surgical technique and apprnpriate patient sclectinn, the results nf micrnfractnre were found tn deterinrate nver time.“3

transplantatinn in the patellnfemnral jnint, encnuraging nutcnrnes have been dne umented. A retrnspective review

11 patients fnund that at an average 10—year fnllnwvup (range, 2.5 tn 1?.5 years), 3 grafts were in place.’2 Fnur

grafts survived lnnger than 10 years, and 2 survived lnn-

Dsten-chnndral Autngraft Transfer

ger than 5 years. Three allngrafts survived mnre than 1f} years hut did nnt survive until final fnllnw-up. Ten nf the

BAT [mnsaicplasty}, gnnd tn excellent nutcnrnes were fnund in 91% nf thnse with a fernnral cnndyle lesinn,

again. Annther study fnund that 5 nf 20 fresh nstenchnndral allngrafts used tn treat patellnfemnral lesinns in IS

a patellnfemnral lesinn.“M Patellnfemnral pain related tn graft harvest was fnund in 5% nf patients. These data

mnnths.”

._I

H

arthrnplasty nr a Lyshnlm scnre nf 64 nr lnwer].‘l‘5 The pnnr nutcnrnes were assnciated with patient age nlder

results nf fresh nstenchnndral allngraft transplantatinn

40 years and with a lesinn smaller than 2 cm?- were mnst likely tn return tn high-impact spurts. Annther study alsn

I: m m III-1 I: E

patients, 49% had a pnnr nutcnme {defined as later knee

ter Universities Ostenarthritis Index were gnnd tn ex—

53 athletes with a mean 4—cm2 defect fnund that 90% had a nnrmal nr near-nnrmal Internatinnal Knee Uncumentatinn Cnmmittee {IKDC} Subjective Knee Evaluatinn Fnrrn scnre at 6-year fnllnw-up.” Patients ynunger than

T:

9-year fnllnw-up. At 10- tn 14-year fnllnw—up cf the same

Dstenchnndral allngraft transplantatinn has been used

cellent.“ At 9-year fnllnw-up, 36% nf patients repnrted imprnvement. A review cf the results after treatment cf

m

undergn the surgery again.“ Hnwever, a deterinratinn nf results was nbserved frnm the 11-mnnth tn the 5- tn

and Tegner Activity Level Scale scnres was repnrted, and

scnres cm the Medical |Dutcnmes Study 36-Item Shnrt Farm Health Survey and Western Untarin and McMas-

DI

underwent DAT {33%) said that they wnuld chnnse tn

At an average 9.6-year fnllnw-up nf patients treated with

36% cf these with a tihia] lesinn, and ?4% cf thnse with

suggest that DAT shnulrl he cnnsidered fnr cnmpetitive

athletes with a 1— tn +c lesinn. Annther study repnrted that at an average 9-year fnllnw-up, 61 nf 69 patients whn

flrfltnpaedic Knnwledge Update: Spnrts Medicine 5

11 patients stated that they wnuld undergn the prncedure

patients did nnt survive at an average fnllnw-up cf 94 Autnlognus Chendrntyte Implantation

Since the first descriptinn nf AG] in 1994, shnrt- tn immediate-term

studies

have

fnund

favnrahle

El 1016 American Academ1r nf Drthnpaedic Surge-ens

Chapter 13: Articular Cartilage of the Knee

outcomes?“ Several long-term studies have recently

become available. At a mean 12.3-year follow—up, 74% of

Comparative Dutcome Studies

patients reported their status as better than or unchanged from that of preceding years.” Ninety-two percent were

Microfracture Versus |liltiIHIiT A level I randomized controlled study of Sill patients com-

year study of 213 patients, the average defect size was 3.4 emi.” At 10-year follow-up, graft survivorship was

years}:52 After 321 months, patients in both groups had

satisfied and would have the procedure again. In a 1271%, and 25% of patients reported improved function.

pared microfracture to DAT in athletes {mean age, 24.3

significant clinical improvement. However, at 12, 14, and SIS months, those treated with DAT had statistically sig

At least one graft had failed in 53 of the patients {25%). A subgroup analysis revealed that concurrent osteotomy

tional Cartilage Repair Society scores than those treated

otomy, 56% without osteotomy}. A study of the results of AC1 for chronic chondral and osteochondral defects

with DAT were able to return to sports activity at the preinjury level at an average 65-month follow-up, compared

age lfl.4 years}? The patients were considered difficult to treat; their mean duration of symptoms was 7.3 years, and

13-year follow-up data, the same patients had significant clinical improvement in follow-up International

significantly increased graft survivorship {33% with ostefollowed 134 patients {mean age, 33.2 years} for an aver— they had undergone an average 1.3 cartilage procedures

nificantly better Hospital for Special Surgery and Interna-

with microfracture. In addition, 93% of patients treated

with 52% of patients who underwent microfracture. In Cartilage Repair Society scores compared with scores

before ADI. Twenty-seven patients {26%} had graft failure at a mean 5.? years. DI the T3 patients with surviving

before surgery.{“3 However, patients in the DAT group had significantly better scores compared with patients

Until recently, no outcome data have been available to support the use of AC] in the patella. In a large mul-

patient activity levels. Fifteen of 23 patients in the DAT group {33%} were able to maintain the same preinju-

cartilage defect of the patella and were followed for at least 4 yearsf"fl There were statistically significant and

microfracture group (32%}. In patients who underwent

grafts, S4 {33%} reported a good to excellent result.

ticenter study, IICI patients were treated with AC1 for a

clinically important improvements in all physical outcome scales, IKDC scores improved from 4D to 69, modified

Cincinnati Knee Rating System scores improved from 3.2 to 6.2, and Western Dntario and McMaster Univer— sities Dsteoarthritis Index scores improved from 50.4 to

13.6. |Due hundred one patients (92%] stated they would

undergo the procedure again, and 95 {35%} rated their

knees as good or excellent at final follow-up. Newer data suggested that earlier bone marrow stim-

ulation procedures such as microfracture may have a

detrimental effect on outcomes after ACI. A review of

in the microfracture group. Similar trends were found in ry activity level compared with 3 of 22 patients in the

DAT, lesions smaller than 11 em1 were associated with a significantly higher rate of return to sports compared with

larger lesions. No difference was found between DAT

and microfracture in muscle strength, patient-reported outcomes, and radiographic outcomes at a mean 9.3-

year follow-up.“ This study involved only 25 patients,

and therefore it is difficult to draw firm conclusions from

the data.

Microfracture Versus ACI

Because few high-powered studies have compared ADI and microfracture, outcome data conflict. A randomized

study of 30 patients found no difference in clinical out-

more than 300 consecutive patients compared outcomes based on whether the patient had undergone a bone

comes at 2- and 5-year fltillow-upfii‘i"IE However, defects

bone marrow stimulation compared with 3% of patients

was not observed after ACI, and ADI was recommended

to

prestudy experience with ADI. A randomized controlled

re re tn 3

marrow stimulation procedure before AC1.“ Graft failure occurred in 26% of patients who had undergone earlier who had not had a bone marrow stimulation procedure. Similar results were found in a comparison study of ADI after unsuccessful microfracture or as a first-line pro-

cedure.“ Significantly more graft failures were associated

with ADI after microfracture i? of 23} than with ACI as a first-line treatment {1 of 23}. Inferior clinical outcome

also was associated with ADI after microfracture.

larger than 4 cm1 were associated with a worse outcome after microfracture than smaller lesions. A similar trend for treatment of large lesions. This study was criticized because most of the involved surgeons had little or no

study with 2—year follow—up compared matrix-applied ADI with microfracture in 144 patients with a mean lesion size of 4.3 CHIS-E? The important exclusion criteria

included malaligmnent requiring osteotomy. The assessed outcomes included the Knee Injury and Dsteoarthritis

Dutcome Score, knee-related quality of life, and repair

tissue quality as based on histologic and MRI findings. For cartilage defects larger than 3.- cm1, treatment with

D 2316 American Academy of Drthopaedir. Surgeons

Drthopaedie Knowledge Update: Sports Medicine S

F. :5

El.

.3

Sectien 3:1Cnee andLeg

matrix-applied AC1 was statistically and clinically better

parapatellar arthretemy, identificatien ef the defect,

and safety eutcemes.

a multicenter prespective study, 25 patients treated with juvenile particulated cartilage had statistically significant

than micrefracture, with similar structural repair tissue

ACI Versus OAT A prospective study cf 40 patients cempared AC1 te DAT.” lvfeyers, Lyshelm, and Tegner activity sceres

were ebtaincd at 3, 6, 12, and 24 menths, and biepsy

specimens were ebtained fer histemerphelegic evaluatien. Beth surgical preccdnres led te imprevement in

than a cemmercial entity with experience in chendrecyte culture precesses.

studies with lenger term fellew-up are needed te deter-

DAT. Cell culturing was dene by the investigaters rather At a mean l.?—year fellewdup, a prespective randem-

iaed study ef lfll} patients with an esteechendral defect feund that 33% cf these treated with AC] had geed te excellent medificd Cincinnati and Stanmerc Functienal Rating scercs cempared with 69% cf these treated with mesaicplasty.“ In additien, arthrescepy at 1 year feund

that 32% ef the patients treated with AC1 had a geed

er excellent repair cempared with 34% cf these treated with mesaicplasty. The leng—term eutcemes ef the same patients were reperted at a minimum 10-year fellewsup.”

Graft failure had eccurred in 10 cf the 53 patients treated

with AC1 {17"}3} and 23 cf the 42 patients treated with mesaicplasty {55%}. Nene ef the five patellar mesaicplasu

ty precedures were successful. Bielegic Techniques

I: re re III-1 I: a:

H

mixture ef hyaline cartilage and fibrecartilage with mere

type 11 than type I cellagen.

ef PEP. A systematic review cf 10 studies ef PEP used in degenerative knee and hip disease did net find evidence ef

ef mechanical alignment. Seven ef the 20 patients whe

._I

analysis ef hiepsied material frem eight patients revealed a

underwent AC1 had undergene earlier abrasien arthreplasty, cempared with 4 cf the Eli patients whe underwent

after DAT, hyalinelike tissue with an interface between

T:

thritis Clutceme Scere at 2-year fellew-upf'l Histelegic

the transplanted and eriginal cartilage was maintained. This study lacked a preeperative radiegraphic evaluatien

DAT, as indicated by Lyshelm sceres. After AC1, biep' sied tissue primarily was filled with fihrecartilage, but

as

imprevements in IKDC and Knee Injury and Dsteear—

Platelet-Rich Plasma Autelegeus platelet-rich plasma {PEP} has been used te treat musculeslceletal cenditiens such as lateral epicendylitis and retater cuff tears. Animal studies have identified petential uses fer PRP alene er as an augmentatien ef ether hielegic treatments fer repairing hyaline cartilagefi'“

symptems, but recevery after AC1 was slewer than after

DI

and initial preparatien similar te the AC1 technique. In

Each ef the available articular cartilage—restering precedures is hampered by specific limitatiens, and this facter

Hewevcr, uncertainty remains as te the in vive efficacy

a shert—tcrm clinical benefit.” High-quality cemparative

mine whether PRP ceuld he efficacieus fer treatment ef articular cartilage cenditiens.

Cerrl Bleed Stem Cell Transplants

Cartistcm ll'viedipest} is a stem cell drug used te treat

articular cartilage defects and estcearthritis. This drug centains mesenchymal stem cells derived frem umbilical cerd bleed. In 2012, Cartistem was appreved fer clini-

cal use by the Feed and Drug Administratien ef Kerea, and it has been appreved fer clinical study at certain US institutiens. Amnietic Stem Cell Transplants The use ef amnietic tissues has attracted censiclerable attentien. Arnnienic stem cell transplants are reutinely used in the treatment ef eye and diabetic feet disease

and are being investigated fer use in cartilage repair and

esteearthritis applicatiens.

Next-Generatien Chendrecyte lmplantatien

has led te increased interest in new hielegic techniques using allegrafts, stem cells, and scaffelds.

The currently used chendrecyte implants censist ef autelegeus cells, but cencern as te cell quality variability

Particulate-cl Juvenile |Itiartilage It has been preved in animal and human medels that

drecyte preducts. Allegeneic implants ceuld be derived frem dener chendrecytes that express high levels ef chen-

juvenile cartilage is superier te adult cartilage in chen-

drecytic activity, cell density, and healing petential."'“"“

DeNeve NT Natural Tissue Graft {Zimmer} was cemmercially intreduced recently as a particulated juvenile

allegraft cartilage frem deners age 13 years er yeung— er. The surgical technique requires a medial er lateral

flrthepaedic Knewledge Update: Sperts Medicine 5

ameng deners has led te investigatien ef allegeneic chendregcnic petential. SL1 tn mary

Articular cartilage repair is a rapidly devcleping erthepae— dic subspecialty. The rate ef pesitive eutcemes generally

El ll] 16 American AcadMy ef Drthnpaedic Surge-ens

lEhapter 13: Articular Cartilage of the Knee

exceeds 30% if the technique is carefully matched to

specific patient and defect characteristics. Débridement is

useful for temporary pain relief and reduction of mechanical symptoms. Microfracture is indicated for treating a small acute femoral condyle defect in a young patient.

DAT has better outcomes than microfracture but is lim-

ited by donor site morhidity. Osteochondral allograft transplantation can he used to treat large osteochondral

defects and revise an unsuccessful earlier cartilage repair procedure, but its use in the patellofemoral compartment is complicated by the difficulty of matching the varied

anatomy. AC1 can more easily be used to treat multiple patellofemoral defects, but it requires intact suhchundral hone. Numerous techniques and products are under de-

velopment and are expected to be ready for clinical use within 5 to it} years. I-{oy Studyr Points

I Initial evaluation of chondral defects requires a

thorough history, physical examination, and radio-

graphic assessment. 1* Associated injuries, malalignment, age, activity level, and expectations should all he considered when

formulating a definitive treatment plan.

1* For patients on whom nonsurgical treatment fails

and who are candidates for cartilage repair andJ'or restoration surgery, DAT or microfracture should

be considered for smaller lesions {c 2—4 emf] and

AC] or osteochondral allograft transplantation for

larger lesions {=- 1-4 cmzi. ' Lesions resulting in abnormal or deficient suhchon-

dral hone may he hest treated with procedures that

address the entire osteochondral unit, such as DAT

or osteochondral allograft transplantation.

in the rabbit knee. I Bonejoim 3mg rim 1930;62{1}:?9-39. Medline Heath CA, Magari SR: Mini-review: Mechanical factors affecting cartilage regeneration in vitro. Hiotechnoi Bioeng 1996;59H]:430-43?. Mediine DUI flhsan T, Lottman Li'v'I, Harwood F, Amiel D, Salt EL: Integrative cartilage repair: Inhibition by heta—aminopropionitrile. J Orthop Res 1999;1?{o}:35fl-351 Medline DUI Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG: Cartilage injuries: a review of 31,516 knee arthroscopies. Artist-occupy 199T;13H}I:456-4fifl. Medline DID] nraen A, Laken S, Heir S, et al: Articular cartilage lesions in 993 consecutive lcnee arthroscopies. Am J Sports Med lflfl‘l-gdljljflll—IIS.Mcdline DDI Hjelle K, Solheim E, Strand T, l'vIuri IL, Erittherg M: Ar-

ticular cartilage defects in 1,0 {11“.} knee arthroscopies. Ar-

throscopy Zflfl2;13{?]:?3fl-?34. Medline

DUI

10. Flanigan DC, Harris JD, Trinl'i TQ, Sistou RA, Erophy RH: Prevalence of chondral defects in athletes“ knees: A systematic review. Med Sci Sports Ettore 2010;42i1flj:1?951801. Medline DUI

A systematic review of 11 level IV studies determined the prevalence of full-thickness chondral defects in athletes‘

knees to he 36%. Patellofemoral defects accounted for 3T%, femoral condyle defects for 35%, and tibial plateau

defects for 25“513.

11. Brophy RH, Zeltser D, 1Wright RT, Flanigan D: Anterior

cruciate ligament reconstruction and concomitant articu—

lar cartilage injury: Incidence and treatment. Arthroscopy 2D10;26[1]:112-120.Medline DUI A systematic review of five studies revealed a 115% to 46% incidence of severe articular cartilage injury in acute anterior cruciate ligament tears.

Annotated References

12. Lewandrowslti KU, Miiller J, Schollmeier G: Concomitant meniscal and articular cartilage lesions in the femorotihial joint. Am I Sports Med 1997:25i4}:436-494. Medline D01

1. Newman AP: Articular cartilage repair. rim I Sports Med

13. Nomura E, Inoue M, Kurimura M: Chondral and osteochondral injuries associated with acute patellar disloca-

to

14. Lefltoe TP, Trafton PG, Ehrlich MG, et al: An exper-

re re cu 3

1993;16fljz3fl9-324. Medline

2. U’Driscoll SW: The healing and regeneration of articular

cartilage. J Bone joint 3mg Am 1993:ED{11}:1T95-1311. Medline

3. Shapiro F, Koide 5, Glimcher M]: Cell origin and differ-

entiation in the repair of full-thickness defects of articular cartilage. J Bone Joint San-g Am 1993;T5{4J:531-553. Medline

4. FuruItawa T, Eyre DR, Koide S, Glimcher M]: Biochemical

studies on repair cartilage resurfacing experimental defects

Eb Iflli'i American Academy of Urthopaedic Surgeons

tion. Arthroscopy 2fi03;19{?}:?1?—?21. Medline Dfll

imental model of femoral condylar defect leading to

osteoarthrosis. J firthop Trauma 1993;?{5}:45 3-461 Medline DUI 15. Messner K, Maletius W: The long-term prognosis for severe damage to weight-bearing cartilage in the knee:

A 14—year clinical and radiographic follow-up in 13

young athletes. Acre flrrhop Sound 1996:E?{1J:165-163. Medlirle DflI

Drrhopaedic Knowledge Update: Sports Medicine 5

F. :15

El.

E

Section 3:1fnee andLeg

15. Gomoll AH. Yoshiolca H. 1iS'i'atanabe A. Dunn JC. Mines T: Preoperative measurement of cartilage defects by MRI underestimates lesion size. Cartilage 2011;2{4}:339—393.

Medline DUI

Seventy-seven patients had ltnee MRI before arthroscopic surgery for a cartilage defect. Defect size was determined on MRI and at time of arthroscopy. MRI underestimated the defect area an average 65% of the time compared with arthroscopic visualization. Leml of evidence: II. 1?. Montgomery SR. Foster ED. Hgo 55. et al: Trends in the surgical treatment of articular cartilage defects of the knee in the United States. Knee Snrg Sports Tranmrttof Arthrosc 2fl14;22{9i:2fl?fl-2fi?5.Modline DUI

Microfracture and chondroplasty accounted for more than

93% of 163.443 knee articular cartilage procedures over a 6-year period. usually in patients age «Ii-CI to .59 years. Uther procedures were more often done in patients younger than 40 years. Level of evidence: IV. IS. 1i'lll'illiams E] III. Harnly HW: Microfracture: Indications. technique. and results. instr Course Lect 2002;56:419423. Medline 19. Chen H. Chevrier A. Hoemann CD. Sun J. Cluyang W. Buschmann MD: Characterization of subchondral bone repair for marrow-stimulated chondral defects and its

relationship to articular cartilage resurfacing. do: 1 Sports Med 2011;35i3]:1?31-1?4fl. Medline

DUI

Bone marrow stimulation procedures were done on 16 skeletally mature rabbits. Repair led to an average bone volume density similar to that of control subjects but the

repaired bone was more porous and branched. Relatively

deep drilling induced a larger region of repairing and remodeling of subchondral bone that was positively correlated with cartilage repair. 2:1}. Chen H. Hoemann CD. Sun J. et al: Depth of subchondral

perforation influences the outcome of bone marrow stim-

ulation cartilage repair. I Cirtbop Res 2011;29{S}:11?ii-

1134. Medline DUI

This study used a rabbit model to compare depth {6 mm versus 2 mm} and type of marrow stimulation [drilling

versus microfracture} on cartilage defects. Clutcomes

included quantitative histomorphometry and histologic scoring. Results demonstrated that deeper versus shallow drilling produced a greater fill of the cartilage defect

UI

to

._I

T:

I: rn a: Iii-1 I: :e

H

with a more hyaline—lilte repair tissue. Microfracture and

drilling to 2 mm resulted in similar quantity and quality of cartilage repair.

21. Chen H. Sun J. Hoemann CD. et a]: Drilling and microfracture lead to different bone structure and necrosis during bone—marrow stimulation for cartilage repair. __i Urtfrop Res 20fl9:2?{11]:1432-1433. Medline DCII Chondral defects were treated with bone marrow stimulation in a mature rabbit model. Microfracture was found to produce fractured and compacted bone around holes. seal-

ing them off from bone marrow content. Drilling cleanly

removed bone from the holes and provided access channels

Clrfltopaedie Knowledge Update: Sports Medicine 5

to marrow conteot. hilicrof'racture was associated with

more osteocyte death than drilling.

22. Eldracher M. Urth P. Cucchiarini M. Pape D. Madry H: Small subchondral drill holes improve marrow stimulation of articular cartilage defects. An: I Sports Med 2D]4:42{11i:2?41-2?Sfl.Medline DUI Suhchondral drilling was done in 13 adult sheep. Cisteochondral repair was assessed at 6 months. Compared with

1.3-mm drill holes. the application of Lil-mm subchondral

drill holes led to significantly better histologic matrix staining. cellular morphologic characteristics. subchondral bone reconstitution. average total histologic score. immu-

noreactivity to type [I collagen. and immunoreactivity to typeI collagen in the repair tissue.

23. IZiohhi a. Nunag P. Malinowslti R: Treatment of full thickness chondral lesions of the knee with microfracture in a

group of athletes. Knee Snrg Sports Trnnrnntof Arthrosc 2flfl5;13[3}:213-221.Medline DUI 24. Garretson RB III. Katolilt LI. Verma N. Beclt PR. Each ER. Cole H]: Contact pressure at osteochondral donor sites in the patellofemoral joint. An: I Sports Med 2flfl4:32i4j:9ti?9'24. Medline DUI 25. Hangody L. Rathonyi CK. Duska Z. Visarhelyi G. Fflles P. l'vfodis L: Autologous osteochondral mosaicpiasry: Surgical technique. ] Bonejofnt Snrg Ant 2Dfl4;fi S{Suppl 11:65?2. Mcdlinc 2S. Jamali AA. Emmerson BC. Chung C. IConvery FR. Eugbee

WU: Fresh osteochondral allografts: Results in the patel— lofemoral joint. Citn Grthop Refer Res 2D flS:43?:1?6-135. Medline DUI

2?. Pylawka TK. Wimmer M. Cole H]. 1iI.i'irdi..'5:fi. Williams M: Impaction affects cell viability in osteochondral tissues during transplantation. }' Knee Snrg 2DD?;2D[2}:1DS-11i}. Mcdlinc 2E. Gfirtz S. Eugbee WI): Allografts in articular cartilage repair. Instr Coarse Lect 2Dfl?:S{i:469-4Sii. Medline 25‘. Koh JL. liiii'irsing K. Lautcflschlager E. Zhang LU: The effect of graft height mismatch on contact pressure following osteochondral grafting: A biomechanical study. Am I Sports Med 2004;32i2}:31?—32fi. Medline DUI

3f}. Hangody L. Kish U. Kdrptiti Z. Udvarhelyi I. Szigeti I.

Eély M: Mosaicplasty for the treatment of articular cartilage defects: Application in clinical practice. Drtfropedfcs

1993:21{?l:251-TSS. Medline

31. Bugbee WD. Convery FR: Usteochondral allograft transplantation. Cfin Sports Med 1999;13{1i:fi?-?5. Medline

DUI

32. LaPrade RF. Bother J. Herzog M. Age] J: Refrigerated osteoarticular allografts to treat articular cartilage defects

of the femoral condyles: A prospective outcomes study.

1' Bone joint Snrg rim zoosa 1i4}:3i]5-311. Medline DD]

El 2016 American AcadMy of Cirrhopaedie Surgeons

Chapter 13: Articular Cartilage ef die [line-e

Twenty-three censecutive patients were treated with refrig‘ erated esteechendral allegra fts fer chendral defects. The average age ef implanted graft was 23.3 days. At 3-year fellew-up, medified Cincinnati and IKDC sceres revealed

a statistically significant imprevement. There were ne graft failures. Level ef evidence: IV. 33. ISemell AH, Prebst C, Farr], Cele I3], Minas T: Lise ef a

type IIIII bilayer cellagen membrane decreases reeperatien rates fer symptematic hypertrephy after autelegeus

chendrecyte irnplantatien. Am ] Speeds Med 3303;33i3uppl 1,1:233335. Medline DUI In a multicenter cemparisen study ef 330 patients treated with periesteum-cevered AC] and 131 patients treated with cellagen membrane—cevered ACI, the 1-year failure rates were similar but there was a significantly higher reeperatien rate fer graft hypertrephy after periesteumcevered ACI {153%} than after cellagen membranecevered AC1 {5 3'3}.

34. Hiemeyer P, Lena P, Kreua PC, et a1: Chendrecyte-seeded

33. Steadman JR, Briggs KK, Redrige J], Kecher M5, Gill T], Redkey WC: IE’Iutcemes ef micrefracture fer traumatic chendral defects ef the knee: Average 11-year fellew-up. Arthrescepy 2333:19i5]:4?7-434. Medline

DUI

39. Mitheefer K, 1Williams E] III, 1|Warren RF, et al: The micre-

fracture technique fer the treatment ef articular cartilage

lesiens in the knee: A prespective cehert study. _I Rene

jefflt 5333 Am lflflfi;3?{9}:1911-192{i. Medline

DUI

4D. Mitheefet K, McAdams T, Williams R], Kreu: PC, Mandelbanm ER: Clinical efficacy ef the micrefracture technique fer articular cartilage repair in the knee: An evidence—based systematic analysis. Am } Sparta Med 2339:3Tflfliflflfi3-2353.Medline DUI A systematic review ef 33 studies including 3,133 patients whe underwent micrefracture fer cartilage injury [average

fellew-up, 41 menths] feund that micrefracture previtles

effective shert-term imprevement ef knee fu nctien but that insufficient data were available en leng-term results.

type LI'III cellagen membrane fer autelegeus chendre— cyte transpla ntatien: Prespective 2-year results in patients with cartilage defects ef the knee jeint. Arthrescep'y

41. IE‘reyal D, Keyhani S, Lee EH, Hui JH: Evidence-based status ef micrefracture technique: A. systematic review ef level I and II studies. Arrbrescepy 1313:23[9}:15?9-1533.

A prespective study ef 59 patients treated with AC1 using

A systematic review ef 15 level I er II studies cempated the clinical eutcemes ef micrefracture with these ef ACI and esteechendral cylinder transfers. Mest studies reperted peer clinical eutcemes. Twe studies reperted the absence ef any significant difference in the results. Small lesiens and relatively yenng patients had gee-d shert-term

2313;23{3l:13?4—1332.Medline eel

a cellagen membrane te seed the chendrecytes feund that the percentage ef patients with knees rated nermal er near

nermal increased frem 33.9% befere surgery te 32.5% at

24—mentb fellew—up en the ebjective Internatienal Car— tilage Repair Seciety rating. IKDC and Lyshelrn sceres increased frem 50.1 peints and 313.5 peints, respectively, he 36.] peints {P c 3.031} and 32.5 peints {P c 3.031}.

Level ef evidence: IV.

35. Ha rrisJD, Ericksen E], Abrams {3121, et a1: Methedeiegic

quality ef knee articular cartilage studies. Arrbvescepy 1313;29{?}:1243-1252.e5.Medline DUI A review ef 194 level I re IV studies feund that ACI was the

meat cemmenly reperted technique {62% ef studies}. The

mest cemmen study weaknesses were related te blinding, subject selectien precess, study type, sample size calculatien, and eutceme measures and assessment. There was imprevement in study quality after 2334.

36. I'vh'nas T, Gemell AH, Resenberger R, Reyce 110, Bryant

T: Increased failure rate ef autelegeus chendrecyte implantatien after previeus treatment with marrew stimulatien techniques. rim ,7 Sperts Med 1033;33i5iflflla903. Medline DUI

In a study ef 3.11 censecutive patients treated with ACI, 263:3 ef grafts were unsuccessful ameng these whe had undergene an earlier bene marrew stimulatien precedure

cempared with 3% ameng these whe had net had a bene marrew stimulatien precedure.

3?. Heras U, Pelinkevic D, Herr G, Aigner T, Schnettler R:

Autelegeus chendrecyte impla ntatien and esteechendral cylinder transplantatien in cartilage repair ef the knee

jeint: A prespective, cemparative trial. J Burns jeirrt Sui-g Am lflfl3;35[2}:135-192. Medline

I3! 2316 American Academy ef flrtbepaedic Surgeens

Medline D0]

results, but at 5— te 13—year fellew—up there was a high rate ef esteearthritis. 41. Gebbi A, Karnataikes G, Kumar A: Leng—term results after micrefracture treannent fer full-thickness knee chen-

dral lesiens in athletes. Knee Snrg Sperts Trustmdtei Arthresc 2314;12i9}:193E—1336. Medline DUI

Sixty-ene cf 6? patients {91%} were available at an av-

erage final '13.1~year and swelling during 3 patients at 1-year fellew—up. Clutceme

fellew~up after micrefracture. Pain strenuens activity was reperted by fellew—up and 35 patients at final sceres deterierated ever time. The

cenclusien was that deterieratien ef the clinical eutceme sheuld be expected after 2 re 5 years. Level ef evidence: IV.

43. Eedi A, Feeley ET, Williams E] III: Management ef articular cartilage defects ef the knee. ] Bette feirrt Surg Am 2310;93i4j:994-1339.Medline DUI

This review article fecused en management and eutcemes related te articular cartilage defects ef the knee. Hangedy L, Debes J, Bale E, Panics G, Hangedyr LR, Eerkes I: Clinical experiences with autelegeus esteechendral mesaicplasty in an athletic pepnlatien: A 1'?year prespective multicenter study. Am ] Speeds Med 2310:33lfi}:1125-1133.Medline DUI In a multicenter study, 354 ef 333 patients whe underwent mesaicplasty were fellewed fer an average ef 9.3 years. Gee-d te excellent results were feund after 91% ef femeral, 363i: ef tibial, and H33 ef patellefemetal mesaicplasties.

Drtbepaedic Knewledge Update: Sperts Medicine 3

H F:

5 re re ru-

3 D.

3

5ecfien3:l€neeand1eg Patellefemeral pain related te graft harvest was ebserved in 5% ef patients. Level ef evidence: IV. 45. Eelheim E, Hegna J, flyen J, nustgulen DE, Harlem T, Strand T: Gsteechendral autegrafting lmesaicplasty] in articular cartilage defects in the knee: Results at 5 tn 9 years. Knee Efllfl;l?{1}:S4-3?. Medline DUI Sixtyrnine patients {median age, 33 years] were available after mesaicplasty fer a full-thickness chendral defect. Mean Lyshelm and visual analeg scale pain sceres imprevcd frem 43 and 61, respectively, at the time ef surgery te 31 and 24 at 12-menth fellew-up {P e [1.001). Sceres deterierated te 63 and 32 at 5- tn 9-year fellew-up {P e {1.01111}. 4S. Selheim E, Hegna J, flyen J, Harlem T, Strand T: Results

at 10 te 14 years after esteechendral autegrafting {me-

saicplasty} in articular cartilage defects in the knee. Knee 2fl13;20{4}:23?-29fl.Medline DUI Seventy-three patients {median age, 34 years} were avail-

able after mesaicplasty fer a full—thickness chendral

defect. Baseline mean Lyshelm and visual analeg scale pain sceres impreved significantly at mid- and lung-term fellew-up. Ferty percent ef patients had a peer eutceme at lung-term fellew-up; mest ef these patients were age 40 years er elder {59%}, were wemen {513’s}, er had a defect ef 3 cm1 er larger {5?‘i'r‘bl. In men yeunger than

412} years with a defect smaller than 3 cm1, the failure rate was 12.5% and the mean Lyshelm scerc was 32.

4?. Gress AE, Shasha M, Rubin P: Lung—term fellewup ef the use ef fresh esteechendral allegrafts fer pesttraumatic lenee defects. Gift: Drtbep Reint Res lflfl5;435:?9-3?. Medline DUI

43. Gress PIE, Kim W, Las Heras F, Backstein I}, Safir D, Fritz-

ker KP: Fresh esteechendral allegrafts fer pesttraumatic knee defects: Lung-term fellewup. Cilia: Drtbep Refer Res 2008;46:5{31flflfi3-131'fl.Medline DUI

49. Eakay A, Csenge L, Papp G, Fekete L: Gsteechendral resurfacing ef the knee jeint with allegraft: Clinical

analysis ef 33 cases. Int Ortbep 1993;233:3131. Medline DU]

50. Raa G, Sal-i: DA, Eacksteiu D], Lee PT, Gress ALE: Dis-

5‘

'U E I'D I11 I11 I: be:

H

tal femeral fresh esteechendral allegrafts: Fellew'up at a mean ef twenty-twe years. I Bette Jeiut Surg Am 2014;36f13}:11l31-11fl?.Medline DUI

In a study ef leng-term eutcemes after fresh allegraft

transplantatien fer pesttraumatic esteechendral and esteechendritis dissecans defects ef the distal aspect ef the femur, 53 patients were fellewed fer a mean 11.3 years. Thirteen patients required further surgery, three underwent graft remeval, nine underwent cenversien te tetal knee arthreplasty, and ene underwent multiple débridements fellewed by amputatien abeve the knee.

51. Chahal J, Gress HE, |ll'I'rress C, et al: Dutcemes ef estee-

chendral allegraft transplantatien in the knee. Armres-

cepy 2fl13;29{3]:5?5-533. Medline

DUI

firthepaedic Knewledge Update: Sperts Medicine 5

Nineteen studies ef a tetal ef E44 knees {mean fellew-up, 53 menths} were included in a systematic review. All patients underwent esteechendral allegra ft transplantatien.

Petty-sis: percent ef patients had cencemita ut precedutes,

and the mean defect size was 6.3 cm1. The everall satisfactien rate was 35%. 52. Terga Spak R, Teitge RA: Fresh esteechendral allegrafts fer patellefemeral arthritis: Leng-term fellewup. Cfffl

Drtbep Refer Res 2fl065444rl 93-100. Medline D01

53. Petersen L, Minas T, Brittberg M, Nilssen A, SjfigrenJanssen E, Lindahl A: Twe— te 9-year eutceme after antelegeus chendrecyte transplantatien ef the knee. Gift: Urtfaep Refer Res lflfifl;3?4:212-134. Medline DUI 54. Petersen L, Erittberg M, Kiviranta I, flkerlund EL, Lindahl A: Autelegeus chendrecyte transplantatien: Eiemechanics and leng—term durability. A»: I Sperts Med 2002;3{1l11fl12. Medline 55. Minas T: Autelegeus chendrecyte implantatien fer fecal chendral defects ef the knee. Elie Drtbep Rein: Res EDIE]1;391{Suppl}:5349-5361. Medline DUI 56. McNickle AG, L’Heureua: DR, Yanke AB, Cele E]: flut-

cemes ef autelegeus chendrecyte implantatien in a diverse patient pepulatien. Am ] Sperts Med 2009;3T{T]:1344-

135i]. Medline DUI

After 13? patients {If-ll] knees} underwent ACI fet a knee defect {mean size, 5.1 cm‘i}, eutcemes were assessed at

4.3—year fellew-up. A significant imprevement after sur—

gery was ebserved en all eutceme measures. Level ef evidence: IV.

57’. Petersen L, Vasiliadis H5, Brittberg M, Linda hl A: Antelegeus chendrecyte implantatien: A leng-term fellew‘up. Am J Sperts Med .2fl10;33l5}:111?—1124. Medline DUI Questiennaires with eutceme measures were sent te 341 patients whe alse were asked te grade their status during the past 10 years as better, werse, er unchanged; 124 patients replied. At an average ef 11.3 years after surgery 34% ef the patients reperted their status as better er the same as in previeus years, and 92% were satisfied and weuld have the ACI again.

53. Minas T, 1|li-"en Keudell A, Bryant T, Gemell AH: A minimum 10-year eutceme study ef autelegeus chendrecyte implantatien. CH1: firteep Reia: Res 1014;4flt11fll-fl.

Medline DD]

At final 12-year fellew-up after ACI fer a symptematic cartilage defects, 53 ef 210 patients {15%} had at least

ene failed AC1 graft. Nineteen patients went en te at—

threplasty, 2? patients had revisien cartilage repair, 1' patients declined further treatment, and 3 patients were

lest te fellew—up. ACI previded durable eutcemes with a

survivership ef 751% at 10 years and imprevcd functien in 1'5 33 ef patients. A histery ef bene marrew stimMatien er treatment ef a very large defect was asseciated with an increased risk ef failure.

fl 213115 American Academy ef Orthepaedic Surge-ens

Chapter 13: Articular Cartilage ef the Knee

59'. Biant LC, Bentley G, Vijayan S, Skinner JA, Carringten 11W: Leng—tcrrn results ef autelegeus chendrecyte implantatien in the knee fer chrenic chendral and esteechendral defects. Am ] Spar-ts Med 2D14;42{9}:21?3-2IS3. Mcdline DUI

In 1134 patients whe underwent AC1 fer a symptematic

cartilage lesien, the mean duratien ef symptems hefere surgery was 2.3 years. The mean number ef previeus surgical pre-cedures en the cartilage defect was 1.3, and the mean defect sire was 422.1 mmi. Twenty-seven patients {26%} had graft failure at a mean 5.? years after ACI. Uf the remaining 23 patients, 46 {-53% cf patients with a surviving graft} had an excellent result, 13 {25%} had a geed result, a {3%} had a fair result, and 3 {4%} had a peer result; 93 cf the Iflfl were satisfied and wenld underge the precednre again. Si}. Gemull AH, |ISillee SD, Cele B], et al: Autelegeus

chendrecyte implantatien in the patella: A multicenter

experience. Arr: j Sperrs Med 2014;42{5}:Ifl24-1IJEI.

Medline

DUI

In a multicenter study {if III:I patients treated fer a car-

tilage defect ef the patella and fellnwed at least 4 years,

eutceme sceres impreved, 92% cf patients weuld cheese te underge ACI again, and 86% ef patients rated the knee as geed er excellent. til. Pestka JIvI, Ee-de G, Salamann G, Sfldkamp NP, Niemeyer P: Clinical eutceme ef autelegeus chendrecyte implani

tatien fer failed micrefracture treatment ef full—thickv

ness cartilage defects ef the knee jeint. Am ] Sperrs Med 2fl12;4fl{2}:325-33I. Medline DUI Patients treated with ACI after unsuccessful micrefracture

had significantly mere failures {2 ef 23 patients} than these whe received ACI as a first-line treatment {I ef 23 patients].

62. Gudas R, Kalesinskas R], Kimtys V, et al: A prespective randemised clinical study {if mesaic esteechendral

autelegeus transplantatien versus micrefracture fer the

treatment ef esteechendral defects in the knee jeint in yeung athletes. Arthrescepy 2Dfl$t2l{9}:1fl5E-1fl?fi. Medline DDI .53, Gndas R, Gudaite A, Pecins A, et al: Ten-year fellew-np ef

a prespective, randemised clinical study ef mesaic estee-

chendral autelegeus transplantatien versus micrefracture fer the treatment ef esteechendral defects in the knee jeint ef athletes. Am ] Spurts Med 201 2,4I}{I 1 1:249? -25DE. Mcdline DUI

In a randemised centrelled study, 6D athletes {mean age, 24.3 years] underwent UAT er micrefracture. Statistically significantly better results were detected in patients in the

UAT greup at 10 -}'car fellew-up {P c {3.0135}. UAT failed

Sarg Sperts Tremrmtef Arthresc 2fl14;22{6]:12fl?‘1215. Mcdline DUI Eleven ef 25 patients with a full-thickness chend ral lesien ef the femur were randemly assigned te micrefracture, and 14 were assigned te mesaicplasty. At a median 33-year

Iellew—up, there were ne significa nt hetween—greup differ-

ences in eutceme measures, isekinetic muscle strength, er radiegrapbic esteearthritis. Level c-f evidence: II. 65. Knutsen G, Engehretsen L, Ludvigsen TC, et al: Antelegens chendrecyte implantatien cempared with micre-

fracture in the knee: A randemiaed trial. }' Eerie jeirst See-g

Arr: 20U4;3fi{3]t455-454. Medline

66. Knutsen {I}, Dregset JU, Engehretsen L, et al: A randemised trial cempa ring autelegeus chendrecyte implantatien with micrefracture: Findings at five years. ] Burrs faint 3mg Arr: 2DflT;39{Ifl}:2Il35-2112. Medline DUI 6?. Saris I3, Price A, 1ifli'idnchnwslci W, et al: Matrix-applied characterized autelegeus cultured chendrecytes versus micrefracture: Twe-year fellew-up ef a prespective randemised trial. Am ,7 Sparta Med 2DI4;42{5}:1334-I394. Medline

DUI

In a randemised centrelled study cemparing the use ef

micrefracture and matrix-applied ACI fer symptematic cartilage defects, the 2-year assessment was cempleted by I32r ef the 144 patients {mean age, 33.3 years; mean lesien size, 4.3 cm-i). Uutcemes sceres favered matrix-applied ACI. Repair tissue quality was geed but did net vary by treatment. The rates ef treatment failure were 12.5%

after matrix—applied AC1 and 31.9% after micrefracturc. Level ef evidence: I.

63. Bentley G, Biant LC, Carringten 11W, et al: A prespective, randemised cemparisen ef autelegeus chendrecyte implantatien versus mesaicplasty fer esteechendral defects in the knee. ] Berra faint. Sarg Br 2flfl3,35{2}:223—23fl.

Medline DUI

{59. Bentley {3, Eiant LC, Vijayan 5, Macmull 5, Skinner JA, ILitarringten KW: Minimum ten-year results ef a prespective randemised study ef autelegeus chendrecyte implantatien versus mesaicplasty fer symptematic articular cartilage lesiens ef the knee. I Bees jeint Sarg Br 2fl12:94{4}:51'l4509. Medline DUI A randemiaed study fellewed 1013 patients {mean age, 31.3 years} fer at least 10 years after ACI er mesaicplasty. Ten ef 53 patients [12%] had failure ef AGI, and 23 ef 42 {55%} had failure ef mesaicplasty {P c {1.0131}. Patients with a surviving graft had significantly better functien af-

ter ACI than mesaicplasty {P = 1102}. Level ef evidence: I.

Ti}. Liu H, Zhae E, Clarke RE, Gan J, Garrett IR, Margerri-

sen EE: Enhanced tissue regeneratien peteetial ef invenile

in 4 patients {14%}, and micrefracture failed in 11 {33%} {P -: 0.0.5}. Level ef evidence: I.

articular cartilage. Am ] Sperrs Med 2013:41I11l:2653-

64. Ulstein S, Areen A, Retternd JH, Leken 5, Engehretsen L, Heir 5: Micrefracture technique versus esteechen-

In a laberatery study, articular cartilage was harvest-

dral autelegeus transplantatien mesaicplasty in patients

with articular chendral lesiens ef the knee: A prespective randemised trial with Icing-term fellew-up. Knee

IE! 2Illfi American Academy ef Urthepaedic Surgeens

266?. Medline

DUI

ed frem juvenile and adult bevine femeral cendyles and

cultured fer 4 weeks te meniter chendrecyte migratien, glycesamineglycan cuntent censervatien, new tissue

Urthepaedic Knewledge Update: Sperrs Medicine .‘i

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Sectionfitlfneeantlleg formation, cartilage cell density, and proliferative activity. |Compared with adult cartilage, juvenile bovine cartilage had significantly greater cell density.I cell proliferation rate,

microfracture. Cine group of animals received five postoperative weekly injections of autologous conditioned plasma. The postoperatively treated animals had significantly

metallopeptidase-Z activity. |Dnly juvenile cartilage was able to generate new cartilaginous tissues in culture.

than the nontreated animals at 3., 6. and 12 months.

cell outgrowth, glycosaminoglycan content. and matrix

3'1. Adkisson HI} IV. Martin Jet. Amendola RL, et al: The potential of human allogeneic juvenile chondrocytes

for restoration of articular cartilage. Am J Sports Med 2H1fl;33{?j:1324-1333.Medline

DUI

In a laboratory study. cartilage samples were obtained from juvenile and adult human donors. The chondrogenic activity of chondrocytes and expanded cells after monolayer culture was measured by proteoglycan assay, gene expression analysis, and histology. Juvenile human chondrocytes were found to have greater potential to restore

articular cartilage than adult cells and can be transplanted

without fear of rejection.

TE. Farr J, Tabet SK, Margettison E. Cole E]: Clinical. radiographic, and histiological outcomes after cartilage repair with particulated juvenile articular cartilage: A 2-year pro-

spective study. An: } Sports Med IDH;42{E}:141?—1415. Medline DID]

Twenty-five patients {mean age, 31!] years; mean lesion size, 23c} were treated with particulated juvenile articular cartilage for a symptomatic chondral defect. Clinical outcomes were significantly improved 2 years after surgery compared with baseline. TZ-weighted MRI suggested that cartilage was approaching a normal level. The repair tis-

sue in biopsy samples from 3 patients was composed of a

mixture of hyaline and fihrocartilage. Staining revealed a higher content of type II than type I cartilage. Level of evidence: I‘v’. 7'3. Milano G, Deriu L, Satma Passino E, et al: Repeated

platelet concentrate injections enhance reparative response of microfractures in the treatment of chondral defects of

the knee: An experimental study in an animal model. Arthroscopy 2fl12513{5j:ESS-?fl1. Medline DID] A full-thickness ehondral lesion on the medial fem— oral condyle was created in 3!} sheep and treated with

better macroscopic, histologic. and biomechanical results

3’4. Milano C, Deriu L, Sauna Passino E, et al: The effect of autologous conditioned plasma on the treatment of focal chondral defects of the knee: An experimental study. hat

I tininnnopatirol Pharrnacoi 2011;14j1, Suppl 211 11114. Medline

The effect of local application of autologous conditioned plasma on full-thickness knee cartilage was investigated in 30 sheep. Cine group of animals received five postoperative weekly injections of autologous conditioned plasma. Histologic evaluation at 3 and ti months showed that these animals had significantly better total scores than the untreated animals. At 11 months, there was no significant between-group difference. The local injections did not produce hyaline cartilage but did promote a reparative response of the cartilage defect until 6 months

after treatment.

3’5. Dold AP, Zywiel MG, Taylor DW, Dwyer T, Theodore— poulos J: Platelet-rich plasma in the management of articular cartilage pathology: A systematic review. Cfin I Sport

Med 2D14;14I[1}:31—43. Medline not

Analysis of 1D studies found that most assessed the use

of PEP in the treatment of degenerative osteoarthritis of the ltnee or hip. Most patients were treated with intraarticular injections, but two studies used PRP as an ad-

junct to surgical treatment. Significant improvements in

joint-specific clinical scores. general health scores, and pain scores were reported at 6-month follow-up, but few studies provided longer term data. No studies reported worse scores compared with baseline at final follow-up. Video Reference

13.1: Chalmers F. Yankc A. Sherman S, Karas "it". Cole B]: Video. Cornhineii Cartilage Restoration and Distal Realignment for Patelfar and Troeftfear Chonrfraf Lesions. Chicago, IL, lflll.

E

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Clrthopaedic Knowledge Update: Sports Medicine 5

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 19

Nonarthroplasty Management of Osteoarthritis of the Knee

Ljiljana Bogunovic. MD

lEharles A. Bush—Ioseph. MD

Table 1

The knee is the most common site of osteoarthritis. With

an aging population, the prevalence of this progressive

disease is increasing. The management of symptomatic osteoarthritis of the knee can be challenging. Although

joint arthroplasty generally is effective after unsuccessfnl nonsurgical management, several other treatment modalities can be successfully implemented before joint arthroplasty is considered.

Key Information From the Patient History Current medications History of injury or prior surgery

Instability Mechanical symptoms Medical tomorbidities

Location of pain {unicompartmental or global} Response to previous treatments

Keywords: osteoarthritis of the knee: nonarthroplasty management of osteoarthritis Introduction

Swelling Symptom duration

previous therapy will help guide future treatment and

Osteoarthritis of the knee is a common source of pain

allow an accurate prognosis to be determined {Table 1}. A patient who is overweight should be asked about any

According to BEIGE estimates, knee osteoarthritis affected 33% of people older than 65 years in the United States.‘

strategy. A comorbidity such as renal or peptic ulcer disease and social factors that could affect the treatment

and disability in adults who are middle aged or older.

Lifestyle changes such as weight loss and exercise as well as medications, injections, and, in some patients,

joint-preserving surgery can help minimize the progress of knee osteoarthritis, manage pain, and delay the need

for joint arthroplasty. Patient Evaluation

History and Physical Examination The evaluation of symptomatic osteoarthritis of the knee begins with a detailed patient history and physical

examination. The patient’s symptoms and response to Neither of the foiiowing authors nor any immediate family member has received anything of vaiue from or has stock or stock options held in a commercialI company or institution reiated directly or indirectiy to the subject of this chapter: Dr. Bogunovic and Dr. Hush-Joseph.

fl lflld American Academy of Drtbopaedic Surgeons

recent weight gain or loss and current weight-maintenance

strategy, such as residence in a nursing home, also should be determined. The patients gait as well as lower body alignment, range of motion, and ligamentous stability should be assessed and documented {Table 2}. Catching or lock-

ing, instability, or an effusion can signal the presence of a mechanical pathology warranting surgical treatment. The lumbar spine and hips should be examined because pathology in one of these locations often appears as pain referred to the knee. The lower extremities should be

examined for evidence of muscular atrophy or weakness, with particular attention to hip abductor and quadriceps

strength. Distal sensation and vascular perfusion {peripheral pulses} should be assessed in all patients, and any abnormalities should be documented. Imaging

Baseline weight—bearing radiographs should be obtained in all patients with symptomatic osteoarthritis of the

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SectionS:Kne-eand1eg knee. A standing PA view obtained with the patient’s knee in 45" of flexion often is preferred over the standard stand-

progression of osteoarthritis of the knee.3'i'Dhesity has been identified as an independent risk factor for

of the posterior femoral condyles and earlier detection

symptomatic disease as much as threefold.” Patients with

ing AP view.2 The flexion view allows better evaluation of subtle joint-space loss than the AP view2 {Figure 1). Additional radiographs should include a lateral view of the affected side and a Merchant or sunrise view of the

patellofemoral joint.

Nonsurgical Management

Weight Loss Maintenance of a healthy body weight is effective for decreasing the severity of symptoms and slewing the

Key Information From the Physical Examination Alignment [va rus or valgus, rigid or flexible} Effusion Instability Ipsilateral hip comparison

Joint line tenderness Lower extremity strength (guaclricelflr. ‘ElluteusfilI Peripheral pulses and sensation Previous incisionis}

Range of motion

osteoarthritis of the knee; it increases the likelihood of

coexisting lrnee malalignment, particularly genu varum, have an even greater susceptibility to the negative effect

of excessive body weights" A clinical practice guideline of

the American Academy of Orthopaedic Surgeons [AAG 5}

recommends weight loss for patients who have symptom— atic osteoarthritis of the knee and are overweight {deli ned

as a body mass index above 25 kgi'm'lii” {Table 3}. Forces at

the knee are magnified to three to seven times the actual body weight, and therefore even a small change in body

weight can have a significant effect on joint loading at

the knee.3 At a minimum, the patient who is overweight should strive to lose 5% of his or her current body weight and to maintain the decreased weight with a combination of diet and exercise.”"” Exercise and Activity

Regular physical activity was found to improve physical

function and quality of life in patients with symptom-

atic osteoarthritis of the knee.1'13'” AADS strongly recommends patient participation in a self-management

program such as the Arthritis Foundation exercise

programfib” Such programs typically extend over 6 to 3 weeks, are offered at a local hospital or community

center, and focus on lower extremity and core muscu-

lature strengthening, low—impact aerobic activity, and

S

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'v !

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l

Standing AP {A} and 45" fIExion PA weight-bearing {Rosenberg} {Bi radiographs of a patient with osteoarthritis.

Wear on the left posterior lateral con dyle can be seen in B.

firthupaedic Knowledge Update: Sports lviedich'ie 5

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 19: Nonartbreplasty Management of Clsteomtln'itis of the Knee

Summary of AADS Clinical Practice Guideline Recommendations Modality

Recommendation

Strength'

Activity and lifestyle Lateral wedge insole for medial osteoarthritis

Cannot suggest

Moderate

Physical activity

Recommend

Strong

Unloader bracing for medial osteoarthritis

Unable to recommend

Inconclusive

Weight loss (patient with body mass index of 25 Icglr‘m2 or higher}

Suggest

Moderate

Acetaminophen

Unable to recommend

lnconclusive

Glucosamine andior chondroitin

Cannot recommend

Strong

NSAIDs {oral and topical}

Recommend

Strong

Clpioids or pain patches

Unable to recommend

Inconclusive

Tramadol

Recommend

Strong

Acupuncture

Cannot recommend

Strong

Electrotherapeutic and manual therapy

Unable to recommend

lnconclusive

Corticosteroids

Unable to recommend

lnconclusive

Growth factors, platelet-rich plasma

Unable to recommend

lnconclusive

Hyaluronic acid

Cannot recommend

Strong

Needle lavage

Cannot suggest

Moderate

Arthroscopic lavage andl'or debridement

Cannot recommend

Strong

Arthroscopic partial meniscectomyr

Unable to recommend

lnconclusivt.I

Valgus proximal tibial osteotomy for medial compartment osteoarthritis

Might recommend

Limited

Medications and supplements

Alternative treatments

Intro-articular injections

Surgical treatments

' lnconclusive = A laclr. of compelling evidence has resu tied in an unclear balance between the benefits and potential harm; practitioners

should not be constrained from following the recommendation. Limited = The quality of the supporting evidence is unconvincing, or wellCond uctecl studies show little clear advantage to one approach over another; practitioners should exercise clinical judgment when following the recommendation. Moderate = The benefits exceed the pets ntlal harm {or the potential harm clearly exceeds the benefit in a negative

recom mendationl. but the quality or applicability of the supporting evidence is not strong: practitioners generally should follow the recommendation but remain alert to new information and be sensitive to patient preferences. Strong - The quality of the supporlj ng evidence is high; practitioners should follow this recommendation unless there is a clear and compelling rationale for an alternative approach.

Data from American Academy of firth opaedic Surgeons: Featment of Dsteoarthritis of the Knee: Evidence-based Guidelines, ed 2. Hosemont. IL, American Academy of Drthopaedic Surgeons, 1m El. http:irwww.aaos.orgfflesea rdliguidelinesll'Treatmentofflsteoarthrifisoftheltneet‘i uideline. pdt. Accessed Dctober 31. 101-1.

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neuromuscular training. Patients receive information on activity modification, healthy eating, stress management,

and disease progressionP-“Ji General activity recommendations for patients with osteoarthritis of the lcnee include avoidance of high—im—

pact activities and repetitive heavy lifting, squatting, crouching, or climbing.” Patients can safely undertake at least 150 minutes of moderate activity each week with

no risk of worsening the disease progre-ssion.“l+111 Activities

IE! EUIE American Academy of Clrchopaedic Surgeons

such as water aerobics, walking, swimming, cycling, and

tai chi can increase cardiovascular endurance, lower esc-

trcmity strength, mobility, and balance, with minimal impact on the knees?“

Physical Therapy A patient who is sedentary or has a persistent deficit in strength or mobility after completion of a self—manageu ment program can benefit from a course of prescribed

Drtbopaedic Knowledge Update: Sports Medicine 5

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Section a: Knee and Leg

—— Summary of AADS Appropriate Use Criteria Recommendations Modality

lilecommendationil

Actlvlty and lifestyle Hinged knee brace andror unloading brace

May be appropriate

Prescribed physical therapy

Appropriate

Self-management program

Appropriate

Medications Acetaminophen

Appropriate

Intra-a rticular corticosteroid

Appropriate

Narcotic for refractory pain

Rarely appropriate

HSAIDs {topical or oral}

Appropriate

Trarnadol

May be appropriate

Surgical treatments Meniscectomy or loose body removal

Rarely appropriate”

Realignment osteotomy

Rarely appropriate

" Appropriate I The treatment is generally acceptable, reasonable for the indications, and liltely to improve the patient's health outcome or survival. May be appropriate = The treatment may be acceptable and reasonable for the Indication. but uncertainty Implles that more researd1

andror patient information is needed to further classify the indication. Ra rely appropriate = The treatment rarely is appropriate for patients with symptomatic osteoarthritis of the ltnee because of the Iaclc of a clear benefitvrislc advantage; the clinical reasons for proceeding with the treatment should be documented in case of an exception.

” May be appropriate for patients with mechanical symptoms. Data from American Acaderny of llilrthopaeelic Surgeons: Appropriate Use Criteria for Hon-arthropi'asty Treatment of Osteoarthritis of the Knee. Rosemont. IL. American Academy of orthopaedic Surgeons. 21113. http:rAvww.aaos.orgrResearchrApprop-riateJJseroaltaucfu|l.p-df. Accessed

October 31. 2011i.

physical therapy?“ Extensor mechanism weakness is

common in patients with symptomatic osteoarthritis

of the knee and has been associated with exacerbation of symptoms and disease progression.”'35 Therapist-su-

H

at the joint during gait and thereby shift axial joint forces preferentially toward the normal compartmentM {Fig-

ure 2]. A biomechanical study found that the greatest

therapy also can be helpful in improving proprioception

scendingf'B Au unloader brace can be helpful for an active patient who wants to delay surgical treatment {osteotomy

use of physical therapy to improve range of motion and

Pain relief during a trial of brace wea ring was found to

and neuromuscular control. Dnly limited data support the

E

spectively?“ Unloader braces exert an external moment

pervised exercises directed at quadriceps strengthening

can be helpful in alleviating pain, decreasing subjective instability, and improving overall function?5 Physical

'U E I'D Ill all i: be:

unicompartmental medial or lateral osteoarthritis, re-

flexibility in patients with osteoarthritis of the knee.” If possible, a prescribed physical therapy program should

load reduction occurred during stair ascending and deor arthroplasty}.

predict a favorable outcome of realignment ostcotomy.“ Medial-side disease was found to be more responsive

include a transition to a patient-directed home program

to bracing than lateral-side disease.2F Bracing can be

Bracing The routine use of a brace is not recommended for man—

no more than lfl'“ of vatus or valgus deformity.“ Insta—

at the completion of formal therapy.

aging the symptoms of osteoarthritis of the knee, but in

effective in the setting of fixed deformity, but most brace manufacturers recommend bracing only for patients with bility, especially excessive medial or lateral collateral laxity in the affected compartment, is a contraindication

some patients the use of an unloader brace was found to

to unloader bracing. Concomitant arthritis of the patel-

treatment with a valgns- or yarns—producing unloader

than off—the—shelf braces, and a custom brace may be

decrease pain and improve functionf'df-H'” According to the 2(113 AAGS Appropriate Use Criteria [Table 4), brace may be appropriate for a patient with symptomatic

firthopaedic Knowledge Update: Sports Medichie S

lofemoral joint is not considered a contraindication.“ lCustom braces were found to be slightly more effective

required to achieve the desired fit and force generation

Q lflld American Academy of Orthopaedic Surgeons

Chapter 19: Nonarthroplasty Management of Dsteoarthritis of the Knee

Figure 2

Photographs shows flte use of a varus unloader brace to treat valgus malalignment {A} and lateral compartment osteoarthritis {B}.

for a patient who is obese.” Patient tolerance is one of

risks and benefits of manual therapy and tlltl'tlfllflngraphy

tribution depends on the stiffness and angulation of the brace, and the brace specifications required to achieve a

Medications

the main limitations of unloadcr bracing. The load dis—

load reduction of more than 25% are not well tolerated

by most patients.IEI

Taping and Insoles

Therapeutic taping can be helpful in managing the symptoms of patellofemoral osteoarthritisfilfl The use of a taping technique such as McConnell taping generates a medially directed force across the patella, provides shortterm pain relief, and improves function?“33 The use of a lateral heel—wedge insole for symptomatic medial compartment osteoarthritis was not found to be effective and is not recommended?”

Alternative Therapy

High-quality studies did not find acupuncture to be ben—

eficial in the treatment of symptomatic osteoarthritis of the knee, and it should not be recommended? Little or no benefit was documented when an electrotherapeutic

modality such as electrical stimulation was nsed.35~3‘5 The

IE! Ellie? American Academy of flrthopaedic Surgeons

have not been establishedfiifidl'

Monsteroidal Anti-inflammatory Drugs

NSAIDs are recommended as a first-line treatment for patients with osteoarthritis of the knee. Both oral and top-

ical HSAID preparations are effective in alleviating pain

and swelling.T Because of their possible renal, cardiovas-

cular, and gastrointestinal adverse effects, HSHIDs should

be used with caution in patients older than Ell years and those with a medical comorbidity. The gastrointestinal effects of a nonselective oral NSAID can be minimised in patients with moderate risk factors by coprcscribing a proton-pump inhibitor or substituting a selective cyclooxygenaseHZ inhibitor.35 Complete avoidance of all oral

NSAIDs is recommended for patients at significant risk for an adverse effect.35 Acetaminophen

The 2fl13 FLAGS clinical practice guideline on managing osteoarthritis of the knee reported a lack of compclu ling available evidence to support acetaminophen use.5+

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ssmsnsmsssansteg Nonetheless, FLAGS still considered treatment with ac-

etaminophen to be appropriate for patients with osteo-

The benefit of intra-articular hyaluronic acid remains

and potential analgesic effects?” Acetaminophen can be particularly helpful in patients who are older than

tion led to a statistically significant improvement in pain,

NSAID use. Treatment and dosage should be maintained

did not meet the threshold for a minimum clinically im-

arthritis of the knee because of its favorable safety profile

69 years or have a comorbidity that precludes long—term within the prescribed limits to prevent hepatotoxicity.“

portant differencefdiif Reliance on this criterion as a

years or have a medical comorbidity because it has no cardiovascular, renal, or gastrointestinal adverse effects.

aluronic acid injections, corticosteroid appeared to be more effective in alleviating pain during the first 4 weeks

Unlike NSAIDs, tramadol has no effect on the inflam— mation associated with osteoarthritis.” flpioids

The routine use of oral or transdertual narcotic medications is not recommended for patients with osteoarthritis

of the knee."'35 A recent systematic review found a sig— nificant risk of adverse events that far outweighed the relatively insignificant pain control benefit.‘m

In a comparison of infra—articular corticosteroid and by after injection, but hyaluronic acid was more effective

beyond 3 weeks after injection.“ A recent systematic review reported a small and clinically irrelevant improve-

ment in pain after hyaluronic acid injection as well as a

significant increase in the risk of serious adverse events

including a postinjection flare reaction.” The addition of corticosteroid to a viscosupplementation injection was

found to decrease the postinjection pain associated with

viscosupplementation alone.“ Practitioners should exer-

Nutritional Supplements

cise clinical judgment when considering this treatment modality by weighing the potential for improving the

erately effective in alleviating arthritis pain.“- Avocado

Growth Factors and Platelet-Rich Plasma The benefits of using growth factors or a biologic agent

knee, but a long-term effect has not been established.”=‘*3

In theory, these agents provide biologic stimulation for

Data from several high-quality studies showed no benefit from the use of a daily glucosamine andfor chondroitin sulfate supplement?~”~”~“ Ginger was found to be modsoybean unsaponifiables also had moderate to high efficacy for short-term pain relief in osteoarthritis of the Injections Corticosteroids

patient’s pain against the risk of adverse events.

such as platelet-rich plasma (PEP) or mesenchymal stem cells in treating osteoarthritis has not been established.

articular cartilage maintenance and possibly repair. A syswmatic review of level I and II studies found a short-term {6-month} beneficial effect of PEP treatment on subjective

lntra-articular corticosteroid injection is effective for

outcomes in patients with mild to moderate osteoarthritis,

and the AADS considers it to be an appropriate treat— ment option.” Corticosteroid injection can be a helpful

A ra ndomiaed controlled study comparing treatment with PRP and treatment with hyaluronic acid found no signifi-

managing the symptoms of osteoarthritis of the knee,

H

but recent analysis, including an evidence-based review by HAD 5, suggested that treatment with hyaluronic acid

Tramadol was found to he as effective as NSAIDs for alleviating the pain associated with osteoarthritis of the knee.?~”~39 This atypical opioid analgesic medication can be particularly useful in patients who are older than fill]

f

debatable. Several studies found that viscosupplementa-

primary metric for treatment efficacy is controversial, however, and the AACIS guideline was criticized for relying on it.“ The effect of intra-articular hyaluronic acid probably depends on several factors including the severity of osteoarthritis, the patient’s age, and limb alignment.

Tramadol

'U E I'D Ill I1! I: I

Hyaluronic Acid

but the risk of nonspecific adverse events was increased.”19

treatment adjunct after unsuccessful nonpharrnacologic

cant between-group difference in patient-rated outcomes

jection.“"'*‘15 Treatment with corticosteroid injection can

patients with mild osteoarthritis {defined as KellgrenuLaw-

or oral NSAID or analgesic therapy. Reliable pain relief lasting approximately 4 weeks can be expected after inreduce symptoms sufficiently to allow initiation of life— style changes such as increased activity. The minimal

interval between injections is 3 months; if more frequent

at 12-month follow—up.m Subgroup analysis revealed a trend toward better patient function after PRP treatment in rence grade 1 or 2}. The rate of adverse reactions, particularly postinjection pain, was higher in patients who

received PEP than in those who received hyaluronic acid.”

pain relief is needed, other treatments should be considered.“ I{Zomparisous of intra-articular hyaluronic acid

The use of PEP for the treatment of osteoarthritis of the knee is not currently approved by the US FDA, and its

was more effective in alleviating painfi‘mf

More investigation into the efficacy, safety, and optimal

firthopaedic Knowledge Update: Sports Medicbie 5

fl lflld American Academy of Orthopaedic Surgeons

and corticosteroid injections found that corticosteroid

off—label use typically is not covered by insurance plans.

Chapter 19: Nonarthroplasty Management of Deteomtbritis of the Knee

preparation of PRP is needed before it can be routinely need for the treatment of osteoarthritis of the knee. Surgical Treatment Arthroscopic Debridement and Lavage

Arthroscopic debridement and lavage of the knee is not

recommended for a patient with a primary diagnosis of

osteoarthritis?” Cine high-level study found no benefit to using this treatment modality.51 In patients with mechanical symptoms secondary to the presence of a loose

body, knee arthroscopy with loose body removal may be beneficial, especially if the patient has mild to moderate osteoarthritis.

_ Contraindications to Realignment Dsteotomy

for Symptomatic Dsteoarthritis of the Knee Relative Contraindications

Absolute Contraindications

|IZ'lbesity Moderate to severe

Contralateral compartment

Age older than 5i] years

“$3333 flf IEES than

Collateral laxity

Fleslon contracture of

osteoarthritis of the knee

Patellofemoral arthritis

DF'ZEUEI rth “115

more than 10”

Arthroscopic Menistectomy

predicting response to surgical realignment.” Arthroscopy before osteotomy often is recommended to confirm the

for patients with osteoarthritis of the knee and a con-

and to allow any concomitant meniscai or chondral pa-

The effectiveness of arthroscopic partial meniscectomy

comitant meniscai tear remains an area of debate. In a

randomised controlled study comparing partial arthroscopic meniscectomy with physical therapy, an intention-to-treat analysis found no between-group differences

absence of osteoarthritis in the remaining compartments

thology to be treated. A medial opening wedge high-tibial osteotomy is be-

coming the preferred realignment technique for isolated medial compartment disease'i"""'3 {Figure 3}. A ra ndomired

in patient—rated outcomes at 12—month follow—up?2 There was a 35% crossover from the physical therapy group

controlled study comparing medial opening wedge and lateral closing wedge high-tibial osteotomies found no

controlled study compared arthroscopic partial menis— cectomy with diagnostic arthroscopy and found no differ-

of alignment at 6—year follow—up.“- At 5—year follow—up, the medial opening wedge technique was associated

to the surgery group, however. A second randomised ence in patient-rated outcomes at 12-month follow-up.”

Exclusion of patients with a traumatic meniscai tear, lateral tear, acnte tear, acnte-on-chronic tear, or radio-

graphic evidence of osteoarthritis limited the relevance

of the study results for the general population of patients with osteoarthritis of the knee.” Additional data sug-

gested that the benefits of partial meniscectomy may be

limited to patients with mild to moderate osteoarthritis

who have a large, unstable meniscai tear and mechanical symptoms-”'5“ These patients may experience symptom—

atic improvement after partial menisectomy. Given the

differences in patient-rated outcomes or maintenance

with more postoperative complications but 14% fewer

conversions to total knee arthroplasty than the lateral

closing wedge technique {3% versus 11%}. The medial opening wedge technique is more sensitive to sagittal

plane alterations of the tibial slope than closing wedge techniques {Figure 4). Overall survivorship of a high-tib-

ial osteotomy for medial compartment disease was found

to range from 33% to 96% at 5-year follow-up, from 63% to 9?% at lfl-year follow-up, and from 5?% to 90% at 15—year follow—updm'fi“I Neither medial not lateral

high-tibial osteotomy affected the functional outcomes

limited indications, nonsurgical treatment including

or survivorship of a subsequent total knee arthroplasty.“

osteoarthritis and meniscai pathology?

otomy can be used.if The outcome of the yarns-producing

physical therapy, NSAIDs, and injection should be tried before surgical intervention is considered for patients with

In patients with lateral compartment disease and valgus deformity, a lateral opening wedge distal femoral oste-

Realignment Osteotomy

osteotomy appears to be less affected by concomitant patellofemoral arthritis than patients with medial com-

ment and progression of osteoarthritis.“*“ Realignment osteotomy rarely is indicated but can be considered for

otomy.“ A 50% conversion rate to total knee arthroplasty was reported within 15 yearsfiI-Ei'

Knee malalign ment is a known risk factor for the developa patient who is active, younger than 55 years, and not

obese and who has moderate varus or valgus deformity, mild to moderate unicompartmental disease, stable co]lateral ligaments, and a near—normal range of motioni-IH'

{Table 5}. A trial of unloader bracing can be helpful in

IE! lfllfi American Academy of flrtbopaedic Surgeons

partment arthritis undergoing a valgus producing oste-

S u rn Ina ty

The nonarthroplasty treatment of symptomatic osteo-

arthritis of the knee is a common clinical challenge.

Drtbopaedic Knowledge Update: Sports Medicme 5

H F:

5 to to to

:l‘ D.

s

Section 3: Knee and Leg

1

Figure 3

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

of biologic therapies such as PEP is under investigation.

In selected patients, nonarthroplasty surgical procedures such as realignment osteotomy can help to alleviate symptoms. In the absence of mechanical symptoms. arthro-

scopic débridement has not been shown to be an effective treatment strategy. Key Study Points

I A variety of nonsurgical treatment modalities can

he used to treat the symptoms and decrease the progression of symptomatic osteoarthritis of the knee. I Weight loss for patients with a body mass index Figure 4

E

'U E I'D Ill all I: hr:

H

Schematic drawings show alteration of the tibial slope with plate positioning in a medial opening wedge osteotomy. A. Direct medial placement of a rectangular wedge plate does not change the slope. B. In a knee with a deficiency in the anterior cruciate ligament. anterior translation of the tibia can be reduced by decreasing the tibial slope with posterom edial placement of a rectangular wedge plate {left} or with a taper wedge plate {right}. I2. Increasing the tibial slope with anteromedial placement of a rectangular wedge plate can decrease posterior tibial

translation in a knee with a deficiency in the posterior cruciate ligament.

above 25 ltgi’mI is effective in decreasing pain and minimizing the progression of symptomatic osteo-

arthritis of the knee.

I Intra-articular corticosteroid injections are effective

for symptomatic management of osteoarthritis of

the knee.

I Ural supplementation with glueosamine andr'or

chondroitin sulfate has no benefit for management of symptomatic osteoarthritis of the knee. I Continued study is needed to identify the benefits of PRP and stem cell therapy in the treatment of osteoarthritis of the knee. I In the absence of mechanical symptoms, knee

Patients may experience substantial pain and disability.

Lifestyle modifications including weightless and exercise

arthroscopy with débridement is not effective in treating osteoarthritis of the knee.

as well as the use of NSAIDs or intra—articular injections

can reliably decrease pain and improve function. The role

firthopaedic Knowledge Update: Sports Medicine 5

fl lflld American Academy of Orthopaedic Surgeons

Chapter 15-": Nenarthreplasty Management ef Dsteeartluitis ef the Knee

Annetated References . Helmick CG, Felsen DT, Lawrence RC, et al; Natienal Arthritis Data Werkgreup: Estimates ef the prevalence ef arthritis and ether rheumatic cendin'ens in the United States: Part I. Arthritis Rheum Zflfl'flfi31:11:15-25. Medline DDI . Resenherg TD, Paules LE, Parker RD, l{Inward DB,

Scett 5M: The ferty-five-degree pestereauterier flexieu

weight-hearing radiegraph ef the knee. J Bene Jeint Surg Am 1933;?0t1fl}:14?9-1433. Medline . Yates A] Jr, McGrery B], Sta rs "1W, 1|Itincent KR, McCardel E, Gelightly TM: AADS apprepriate use criteria: Dpti-

miaing the nee-arthremasty management ef esteearthritis

ef the knee. J Am. Aced Drthep Surg 2014;22H}:261-261

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The 2013 AADS apprepriate use criteria fer the nenarthreplasty management ef esteearthritis ef the knee were reviewed and applied te examples. . Changulani fvi, Kalairaiah ‘1', Feel T, Field RE: The relatienship between ehesity and the age at which hip and knee replacement is undertaken. J Bene jeint Surg Br

aeeseenpseeessmeetm: net

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DUI

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aeiensciayessa—asss.Medusa net

A retrespective review ef patients undergeing hip and knee replacement feund that ehesity [hedy mass index greater than 25} was asseciated with signifies ntly decreased age at the time ef hip er knee arthreplasty. Level ef evidence: IV. . Bruyiere ID, Ceeper C, Pelletier J-P, et al: An algerithm rec-

emmendatien fer the management ef knee esteearthritis

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Guidelines fer the nenarthreplasty management ef es—

teearthritis ef the knee were established by the Eurepean Seciety fer Clinical and Ecenemic Aspects ef Usteeperesis and Dsteearthritis, which is cnmpnsed ef rheumatelegists, clinical epidemielegists, and clinical scientists.

. Sewers ivi: Epidemielegy at risk facters fer esteearthritis: Systemic facters. Curr Dpin Rheumetei 2001;13i5}:44?— 451. Medline DDI

ID lfllfi American Academy ef Drthepaedic Surgeens

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liuesiTreatmentefDsteearthritiseftheliueefluideline.pdf.

Accessed Dcteher 31, 2014.

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Drthepaedic Surgeens clinical practice guideline en the treatment ef esteearthritis {DA} ef the knee. J Bene Jeint SurgAm 2fl10592{4}:99fl-993. Medline DE]

The first editien ef the American Academy ef lDrthe-

paedic Surgeens evidence—based guidelines fer the nenarthreplasty management ef esteearthritis ef the knee was reviewed. 11. Christensen R, Bartels EM, Astrup A, Eliddal H: Effect ef weight reductien in ebese patients diagnesed with knee esteearthritis: A systematic review and meta-analysis. Ann Rheum Dis BUDAEAHHJS-Afifl. Medliue DDI 12. Felsen DT, Zhang Y, Antheny lf, Naimark A, Andersen JJ: Weight less reduces the risk fer symptematic knee esteearthritis in wemen: The Framingham Study. Ann intern Med 1952;116[?}:335-539. Medline DD] 13. Messier 5P, l'viihalke 5L, Legault C, et al: Effects ef intensive diet and exercise en knee jeint leads, inflammatien, and clinical eutcemes ameng everweight and ehese adults with knee esteearthritis: The IDEA randemieed clinical

trial. ye are seisgsieunnaesaavs. Medline ecu

A randemiaed centrelled study ef adults whe were everweight and had esteearthritis ef the knee feund that cembined diet and exercise led tn impreved weight less,

reductien ef interleukin-e levels, and impreved qualityefnlife sceres cempared with diet er exercise alene. Level ef evidence: I.

14. Messier 5P, Leeser 11F, Miller GD, et al: Exercise and dietary weight less in everweight and ebese elder adults with knee esteearthritis: The Arthritis, Diet, and Activity Premetien Trial. Arthritis Rheum 212104;?Elli}:1501 —1 51i]. Medline DUI 15. American Academy ef IDrthepaedic Surgeens: Apprepri— site use criteria fer nen-nrthrepiesty treatment ef esteeurthritis ef the hnee. Resement, IL, American Academy ef Drthepaedic Surgeens, H.113. l'Ittpaf'iwww.aaes.ergiIf ResearchiApprepriate_Useieakaucfull.pdf. Accessed Dcteher 31, 2fl14. The AADS apprepriate use criteria included methedelegy and guidance fer the nenarthreplasty management ef

esteearthritis ef the knee.

16. IIL'leleman S, Briffa Nit, Ca rrell G, Inderjeeth 1'3, Geek N, McQuade J: A raedemised centrelled trial ef a self-man-

agement educatien pregram fer esteearthritis ef the knee

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seasonasassaneteg delivered by health care preiessienals. Arthritis Res Ther

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A randemized cnntrnlled study feund better patient-

repnrted nutcnmes in patients with esteearthritis whn

underwent a self-management pregram, in cemparisen with centrel subjects. Level ef evidence: II. 1?. Jevsevar D5: Treatment ef esteearthritis ef the knee: Evidence-based guideline, 2nd editic-n. f Arrt Acad Cirtbnp Stirg 2fl13;21{9}:521-5?E. Medline DflI The secend editinn ef the AACIS evidence-based clinical

practice guideline en the nenarthreplasty treatment ef esteearthritis ef the knee was reviewed.

13. Euckwalter JA, Lane NE: Athletics and esteearthritis. Am I Sperts Med 199?;25ifi]:8?3-831. Medline DID] 15'. Earbeur FIE, Heetman JM, Helmick CG, et a1: Meeting physical activity guidelines and the risk nf incident knee nsteearthritis: A pepulatien-based prespective cehert study. Arthritis |Care Res {Hebekers} 2014;66[1}:139-H6.

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A. retrnspective review of 1,522 adults feund ne asseciatien between high levels nf physical activity and the dcvelepmeut ef symptnmatic estcearthritis ef the knee.

Level ef evidence: IV.

2E. Fransen M, McEennell 5: Exercise fer esteearthritis ef the knee. Cecivrarte Database Syst Rev 2|Jfl H;fl[4}:CDDfl-‘-l326. Medline

21. Barrels El'vl, Lund H, Hagen KB, Dagfinrud H, Chris-

tensen R, Danneskield—Samsae B: Aquatic exercise fer

H

A prespective study ef 1,329 patients feund that quadri-

ceps muscle strength had a pretective effect against the develepment ef symptnmatic estcearthritis ef the knee.

Le::e1 ef evidence: II.

2d. Deyle GI), Hendersen NE, Matekel RL, Ryder MG, Garber ME, Allisc-n 5C: Effectiveness ef manual physical therapy and exercise in estenarthritis cf the knee: A randemised,

centrelled trial. Am: Iuterrs Med ace 0:] 32t3}:1‘i’3 431. Medline IJflI

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The management ef active patients with symptnmatic

esteearthritis ef the knee was reviewed.

23. Kuttner I, Kiither S, Heinlein E, et a]: The effect {if valgus braces en medial cempartmcnt lead ef the knee jeint: In vive lead measurements in three subjects. ,i Biemech

2011;44{?]:1354-1360.Medline net

An in viva hie-mechanical study feund significant reductiens in jeint leading in stair ascending {26%) and stair descending {24%) with the use ef a valgus unleader brace. 29. Draganich L, Reider E, Rimingten T, Pietrewski G, Mallik K, Nassen S: The effectiveness ef self-adjustable custem and eff-the-shelf bracing in the treatment ef varus gnnarthresis. ] Eerie jeiut Stirg Aer: 2i] [16:3 3(12}:2 6452652.

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3!]. Minalaff P, Saier T, Erucker PU, I-Ialler E, Imheff AE,

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effect" fellewing valgus high tibial estcetemy. Hrtee

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A systematic review ef randemised clinical studies inves— tigated the use ef tai chi as a treatment ef esteearthrin's and identified evidence nf effectiveness in centrnlling pain

A prespective study cf 43 patients with medial cnmpartment esteearthritis feund that temperary relief with unleader bracing ceuld predict pain relief after valguspreducing high-tibial nsteetemy. Level ef evidence: III.

23. Hertebiigyi T, |Garry J, Hnlbert D, Devita P: Aberratinns

31. Pelle FE, Jacksen RIF: Knee bracing fer unicemparnnental estenarthritis. I Am Acad Drtbep Surg 2flfld;14{1]:.5 -11.

and impreving physical functien. Level ef evidence: III.

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the treatment ef knee and hip esteearthritis. Cecbrerte

Database Syst Rev 200?:4:CDDG5523. Medline

'U E I'D Ill I1! I: be:

esteearthritis. Med Sci Sperts Esters lfllflgflflliflfllib

in the ceutrel ef quadriceps muscle ferce in patients with knee esteea rthritis. Arthritis Rheum 2Dfl4:51{4}:562-569. Medline DUI

Sega] NA, Glass NA, Turner ], et a1: |Quadriceps weakness predicts risk fer knee jeint space narrewing in wemen iu the MUST cehert. Usteeartbritis Eartiiege 2fllfl:13{61:269-225.Medline DUI A prespective lengitudinal study feund an asseciatien between quadriceps weakness and tibiefemeral jnint space

narrewing in wemen ever time. Level ef evidence: III.

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32. Hinman R5, |Cressley KM, McCennell J, Bennell KL:

Efficacy ef knee tape in the management ef estee-

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33. We rden 5], Hinman R5, 1iiiiatsen MA Jr, Avin KG, Eialecerknwski AE, |IErInIssley KM: Patellar taping and bracing

fur the treatment ef chrenic knee pain: A systematic review

and meta-analysis. Arthritis Rheum 2|] fl3:59{1}:?3-33. Medline DD]

25. Segal NA, Glass NA, Felsnn DT, et al: Effect uf quadriceps strength and preprieceptien er: risk fer knee

firtbepaedic Knewledge Update: Sperts Medichie 5

fl lfllfi American Academy ef Urthepaedic Surge-ens

Chapter 15-": Nunertbrnplasty Management cf Cstenartltricis cf the Knee

34. Malvankar S, Khan W5, Mahapatra A, ad GS: Htiw

lcnee nstenarthritis: An analysis with marginal struc-

effective are lateral wedge nrthntics in treating medial cempartment estenarthritis cf the knee? A systematic review cf the recent literature. Dpert Drthnp I 2D12;fi:54454?. Medline DUI

tural mc-dcls. Arthritis Rhenmetni IDIS:E?{3]:?14-?33. Medline DIDI

A systematic review feund II'D lung—term benefit uf using

tcms er mndifying disease prngressinn. Level nf evidence: I.

lateral shee wedge nrthc-ses fer the symptnmatic treatment flf medial cnmpartment nstenarthritis. Level ctf evidence: IV.

3.5. McAlindnn TE, Bannuru RR, Sullivan MC, et al: UARSI

guidelines fer the nun-surgical management nf knee estee-

A systematic review fnund nu benefit tn glucnsarninechnndrnitin supplementaticm fnr relieving patient symp41. Barrels EM, Fnlmer VH, Eliddal H, et al: Efficacy and safety ef ginger in nstcearth titis patients: A meta—analysis ef randcrmired placebe-cnntrnlled trials. Osteoarthritis Certiinge 1015;23i1}:13-21. Medline [101

A systematic review fnund mndest pain reductitm in patients with esteearthritis whe were treated with supplemental ginger. Level ef evidence: II.

arthritis. Clstenerthritis Ccrtiiege 2fl14;22{3}:363-338. Medline DUI The |[flame-arthritis Research Society Internatinnal es-

tablished guidelines fer the nnnsurgical treatment nf symptematic estcearthritis cf the knee.

36. 1t’ilmaa CICI, Senecak D, Sahin E, et al: Efficacy.r c-f

43. Camcrcn I'vI, Chrubasik 5: IDtal herbal therapies fer treating estenarthritis. Cechrttrte Den-these Syst Rev 2U14;5:CDDG194?. Medline A systematic review fnund a painurelieving benefit frnnl supplementatinn with avncade-scybean unsapnnifiables fer symptemstic treatment ef estecarthritis cf the knee ccmpared with placebn. Level nf evidence: I.

EMC-binfeedback in knee esteearthritis. Rhenmetni Ittt lfllflfifliihflfllflfiz.Medliue D-DI A randnmited clinical study nf patients with nstenarthritis

fnund imprnvement in functinnal nutcnmes and repnrted

pain with regular lewer extremity strengthening exercise but nn additinnal benefit crf electrnmyc-graphic hie-feedback therapy. Level nf evidence: II. 3?. Rutjes AW, jfini P, da Cnsta ER, Trelle S, Niiesch E, Fle-

ichenhacb S: Viscnsupplementatinn fnr nstenarthritis nf the knee: A systematic review and meta—analysis. Arne ire-tern Med lflllfliflfiiflflfl-IBI. Medline DDI

A systematic review nf randnmited clinical studies found a small, clinically irrelevant benefit nf intra-articular viscnsupplementatinn fer the symptcmatic treatment cf

esteca rthritis cf the knee.

33. Craig DC, Bates CM, Davids-an J5, Martin KC, Hayes PC, .Simpsen K]: Staggered nverdnse pattern and delay to hnspital presentatinn are assnciated with adverse nutcnmes

fellewing paracetamnl-induced hepatntniticity. Br I Ciin Phermecei 2012;?3t2j:235-294. Medline DDI A retrnspective review cf {563 patients with paracetamelinduced liver injury emphasized the danger nf staggered dnsing in nlder patients.

39. Cepeda M5, Camargn F, Zea C, Valencia L: Tramadnl

fer nstecarthritis: A systematic review and metaanalysis.

j Rheametni 2fl0?:34{3}:543-555. Medline

4G. da Cesta ER, Niicsch E, Kasteler R, ct al: Oral nr nansden ma] epic-ids fer estenarthritis cf the knee er hip. Ceehmrte Database Syst Rey 21".! 14:9:{313003115 . Medline A systematic review fnund a significantly increased risk

cf adverse events with the use ef nnntramadel npinids

fer the treatment cf cstena rthritis cf the knee ccmpared with a small, pnssibly clinically irrelevant reductitm in patient—repnrted pain. Level nf evidence: II. 41. Tang 5, Eatnn CE, McAlindnn TE, Lapane KL: Effects

nf glucnsamine and chnndreitin supplementaticm en

ID EDIE American Academy nf Drtbnpaeclic Surgeens

44.

Cheng CIT, Seuadalnitski D, Vrenman B, Cheng J: Evidence-based knee injectinns fer the management nf arthritis. Pairs Med lflllgldifilfidlI—Tfid. Medline DUI A systematic review feund benefit in intra-articular stereid injectinns fer relief nf symptnms in estecarthritis cf the knee. Level cf evidence: II.

45. Bellamy N, Campbell J, Rebinsnn V, Cree T, Enume R,

Wells G: Intraarticular curticnsternid fnr treatment nf

esteeatthritis cf the knee. Cnchmne Dntehese Syst Rev 2i] flfitlilltflflfl 05323. Medlinc

46. Eannu ru ER, Natev N5, Dbadan IE, Price LL, Schmid

CH, IvIcAlinden TE: Therapeutic trajectnry cf hyalurcmic acid versus certiccrsternids in the treatment cf knee eaten-

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DDI

A systematic review cempared hyalurenic acid tn certicnsternids fur the treatment cf nstenarthritis cf the knee. Pain relief was better at 4 weeks after stereid treatment but better beynnd 3 weeks after hyalurenic acid treatment. Level cf evidence: I. 4?. Bannuru RR, Vaysbrc-t EE, McIntyre LF: Did the American Academy nf |Drthtipaetlic Surgenns nstenarthritis

guidelines miss the mark? Arthrnscnpj' 2fl14:3fli1}:Efi-39. Mcdline DCII

Cemmentary en the EDIE: AADS clinical practice guideline argued against the use cf the minimum clinically impertant imprnvement criterinn in assessing the efficacy nf

viscnsupplementatinn fer the treatment nf cetenartbtitis cf the knee.

43. de Campus CC, Reecnde MU, Paile AF, Frucchi R, Ca-

margn DP: Adding triamcinelcme imprcves viscesupplementatinn: A randnmiaed clinical trial. Cit'tt [3|tt Relnt Res 1013:4?1{21:613—52fl. Medline DCII

Drthnpaedic Knnwledge Update: Spnrts Medichie 5

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5 re re ru-

3 D.

e

Sectiundfl‘fneeandleg A pruspective cuhurt study uf 1fl4 patients fuund impruvement in patient-rated uutcumes during the first week after curticusteruid injectiun cumbined with viscusupplemen-

tatiun cumpared with viscusupplementatiun alune. Level uf evidence: II.

4.9. Rhushbin A, Leruus T, Wasserstein D, et al: The efficacy uf platelet-rich plasma in the treatment uf symptumatic knee usteuarthritis: A systematic review with quanti-

tative synthesis. Artfrruscupy 2fl13519{12]:2fl3?-1{i43.

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Iup DD: The rule uf knee alignment in disease prugres-

50. Filardu G, Run E, Di Martinu A, et al: Platelet-rich plasma

53. Bunasia DE, Dettuni F, Site (I, et al: Medial upening wedge high tibial usteutumyr fur medial cumpartment uverluadiarthritis in the varus knee: Prugnustic facturs. Am I Spurts Meal 2fl14;42{3j:dfifl-593. Medline DUI

cuntrulled trial. EMU Mnseufusiaeiet Dfsurri' 2fl12;13:229.

Medline DUI

A pruspective study uf If]? patients fuund a trend tuward clinical impruvement 1 year after PEP injectiun cumpared with hyalurunic acid injectiun in patients with mild usteuartbritis uf the knee, but there was nu difference in uutcumes in patients with muderate disease. Level uf evidence: III. 51. Siparsky P, Rysewica M, Petersen E, Bart: R: Arthruscupic treatment uf usteuarthritis uf the knee: Are there any evidence—based indicatiunsi' Eiia Urtfaup Reins Res Zflfl?:455{455}:ID?-112.Medline DUI 52. Kata JN, Eruphy RH, Chaissun (IE, et al: Surgery versus physical therapy fur a meniscal tear and usteuartbritis. N Eng! ] Med 2fl13;363{13}:16?5-1fifi4. Medline DUI A multicenter pruspective study fuund nu difference in

uutcumes in patients with usteuartbritis and a degenerative

meniscal tear based un treatment with physical therapy ur arthruscupic meniscectumy. Level uf evidence: I. 53. Sihvunen R, Paavula M, Malmivaara A, et al: Finnish Degenerative Meniscal Lesiun Study {FIDELITY}

l[.iruup: Arthruscupic partial meniscectumy versus sham

surgery fur a degenerative meniscal tear. N Eng! j Med .2013;369{25}:1515-2524.Medline DUI

H

5?. Shanna L, Sung], Felsun DT, Cahue S, Shamiyeh E, Dunsiun and functiunal decline in knee usteuartbritis. IA MA

vs hyalurunic acid tu treat knee degenerative pathulugy: Study design and preliminary results uf a randumized

E

56. Eruuwer GM, van Tul AW, Eergink AP, et al: Assuciatiun between valgus and varus alignment and the develupment and prugressiun uf radiugraphic usteuartbritis cf the knee. Arthritis Rheum Eflfl?;56{41:11fl4-1111. MetlIine DUI

A systematic review fuund impruved patient-rated functiun with intra-articular PEP injecriun cumpared with nurmal saline ur hyalurunic acid iniectiun in patients with usteu-

artbritis uf the knee. Level uf evidence: II.

'U E I'D Ill I1! I: he:

A systematic review fuund nu benefit tu arthruscupic meniscal débridement fur degenerative meniscal tears cumpared with nunsurgieal treatment ur sham surgery. Level uf evidence: I.

A multicenter pruspective study fuund nu difference in patient-rated uutcumes at 1-year fulluw-up in patients with usteuartbritis and a degenerative medial meniscal tear based un treannent with sham surgery er arthruscupic medial meniscectumy. Level uf evidence: I. 54. Dervin GF, Stiell IG, Rudy K, Grahuwski J: Effect uf

arthruscupic débridement fur usteuartbritis uf the knee

un health—related quality uf life. ] Buae jellies Sarg Am

lflfl3:E5-R{I]:1l}-19. Medline

55. Khan M, Evaniew bi, Bedi A, Ryeni UR, Ehandari Iv'I: Arthruscupic surgery fur degenerative tears uf the meniscus: A systematic review and meta-analysis. EMA] 2fl14;136i14i:105?-1l]64. Mudline DUI

Drtbnpaedic Knuwledge Update: Spurts Medich'ie 5

Zflfl1;236{2}:ISE-195.Mcdlinc DUI

A study uf 113 patients fuund that patient age ulder than 56 years and pustuperative flesiun uf less than Ill)“ were risk facturs fur a puur uutcume after high-tibial usteutumy

fur medial cumpartment arthritis. Level uf evidence: V.

59. Flecher K, Parratte S, Auhaniae JIv'I, Argensun IN: A IZ-EE—year fulluwup study uf clusing wedge high tibi— a] usteutumy. Effie Urtbup Refer Res 2fl06:452:91-96. Medline DUI 60. Akiruki S, Shihakawa A, Takinawa T, Yamanaki I, Huriuchi H: The lung-term uutcume uf high tibial usteutumy:

A ten— tu 1i] —year fulluw—up. I Be as juint Surg Br lflflfltflflfi 1:592'596. Medline

DUI

. Amendula A, Eunasia DE: Results uf high tibial usteutumy: Review cf the literature. Int Urriiup 2i] 1G:34i2}:155-16{l. Medline DUI A review uf the lung-term survival uf high-tibial usteutumy

fuund that the facturs assuciated with a successful uutcume

in patients yuunger than {it} years were isulated medial cumpartment usteuartbritis, guud range uf mutiun, and ligamentuns stability. 62. Duivenvuurden T, Eruuwer RW, Eaan A, et al: lliEum-

parisun uf clusing—wedge and upening—wedge high tibial

usteutumy fur medial cumpartment usteuartbritis cf the knee: fl. randumiaed cuntrulled trial with a six-year fulluw-up. ] Burrs juint Surg Am lfl]4;96{1?}:1415-1432. Medline DUI A randumised study cumpared medial upening wedge high-tibial usteutumy with lateral clusing wedge usteutumy and fuund nu difference in clinical uutcume ur

radiugraphic alignment at 6-year fulluw—up. Medial upen-

ing wedge usteutumy was assuciated with a luwer rate uf cunversiun tu tutal knee arthruplasty but a higher rate uf early cumplicatiuns. Level uf evidence: I]. 63. Ilussi E, Eunasia DE, Amendula A: The rule uf high tibial

usteutumy in the varus knee. } Am Reed Urtbup Sarg lflllfl 9i]fl]:5.9fl'595. Medline

D lflld American Acadmny uf Urthupaedic Surge-ens

Chapter 15-": Nflflflflhl'fl-Plflfltf Management nf Detenartbriris cf the Knee

The indicatic-us, surgical technique, and cnmplicatiuns cf high-tibial DEtEfltflmy in tbe earns knee were reviewed.

64. ‘r’asuda K, Majima T, Tsucbida T, Kaneda Ii: A ten- tn

15-year fellnw-up e-bserratinn nf high tibial nsteiitnm}r in medial cnmpartment nstenarthrnsis. Gift: 01'1“p Refnt Res 1992;232:135-195. Medline

65. Prestun 5, Hnward J, Naudie D, Snmertille L, McAuley ]: Tntal knee arthrnplast}? after high tibial nstec-tnmy: Nu differences between medial and lateral nstentnm‘jtr apv prcraches. Cffrt Drtbnp Refer Res lfll4;4?2{1]:195-11fi. Medline DUI

A retrnspective review nf 16.5 patients fnund nn differ-

ence in functinnal nutcnme e-r survival-ship in patients when had undergene a medial npening wedge er lateral clnsiug wedge high-tibial Dfitfifltflmfir befnre tntal knee

arthrnplasty. Level cf evidence: IV.

66. Eackstein D, Mnrag G, Hanna 5, Safir 0, Grass A: Lang-term fullnw-up ef distal femnral tarus nstentnmjr of the knee. J Artbrnpfnsty ZflflTflEH, Suppl 11:2-6. Medline DUI 6?. Wang JW, Hsu CC: Distal femnral varus nstentnm}?

fur nstenarthritis {if the knee. ’1' Butte Jail-rt Surg Am Zflfl5;3?[1}:12?-133.Medline DUI

63. Knsashvili Y, Safir D, Grass A, Mnrag G, Lakstein D, Backstein D: Distal femnral 1.rarns estentnmjt fnr lateral nsteuarthritis nf the knee: A minimum ten-year fellnw-up. Int Grtbnp lfl 1i};34{2}:149-154. Medline DUI A retrnspectitre review {if an reitnrship and nutcume after distal femnral earns ester-tam}? fur lateral campartment nsteearthritis and valgus alignment found that at 15-year fulluw-up appreeI-rimatellir half {if patients had undergcrue

cemrersinn tn tntal inint artbrnplastt. Level nf evidence: W.

l"'"." E

5 re re ru-

3 D.

a

IE! lfllfi American Academy nf flrthnpaeclic Surgeries

Drthnpaedic Knnwledge Update: Sparta Medicine 5

®

Chapter 20

Meniscal Injuries Stephanie W. Mayer. MD

Johnathan A. Bernard. MD. MPH

Scott A. Rodeo, MD

The menisci are fibrocartilaginous structures with gross and microscopic structural properties that provide load distribution, lubrication, and stability to the knee joint. Diagnosis of a symptomatic meniscal tear requires a thor—

ough patient history, a physical examination with meniscus-specific tests, and often, imaging studies. The anatomy,

function, and vascular supply of the menisci have implications for the treatment of a meniscal tear. The long-term outcome after a total or subtotal meniscectomy is likely to include osteoarthritis. Biomechanical studies found

an increase in contact pressure after subtotal meniscectomy or a high-grade radial tear causing loss of the ability to absorb hoop stresses. Strain on the anterior cruciate ligament {AOL} in medial meniscus—deficient knees and strain on the medial meniscus in ACL—deficient knees proves the important stabilising function of the meniscus.

These results have led to an increase in the number of meniscal repairs performed to preserve load absorption and stabilization. Clinical and mdiographic healing rates of sex. to 35% have been reported after repair. Meniscal repair with concomitant ACL surgery leads to a higher rate of healing than isolated meniscal repair, probably

because of the release of bone marrow—derived stem cells during tunnel reaming. Irreparable tears and postmeniscectomy pain syndrome are common in young patients and are difficult to treat. Collagen scaffold implants and

synthetic polyurethane scaffolds have had promising results in animal and human studies for filling large defects

after partial meniscectomy. Relatively young patients who need to undergo total or subtotal meniscectomy as a primary procedure may be candidates for meniscal allograft transplantation. Biomechanical studies found that

strain on the ACL is reduced and knee kinematics and contact pressures are improved to near-baseline levels after:

transplantation.

He ords: meniscus; meniscal trans lant yw p

lntrod uction

1

. . . Importance of radial, horizontal, and root tears of the

meniscus. Advances in imaging have improved the char-

acterixation of normal and pathologic menisci. Research

The medial and lateral menisci have important roles in

into biologic and meniscal collagen implants is expanding the treatment options for patients with meniscal pathol-

both static and dynamic stability to the knee. The hisr tologic and biologic composition of the menisci allows

lograft transplantation have led to improvements in this technique for carefully selected patients.

the knee joint. Their unique anatomic structure provides load distribution, proprioception, and lubrication, and biomecbanical and clinical results have confirmed the

Dr. Rodeo or an immediate family member serves as a

paid consultant to Rotation Medical and has stock or stock options held in Cayenne Medical. Neither of the following

authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly

or indirectly to the subject of this chapter: Dr. Mayer and Dr. Bernard.

@ lfllfi American Academy of Drthopaedic Surgeons

ogy. Short-term and long-term studies of meniscal al-

l-‘r' FT. :5

The menisci are wedge-shaped fibrocartilaginous struc-

tures situated between the femoral condyles and the tibial plateau. These structures have many functions in the

knee including proprioceptive feedback, load distribu-

tion during physiologic loading, joint lubrication during motion, and maintenance of tibiofemoral joint stability and congruity.“ The substance of the menisci is a solid

extracellular matrix and water. Fibrochondrocytes are the predominant meniscal cell type, and they produce the

Orthopaedic Knowledge Update: Sports Medicine 5

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Section 3:1Cnee antlLeg

MHHF‘“ cross-aeolian

Flandom ooliagen fiber

l'iEll'ilrol'l-i at suites-a

Ciroimierential oollagen fiber bundles

Figure 1

Schematic drawing shows the collagen fibers

of the meniscus. The superficial collagen fibers

are randomly oriented to resist sheer stress. The deeper fibers are oriented circu mferentially to dissipate loads as hoop stresses. The circumferential fibers are secured by radially oriented tie fibers.

Figure 2

Illustration shows the menisci and the proximal tibial plateau. The medial meniscus [MM] is I: shaped. The insertion ofthe posteromeclial meniscal root lpMMl {arrows} is shown just anterior to the posterior cruciate ligament [PC L}. The insertion of the anterom eclial

meniscal root laMM} is shown on the anterior

tibial plateau extending down the anterior

proximal tibia. The lateral meniscus is more circular in shape than the medial meniscus. and

extracellular matrix. Type I collagen comprises most of

the extracellular matrix; smaller amounts of types II, III,

V, and VI collagen also are present. Dther components are proteoglycaus such as aggrecan. Proteoglycans consist of a protein core covalently bound to negatively charged

glycosaminoglycan polysaccharides. Proteoglycans attract and bond to water, which comprises 65% to 75% of the meniscal volume. Type I collagen is most abundant in the

superficial zones of the menisci to provide tensile strength. Proteoglycans and water are found in the deeper zones

a:

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just lateral to the anterior cruciate ligament [ACLi on the tibial plateau. The posterior

lateral meniscal root {pM L} is shown with its

anterior meniscofemoral ligament {ligament of Humphrey] laMFL). The most common

lntermeniscal ligament. the transverse ligament

{TL}. is shown connecting the anterior horns of

the medial and lateral menisci. MEL = medial

collateral ligament.

and provide compressive strength.

medial meniscus is attached to the deeP medial collateral

collagen fibers are oriented in a circumferential pattern

horn also is attached to the tibia by the meniscotibial liga-

The collagen fibers are randomly oriented on the su— perficial aspects of the menisci. In the deeper zones the

DI

the anterolate ral meniscal root {aML} inserts

ligament fibers and the joint capsule, and its mobility therefore is limited. The inferior aspect of the posterior

and stabilized by intermittent radially oriented tie fibers that anchor the circumferential fibers {Figure I}. This ori-

ment or coronary ligament.3 The lateral meniscus is more circular in shape than the medial meniscus, and it has

absorption and dissipation of the hoop stresses from axial loading during weight hearing by 5(1% in knee extension

lateral meniscal attachment the popliteomeniscal fascicles extend from the meniscus to the posterior capsule and cre-

entation provides tensile strength superficially as well as and as much as 35 '3’l- in flexion. In these ways the menisci

protect the articular cartilage from excessive loads and contribute to joint congruity during weight hearing.

The medial and lateral menisci have different gross anatomic features (Figure 2}. Each has an anterior horn,

equal-size anterior and posterior horns. At the posterior ate the popliteal hiatus as the popliteus tendon becomes

intra—articular. The meniscofemoral ligaments connect the posterior horn of the lateral meniscus and the medial

femoral condyle. The anterior meniscofemoral ligament

a body, and a posterior horn. The medial meniscus is

of Humphrey courses anterior to the posterior cruciate ligament, and the posterior meniscofemoral ligament of

medial tibial plateau. The posterior horn is approximately 11 mm wide, and the anterior horn is slightly smaller. The

ament. Because the lateral meniscus has less continuous attachment to the capsule than the medial meniscus it

semicircular or C shaped, and it covers sex. to fifl'iia of the

Drtbopaedic Knowledge Update: Sports Medicme 5

1i'Iiirisherg courses posterior to the posterior cruciate lig-

El 1016 American Academ1r of Cirrhopaedic Surgeons

Chapter ll]: Meniscal Injuries

has mere mebility, which may cenfer a pretective effect.

The mest cemmen cennectien between the medial and

lateral menisci is the transverse intermeniscal ligament, which is present in 60% te 94% ef knees. A pesterier and medial er lateral eblique intermeniscal ligament alse

can he presents”l The vascular supply ef the menisci cemes frem the

superier, middle, and inferier geniculate arteries. The

peripheral 10% te 3D% ef the meniscus is well vascularized by synevial and capsular branches {Figure 3].

The anterier and pesterier reet attachments are well

vascularized by synevial branches."r Zenes ef the me— nisci are described based en this vascular anatemy. The euter third, the well—vascularized regien, is called the red-red zene. The middle third is the herder between

Image shews a cress-sectien ef the medial

meniscus. The vascular supply penetrates the

the vascularized and avascular zenes and is called the

euter 10% te ssss ef the meniscus {the red-

supply and is called the white-white zene. The lecatien ef a meniscal tear threugh the zenes partly determines

avascular regiens [the red-white zene}. The

with vascularity. The pertien ef the menisci that is net well vascularized receives nutritien threugh diffusien

permissien trern Arneczlty 5P. Warren HF: Micrevasculature et the human meniscus. Am J Sperts Med 1932;10I2]:9[l-95.}

red—white zene. The inner third is deveid ef a vascular

the treatment because the petential fer healing increases during leading. Neural elements are feund mestly in the

periphery ef the anterier and pesterier herns. The menisci are believed te have a rele in preprieceptien because ef

red rene}. The middle third ef the meniscus is the tra nsitien zene between the vascular and

inner third at the meniscus is avascular {the white—white zene]. PCP = perimeniscal capillary plexus, F = femur, T = tibia. {Repred uce-d with

cemplex meniscus tears"

111e Hele ef the Menisci in Lead Sharing

The Medial and Lateral Menisci as Stabilizers Biemechanical studies have centrihuted te insight inte the functien ef the menisci as dynamic stabilizers under spe-

lead between the femur and tibia threugh develepment ef heep stresses that rely en intact circumferential cel-

increased tibial translatien and strain en the ACL during anterier tibial translatien that eccurs with Lachman test-

this cenfiguratien.

During weight bearing, the menisci effect and diffuse the lagen fibers. Biemechanical studies feund that a partial

meniscectemy necessitated by the presence ef a buck et-handle er peripheral lengitudinal tear increases peak

tibiefemeral centact pressure by 65% te 110% and that

a tetal meniscectemy increases the pressure by as much as 235%} In a cadaver study, an incremental increase in peak centact stress and a decrease in centact area were found as the size ef radial tears increased and as a larger ameunt ef meniscal tissue was remeved.‘5 a radial tear 5fl% er ?5% ef the width ef the medial meniscus and a partial er tetal meniscectemy caused a substantial change frem the intact state. Dnly a radial tear mere than 90% ef the width ef the medial meniscus er a partial menis-

cific cenditiensJ'l Sectiening ef the medial meniscus led te

ing.2 hnether sectiening study feund that in the absence

ef an intact ACL, the medial meniscus acts as a secendary stabilizer during anterier tibial translatien.l The lateral meniscus was fun nd te be an impertant stabilizer fer re-

tatery and valgus leads during the pivet shift maneuver in BEL-deficient knees.‘ The anterier translatienal stability

cenferred by the ACL pretects the pesterier hern ef the

medial meniscus. These results emphasize the impertant static and dynamic rele ef the menisci in knee kinematics. pg FT. :5

A thereugh patient bistery is impertant fer beth the di-

cectemy ef such a radial tear substantially increased peak centact pressure and caused the peak centact te shift re

agnesis ef a meniscal tear and treatment decisien making. The patient’s demegraphic prefile, preinjury level ef

Eifl‘it': ef the width ef the lateral meniscus and a partial meniscectemy were feund te significantly increase cen-

injury can guide the examiner teward an accurate diag~ nesis and an apprepriate treatment plan. Patients with

a mere pesterier lecatienF A lateral radial meniscal tear tact pressures.fl These biemechanical data explain the

clinical ebservatien ef meniscal extrusien and pregres— sive degenerative esteearthritis in knees with a radial er

El Ifllii American Academy ef flrdtepaedie Surgeries

activity, earlier symptems er injuries, and mechanism ef a traumatic tear may have pain enset during a twisting

mechanism er deep flexien. Dccasienally a pepping sensatien is reperted. Appreximately ene-half te twe-thirds

Drrhepaedic Knewledge Update: Sparta Medicine .5

re re as 3

El.

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Section 3:1i2nec andLeg

A

Figure 4

I

I

.

Sal-Ir]!

of patients have knee swelling. Mechanical symptoms

such as catching or frank locking were observed in 12%

to 69% of patients in two recent studies; these are impor—

tant symptoms because they suggest an unstable teardfl'v11 The physical examination should begin with assess-

ment of overall lower limb alignment and inspection for

external signs of trauma or the presence of an effusion. Active and passive range of motion is recorded with a

notation of any mechanical block to motion. The status

of the collateral and cruciate ligaments is important to test because the presence of an injury affects treatment

decision making. Palpation of the joint line may elicit

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1

.

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-'.-.'. fa.

can he particularly challenging because the tests lose their accuracy for meniscal jgiathology.”L11 However, the combination of joint line tenderness and a positive McMurray

or Thessaly test has sensitivity and specificity approaching

those of an isolated meniscal tear.IEI

Radiographic evaluation of a patient with knee pain

should begin with weight—bearing radiographs includ-

ing AP in extension, lateral, and PA 45“ flexion views in addition to a Merchant view of the patellofemoral joint.

Signs of osteoarthritis or trauma can provide clues to the

internal environment of the knee and the status of the

meniscus before the onset of acute pain. Osteoarthritis

can signify a degenerative meniscal tear, and trauma can

Mchdurray, Apley, and Thessaly tests should he interpreted for pain as well as mechanical signs. The McMurray

tears can he well evaluated with proton density—weighted

be associated with an acute tear. MRI is useful for con--

common location for tenderness. The meniscususp-ecific

firming a clinical suspicion of a meniscal tear. Meniscal

test involves taking the knee through a range of motion

MRI. A tear can be described as longitudinal {vertical}, horizontal, radial, flap, parrot beak, bucketbhandle, de-

test, the patient is prone with the knee flexed to 9i)”; the

tending to the articular surface from within the normally

examiner applies an axial load while the tibia is rotated internally and externally. For the Thessaly test, the patient to

.-..'

tenderness in the region of a tear. Posterior horn tears are most prevalent, and therefore the posterior joint line is a

while internally and externally rotating the tibia relative to the femur and applying an axial load. For the Apley

UI

L‘r -.

Proton density—weighted magnetic resonance images show meniscal tears. A, Sagittal view shows a complex medial meniscal tea r; the signal extends to the articular surface. B. Coronal view shows a horizontal cleavage tear of the medial meniscus at the junction of the body and posterior horn. C. Sagittal view shows the double-posterior cruciate ligament sign, which is consistent with a bucket—handle tear with the fragment displaced into the notch.

stands on the affected leg and performs a one-legged

squat of approximately 20”. During flexion and exten— sion the patient also rotates the torso to create intents]

and external rotation of the tihiofemoral joint. Each of

these functional tests is designed to trap the pathologic meniscus under axial load and rotation, and pain andfor

mechanical symptoms should be recreated. In a patient with an isolated meniscal tear, joint line tenderness was

generative, or complex. The criteria for MRI diagnosis of a meniscal tear include increased signal intensity ex-

lowvsignal meniscal substance; distortion of the shape or size of the meniscus, which signifies missing meniscal tissue; or a displaced meniscal fragment” {Figure 4}. The

sensitivity and specificity of 1.5-Tesla {T} and 3.0-1" MRI diagnosis of medial meniscal tears, as confirmed with arthroscopy, were found to be 93% to 96% and 33%

to 913%, respectively.” MRI was less sensitive {T?% to

81%} but more specific {93% to 99%} for lateral meniscal tears. In general, 1.5-T MRI was slightly less sensitive

found to be an accurate test in 31% to Qfl‘if. of patients

and specific than 3.0—T MRI, but the difference did not reach significance. A report of Sfl-T MRI for detecting

61% to SG% for the Thessaly test.‘“*” With associated ligamentous or ehondral injury, the physical examination

and specificity of 3%.” These findings may be attributable to the radial orientation of many posterior root

compared with 5TH: to WEE: for the Melviurray test and

Drthopaedic Knowledge Update: Sports Medichie .5

posterior meniscal root tears found sensitivity of T?%

El 1016 American AcadMy of Cirrhopaedic Surgeons

Chapter 1i]: Meniscal Injuries

tears, which makes them mnre difficult tn see an MRI. The patient histnry and physical enaminatinn remain

the mnst impnrtant diagnnstic tnnls. Tn be cnnsidered a pertinent finding, a meniscal tear seen cm MRI shnuld cnrrespnnd tn the patient's histnry and pnsitive clinical

eaaminatinn findings.

Figure 5

The treatment nptinns fnllnwing diagnnsis nf a sy mptnmatic meniscal tear include nbservatinu, excisinu (a partial

meniscectnmy}, repair, and replacement. The treatment shnuld be tailnred tn the patient and the type nf tear. Db-

servatinn can be chnsen fnr stable peripheral tears smaller

than 5 tn 10 mm, snme degenerative tears that dn nnt cause mechanical symptnms, and tears in the setting at

Arthrnscnpic views shnwing a lnngitudinal tear in the vascular red—red anne cf the medial meniscus {A} and repair nf the tear with vertical

mattress sutures {E}.

their preinjury level nf spnrts activity cnmpared with nnly

half nf thnse whn underwent a partial meniscectnmy.”

ical symptnms; tears in the avascular anne, such as radial nr flap tears; and degenerative tears withnut substantial

Similarly, at 4-year fnllnw—up, patients whn underwent repair nf a medial meniscal rnnt tear had less prngressinn nf nstenarthritis and better clinical scnres than thnse whn underwent partial medial meniscectnmy.IE Preservatinn nf the integrity cf the articular cartilage nn quantitative

During partial meniscectnmy, the unstable pnrtinu nf I:he meniscus is identified and excised, and the adjacent

This finding suppnrts the repnrted clinical results. With increasing evidence that hath meniscal injury

iutn the excised segment. The surgenn shnuld preserve as much meniscal tissue as pnssihle and avnid creating a

repair as the treatment nf chnice fnr meniscal tears. The

substantial nstenarthritis. Unstable tears causing mechan— nstenarthritis can be treated with partial meniscectnmy.

tissue is shaped intn a smnnth and stable cnntnur leading defect traversing the entire width cf the meniscus. Clinical

studies with lnng~term fnllnw-up nf partial meniscectnmy

MRI has been assnciated with healed meniscal repairs.” and partial meniscectnmy are linked tn the develnpment nf nstenarthritis, there has been a shift tnward meniscal

gnal nf meniscal repair is tn prnvide the meniscus with

fnr the treatment nf meniscal tears fnund an increase in

structural suppnrt and the ability tn heal and therefnre tn preserve its integrity and functinn. In general, traumatic

Partial meniscectnmy fnr the treatment nf radial tears that were within 1 cm cf the pnsterinr hnrn insertinn led tn

in patients ynunger than 30 years age are believed tn be mnst amenable tn a successful repair, althnugh gnnd re-

?7rmnnth fnllnw—up.” At 5- tn T—year fnllnw—up nf 46 patients, nue-third had prngressinn nf Kellgren-Lawrence

Althnugh the mndii'ied Lyshnlm Knee IQuestinnnaire scnre nften significantly imprnved after partial meniscectnmy,

patients" {Figure 5}. Because nf their blnnd supply, tears in the red-red anue are mnst likely tn heal, fnllnwed by tears in the reduwhite anne.‘I Whiteuwhite anne tears are avascular and thus have limited pntential fnr healing. The failure and renperatinn rate was fnund tn be higher

niscal tears, both the shnrt- and lnng-term renperatinn

medium—term fnllnw—up."f'*1l"11 Enncnmitant ACL recnnstructinn pnsitively cnrrelated with healing, “~13 and age

nstenarthritic changes within the affected cnmpartment. prngressinn nf nstenarth ritis in 35% nf patients at a mean

grade 1'} tn 2 nstenarthritis tn grade 3 nr 4 nstenarthritis.

nnly 56% nf patients repnrted pain imprnvement. In a systematic review nf treatment fnr traumatic mer rates were higher after meniscal repair than after menis-

cectnmy {16.5% versus 1.4% and 203% versus 3.9%,

respectively)?“ Hnwever, there were nn plain radingraphic

degenerative changes in 73% nf knees after meniscal re-

pair, cnmpared with {54% nf knees after meniscectnmy. These results were cnrrnhnrated hy annther study that

lnngitudinal tears nccurring in the red-red {vascular} acne sults alsn were fnund in reduwhite anne repairs in ynung

fnr medial than lateral meniscal repairs at sbnrt- and

ynunger than 3'3 years trended tnwa rd a pnsitive cnrrela-

tinn with healing.” Tears lnnger than 1 cm and tnbaccn smnking negatively affect healing rates.” Viden 20.1: All-Inside Meniscus Repair -

FAST-FIX. Walter R. Sheltnn, MD (1?. min)

cnmpared partial meniscectnmy and inside-nut repair at

lnngitudinal tears.” Almnst 30% nf patients with arthrnscnpic meniscal repair had an nstenarthritis prngressinn

cnmpared with nnly 40% nf patients with meniscectnmy

at 3— tn Ill-year fnllnw—up. Mnre than 96% nf the patients whn underwent arthrnscnpic meniscal repair returned tn

Eb Ifllti American Academy nf Urthnpaedic Surgenus

1|Illiclen 20.2: All-Inside Meniscus Repair MarFire Maeen. Keith W. Lawhnrn,

MD (3 min]

Drthnpaedic Knnwledge Update: Spnrts Medicine 5

pg FT. :5

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Sectinn 3:1I'inec andLeg

such as a tibial plateau fracture. Arthrnscnpic repair can be dnne using an nutside-in, inside-nut, nr all-inside tech-

a hnrisnntal mattress cnnfiguratinn. nnnther study simulated inside-nut vertical mattress suture fixatinn and cnmpared it with fixatinn using several available all-inside devices; inside-nut repair had a failure lnad nf F3

hnrn nr meniscal bndy tear, which is difficult tn reach using an inside-nut nr all-inside technique. Spinal needles

after 130 cycles, and all except nne all-inside device had cnmparable perfnrmance:15 The clinical results nf all-su-

flpen repair has largely been replaced by arthrnscnpic

repair unless an arthrntnmy is needed fnr annther injury, nique. flutside—in repair nften is chnsen fnr an anterinr are placed frnm nutside the jnint thrnugh the meniscal

tear, and suture is shuttled thrnugh the needles under arthrnscnpic nbservatinn. A small skin incisinn is made, with care tn avnid entrapping any superficial snft tissue. An inside-nut repair cnmmnnly is used fer a pnstcrinr hnrn

are placed with the use nf specialised guides thrnugh the meniscal tear and are retrieved nutside the jnint. Suture is

ta-analysis nf studies with mnre than 5 years nf nutcnrne data repnrted a success rate nf T6.1% when the nutside-in

nr pnstcrinr meniscal bndy tear. Lnng, flexible needles

technique was used fnr isnlated meniscal repairs.12 In-

used in the accessnty incisinns tn prntect the pnpliteal

a T5.?% success rate. A systematic review nf insideanut

neurnvascular structures as well as the saphennns nerve and vein medially er the pernneal nerve laterally. MRI at an average 43-mnnth fnllnw-up after inside-nut me-

clinical healing rates nf 33% and 31% fnr inside-nut and

The ability tn return tn spnrts after meniscal repair has

Multiple devices are cm the market, each nf which is insert—

and inside—nut repairs had a higher rate nf nerve injury.

been investigated. A study nf elite athletes fnund that 31%

were able tn return tn spnrts an average nf 5.6 mnnths

ed thrnugh a standard anterinr pnrtal using a guide. The

after surgery.m In this active pnpulatinn, the failure rate was 26.?% at an average nf 41.?r mnnths. A study nf

allrinside devices mnst suitable fnr tears in the pnstcrinr hnrn nr midbndy nf the meniscus. Despite the small risk nf

return tn the same activity level an average nf 4.3 mnnths after surgery. At 5-year fnllnw—up, 45% were still partic-

the pnstcrinr capsule tnn deeply, a recent review nf patients treated with smnnd-generatinn all-inside devices repnrted

It can be difficult tn interpret imaging after meniscectnmy nr meniscal repair. The diagnnstic criteria fnr a

insertinn devices currently nn the market mimic inside—nnt suture cnnfiguratinns tn make the device mnre user-friend-

the native meniscus was remnved are the same as fnr a primary tear, and the diagnnstic accuracy is similar. Tears

fixatinn mechanism reduces the risk nf device migratinn nr

repair may reach the vascular xnne nf the meniscus, and these tears heal with fihrnvascular tissue that can mimic

trajectnries pnssible thrnugh an anterinr pnrtal make the injury tn pnpliteal fnssa structures if the device penetrates nn neurnvascular cnmplicatinns."-‘l The secnnd-generatinn

H

tears withnut cnncnmitant ACL recnnstructinn fnund

the advantage nf being less invasive than inside—nut nr and therefnre less risk nf superficial vessel nr nerve injury.

I: [I'll tn III-1 I: as

and all-inside repairs nf isnlated bucket-handle meniscal all—inside repairs, respectively.” All—inside repairs led tn mnre lncal snft-tissue irritatinn and implant migratinn,

nutside-in techniques, with nn required accessnry pnrtal

._I

side-nut repairs nf ACL-intact and ACL-recnnstructed knees had a ??.?% success rate, and all-inside repairs had

niscal repair with vertical mattress suturing shnwed a 130% healing rate fnr partial tears and a 30.3% rate

fnr full—thickness tears.” All—inside meniscal repair has

T:

nutside—in repairs, and 33% fnr all—inside repairs. A me-

shuttled thrnugh the tear and tied nver the capsule thrnugh the npen pnstcrinr incisinn. Accessnry incisinns are nec-

essary fer needle retrieval and [met tying. Retractnrs are

an

ture and all—inside techniques were generally equivalent

in several recent systematic reviews and meta-analyses. A systematic review nf heterngenenus meniscal repairs with nr withnut cnncnmitant ACL recnnstructinn fnund that 613% nf repairs cnmpletely healed." The cnmplete healing rate was 62% fnr inside-nut repairs, 56% for

and a knnt is tied directly nn the nutside nf the capsule

DI

tn 33 N and a mean displacement nf 2.5 3 tn 2.15 mm

ly and safe fnr the articular cartilage. The imprnved suture lnnsening. Midterm nntcnmes are prnmising; at an average 75-year fnllnw-up nf 33 all-inside meniscal repairs, 34%

were healed accntding tn clinical criteria.“ Binmechanical studies cnmparing the strength nf inside-nut and nutside-in all-suture repairs had cnnflict-

ing findings. A systematic review cf 41 studies cm the lnad tn failure nf suture repairs cnmpared with repairs

using all-inside devices found a higher lnad tn failure

with suture repairs.” A vertical mattress suture cnnfig— uratinn was fnund tn have a greater lnad tn failure than

Drrhnpaedic Knnwledge Update: Spnrts Medians: 5

highslevel snccer players fnund that 39.6% were able tn ipating in snccer.2E4

retear after a meniscectnmy in which less than 25% nf requiring a mnre extensive meniscectnmy nr a meniscal

the hyperintense signal nf a retear. Based nn MRI ap-

pearance, tears are classified as fully healed if there is nn fluid signal in the repair site, partially healed if fluid extends intn less than 50% nf the width nf the repair site,

and nnt healed if fluid extends intn mnre than 53% nf the repair site width. Failure nf meniscal repair can be attributed tn inade-

quate meniscus fixatinn strength, pnnr vascular supply at the repair site, nr cnncnmitant knee instability caused by

El 1016 American AcadMy nf Drrhnpaedic Surge-ens

|iiillapter 1d: Meniseal Injuries

ligamentous laxity. The medial and lateral menisci have a secondary role in stabilizing the knee. and repairing a posterior horn meniscal tear in an ACL—deficient knee without correcting anterior laxity can lead to a retear or compromised healing.‘ The reason for the failure should

repair to increase vascularity and resulting migration of vascular-derived undifferentiated cells to the repair

repair or a partial meniscectomy is preferable. Revision

meniscal repair adhered well to sites of meniscal injury

be considered in deciding whether a revision meniscal

meniscal repair was evaluated in 15 patients who had

undergone primary repair using different techniques.“ The revision repair failed in five patients at an average of 25 months after surgery. The presence of degenerative changes at all five revision repair sites suggested that avas— cularity or instability played a role in the degeneration of the meniscal tissue. In the patients who did not have a

retear after the revision repair, the average Lysholm score improved to 9‘14 of 100. @

Video 20.3: Posterior Horn Medial Meniscus Hoot Repair. Dharmesh Was. MD. and

|t'lhristopher D. Harner. MD [14 min]

site. There also is interest in the direct application of

pluripotent stem cells into the joint for augmentation of healing in meniscal repair.“ In animal models. synovial mesenchymal stem cells injected intra-articula rly during and differentiated into meniscal fibrochondrocytes, thus

improving the amount of meniscal tissue formation 1 to 4 months later.“ A human study of intra-articular injection

of bone marrow—derived mesenchymal stem cells found

that the meniscal volume substantially increased in 24% of patients within 1 week of meniscectomyf55 Patients who

also had osteoarthritis had substantial improvement in

pain. In a rabbit model, adipose-derived stem cells delivered to the site of a longitudinal meniscal tear were found to improve the healing rate and amount of regenerated

meniscus in both the vascular and avascular zones.“ The effect of adipose-derived stem cells was most apparent after acute repairs.

Concomitant ACL reconstruction was found to be

positively correlated with meniscal healing rates, prob-

The role of the posterior meniscal root attachment and

ably because bone marrow—derived meseuchymal cells were released during tunnel reaming.”13 Bone marrow

attention recently. Both degenerative and traumatic tears can occur. A traumatic tear often is associated with mul-

tercondylar notch recently was reported for augmentation of healing of avascular horizontal cleavage tears.“ The

Hoot Tears

the underestimated prevalence of this injury have received tiligamentous knee injury or injury occurring during deep

knee flexion. The medial posterior root is less mobile than the lateral root and therefore is more susceptible

to isolated injury; in contrast, a lateral root tear is most common in association with ligamentous injury. Tears of

the posterior medial meniscal root can increase contact

pressure, external rotation, and lateral tibial translation,

stimulation achieved by drilling a 5-mm hole into the in-

clinical healing rate was 91%, and 3% of patients had

complete healing at secoudplook arthroscopy. A relatively short duration of meniscal symptoms was associated with a superior clinical outcome score. E.

1H'ideo 2114: All Arthroscopic Meniscus

Repair with Biological Augmentation.

which are corrected with repair of the posterior medial

Nicholas A. SgaglaE, MD, and Eric Chen,

the contact area and increases contact pressure in the

Platelet-rich plasma {PEP} is a source of anabolic growth factors such as insulin-like growth factor—1,

meniscal root”!31 Similarly, a lateral root avulsion or a radial tear within 9 nun of the root substantially decreases lateral compartmentfi‘L“ Repair of medial and lateral

root tears substantially decreases the contact pressures within the medial and lateral compartments.

M D [23 min}

vascular endothelial growth factor, fibroblast growth factor—2, transforming growth factor—l3, and platelet-de-

rived growth factor-AB, all of which have been isolated

The mechanism of healing in the vascular portion of the

from meniscal repair tissue.” There is evidence that PRP application at the site of meniscal repair increases the

fibrin clot formation followed by migration of undifferw entiated mesenchymal cells from the vasculature, which

and improves the histologic appearance of the healing meniscus both in vitro and in vivo.” Only small retro-

Biologic Treatnents

meniscus involves an initial inflammatory response and leads to new matrix formation and healing through E—

brous scar tissue. Synovial cells also can participate in the repair response. This process has led to a recommendation that trephination of the peripheral meniscus and capsule

and synovial abrasion should be done during meniscal

IE! Elllti American Academy of flrthopaedic Surgeons

adherence and content of fibroblasts and chondrocytes spective studies have compared meniscal repair with and

without the application of PRP.“'3'1"1 Cine study found no between-group difference in clinical outcomes scores, reoperation rate, or the proportion of patients who returned

to work or sports.“ Another study reported no difference

Drthopaedic Knowledge Update: Sports Medichre .‘i

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3 D.

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5ecfion3:Kneeand1eg in reoperation rate or overall clinical outcome scores but did find improvement in pain and sports parameters in patients who received PEP. Improvement in the MRI appearance of PEP-treated repairs also was reported; 0 of 1? control patients and 5 of ’1? repairs supplemented with PRP had a normal meniscus signal intensity.“

Collagen Implants For patients with irreparable meniscal injury and sub— stantial meniscal loss, synthetic scaffolds may pmvide a

new treatment option. A composite type I bovine colla-

gen—glycosaminoglycan scaffold was found to support the formation of meniscus-like tissue when attached to a meniscal rim.“- The scaffold was infiltrated by synovial

andl'or vascular-derived cells and replaced by host meniscuslike tissue. Long-t clinical data are promising.

A retmspective review found that patients treated with

collagen meniscal implants fer an irreparable medial me-

niscal tear had better clinical, radiologic. and functional outcomes at lfl-year follow—up than patients treated with

partial medial meniscectomy alone.“2 A prospective cohort study of 33 patients compared a medial collagen meniscal implant with a partial meniscectomy. At an average 133-month follow-up, patients who received the medial meniscal implant had substantially better visual

analog scale pain scores as well as significantly higher functional outcomes as measured using the Tegner Activity Level Scale. International Knee Documentation Committee Subjective Knee Evaluation Form, and Med

ical Outcomes Study Sid-Item Short Form Health Survey

scores.41 Patients with an irreparable lateral meniscus tear

or a history of partial lateral meniscectomy also had substantial improvement in clinical outcome scores at 2-year follow-up, with no progressive cartilage degeneration.43

for postmeniscecromy syndrome after medial or lateral partial meniscectomy had significant improvement in all

clinical outcome scores, and 92.5% had stable or im-

proved International Cartilage Repair Society cartilage status.“ In 9 of 52 patients {113%} treatment failed, but 2 of these patients were asymptomatic and the failure

was discovered during protocol-stipulated second-look

arthroscopy. Six of the nine treatment failures were a

lateral tear, where mobility and the complex anatomy of the meniscal attachments create a biomechanically

challenging procedure. Another recent study on the use

of a polyurethane scaffold for lateral meniscal defects and postmeniscecromy pain found substantial improvement in

pain and clinical outcome scores at 24-month follow-up.“

Three of the 54 patients {5.5%} required reoperation because of persistent pain, and 2 of these patients were found to have a small tear at the edge of the scaffold.

Meniscal Allegraft Transplantation

Meniscus replacement with allograft tissue appears to

be a viable treatment for patients younger than 5D years with pain and dysfunction from meniscal pathology warranting subtotal or total meniscectomy. A biomechanical study found that meniscal allografr transplantation restores normal knee contact mechanics and restores strain on the ACL with anterior translation to baseline?” The described techniques include arthroscopically assisted and open procedures as well as methods of fixation such as

transplantation with bone plugs attached to the anterior

and posterior horns, a common bone bridge attached to both horns, and suture fixation only {Figure 6}.

Video 20.5: Lateral Meniscus Transplanta-

tion. Benjamin 5. Shaffer, MD {6 min}

In a prospective randomised study of the use of collagen

implants, patients with no history of surgery and patients who had undergone previous meniscal surgery received a

collagen scaffold implant or a partial meniscectomyl"l Pa-

E

'U E I'D Ill I1! I: be!

H

Video 20.5: Lateral Meniscus Transplan-

tients who received the collagen implant had significantly

tation - Bridge-in-Slot. Brian J. Cole, MD, IVIBA (15 min}

niscal surgery gained 42% of lost activity 5 years after

Video 10.1: Medial Meniscus Transplantation - Double Bone Plug. Thomas E.

increased meniscal volume at second-look arthroscopy, compared with baseline. Patients with a history of me-

collagen scaffold implantation, which was substantially more than those who received meniscectomy alone.“

Carter. MD (11 min}

An acellular. biodegradable, synthetic polyurethane

scaffold has been developed for medial and lateral meniscal defects. This scaffold is highly porous and allows

vascular and fibrochondrocyte ingrowth. In animal mod—

els there was vascular ingrowth and matrix deposition onto the scaffold at 2 weeks. and by 3 months the pores were filled with fibmvascular tissue.“ At 2-year follow—up patients who were treated with the polyurethane scaffold

Drrhopaedic Knowledge Update: Sports Medicine 5

Video 20.3: Medial Meniscus Transplan-

tation During AEL Repair. John C. Hichmend. MD II? min}

Three- to 4-year outcomes were reported for medial and lateral meniscal allograft transplantation in patients with or without a history of meniscal surgerydi-i“ After

fl lflld American Academy of Urrhopaedic Surge-ens

Chapter as: Meniseal Injuries

Medial k.

I"—-

B Figure IE

Schematic drawings shew {A} medial meniscal allegraft transplantatinn using hene plugs and {I} lateral meniscal allngraf'i transplantatinn using a lame bridge secured tn the capsule th rnugh trartsnssenus tunnels and peripheral sutures.

meniscal allngraft transplantatinn, patients had substantial irnprnvement in clinical nutcnme scnres en the mean Lyshnlm, Knee Injury and Dsteearthritis IDutcnme Scnre,

the ACL fniinwing subtntal meniscectnmy nr high-grade radial tear have led tn an increase in the number nf me— niscal repairs perfnrmed tn preserve the lead ahsnrptinn

and Knee Seciety Scnre measures as well as radingraphic measures nf nstenarthritisfhm Seventy-seven percent nf

radingraphic healing rates nf 60% tn 35% are repnrted af~

internatinnal Knee Dncumeutatinn Cnmmittee, Tegner,

high schnnl and higher level athletes were able tn return

tn spnrts activity.“ Based nn secnnd—lnnk arthrnscnpy

and MRI, 31.3% nf patients had a satisfactnry nutcnme.

Midterm fnllnw—up nf arthrnscnpically assisted meniscal

allngraft transplantatinn alsn fnund prnmising results.“

Patients had imprnvement nver baseline scnres en the Knee Injury and Dstenarthritis |l.'3Iutcnme Scnre subscnres

for pain, ether symptnms, activities nf daily living, spurts activity, and Quality ef life as well as the visual analng pain scale, Medical lI'Ciutcnmes Study Shnrt Perm—36, and

Lyshnlm scnres. Lnng-term fellew-up nn npen meniscal

allngraft transplantatinn using crynpreserved allngraft

fnund a 29% failure rate.52 Ebert—term nutcnme scnres were better than baseline scnres but deterinrated at lnngterm fnlinw-up. The mnst impnrtaut factnr determining nutceme was the extent nf cnncnmitant articular cartilage

degeneratinn; better results were reported in patients with minimal degenerative changes.

and stabilizatinn prnperties nf the menisci. I{Slinical and ter repair. Meniscal repair with cnncnmitant ACL surgery leads tn a higher rate nf healing than isnlated meniscal

repair, and tears repaired in smnkers and tears larger than 1|] mm have a lnwer rate nf healing. Irreparahle tears and pnstmeniscectnmy pain syndrnme are cnmmnn in

ynung patients and are difficult tn treat. Cnilagen sca ffnld implants and synthetic pnlyurethane scaffnids have had

prnmising results in animal and human studies fer filling

large defects after partial meniscectnmy. Relatively ynung

patients whn undergn tntai nr suhtntal meniscectnmy' as a primary prncedure may be candidates fer meniscal

allngraft transplantatinn. Binmechanical studies found that strain en the ACL is reduced and knee kinematics

and centact pressures are imprnved tn near-ba seline levels

after transplantatinn. Key Study F'nints

Ir The menisci are impnrtant lead-distributing and stabilizing structures in the knee.

I Repairs nf tears in the red-red aene and repairs with Summary

The menisci have been shnwn tn prnvide lnad distributinn, lubricatinn, and bnth translatinnal and rntatnry stability

tn the knee jnint. Studies shnwing an increase in centact

pressure en the articular cartilage and increased strain nn

IE! lfllfi American Academy nf Cirrhnpaedic Surgenna

cnncnmitant ACL recnnstructinn are the must likely

tn cempletely heal.

' Results nf meniscal scaffnld implantatinn and

allngraft transplantatinn have shnwn prnmising results.

Drthnpaedic Knnwledge Update: Spnrts Medicbse 5

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Sectinn s: Knee and Leg Annotated References

fnr treatment. Artbrnscepy lflll:23{3}:3?2-331.

1. Musahl V, Citak M, D'Lnughlin PF, Chni D, Eedi A, Pearle

.fi. binmechanical study fnund that a radial tear nf the pns-

the stability cf the anterier cruciate ligament-deficient

meniscectemy ef such a tear significantly increased ceutact pressures and decreased centact area. Repair significantly decreased peak centact pressure.

Medline DUI

AD: The effect nf medial versus lateral meniscectnmy nu lrnee. Am ] Sperts Med lfllfl;33{3}:1591-159T.

A binmecha nical study evaluated the effect nf the medial and lateral menisci en ACLadeficient lrnees. The media] meniscus was fnund tn he a secendary stabilizer tn anterier translatien, but the lateral meniscus was a mere impertant stabilizer during the pivnt shift test. . Spang JT, De rig HE, Masseeca A, et al: The effect ef medial meniscectnmy and meniscal allngraft transplantatinn

nn knee and anterier cruciate ligament binmechanics.

Artbrnscepy Zfl'lfi;lfiili:191-Efll. Medline

DUI

A binmechanical study evaluated strain at the ACL with tibial displacement in intact, tetal meniscectnmy, and

medial allngtaft transplantatinn cnuditiens. Medial me—

niscectemy ptnduced the greatest tibial displacement and strain nn the ACL. Medial meniscal allngraft transplantatieu restnred unrmal cnnditinns. fimigielski R, Becker R, Zdannwica U, Cisaelt E: Medial meniscus anatnmy: Frnm basic science tn treatment. Knee Serg Sperts Traumatel Artfiresc EDIS;E3{I}:3-I4.

Medline DUI

This anatcrmic study nf the medial meniscus fncuses nu the peripheral attachments nf the medial meniscus tn divide it intn five distinct annes. An understanding ef the peripheral anatemy ef the meniscus is impertant during meniscal repair. . Arnncaky 51", Warren RF: Micrnvasculature nf the human meniscus. r'lnt _,I Spnrts Med 1931;1fll21flfl-95. Medline DD]

i‘

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

H

terinr tnnt fill ‘34:. nf the width ef the meniscus er a partial

Badlani JT, Eerrere C, lGnlla S, Harrier CD, Irrgang J]: The effects nf meniscus injury en the develnpment nf lrnee esteearthritis: Data free: the esteearth ritis initiative. An:

I Spur-ts Med 3013;41ifiislli’13-1244. Medline

DUI

A case centre] study fnund that medial meniscus extrusinn, cnmplesr tears, and large radial tears were mnte

cnmmnn in patients with nsteeatthritis than in centre] subjects. Level ef evidence: III.

10. Knnan 5, Rayan F, Haddad F5: De physical diagnnstic tests accurately detect meniscal tears? Knee Serg Sperts Trenmntni Arthrnsc 1Dfl9;1?{?l:fiflfi-SII. Medline DUI Jnint line tenderness was fnund tn he superinr tn the

McMurray er Thessaly test fer the diagnnsis nf iselated

meniscal tears cenfirmed at arthrnscnpy. The cnmbiuatinn nf jnint line tenderness and nne nther test imprnved diagnnstic accuracy. 11. Gnessens P, Keijsers E, van Geeuen R], et al: Validity nf the Thessaly test in evaluating meniscal tears cnmpated with arthrnscnpy: A diagnnstic accuracy study. I Drtfiep Spnrts Phys Ther 2015;45{1]:13-24, El. Medline DUI Per the evaluatinn nf pnssible meniscal tears the Thessaly

test had sensitivity nf 64% and specificity nf 53%, the

McMurray test had sensitivity ef Tfl‘iis and specificity nf 45%, and eembined testing had sensitivity ef 53% and specificity cf 62%. These values were lnwer than repnrted

in the nriginal descriptieu.

Barata ME, Fu FH, Mengatn R: Meniscal tears: The effect ef meniscecteruy and ef repair nu iuttaarticular ceutact areas and stress in the human knee. A preliminary repert. Am] Spnrts Med 1935;14l4]:2?l}-2?5. Medline DUI

12. Mirsatelneei F, Tekta Z, Bayaaidchi M, Ershadi 5, Afshar A: Validatinn ef the Thessaly test fer detecting

Lee S], Aadalen K], Malaviya P, et al: Tibiefemnral centact mechanics after serial medial meniscectnmies in the human cadaveric knee. An: 1 Sparta Med Eflflfi;34{li}:13341344. Medline DUI

line tenderness was mnst sensitive and the McMurtay test

. Bedi A, Kelly NH, Baad M, et al: Dynamic centact mechanics ef the medial meniscus as a functinn nf radial tear, repair, and partial meniscectnmy. I Enne Inert Surg Am 1fl10592{6}:1393-14flfi.

A biemechanical study fnund that radial tears invelving fifl‘i-i. ef the width ef the meniscus caused an increase in peak cnutact pressure and alteratien nf its lncatinn. Par-

tial meniscectemy further increased pressures. Inside-nut repair reduced pressures re a level similar te that ef the intact state. Medline DUI

. Bedi A, Kelly M, Bead M, et al: Dynamic eentact mechanics nf radial tears nf the lateral meniscus: Implicatinns

Drthepaedic Knnwledge Update: Sperrs Medicine 5

meniscal tears in anterier cruciate deficient knees. Knee 101D;1?I{3}:221-223.Medline DDI

In patients with cnmbined ACL and meniscal injury, jeint was mest specific fer diagnnsis ef the meniscal tear.

13. 1iii'an Dyck P, Va nhnenacker PM, Lambrecht V, er al: Pre—

speetive cemparisen ef 1.5 and Bail-T MRI fer evaluating the knee menisci and ACL. f Enne fninr Surg Am 1013;95llfllfllfi-914.Mcdline DUI

Sensitivity and specificity fnr diagnnsis nf medial and

lateral meniscal tears was higher when 3.fl-T MRI was used rather than 1.5-T MRI, but the difference was nnt significant. Sensitivity was higher fnr medial tears, and specificity was higher fer lateral tears. Level ef evidence: I. 14. LaPrade RF, He CP, James E, Crespe B, LaPradc CM, Matheny LM: Diagnnstic accuracy ef 3.!) T magnetic resnnance imaging fur the detectinn nf meniscus pnsterinr

rnet pathnlegy. Knee Burg Spnrts Trestmntnl Arrhrnsc

lfllfi;23{1j:152—151Medline

DUI

fl lfllfi American Academy ef Urthnpaedic Surge-ens

|Iiiihapter ED: Meniscal Injuries

Mederate sensitivity and specificity was fennd fer MRI

diaguesis ef men iscal reet tears cenfirmed at arthrescepy. Level ef evidence: II. 15. Han SE, Shetty GM, Lee DH, et al: Unfaverahle results ef partial meniscectemy fer cemplete pesterier medial

meniscus reet tear with early esteearthritis: A .5 — te 3-year fellew-up study. ‘Arthreseepy lfllfl;13{lfl}:1326-1332.

Medline DDI

At a mean 5-year fellew-up, a retrespective study cf 46 patients whe underwent arthrescepic partial menis-

Seyear fellew—up. Am I Sperts Med 2339:3Ti6]:1131e1134. Mcdline DUI After meniscal repair 31% cf elite athletes were able te return te sperts at a preinjury level, despite a 243i:- retear rate. Medial repairs had the highest failure rate. Level ef evidence: IV.

21. Lyman 3, Hidalta C, Valdez AS, et al: Risk factel's fer meniscectemy after meniscal repair. Am I Sperts Med 2313:41t12}:2??2-2??3.Medline I101

16. Fasten E3, Steclt MV, Brephy RH: Meniscal repair versus

The everall rate ef meniscectemy after meniscal repair was 3.9%. A regressien analysis feund that cencemitant REL recenstructien was a risk facter fer meniscectemy after repair. Patients whe underwent iselated meniscal repair were at lewer rislt if they were elder than 43 years er had nndergene lateral repair er if the surgeen had perfermed a large number ef meniscal repairs. Level ef evidence: III.

reeperatien rates and clinical eutcemes. Artbrescepy 2311;2?{9}:12?5-1233. Medline DUI

. Nepple J], Dunn WR, Wright RW: Meniscal repair

cectemy ef a pesterier medial meniscal reet tear feund

imprevement in clinical parameters after arthrescepic meniscectemy but a 35% radiegraphic pregressien ef esteearthritis. Level ef evidence: IV.

partial meniscectemy: A systematic review cemparing

A systematic review ef partial meniscectemy and meniscal repair feund that partial meniscectemy resulted in a lewer reeperatien rate but a higher rate ef pregressien ef radiegraphic degeneratien. Meniscal repairs cencemitant with ACL recenstructien had a lewer failure rate. Level ef evidence: IV. 1?. Stein T, Mehling AP, Welsch F, ven Eisenhart—Rethe R, J3ger A: Lung-term eutceme after arthrescepic meniscal repair versus arthrescepic partial meniscectemy fer traumatic meniscal tears. An: ] Sperts Med 2313;33f3}:15411543. Medline DD]

A cehert study cempared the eutcemes ef arthrescepic

meniscal repair and arthrescepic partial meniscectemy in 31 patients. At mid- and leng-term fellew up, patients whe underwent repair had better sperts activity and ne esteearthritic pregressien cempared with these whe underwent partial meniscectemy. Level ef evidence: III.

13. Kim 53, Ha JR. Lee 3W, et al: Medial meniscus met tear refixatien: Cemparisen ef clinical, radielegic, and arthre-

scepic findings with media] meniscectemy. Arthrescepy

lflll;2?{3}:34E—354.Medline no:

A retrespective study cempa red medial meniscus reet re— pair and partial meniscectemy in 53 censecutive patients. At a mean 43.5-menth fellew-up, arthrescepic repair

yielded better clinical and radiegraphic results than partial meniscectemy. Lewl ef evidence: III.

19. Neyes FR, {Eben RC, Barber-Westin 5D, Fetter HG: Greater than IH-year results ef red-white lengitudinal meniscal repairs in patients 23' years ef age er yeunger. An: I Sperts Med 1311;39{5}:1333—1311 Medline DDI

The success rate was 62% after repair ef lengitudinal tears

extending inte the red-white acne in patients age 30 years er yeunger. In healed repairs. quantitative cartilage sceres

en MRI were net significantly different frem these ef the uninjured knee. Level ef evidence: IV.

II}. Legan M, Watts M, Gwen J, Myers P: Meniscal repair in the elite athlete: Results cf 45 repairs with a minimum

I3! 2313 American Academy ef flrthepaedic Snrgeens

eutcemes at greater than five years: A systematic literature review and meta-analysis. I BDHE Jeirtt- Surg Am 2312;94f24'Jfllll—2121Medline DUI

A systematic review ef studies reperting eutcemes ef meniscal repair with a minimum 5—year fellew—up feund that the everall rate ef failure was 23.1% There was en statistical difference in eutcemes ameng patients whe underwent medial er lateral repair, and simultaueeus ACL

recenstructien did net affect results. Level ef evidence: IV.

23. I-Ialtlar U, Den mes F, Basaran SI-I, {Ian beta MK: Results ef arthrescepic repair ef partial- er full-thickness lengitudinal medial meniscal tears by single er deuble vertical

sutures using the inside-eut technique. An: ] Sperts Med 2013;41f3}:595-533.Medline

DUI

A retrespective review ef inside-nut repair ef lengitudinal medial meniscal tears with er withent ACL recenstructien

fennd that at an average 49.3-menth fellew—up, 33.4%

were healed by clinical and radiegraphic analysis. Patients whe had undergene ACL recenstructien er had a tear smaller than 2 cm er whe did net smelce tebacce had a

higher rate ef healing. Level ef evidence: IV.

24. Eegunevic L, Kruse LM, Haas AK, Husten L], Wright R‘IV: Uutceme ef all-inside seceud-generatien meniscal repair: Minimum five-year fellew—up. ] Rene Jeiut Surg Am 2014;96t15]:1333-1331 Medline DGI A retrespective review ef the 5-year eutcemes ef T5 pa-

tients treated with the all-inside FAST—FIR meniscal repair

system {Smith 3: Nephew} feund a 16% failure rate. There was ne difference between iselated meniscal repairs and repairs with cencemitant ACL recenstructien. Level ef

evidence: IV.

15. M Eucltland D, Sadeghi P, Wimmer MD, et al: Meta—anal— ysis en biemechanical preperties ef meniscus repairs: Are devices better than sutures? Knee 3mg Sperts Tranmdtef Artfaresc 2315,23f1l:33-3R Medline DUI

Meta-analysis ef biemechanical studies cemparing all-suture meniscal repairs and all-inside devices feund that all-suture devices had a higher lead te failure and stiffness

Drthepeedic Knewledge Update: Sperts Medicine 5

H F:

5 ta m u:-

:1 D.

3

sectionattnseanateg than all-inside devices. Vertical mattress suture configuration was stronger than horizontal mattress suture configuration. 1S. Barber FA, Herbert MA, Eava ED, Drew DR: Biomechanical testing of suture-based meniscal repair devices containing ultrahigh-molecular-weight polyethylene suture: Update 2:011. Arthroscopy EDIE:ES{E‘J:SZ?-SS4. Mediine DUI A biomechanical study of the load to failure of all-su-

32. LaPrade CM, Janssou K5, Dornan G, Smith SD, Wijdicks CA, LaPrade RF: filtered tihiofemoral contact mechanics due to lateral meniscus posterior horn root avuisions

and radial tears can be restored with in situ pull-out su-

2?. |Grant Jill, 1||Wilde J, Miller ES, Bedi A: Comparison of in-

A cadaver biomechanical study compared contact area and pressures in intact lateral menisci, lateral menisci with a footprint teat, root avulsion, or radial tear 3 mm or 6 mm from the posterior root, with repair of each of the injured states. Avulsion of the root and the radial tears significantly decreased the contact area and increased the peak pressure. In situ pullout suture repair decreased peak pressures.

meniscal tears: A systematic review. An: J Sports Med

2011;40j2]:459-4SS.Medline DUI

A systematic review of 15' studies comparing inside-out and all—inside repairs found a Hit: rate of clinical failure for inside-out repairs and a 19% rate for all-inside repairs. Patient-reported outcomes were similar. Herve irritation was more prevalent with inside-out repairs, and implant-related complications were more prevalent with all-inside repairs. Level of evidence: I‘v".

23. Alvarez-Dian P, Alentorn-Geli E, Llobet F, lII'iranados N,

Steinbacher G, Cugat R: Eemrn to play after all-inside meniscal repair in competitive football players: A minimum

5—year follow—up. Knee Snrg Sports Trantnatoi Arthrosc Ii] 14. Medline

DDI

A retrospective review of the rate of return to sport of 39 male soccer players who underwent all-inside repair of a complete longitudinal tear found that 39.6% returned to the same level after initial recoveryr and 63% required meniscectomy before return to sport. At 5-year follow-up, 4.5% continued to play soccer, of whom 23% were playing

at the same level. Level of evidence: IV.

33. Padalecki JR, Jansson KS, Smith SD, et al: Biomechanical consequences of a complete radial tear adjacent to the

medial meniscus posterior root attachment site: In situ

pull-out repair restores derangement of joint mechanics. An: I Sports Mari 2014;42i3}:699-?fl1 Medline DUI

ii. cadaver biomechanical study compared contact area and pressures in intact lateral menisci, lateral menisci with a footprint tear, root avulsion, or radial tear 3.- mm, S mm, or 9' mm from the posterior root, with repair of each of the injured states. flvnlsion of the root and the radial tears

significantly decreased the contact area and increased the

peak pressure. In situ pullout suture repair decreased peak pressures and increased contact area to a level similar to that of the intact meniscus. 34. Horie M, Driscoll MD, Sampson HW, et a1: Implantation

of allogenic synovial stem cells promotes meniscal regen—

eration in a rabbit meniscal defect model. I Bone joint Snrg Atn 2012;94i3}:?i}I-?IE. Medline

29. Imade S, Kumahashi N, Kuwata S, Kadowaki M, Ito S, Uchio Y: Clinical outcomes of revision meniscal repair: A case series. An: 1 Sports Med 213 14;42{l}:350-351 Medlinc DUI

DUI

Injection of synovial stem cells into meniscal defects in rabbits increased the quantity of regenerated meniscal tissue 4 and 12 weeks after implantation. Tissue quality scores were improved 12 and 24 weeks after implantation. Implanted cells adhered to the defects and became

A retrospective study compared 1.5 revision meniscal re-

differentiated into type I and II collagen—expressing cells.

unsuccessful, but patients with a successful revision had significant improvement in their clinical outcome scores. Degenerative meniscal tissue was found at the repair site in all unsuccessful revision repairs. Level of evidence: IV.

35. Vangsness CT Jr, Farr] II, Boyd ], Dellaero DT, Mills

pairs and 96 primary repairs. Five revision repairs were

H

to that of the intact meniscus.

ture repairs. I Bone Joint Snrg An: 2fl14:96[S}:4?1-4?9. Medline DDI

side-out and all-inside techniques for the repair of isolated

'U E I'D Ill I1! I: but:

a meniscal tear created contact pressure and area similar

ture constructs and all-inside devices found that vertical

mattress sutures were stronger than all-inside devices, but there was no significant difference between all-suture devices and all except one all-inside device.

3‘

A controlled laboratory study compared knee contact pressures in intact medial menisci and medial menisci with a radial split tear, vertical tear, or repaired tear. Repair of

ER, LeRoun-Williams M: Adult human mesenchymal

stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: A random-

3f}. Allaire R, Muriuki M, Gilbertsou L, Harner CD: Biome—

ized, double—blind, controlled study. f Bone joint Snrg An: 2014:9Sl2]:9fl-SS. Medline DUI

31. Muriuki MG, Tuason DA, Tucker 13G, Harner |ED: Chang-

A randomised, controlled study found that 6% to 24% of patients who received one of two different concentrations of allogeueic stem cells had a 1.5% or greater increase in meniscal volume after partial medial meniscectomy. None of the control subjects reached this level. Patients with osteoarthritis had a significant reduction in pain. Level of evidence: I.

chanical consequences of a tear of the posterior root of the medial meniscus: Similar to total meniscectomy. ] Bone joint Snrg ritn Eflflflflflifljdffll—ISSI. Medline DUI

es in tihiofemoral contact mechanics following radial split and vertical tears of the medial meniscus an in vitro investigation of the efficacy of arthroscopic repair. 1 Bone

Joint Sttrg Ant 1fl11;93{12}:1fl39-1fl95. Mcinc

Drthopaedic Knowledge Update: Sports Medicine 5

DUI

fl lfllfi American Academy of Orthopaedic Surgeons

|Killsmter ED: Meniscal Injuries

36. Ruiz—[bin MA, Diaz—Heredia J, Garcia-des I, Gonzas

A case-control study found that patients treated with repair of a horizontal cleavage tear augmented with PRP injection had higher Knee Injury and Dateoarthritis Dutcome Score {EGGS}, and EGGS pain and sports subscores

Isa-Lisan F, Elias-Martin E, Abraira V: The effect of the addition of adipose'derived mesenchymal stem cells to a meniscal repair in the avascular zone: An experimental study in rabbits. Arthroscopy 2011;2?{11}:IESS-1696. Medline DUI

An animal study found that the addition of adipose-derived allogeneic stem cells to acutely repaired longitudinal tears in the avascular zone of the medial meniscus significantly improved histologic properties at 12 weeks compared with those of control animals. The difference was less robust after delayed repair.

were significantly higher. Five patients treated with PRP had complete resolution of MRI findings of meniscal injury. Level of evidence: III.

42. Eaffagnini S, Marcheggiani l'vIuccioli GM, Lopomo N, et al: Prospective long-term outcomes of the medial collagen

meniscus implant versus partial medial meniscectomy:

A minimum I'D—year follow—up study. Am J Sports Med 2fl11;39{5 i:9??—SSS. Medline DUI

3?. Ahn JH, Kwon D], Nam TS: Arthroscopic repair of hotizontal meniscal cleavage tears with marrow-stimulating technique. Arthroscopy 1015:31{1}:92-BS. Medline DDI In a retrospective review, 32 horizontal cleavage tears extending into the avascular sons were treated with repair and augmentation with bone marrow stimulation through

drill holes in the intercondylar notch. Clinical outcomes

scores improved, and 91% of patients were clinically healed. At second-look arthroscopy ?S% were healed and 13% were partially healed. Level of evidence: IV.

A prospective cohort study compared the results of medial meniscal collagen implantation and partial meniscectomy. Clinical outcome scores and MRI findings were better after medial meniscal collagen implantation at III-year follow-up. 43. Zaffagnini S, Marcheggiani Muccioli GM, Eulgheroni P, et al: Arthroscopic collagen meniscus implantation for

partial lateral meniscal defects: A 2—year minimum follow-up study. Am I Sports Med 2fl12:40{1fl}:2231-223 3. Medline DUI

SS. Braun H], Kim H], lChu CR, Dragon JL: The effect of

A case study evaluated 2-year outcomes of lateral me-

human synoviocytes: Implications for intra-articular injury and therapy. do: I Sports Med 2014;42i5}:1204 -121Il. Medline DIDI

and function was improved compared with preoperative levels without significant change to cartilage in the lamral compartment. Level of evidence: IV.

platelet-rich plasma formulations and blood products on

This review article on the current use of PEP discusses its use in tendinopathy as well as the early results of use in meniscal and ligament healing. Although there are promising results in preliminary studies, no conclusive evidence

on the use of PEP for meniscal or ligament healing has been proven.

39. Kwalt HS, Nam J, Lee JH, Kim H], 1foo J]: Meniscal rev pair in vivo using human chondrocyte-seecled PLEA mesh scaffold pretreated with platelet-rich plasma. I Tissue Eng Regen Med [Published ouline ahead of print June 19, 2fl14]. http:iids.doi.orgi1fl.IfifllftermdSSS DDI PRP pretreatment on a polyilactic-co-glycolic acid] mesh scaffold enhanced the healing capacity of the meniscus

with human chondrocyte—seeded scaffolds in an animal

model. Sis: of IS menisci healed and 9 partially healed when implanted with the PEP-treated scaffold.

4D. Griffin J‘W, Hadeed MM, Werner BC, Diduch DR, Carson ET, Miller MD: Platelet-rich plasma in meniscal repair: Does augmentation improve surgical outcomes? CH1: CirIibop Refer Res EDIS;4?3[S}:IfifiS—Ifi?l. Medline Dfll A retrospective comparative study found no between—group differences in reopetation rate, functional outcomes scores, return to work, or return to sports in patients

treated with or without PEP during meniscal repair. Level

of evidence: III.

41. Puiol N, Sallc Dc Chou E, Boisrenoult P. Beaufils P: Platelet-rich plasma for open meniscal repair in young patients: Any benefit? Knee 5mg Sports Trenmatof Arthrosc 2fl15;23{1]:SI-SS. Medline Dfll

ID EDIE American Academy of Drthopaedic Surgeons

niscal collagen implantation. Pain was decreased pain

44.

Rodltey WU, DeHaven HE, Montgomery WH III, et al:

Comparison of the collagen meniscus implant with partial

meniscectomy: A prospective randomized trial. 1 Bone Joint Sarg Am lfifl3;9fl{?}l:1413-1426. Medline DflI 45. Maher sa. Rodeo sa. Doty SB, et al: Evaluation of a porous polyurethane scaffold in a partial meniscal defect ovine model. Arthroscopy 2fl1fl;26{11}:15 1D—1519.

Med’line DUI

Lateral meniscal defects were created in sheep, and a polyurethane scaffold was implanted into half of the animals. There was no significant chondral damage beneath the scaffold. Fibrochondrocytes were well integrated inm the

scaffold within 3 months.

46. 1ii'erdonlst P, Beaufils P, Bellemans J. et al; Actifit Study IGroup: Successful treatment of painful irreparable partial meniscal defects with a polyurethane scaffold: Twoyear safety and clinical outcomes. Am ,i' Sports Med

2fl12:4fl[4}:344-SSS.Medline DUI

A retrospective review of patients with postmeniscectomy syndrome who were treated with polyurethane scaffold

implantation found clinically and significant improvement in clinical outcomes. Implantation failure occurred in 113%, and stable or improved cartilage grading was noted in 92.5% of patients. Level of evidence: IV.

4?. Eouyarmane H, Beaufils P, Pujol N, et al: Polyurethane

scaffold in lateral meniscus segmental defects: Clinical

outcomes at 24 months follow—up. flrtbop Trenmstoi Surg Res 2fl14;1{lfl{1}:lSS-IST. Medline DUI

Drthopaedic Knowledge Update: Sports Medichse S

H F:

5 re re ru-

3 D.

s

Sectien 3:Knee andLeg

A prnspective rnulticenter studyr cf 54 patients with lateral pnstnieniscecuctnvfpr svndrnme whn were treated with pulvurethane scaffnld implantatinn feund significant imprnve-

ments in clinical nutceme scares. Level nf evidence: IV. 43'-

Paletta GA Jr, Manning T, Snell E, Parker It, Eergfeld J: The effect nf allngraft meniscal replacement en intraarticular cuntact area and pressures in the human knee: A hinrnechanical study. An: I Spurts Med 199?,15i5}:691-

693. Medline DUI

45'. Chalmers PM, Karas V, Sherman 5L, Cele B]: Return tehigh-level spurt after meniscal allngrafl: transplantatinn. Artizrnscnpv 1013;19:353-544. Medline DUI

A retrnspective case stud}r evaluated return tc: spurts cf 13 patients after meniscal allugrai't transplantatiun. At a mean

3.3-}rcar fullnw—up, 11% had returned tn their appruved

level cf return tn plav and had cnncnmitant imprevement in clinical nutcutne scnres. Level uf evidence: IV. .50. Kim JM, Lee HS, Kim KH, Kim KA, Bin SI: Results nf meniscus allugraft transplantatiun using hcne fixatinn: 110 cases with nhjective evaluatinn. Ann } Spurts Med 2011;40l5]:101?—1034.Medline DUI A retrnspective case stud},r e]? 115 knees after meniscal allngraft transplantatinu fennel significant clinical and functinnal nutccune imprcvements at 49.4-rnnnth fulluw-up. Level e-f evidence: IV. 51. Vundelincltx E, Bellernans J, Vanlauwe J: Arthrlljscnpicall‘}.r

51. van der Wal R], Thcmassen B], van Arkel ER: Lung-

tern1 clinical cutcnme nf npen meniscal allugraft trans-

plantatien. An: 1 Sports Med 1009;31i11}:1134-1139.

Medline DUI

A case stndv cf 63 npen meniscal ails-graft transplantatinns evaluated the clinical uutcnmes and failure rate at

13.0-vear fullnw—up. The punrest results were nhservcd

after medial ails-graft transplantatien and in wemen. Level cf evidence: IV. 1iiieleu References 10.1: Sheltc-n WE: Aii-Insicie Meniscus Repair - FAST-FIE [viden excerpt]. Jacksun, M5, 1011. 10.1: Lawhnrn KW: Aii-Insirie Meniscus Repair - MaxFire Maeen [viden excerpt]. Fairfax, VA, 1011. 10.3: Vvas D, Harner CD: Pnsieriar Hnrn Medial Meniscus Rant Repair [viden excerpt]. Elawnnx, PA, 1011. 10.4: Sgagliene HA, Chen E: Aii-Artiirnscnpic Meniscus Repair witir Biaingical Augmentaiinn [viden excerpt]. Rnsetnunt,

IL, American Academy.r nf Drthepaedic Surgenns, 1011.

10.5: Shaffer BS: Laterai Meniscus Transpianiaiiun [viden

excerpt]. Easement, IL, American Academy,r cf Orthnpaedic

Surgeens, 1011.

assisted meniscal allngraft transplantatiun in the knee:

10.6: Cale E]: Laserai Meniscus Transpiantatian - Bridgein-Sins [viden excerpt]. Easement, IL, American Aeademv cf flrthc-paedic Surgeuns, 1011.

A case stud].r cf 50 meniscal allngrafr transplantatiuns

10.1: Carter TR: Media! Meniscus Transpianiaiinn - Dnubie Bane Ping [viden excerpt]. Phennix, AZ, 1011.

A medium-term subjective, clinical, and radingraphical nutcnme evaluatinn. Am I Spurts Meci 1010;3fl{11}:11401141'. Medline DDI feund imprnvement in measured clinical nutcnme scares

and functinn. There was an increase in nstenarthritis in 53% nf patients. Level nf evidence: IV.

10.3: Richmnnd JC: Mea'iai Meniscus Transpianiasinn During ACL Repair [viden excerpt]. Enstnn, MA, 1011.

DI

:u

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T:

I: a: a: III-1 I: a:

H

Drrhnpaedic Knnwledge Update: Sparta Medicine 5

El 1016 American Academy at Drrhnpaedic Surge-ans

Chapter 21

Leg Pain Disorders

Iustin Shu "Fang. MD

Thomas M. DeBerardino. MD

Abstract

Exertional leg pain can be a difficult spectrum of disor-

ders to diagnose and treat. Medial tibial stress syndrome, tibial stress reaction, and tibial stress fractures are overuse disorders that can cause substantial time away

from competition. The keys to preventing stress fracture include adequate dietary consumption of calcium and

vitamin D, and ether targeted interventions in at-risk

populations. Nonsurgical management usually allows patients to return to their earlier activity level, although

prolonged rest often is needed. Surgical intervention

can be considered for a patient with a recalcitra nt stress fracture or a high-risk fracture of the anterior tibia or an

athlete who needs to remrn to sports quickly. Current

diagnostic criteria for chronic exertional compartment syndrome can lead to high rates of false-positive results.

Criteria using improved standardized excrcise testing

Introduction

Eacrtion—rclated leg pain is common among people who are physically active. As many as Sfl‘iiis of collegiate ath-

letes seek health care for leg pain.1 Leg pain can present

a clinical conundrum because the symptoms of several disorders are similar, and a meticulous workup is required to reach the correct diagnosis. Medial tibial stress syndrome {MTSS}, stress reaction and fracture, chronic

exertional compartment syndrome {CECE}, and popliteal

artery entrapment syndrome {PRES} should be considered

in the differential diagnosis. Recent research has examined the clinical characteristics, risk factors, diagnostic

modalities, treatment options, and outcomes of conditions

causing leg pain.

Medial Tibial Stress Syndrome

may have greater sensitivity and specificity. Surgical release is successful for pain relief in chronic exertional

l'vlTSS, often called shin splints, is a common cause of leg pain. The incidence in athletic and military populations

recognition and treannent of popliteal artery syndrome is critical to a good outcome.

of the soleus, posterior tibial tendon, and flea-cor digito-

compartment syndrome but may not lead to a return to full sports activity or active military duty. Early

Keywords: chronic esertional compartment syndrome: leg pain: medial tibial stress syndrome; popliteal artery entrapment syndrome; tibial stress fracture; tibial stress reaction Dr. fleEerardino or an immediate family member has received royalties from Arthreic serves asa paid consultant to Arthrex; has received research or institutional support from

Arthrer, Histogrenics. and the Muscuioslteletal Transplant Foundation; and serves as a board member; owner; officer; or committee member of the American Drthopaedic Society

for Sports Medicine. Neither Dr Yang nor any immediate

family member has received anything of value from or has stuck or stock options held in a commercial company

or institution related directly or indirectly to the subject of this chapter.

@ lfllfi American Academy of Drthopaedic Surgeons

is 20% to 44%?" MTSS is characterised by pain on the medial border of the tibia, typically near the origin

rum longus.” This posterior medial pain has led some authors to conclude that traction of these muscles leads

to an enthesopathy, periostitis, and pain.” However, in

some patients dual—energy :cvray absorptiometry and CT reveal relative osteopenia of the anterior tibia.” This finding suggests that MTSS is on a spectrum of tibial

stress injuries that includes tendinopathy, periostitis, periosteal remodeling, and tibial stress reaction.5 Pain with

palpation and the presence of edema are highly sensitive

pg

athletes, the pool of at-t‘isk individuals has been expand-

m m or 3

for this spectrtnn of disorders.”I Although MTSS is common in running and jumping ed. A prospective study of naval recruits found that MTSS was twice as likely to develop in women as in men.‘ Elt-

cessive pronation of the foot was found to be a key risk

factor in two biomechanical studies of foot posture during walking and running.”ll Patients with l'vlTSS had greater

medial longitudinal arch deformation while walking or

standing than healthy control subjects. Early heel rise, forefoot abduction, and apropulsive gait were significantly

Orthopaedic Knowledge Update: Sports Medicine 5

FT. :5

El.

E

Sectien 3:1i'inee audLeg

different in patients with MTSS. Relatively small internal

and external hip range nf mntinn, high bndy mass index,

and lean calf girth as well as a histnry nf MTSS alsn have been identified as risk factersfih13E Anthrepemetric para meters including thigh length, leg length, fnnt length, and

leg circumference as well as limb length alignment had nn asseciatien with MTSS.”~” Individuals whe had partic-

ipated in an athletic activity fer fewer than 5 years were

fnund tn be substantially mnre likely tn have MTSS than these whe had participated fer a lenger peried ef time.-1 Individuals whn used a fnnt nrthnsis were fnund tn be at increased risk fer MTSSF Multivariate analysis fnund that tebacce smelcing cenferred a ninefeld increased risk nf MTSS.” MTSS is self-limiting with prnper treatment. In a prespective cehert study, 3? ef 33 runners with MTSS had

-_ The Fredericseu MRI Grading System fer Bene Stress Reactien and Fracture Hill Grade iJ

i'iinrmal MRI findings

1

Mild tn mederate perinsteal edema en T2-weighted images enlyr

hie fecal bene marrew abnnrmelity 1

Severe perinsteal edema and bene

3

Mederate te severe edema ef

secutive sessiens nf running at least 50H m. In a study

nf Dutch military recruits, the average time tn recnvery was 53 days.” I'viest treatment regimens censist ef active

rest fnllnwed by a gradual return tn running, which be-

gins nnly when lnw—impact activity such as walking nr cycling predeces ne pain.” Return-te-running pregrams vary, but implementatien shnuld be gradual. Running

distance sheuld increase ne mnre than 10% per week

en heth T1- and T2-weighted images

Adapted with permissinn frnm Fredericsnn M, Bergman AG, Huffman KL, Dillingham M5: Tibial stress reactien in runners: Cerrelatien ef

clinical symptems and scintigraphy with a new magnetic resenance imaging grading system. Am .i' Spurts Med 1995;23[4}:472-4B1.

anterinr cnrtesr nf patients with MTSS alsn may be part

tn be a treatment nptinn fer patients with MTSS ef mnre than 6 mnnths’ duratinnfi‘l ESWT is believed tn induce

H

Severe bene marrew edema

the feet in patients with MTSS, althnugh it did nnt relieve the symptnms.m Using a fnnt nrthnsis was fnund tn be

extracerpnreal sbnck wave therapy (ESWTI was fnund

I: in cu Iii-1 i: S:

Lew-signal fracture line en all sequences

tified a pregressinn ef injury frnm perinsteal edema tn pregressive bene marrew invelvement and ultimately

by 50% in 15 nf 2i} rtmners with MTSS, but this effect might have been prnduced by rest alnne. Lew-energy

._I

4

tn adding calf strengthening and stretching er the use nf cempressien steckings tn a return-te-running pregram.”

helpful during a 3-week study perind.21 Fain was reduced

T:

images

tibial stress fracture. Radiegraphs may shew a perinsteal

Rehabilitatinn taping was fnund tn decrease lnading nf

as

bnth the perinsteum and bene

and sheuld he immediately decreased if symptems return.

In a randnmized cnntrnlled study, an benefit was fnund

DI

marrew edema en TEE-weighted images enly

marrew en T1- and T2-weighted

cemplete recnvery at an average nf ?2 days (range, 15 tn

531 days}." Recnvery frem injury was defined as absence ef pain in the affected anatemic lecatien after twe cen-

Descriptien

perinsteal detachment and micrnfractures nf the trabecu-

lae, which can stimulate healing. At 15—mnnth fnllnw—up nf 4'? patients with chrnnic MTSS whn underwent ESWT

in additinn tn a hnme therapy prngram, 40 had returned

tn spurts at the preinjury level. In cnmparisnn, nnly 22 nf 4? patients whn underwent hnme therapy alnne had returned tn the prcinjury spert level. Tibial Stress Fteactinn

011 the spectrum ef tibial stress disnrders, the severity

nf tibial stress reactinn is between that nf MTSS and

flrrhepaedic Knewledge Update: Sperts Medicine 5

reactinn and certical thickening?! An MRI study iden-

tn certical stress fracture”l [Table I}. |Ulstenpenia in the

nf the prngressinn.” The etielegy is believed tn be inadequate bnne remndeling after damage. Figure 1 shnws a

theeretic cascade ef events.15' Tibial stress reactiens nften are asymptnmatic. A study

nf 21 cellegiate lung-distance runners whn were asymptnmatic fnund that 9 (43%} had grade I, 2., er 3 MRI

changes indicative ef a tibial stress injury.” Hnne had grade 4 changes. Five patients had bilateral invelvement.

The mnst cnmmnn finding was severe perinsteal edema and bene marrew edema with T2 weighting, as is cnnsistent with a grade 2 injury. Nnne nf the patients became

symptnmatic during the subsequent year. This study highlights the value nf the clinical histnry and physical examinatinn in treating tibial stress reactinn {Figure 2}, Tibial Stress Fracture

Stress fractures are the meet severe bene stress injuries.

The histery and physical examinatien are characteristic,

El II] is American Academ~y ef Cirrhepaedic Surge-ens

Chapter 11: Leg Pain Disnrders

the Internatinual Dlympic Cnmmittee recently prnpnsed

guidelines fnr the evaluatinn nf risk factnrs, treatment,

and return tn play fnr at—risk female athletesfif'ri" The Female Athlete Triad Cnalitinn Cnnsensus Statement in-

cludes a scnring system fnr an athlete‘s diet, bndy mass

index, age nf first menarche, menses regularity, bnne mineral density, and previnns stress fractures.“ The re-

sulting scnre can guide the physician in deciding whether

the athlete shnuld be returned tn play. The Internatinnal Olympic Cnmmittee guideline is similar in that it includes many aspects cf the athlete’s health by calculating the

sn-called relative energy deficiency {which emphasizes maintaining energy availability by the fnllnwing fnrmu-

la: energy availability = energy intake — exercise energy expenditure}, but it is related tn bnth male and female

athletes?1 A similar mndel has been created for predicting

the risk nf stress fracture in military recruits?2

A study nf 391 recruits at the United States Military Academy fnund that the incidence nf stress fracture was

nanny-ans relnndeilru

l Mind shill-l

prep-flee

' {bane were Illdfflf malarial}

_

maul-Inn

alumnae

l Imiuflnnl

almnst fnur times higher in wnmen than in men.“ Hav-

ing a relatively small tibia and femur increased the risk

nf stress fracture. A histcry nf physical training lnwered

the risk, particularly in men. aen with a relatively

shnrt time since menarche had an increased risk nf stress fracture. In a binmechanical study, runners whn had an earlier tibial stress fracture had greater peak hip adduc-

tinn and rearfnnt eversinn angles during the stance phase nf running than healthy cnntrnl subjects. These factnrs

may lead tn altered lnading within the lnwer extremity

l

| W

bnnafracu's

Prnpnseel pathnphysinlngy nf tibial strem injury.

and the diagnnsis is made with radingraphs, CT, bnne

scan, and MRI. Apprnximately half nf all stress fractures

nccur in the tibia.13 The repnrted incidence nf tibial stress fractures was fnund tn range frnm 4% tn lfl'ih based cm

the pnpulatinn; thnse at risk typically include lnng-distance runners, track and field athletes, jumping athletes,

and thus predispnse the persnn tn stress fracture.33 Similar binmechanical studies fnund that varying fatigue patterns in lnng~dista nce runners cnntribute tn a reduced tnletance

fnr impact.M Psychnlngical stressnrs alsn were fnund tn increase the risk nf tibial stress fracture.” The shnckuabsnrbing effect cf the fnnt may have a

rnle in tibial stress fracture. Runners whn had an earlier stress fracture were fnund tn have greater plantar flexnr musculntendinnus stiffness, greater Achilles tendnn stiff-

ness, and less Achilles tendnn elnngatinn during maximal

isnmetric cnntractinn in cnmparisnn with healthy runnets.“5 The use nf a treadmill fnr running and increased

1.4.}

use nf fnnt insnles were nf nn benefit in preventing tibial

re cu in 3

and military recruitsffi'“ A year-lnng prnspective- study

fnnt prnnatinn may reduce the risk nf tibial stress fracturefiwv“HI Hnwever, a systematic review fnund that the

ial stress fractures nccurred during the first 6 mnnths nf training.” In cnntrast, stress fractures cf the metatarsal

stress fracture.“ Recent research has emphasized the impnrtance nf

nf elite Israeli military recruits fnund that almnst all tibwere mnst likely tn nccur during the secnnd ti mnnths

nf training. a bnne mineral density, lnw bndy mass in the lnw-

er extremities, menstrual imbalance, and a lnw-fat diet are assnciated with stress fractures as well as MTSS in wnmeuJEJ-UE-fl The Female Athlete Triad Cnalitinn and

Eb Ifllii American Academy nf flrflinpaedic Surgenns

calcium and vitamin D hnmenstasis in preventing and

treating stress fractures. High levels nf circulating parathyrnid hnrmnne with subsequent bnne turnnver is an established risk factnr fnr nstenpnrntic fracture, and a high parathyrnid level may be an independent risk factnr fnr stress fracture.“ Several randnmiaed placebn-cnntrnlled

Drrhnpaedic Knnwledge Update: Spnrrs Medicine 5

FT. :5

El.

E

Sectien 3:1Cnee andLeg

Paptlteat altary

entrapment

syndrome Bh tunic eaertianal

eurnpartment

ayndreme

Marital Tibial stress syndmma Tibial stress reaction Tibial atraaa traehire

Drawing shewing cemmnn causes and Iecafiens ef eaartienal-relatad leg pain.

studies suggested that daily censumptien ef LUCIE mg of supplemental calcium and Ltlflfl IU ef vitamin D reduces mineral density.‘”-“.2 Same bene remedeling was found tn

ESWT has been effective in treating athletes with a recalcitrant stress fracture. A study ef five athletes treated with ESWT fer a stress fracture cf mere than 6 months" duratien reperted that ESWT was effective.” A ra ndem-

macelcgic inhibitien cf bene tu rnever did net reduce the

ceupled electric field stimulatien used 15 hc-urs a day to

the risk ef stress fracture by 2.0% and impreves bcme

be critical tn repairing accumulated micredamage; phar-

incidence nf stress fractures.” These studies suggest that military recruits and running athletes age 14 te 50 years should ensure sufficient calcium and vitamin D intake temeet er exceed the currently recemmended dietary al-

lewanees [1,Dflfl tn 1,300 mg and Silt} II], respectively}.“ The use cf rest. restricted weight bearing, and im»

a:

._I

T:

I: at ca It: I: a:

H

stimulate bene grewth after acute stress fracture fnund nu between-greup difference in time ta healing.” Hewever,

cempliance with rest was asscIciated with reduced time tu

healing, and nencempliance with rest was assnciated with increased time tn healing. The study suggested that capacitively cuupled electric field stimulatien can be indicated

mebiliaatien has led an geed lung—term results. Df 26 military recruits with a tibial stress fracture whe were

for a severely injured nr elite athlete er military recruit whe is metivated te rest by a desire tn return te- activity.

years after initial injury tn answer questiens en the lung— term censeqnenees ef the fracture. Nnne reperted any

high—risk stress fracture in athletes whe must return to spa-rt quickly. An anterier tibial stress fracture is less

military as a result cf the stress fracture.” Modalities such as pulsed ultrasnnnd have been prnpnsed fer managing

tibial stress fracture. Hennnien rates higher than 513% and healing delayed as much as 11 menths have been

treated with rest and immebiliaatien, 13 were available 10

DI

ieed placebo-centralled cemparisen study nf capacitively

limitaticm c-f active military duty er separatien frem the stress fractures. Altheugh the exact mechanism cf pulsed

Surgical interventic-n has been suggested te treat a

cemmc-n but carries greater risk than a pesteremedial

reprcrrtedd‘i“jfl Such a difficult at lung recevery can be ca-

ultrasnnnd is unlcnewn, it is believed tn induce aggrecan and pruteeglyean synthesis in ehnndrneytes, leading te-

reer ending fer a prufessienal athlete. Intramedullary nailing nf ehrenie anterinr tibial stress fractures eften is

demiaed deuble—blind study, 43 patients with tibial stress fracture were assigned to pulsed ultraseund er placebe treatment. There was an significant between-greup difference in healing time.“6 Further study ef this medality may be needed.

asseciated cemplicatiens include infectien and insertion

increased endechendral essificatien. Hewever, in a ran-

flrritnpaedic Knnwledge Update: Sparta Medicine 5

effective fer relieving pain and increasing healing, but the

site pain?I Recent studies fecused en anterinr tensien-ba nd plating

with a cumpressinn plate at the anterelateral tibial surface. The thenretic advantage nf this technique ever the use nf

El 1016 American Academ~y ef Drrhnpaedie Surge-ens

Chapter 11: Leg Pain Diserders

an intramedullary device is that the plate placed anterier

between-greup difference eccurred while patients and

te the central axis ef the bene has a mechanical advantage

centrel patients carried a 15-kg backpack, the treadmill

average ef lfl' weeks te 3 menths after surgery.51=fl Drill-

mm Hg during this specific treadmill exercise had better

in neutralizing tensile ferces and fracture micremetien. Full healing and return te activities was reperted at an ing and anterier laminefixatien alse were reperted, with healing rates cf 50% and 93%, respectively.“ |Ehrenic Exertienal Cempartment Eyndreme

CECE is a relatively cemmen cause ef leg pain. The an-

incline was increased re 5%, and the treadmill walking pace was set at 6.5 kmr‘h fer 5 minutes.” A cuteff ef 105 diagnestic accuracy than the Pedewits criteria. The use cf MRI and ultraseund has been suggest-

ed fer suppertiug a CECE diagnesis. In a study ef 79

censecutive patients, abnermal signal en pestexercise

Til-weighted MRI was well cerrelated with increased

intracempartmental pressures, with 95% sensitivity and

nual incidence ef CECE ranges frein 2.7% re 33% and is secend enly tc that ef l'viTEE {13% tc «111943).1 A patient

3?% specificity.“ An ultraseund study feund an increase in anterier cempartment fascial thickness during exercise

relieved by rest, and subsequent examinatien ef the patient typically is nermal. The symptcms ccmmenly are

patients.” Ultraseund dees net appear te be necessary fer guiding reutine deep er superficial pestericr leg cempart-

in which exercise induces high pressure within a clesed myefascial space, with a resulting decrease in tissue per-

accurate fer needle tip placement.““'5 The symptcms cf CECE appear tc be persistent. At

with CECE usually reperts pain during exercise that is

bilateral. CECE has been defined as a painful cenditien fusien and ischemia. CECE semetimes is accempanied

in patients with CECE cempared with nermal centrel

ment pressure testing because direct palpatien is similarly an average 4—year fellew—up ef 12 military recruits in

by temperary neurelegic impairments. A biepsy examinatien ef the stiffness and thickness ef leg fascia in pa-

whem CECE was diagnesed and managed nensurgically, the initial ICMP measurements {taken immediately after

ne between-greup differences.55 This finding suggests that CECE is net determined by structural and mechan-

and all 11 patients still had typical symptems.“ Neusur— gical treatment with betulinum texin A injectien recently

elevated risk ef CECE was cerrelated with increasing age,

Injectien inte the anterier and lateral cempartments led te an Il'vlCP reductien ef appreximately 60% at an aver-

tients with CECE and nermal centrel subjects detected ical preperties ef the leg. In the military pepulatien, an

female sex, white race, junicr enlisted rank, and Army service.“5 Wemen and running athletes are at particular

risk in the civilian pepulatien.” CECE in the anterier er lateral cempartment is mest cemmen and has the best treatment and recevery pregnesis. The deep pestericr

cempartment can be invelved, but the results ef surgery are likely te he inferier cempared with these ef CECE in ether cempartments.“

The mest cemmen diagnestic teel fer CECE is mea—

surement ef intramuscular cempartment pressure {IMCP}. Invasively measured IMCI’ rese with a typical clinical picture ef CECE in 45 ef 131 patients {34%} with exer—

exercise} remained elevated in 16 cf the 21 affected legs, had geed shert—term results in 16 patients with CECE.“

age 4—menth fellew-up. Exertienal pain was cempletely eliminated in 15 ef 16 patients {94%}, but there was a

statistically significant decrease in muscle strength. It is

unknewn whether the strength reductien was clinically

significant. Surgical release ef the cempartment affected by CECE

has been the treatment ef cheice, altheugh its effective-

ness has been questiened. In a retrespective study ef 611 patients with CECE in a military pepulatien, 44.73%

reperted symptem recurrence and 2?.?% were unable

cise-induced leg pain. The widely used Pedewita criteria

te return te full activity.” Decumeuted surgical cemplicatiens eccurred in 153%, 113% were referred for

with the patient supine at discrete time peints befere and after an exercise challenge. A pesitive test is defined as

surgical revisien er repeat release.“ These data were tensistent with earlier studies that feund a 20% re 3fl%

fer the diagnesis ef CECE are based en IMCP measured

a pressure measurement abeve 15 mm Hg befere exer-

cise, abeve 3i] mm Hg 1 minute after exercise, and abeve 2!] mm Hg 5 minutes after exercise.” Recent systematic reviews questiened the validity cf these criteria fer cen-

firming a diagnesis ef CECE because ef a lack ef centre] and uermative IMCP datafifl'“ In a recent cemparisen ef patients with CECE and nermal centrel subiects, the

diagnestic usefulness ef IMCP was impreved when it was measured centinueusly during exercise. The greatest

Ci Iflld American Academy ef Crthepaedic Eurgeens

medical discharge because ef CECE, and 5.9% required

rate ef inability te return te active duty ameng military recruitsf'il'i'1 In a study ef 13 elite athletes, 11 (34%] were

able te return te their spert at the same level at a mean

ef 1fl.6 weeks after surgical fascietemy. Patients whe

had a feur—cempartment release required mere than 3.5 weeks lenger te return te full sperts activity. Surgical

technique may play a rule. A recent study in a swine

medel feund a streng cerrelatien between fascietemy length and reductien in intracempartmental pressure. The

Drthepaedic Knewledge Update: Eperrs Medicine 5

1.4.} FT. :5

e m a: 3

CI.

E

Sectien 3:1l'2uee andLeg

researchers. suggested that a Efl‘i’fs er greater fascia] release is necessary te return the intracempa rtmental pressure te a value at er near its baselinef’3| Hewever, ether experts have recemmended a limited release in scme patients?1 In a retrespective study ef T3 patients with CECS, these

yeunger than 23 years {high scheel er cellege athletes} had

a better surgical result than elder patients. In additien,

an iselated anterier cempartment release led te greater

patient satisfactien and a better functienal eutceme than a cemhined anterier and lateral release.” Pepliteal Artery Entrapment Syndreme

PAES is a rare but painful and petentially limb—threat—

needed. The widely used Pedewits criteria fer the diagne-

sis ef CECS may have a high false'pesirive rate; a walking treadmill test en an inclined surface while carrying a 15kg weight may have better diagnestic accuracy. Surgical

quesriened in the military pepulatien. Early detectien and Decempressien alene is eften eneugh if diagnesed early;

and bypass grafting is eften needed in the ch renic setting. Key Study Peints

and aberrant fibreus baudsfhi'i' PAES and CECE eccur in

It MTSS, tibial stress reactien, and tibial stress frac—

the same patient pepulatiens, and they must be differenti—

ated with cempartmenr pressure testingfffl-fl The diagnesis mest eften is based en prevecative resting.”Ell Ferced

ankle plantar flexien and a single—leg hep can repreduce

the symptems. These tests alse can reveal a decrease in arterial bleed flew with direct palpatieu, duplex ultraseund, angiegraphy, er the ankle-brachial index?‘1

Early detectien and interventien can limit the pregress ef PAES and lead re a mere faverable eutceme by

minimizing arterial damage.“ At 2-year fellewuup, beta

ulinum texin A iniecrien inte the medial head ef the gas— trecnemius was feund te lead te cemplete reselutien ef symptems in a patient with an earlier bilateral pepliteal

arterielysis witheut resectien ef the medial gastrecnemius head.”M Surgical interventien is the standard treatment ef

H

gical management usually allews patients re return re their earlier activity level, altheugh prelenged rest eften is

ntius muscle; ether variatiens include a medial ceurse ef

the pepliteal artery, medial gastrecnemius hypertrephy,

r: in re III-1 I: E

The spectrum ef tihial stress diserde rs can he distinguished by histery, examinatien, and imaging. Hensur—

interventien can limit the pregress ef PAES and lead re a mere faverable eutceme by minimising arterial damage.

cal variatiens can cause PAES, the meat cemmen being an ahnermal attachment ef the medial head cf the gastrecne-

as

Summary

femeral cendyle during ankle plantar flexien. fiver time,

leading teaneu rysms er stenetic lesiens. Several anatemi—

._I

these whe underge decempressien plus bypass.”3'“r35

release ef the cempartment affected by CECS has been the treatment ef cheice, altheugh its effectiveness has been

the intimal wall ef the pepliteal artery can be damaged,

T:

decempressien alene tend te have better eutcemes than

ening diserder that predeminantly eccurs in athletes yeunger than 3l} years. The pepliteal artery becemes centpressed by the varieus seft tissue against the medial

DI

activities after surgical interventien; these whe underge

patients with ischemic symptems, altheugh the rarity ef

the cenditien means that ne highrlevel eutceme studies exist. Decempressien ef the lesien by releasing the medial

head ef the gastrecnemius eften is necessary te prevent

recurrence.El In patients with leng—standing entrapment, the pepliteal artery may have irreversible damage and

tures are everuse diserdcrs that particularly affect

wemen, endurance athletes, and military recruits. The keys te preventing stress fracture include ade-

quate dietary censumptien ef calcium and vitamin D. Nunsurgical management usually allews patients

te return te their earlier activity level, altheugh

prelenged rest eften is needed. Surgical interventien can he censidered fer a patient with a recalcitrant

stress fracture er a high—risk fracture ef the anterier

tibia er an athlete whe needs re return te sperts quickly. * Current diagnestic criteria fer CECE use IMCP and can lead re high rates ef false-pesitive results. Criteria using impreved standardised exercise testing

may have greater sensitivity and specificity. Surgical

release is successful fer pain relief in CECE but may

net lead te a return te full sperts activity er active

military duty.

it Early detectien and treatment ef PAES are critical

fer preventing chreuic vascular disease and relieving symptems.

atherescleresis, aneurysm, and thrembesis can devel-

ep. In these patients, bypass grafting is the treatment ef cheice ameng vascular surgeens. With bypass grafting, leng-terrn arterial patency frern Fife te 10fl% has been

reperted, and results are best after iselated pepliteal artery ecclesienfifa'l‘ Many patients return re their previeus

flrdtepaedic Knnwledge Update: Sperrs Medicine 5

El 1016 American AcadMy ef Urrhnpaedic Surgenns

Chapter .11: Leg Pain Disarders

Annatated References Gearge EA, Hutchinsan MR: Chmnic exertianal campartment syndrame. Cite Sparta Med 201 2:3 1f2}:3 [11319. Medline DD] The literature an the epidemialagy, diagnasis, and treatment af CECE was reviewed. Hubbard T], Carpenter EM, lEardava ML: Cantributing

factars ta medial tibial stress syndrame: A praspcctive investigatian. Med Sci Sparta Exerc 2G0?;41I{3}:45 [1496. Medline Ill-DI

The factars mast influencing the develapment af MTSS were faund ta be a bistary af MTSS and stress fracture,

years af running experience, and use af arrhases. Level af evidence: III.

1t'agi 5, Muncta T, Scltiya I: Incidence and risk factars far medial tibial stress syndrame and tibial stress fracture in high schaal runners. Knee Snrg Sparta Tranmataf Ar-

thraac amsansyaas—asa. Medline bar

A significant relatianship was fannd between ba-dy mass

index, internal hip ratatian angle, and MTSS in female athletes. Leml af evidence: II.

1fates B, White S: The incidence and risk factars in the develapment af medial tibial stress syndrame amang naval recruits. Am I Sparta Med lflfl4;31|{3]:??2-Tflll. Medline DUI Galbraith RM, Lavallee ME: Medial tibial stress syndrame: Ganaervative treatment aptians. Curr Ree Mascnlaakefet Med lflflfigllfilflllfll Medline DUI The literature an nansnrgical treannent aptians far MTSS was reviewed. Maen MH, Tel JL, Weir A, Steunebrink M, De Winter TC: Medial tibial stress syndrame: A critical review. Sparta Med 2fl09539{?}:513-546. Medline D0] The literature an MTSS was reviewed.

Shin palpatian test and shin aedema teat. Br 1 Sparta Med

2012;46{12}:361-Sfi4.Medline DUI

The relatianship between twa clinical test results and a future diagnasis af MTSS in military recruits was examined. Level af evidence: II. 11. Tweed JL, Campbell 191., Avil 5]: Eiamecbanical risk factars in the dcvelapmcnt af medial tibial stress syn— drame in distance runners. I An: Padictr Med Assac lflflfl;93[fi}:436-444.Medline DUI 12.. Bandhalm T, Baysen L, Haugaard S, Zebis MK, Eenclre J: Feat medial langitudinaI-arch defarmatian during quiet standing and gait in subjects with media] tibial stress syndramc. 1 Fact Ankle Snrg Eflflflg4?{2}:39~95. Medline DUI 13. Maen MH, Bangers T, Eakker EW, et al: Risk factars and pragnastic indicatars far medial tibial stress syndrame. Scand I Med Sci Sparta 1fl11;22{1}l:34-39. Medline DUI Risk factars and pragnastic indicatars far MTSS were ex-

amined. Decreased hip internal range af matian, increased ankle plantar flexian, and pasitive navicular drap were assaciated with MTSS. fl. higher bady mass index was assaciated with an increased time ta full recavery. Level

af evidence: II.

14. Sabeti V, Khashraftar Yaadi bl, Biaheh bl : The relatianship between shin splints with anthrapamcttic characteristics and same indicatars af bady campasitian. ,1 Sparta Med Phys Fitness [published anline ahead af print Dctab-er ii, 1014]. Medline

Anthrapc-metric characteristics and budy campasitiar: indicatars may net be risk facte-rs far shin splints. Level af evidence: III.

15. Eaissi GR, Cherati AD, Mansaari FED, Raai MD: The reIatianship between Iawer extremity alignment and medial tibial stress syndrame amang nan-prafessianal athletes. Sparta Med Artbraac Rehabil Tber Tecbnai 2G 09:1{1]:11. Medline DD]

Bauché RT, Jahnsan CH: Medial tibial stress syndrame

A significant relatianship was fannd bervveen navicular drap and MTSS. There was na significant relatianship between Iawer extremity alignment and MTSS. Level af

el invalving fascial tractian. _,I An: Padt‘atr Med Asaac 2Dfl?;9?{1]:31-36.Medline DUI

16. Sharma J, Gallic:ir J, Greeves J, Spears III: Eiamechani-

[tibial fasciitis}: A prapased pathamechanical mad-

Gaeta M, Minutali F, Scribana E, et al: CT and MR imaging findings in athletes with early tibial stress injuries: Camparisan with bane scintigraphy findings and emphasis an carrical abnarmalities. Radiafagy EU US#35{11:553—

.561. Medline DD]

Magnussan HI, Westlin NE, Nyqvist F, Giirdsell P, See-

man E, Karlasan MK: Abnarmally decreased regianal bone density in athletes with medial tibial stress syndrome.

An: ,1 Sparta Med 1001;29l6]:?11-?1S. Medline

1i]. Newman P, Adams I1, Waddingtan G: Twa simple clinical

tests far predicting anset af medial tibial stress syndrame:

4D Ifllti American Academy af Drrhapaedic Surgeaas

evidence: II.

cal and lifestyle rial: factars far medial tibia stress syndrame in army recruits: A praspective study. Gait Pasture

ID11;33{3]:361-365.Medline DUI

fin imbalance in feet pressure with greater pressure an

the medial side than an the lateral side was the primary rislc factar far MTSS. Level af evidence: II. 1?. Nielsen RD, Rannaw L, Rasmussen S, Lind M: A prespective study an time ta recavery in 2.54 injured navice runners. PLaS Cine 2014;9{51m9933’1 Medline

DUI

MTSS was the mast camman injury amang runners, fal-

Iawed by patellafemaral pain, medial meniscal injury, and

Achilles tendinepathy. Half cf the patients were unable

Drrhapaedic Knawledge Update: Sparta Medicine .5

1.4.} FT. :5

m n: e: 3

El.

E

5ectien3:1fneeand1.eg

te run 500 m twice witheut pain 111} weeks after injury. Almest 5% cf patients received surgical treatment. 18. Ualle RA, Plakke M, Silvis ML: Cemmen leg injuries ef lung-distance runners: Anatemical and hiemechanical appreach. Sperts Health 2D11;4I[6}:43 5-495. Medline DUI 15'. Meen MI-I, Heltslag L, Eakker E, et al: The treatment ef medial tibial stress syndreme in athletes: A tandemized clinical trial. Sperts Med Arrbmsc Rebebil' Thar Tecbnel 2fl12:4:12. Medline DUI A cemparisen ef three functienal rehabilitatien pregrams

fer MTSS is graded running pregram alene, with stretch-

ing and strengthening exercises fer the calves, er with a spurts cempressien stecking] feund ne eutceme differences. Level ef evidence: I. 2f}. Griebert MC, Needle AR, Mc’Cennell J, Kaminski TW:

Lewer—Ieg Kinesie tape reduces rate ef leading in par-

ticipants with media] tibial stress syndreme. Phys Ther Spert 2014 Jan 29. Epub ahead ef print. pii: 51466353Kl14}flflflfll-9.Medline DUI Rehabilitatien taping decreases the rate ef medial leading

in patients with MTSS and may he a useful adjunctive treatment. Level ef evidence: III.

at the Wemen‘s Natienal Basketball Asseciatien Cemhine. Am J Sperts Med 2013;41l3]:645-65L Medline

DUI

The percentage ef players at the Wemen's Natienal Easketball Asseciatien Cembine whe reperted a histery ef

stress fracture was 13%. Level ef evidence: III.

13. Finesmne A, Milgrem U, 1|llll'elf U, Petrev K, Evans R, Meme D: Epidemielegy ef metatarsal stress fractures versus tibial and femeral stress fractures during elite training. Feet Ankle Int 2011;32l1}:16-ED. Medline DUI The incidence ef stress fracture ameng military recruits

was highest during the first 6 menths ef training but de

Earlier physical training in men, length ef estregen expesure in wemen, and leg bene dimensiens in beth sexes were fen nd te have enly a miner rule in the develepment ef stress fractures in physically fit military cadets. Level ef evidence: III.

The literature en management and preventien ef bene

H

nafin JA: lniury prefile in elite female basketball athletes

Rempe JD, Cacchie A, Furia JP, Maffulli N: Lew-energy extracerpereal sheck wave therapy as a treatment fer medial tibial stress syndreme. Am ,1 Sperts Med 2fl1fl;33{1]:125-132.Medline DUI

13. Warden 5], Davis 15, Fredericsen M: Management and preventien ef bene stress injuries in lengrdistance runners. J Urtfsep Sperts Phys Ther 2014;44llfl}:?49-?65. Medline DUI

1: re :11 III-1 I: E

2?. McCarthy MM, Vees JE, Nguyen JT, Callahan L, Han-

29. Eesman F, Ruffing J, Zien M, et al: Determinants ef stress fracture risk in United States Military Academy cadets. BDHE 2013;55l2}:359-365. Medline DUI

subjects. Level ef evidence: III.

T:

Earlier fracture is the mest rebust predicter ef stress fractures in heth wemen and men. Lew bedy mass index, late menarche, and earlier participatien in gymnastics er dance were identifiable risk facters fer stress fractures in girls. Participatien in basketball appeared te be pretective in buys and may represent a medifiable risk facter fer stress fracture. Level ef evidence: 111.

Uff-the- shelf ertheses and calf stretching may be effective in the initial treatment ef runners with MTSS.

DUI

15 menrhs after injury, cempared with 22 ef 4? centrel

ts

fractures in adelescent runners. Med Sci Sperts Exerc 2fl13;45[1{l]:1343-1351.Medline DUI

creases after 6 menths, pessibly because ef individual adaptatiens. Level ef evidence: III.

Ferty cf 41" patients whe received ESWT fer MTSS were able te return te their spurt at the preinjury level

DI

ericsen M: Identifying sex-specific risk facters fer stress

21. Leuden JE, Delphine MR: Use ef feet ertheses and calf stretching fer individuals with medial tibial stress syndreme. Feet Ami: fe Spec 2010;3[1h15 -2l}. Medline

._I

26. Tenferde AS, Sayres LC, McCurdy ML, Sainani KL, Fred-

stress iniuries in leng~distance runners was reviewed.

14. Fredericsen M, Bergman AG, Heffman KL, Dillingham

M5: Tibial stress reactien in runners: IZlerrelatien ef

clinical symptems and scintigraphy with a new magnetic resenance imaging grading system. Am J Sperts Meal 1995;13{4}:4?1—431.Medline DUI 2.5. Bergman AG, Fredericsen M, He C, Mathesen GU: Asymptematic tibial stress reactiens: MRI detectien and clinical fellew-up in distance runners. AIR Am I Reentgenel Eflfl4:183[3]:1535-638. Medline DU]

Urthepaedic Knewledge Update: Sperts Medicine 5

311}. De Seusa MJ, Nattiv A, Jey E, et al; Female Athlete Triad Cealitien; American Cellege ef Sperts Medicine; American Medical Seciety fer Sperts Medicine: American Bene

Health Alliance: 2014 Female Athlete Triad Cealitien

censensus statement en treatment and return te play ef the female athlete triad: lst Internatieual Cenference held in San Francisce, GA, May 2012, and 2nd Internatienal Cenference held in Indianapelis, IN, May 2313. ln

J Spert Med 1014;14{1J:95-11fl. Medline

A scering system was presented in which a female athlete’s diet, bedy mass index, age ef first menarche, menses regularity, bene mineral density, and histery ef stress fracture were tabulated. Level ef evidence: II. 31. Meuntiey M, Sundget-Bergen J, Burke L, et al: The [DC censensus statement: Beyend the female athlete triad. Relative energy deficiency in spert [RED -5}. 1311”,]r Sperts ill-liedl 2fl14t4fllflt491-491Medline DUI The Internatieual Ulympic Cemmittee guideline calc ulated the se-called relative energy deficiency te assess risk facters in female athletes. Level ef evidence: [1.

El ll] 16 American AcadMy ef Urthepaedic Surge-ens

Chapter .11: Leg Pain Diserders

32. Meran DS, Finestene as, Arbel ‘t’, Shabshin N, Laer A:

it simplified medel te predict stress fracture in yeung elite cembat recruits. I StrengthI Cenri Res 1011;16{9]:25352592. Medline DUI

39. Snyder RA, Deflngelis JP, Keester MC, Spindler KP, Dunn WR: E'Iees shee insele medificatien prevent stress fractures? A systematic review. HSS J lflfl9;5[2]:92-93. Medline DUI

A yeung male recruit fer an elite cembat unit was at a

The use ef shee inseles fer preventien ef stress fracture

greater risk ef develeping stress fracmre if he had a histery ef aerebic training less than 2 times per week fer mere than 4i] minutes per sessien and had a waist circumference smaller than 3’5 cm. Level ef evidence: III.

was systematically reviewed.

40. Vilima ki Vii, Alfthan H, Lehmuskallie E, et al: Risk fac—

ters fer clinical stress fractures in male military recruits: A prespective cehert study. Berle lflflS;3T{E}:2i’i?—2T3. Medline DUI

.33. Milner CE, Hamill J, Davis IS: Distinct hip and rearfeet kinematics in female runners with a histery ef tibial stress fracture. J Urtisep Sperts Phys Ther lfllfl:4fli2}:59-EE. Medline DUI

Runners with a histery ef tibial stress fracture had greater

peak hip adductien and rearfeet eversien angles during

the stance phase ef running than healthy centre] subjects. fl: censequence may be altered lead distributien within the lewer extremity, creating a predispesitien te stress fracture. Level ef evidence: III.

41. Lappe J, Cullen I}, Haynatski G, Recket R, Ahlf R, Thempsen K: Calcium and vitamin D supplementatien decreases incidence ef stress fractures in female Navy recruits. J Bene Miner Res 2DDS:23{S}:741-T49. Medline DUI 42. Gaffney-Stemberg E, Lute L], Reed JC, et al: Calcium and vitamin D supplementatien maintains parathyreid

hermene and impreves bene density during initial military

training: it randemited, deuhle-hlind, placehe centrelled trial. Bene 2D14:53:4E-Sfi. Medline DUI

34. Clansey AC, Hanlen M, Wallace ES, Lake M]: Effects ef fatigue en running mechanics asseciated with tibial stress fracture risk. Med Sci Sperts Esterc 2&12:44{10}:191?1923. Medline

Calcium and vitamin D supplementatien can maintain and impreve bene health during perieds ef elevated bene turn-

DUI

ever such as initial military training. Level ef evidence: I.

The identified risk facters fer impact-related injuries such

as tibial stress fracture are medified by fatigue, which is

asseciated with a reduced telerance fer impact. These findings are impertant fer identifying individuals at risk fer injury frem lewer limb impact leading during running.

43. Milgrem C, Finestene A, Hevack V, et al: The effect ef

prepbylactic treatment with risedrenate en stress fracture incidence ameng infantry recruits. Bene 20 (14:35[2}:413-

424. Medliue

Level ef evidence: III.

35. Meran DS, Evans R, Pirhel '1’, et al: Physical and psyche-

legical stressers linked with stress fractures in recruit training. Scand J Med Sci Sperts 2013:23{4J:443-4SD. Medline DUI

44.

DUI

Institute ef Medicine: Dietary Reference intrtftes fer Caicinrn and Vitamin D. Washingten, DC, Natienal Picademy ef Sciences, 201i].

Dietary intake ef calcium sheuld he 1,0043 te 1,3 Eli] mg and

Psychelegical facters may have a rule in predicting stress fracture develepment. Level ef evidence: IV.

dietary intake ef vitamin D sheuld be EGG l'U accerding te current guidelines.

3S. Pamukeff UN, Blackburn JT: lCemparisen ef plantar-

45. Kilceyne KC, Dickens JP, Rue JP: Tibial stress fractures in an active duty pepulatien: Lung-term eutcemes. J' Snrg

fleiter musculetendineus stiffness, geemetry, and archi-

tecture in male runners with and witheut a bistery ef tibial stress fracture. I App! Biernech 2015:31i1}:41-4?. .Medline DUI Runners with a histery ef stress fracture had greater plan-

tar fleiter musculetendineus stiffness, greater Achilles ten—

den stiffness, and less Achilles tenden elengatien during maximal isemetric centractien than healthy runners. Lem] ef evidence: IV. 3?. Hetsreni I, Finestene fl, Milgrem C, et al: The rele ef feet prenatien in the develepment ef femeral and tibial stress fractures: A prespective biemechanical study. Ciin I Spert Med Eflflfltlflflitlfi-ZSJ. Medline

DUI

33. Milgrem C, Pinestene A, Segev S, Ulin C, Arndt T,

Ekenman I: Are evergreund er treadmill runners mere likely te sustain tibial stress fracture? Br J Sperts Med lflfl3,3?il}:16fl-163.Medline

DUI

4D Ifllti American Academy ef Urthepaedie Surgeens

Urthep ass 1fl13;21i1}:5fl-53. Medline DUI

Tibial stress fractures in military recruits mest eften were iselated, and they did net affect the ability re cemplete military training er lead te decreased physical activity at 10-year fellew-up. Level ef evidence: IV. 4S. Rue JP, Armstreng Dill? III, Frassica FJ, Deafenhaugh .l'vI, Wilckens JH: The effect ef pulsed ultraseund in

the treatment ef tibial stress fractures. Urinepedics

EDU4;27{II}:1192-1195. Medline

4?. Taki M, Iwata U, Shiene M, Kimura M, Takagishi I-i: Entracerpereal sheck wave therapy fer resistant stress fracture in athletes: A repert ef .5 cases. ArnJSperts Med 1Dfl?;35{?}:1133-1192. Medline DUI 4S. Eeclc ER, Mathesen GU, Bergman G, et al: De capaci-

tivelyT ceupled electric fields accelerate tibial stress fracture

healing? A randemieed centrelled trial. Am J Sperts Med 2Dflfl;3fi{3}:S4S-SS3.Medline DUI

Urrhepaedie Knewledge Update: Sperrs Medicine 5

1.4.} FT. :5

rs rs tn 3

CI.

s

Eection 3:Rnee andLeg

45'. Beals REC, Cook RD: Stress fractures of the anterior tibial

diaphysis. Urtlanpedfcs 1991;14lE}:EEE-E?S. Medlirle

SD. Bart ME, Kemp E, Kerslalte R: Delayed union stress fractures of the anterior tibia: Conservative management. Br J Sports Med 2Gfl1;35{1}:?4—??. Medline DD] 51. Young AJ, McAllister DR: Evaluation and treatment of tibial stress fractures. Cliu Sports Med EGGEESIIHII‘L 123, x. Medline DDI

.52. Borens CI, Een MK, Huang RC, et al: Anterior tension

band plating for anterior tibial stress fractures in high-performance female athletes: A report of 4 cases. J Clrtlaop Trauma lflflfi;2fl{5}:425-430. Mndline D‘DI

Preoperative intracompartmental pressures measured at rest and after a standard exercise test may predict the

success of surgery for deep posterior compartment CECE of the lower limb. Lewl of evidence: I‘ll.

fill. Tiidus PM: Is intramuscular pressure a valid diagnostic criterion for chronic exertinnal cnmpartment syndrome?

Bone grafting was found to be unnecessary. Level of evidence: I'll.

A systematic review concluded that use of the currently accepted diagnostic criteria for anterior tibial intramuscular pressure before, during, and after exercise would include

55. Dahl M, Hansen P, Etdl P, Edmundssnn D, Magnussnn EP: Stiffness and thickness of fascia do not explain chronic exertinnal compartment syndrome. Clin Drtlvop Refer Res 2fl11;469{12h3495-35i}fl.Medline DDI bln difference was found in fascial thickness and stiffness between patients with CECE, with or without diabetes, compared with healthy individuals. This finding suggests that structural and mechanical properties are unlikely tn explain CECE. Level of evidence: II. SE. Waterman ER, Liu J, Newcnmb R, Echnenfeld AJ, Cl'tt JD, Belmont P] Jr: Risk factors for chronic exertinnal

compartment syndrome in a physically active military

population. Ass Jr Sports Med 2fl13;41{11}:254S-254E.

T:

Medline DDI

H

The epidemiology of CECE was examined in a physically active military pnpulatinn. Eex, age, race, military rank, and branch of service were important factors associated with the incidence of CECE in this at-rislt population. Level of evidence: II.

I: n: to III-1 I: E:

SB. 1iiiii'inltes MB, Hoogeveen AR, Hourerman E, Ciesberts A, Wijn PF, Echeltinga MR: Compartment pressure curves predict surgical outcome in chronic deep pnsterinr compartment syndrome. Am ,i' Sports Med 201 2:4GIE}:IEEE' IRES. Medline DCII

Anterior tibial tension-hand plating was found tn lead to prompt fracture consolidation and was a good alterna-

Surgical treatment of nonnnited tibial stress fractures with laminnfixatinn may be superior tn tibial fracture site drilling. Level of evidence: I‘v'.

to

sures. Anterior and lateral compartment pressures were elevated in 43.5% and 35.5% of patients, respectively. Level of evidence: III.

59. Pedowita RA, Hargens AR, Mubarak E], Gershuni DH:

S4. Liirnatainen E, Earimn J, Hulkltn A, Ranne J, Heilrltilii J, lDrava E: Anterior mid—tibial stress fractures: Results of surgical treatment. Scand J Sarg lflfl?:93i4}:244~249. Medline

._I

Women accounted for 60.1% of those with elevated pres-

53. Crux HE, de Hollanda JP, Duarte A Jr, Hungria Nero JE: Anterior tibial stress fractures treated with anterior tension band plating in high-performance athletes. Knee Surg Sports Trdxmntnl Arllrrnsc 2fl13;21lli}:144?-14Sl}. Medline DCII

tive treatment of anterior tibial cortmt stress fractures.

UI

The average age of patients with CECE was 14 years.

57. Davis DE, Railrin E, Carras DH, 1|Il'itanao P, Labrador H, Espandar R: Characteristics of patients with chrnn-

ic exertinnal compartment syndrome. Foot Ankle Int 2fl13;34llfl}:1349—1354.Mcdlinc

Modified criteria for the objective diagnosis of chronic cnmpartment syndrome of the leg. Arr: J Sports Med 199fl;13{1}:35—4D.Medline DCII

Clln fSporr Med lfl14;24{11:E?-33. Medline nor

many individuals without symptoms of CECE.

51. Roberts A, Franklyn-Miller l‘L: The validity of the diag-

nostic criteria used in chronic exertinnal compartment

syndrome: ll systematic review. Scand I Med Sci Sports 2012:22i5}:EES-SEE.Medline DDI In a systematic review of the validity of diagnostic criteria for CECE, the use of protocol-specific upper confidence limits was recommended to guide the diagnosis after onsuccessful nonsurgical management.

61. sweid D, De] Euono A, Malliaras P, et al: Systematic review and recommendations for intracompartrnental pressure monitoring in diagnosing chrnnic exertinnal

compartment syndrome of the leg. Clin J Sport Med ZDIZflZHJfiEE-ETU.Headline

DCI'I

A systematic review concluded that new diagnostic criteria should be established for CECE. 63-. Roscoe D, Roberts A], Hulse D: Intramuscular compartment pressure measurement in chronic exertinnal cnmpartment syndrome: blew and improved diagnostic criteria. Am 1 Sports Med lfllS:43l2}:392-393. Medline DDI In patients with symptoms consistent with CECE, the diagnostic utility of IMCP was improved with continuous measurement during exercise. Level of evidence: II. E4. Ringler MD, Litwiller DV, Felmlee JP, et al: MRI accurately detects chronic exertinnal compartment syndrome: A validation study. Skeletal Radiol 2013:41{3]:335-392.

Medline DDI

DUI

Clrthopaedie Knowledge Update: Eports Medicine 5

ID ll] 16 American AeadMy of Drthopaedie Surgeons

Chapter 11: Leg Pain Diserders Exercise-based MRI was mederately reliable and repreducible as a neninvasive screening test fur CECE. Level ef evidence: III.

service members has net been reliably successful. |[Iinly half ef military service members had cemplete reselutien ef symptems, and at least 25% were unable te return tn

65. Eajasel-taran E, Beavis C, Aly AR, Leswiclc D: The utility ef ultraseund in detecting anterier cempartment thickness changes in chrenic exertienal cempartment syndreme: A pilet study. Clin I Epert‘ Med 2fl13;33{4]:3fl5-311. Medliue DUI

‘FI. McCallum JR, Ceelt JE, Hines AC, Ehaha JE, Jest JW, Circbewski JR: Return te duty after elective fascietemy fer chrenic exertienal cempartment syndreme. Feet Ankle

full active duty. Level ef evidence: IV.

Int 2014;35i9}:ETI-E?5. Medline

DUI

Patients with CECE had an increase in anterinr cempartment fascial thickness en ultraseund cempared with centrel subjects. It is unclear whether this finding can be used fer reliable neninva sive screening. Level ef evidence: III.

A return In full military duty was repnrted fer 41% ef

66. Peck E, Finneff JT, Smith], Eurtiss H, Muir], Hellman JH: Accuracy ef palpatien-guided and ultraseund-guided needle tip placement inte the deep and superficial pesterier

T2. Reberts A], Krishnasamy P, Quayle JM, Heughten JM: Outcemes ef surgery fer chmnic exertienal cempartment syndreme in a military pepulatien. I R Army Med Cerps 1015:161{1}:41-45.Medline DUI

leg cempartments. An: } Spur-ts Med 2011;39ifljflfiififl19M. Medline 'DDI

Needle tip placement inte the deep and superficial pesterier leg cempartments was relatively accurate with palpatien guidance, regardless ef the practitiener’s level ef experience, and accuracy did net impreve with the use ef ultraseund guidance. Level ef evidence: II. 6?. Van der 1iiiial “WA, Heesterbeelt P], 1|vian den Brand JG, Verleisdenlt E]: The natural ceurse ef chrenic exertienal cempartment syndreme ef the lewer leg. Knee Eurg Siberia Trenntnt‘ni Artnresc 2015;13{?}:2136-1141. Medline DUI The natural ceurse ef CECE appears te include persistent symptems. Level ef evidence: W. 63. IsnerrHerebeti ME, Dufeur SP, Blaes C, Lececq J: Intramuscular pressure b-efere and after betulinum texin in chrenic exertienal cemparnnent syndreme ef the leg: A

preliminary study. Am J Sperts Med 2fl13;41{11}:15532556. Medline DUI

Injectien with betulinum tesin A reduced intramuscular pressure and eliminated exertienal pain in patients with anterier er anternlareral CECE as leng as 9 mentbs later.

The mede ef actien ef betulinum teszin A is unclea r. Level ef evidence: IV.

69. Waterman BR, Laughlin M, Kilceyne K, Camemn KL, flwens ED: Surgical treatment ef chrenic exertienal cempartment syndreme ef the leg: Failure rates and pestep-

erative disability in an active patient pepulatien. j Bene

Jeni-n: Enrg Ans 2fl13;95{?}:592-596. Medline

DDI

CECE- is a substantial centributer tn the rate ef lewer es— tremity disability in the military pepulatien. Almest half ef all service members undergeing fascietnmy reperted

persistent symptems, and ene in five had unsuccessful

surgical treatment. Invel ef evidence: IV.

TU. Dunn JD, Waterman BR: Chrenic enertienal cempart-

ment synd reme ef the leg in the military. Ciin Sperts Med Efl14;33{4}:593-T05.Medline

DUI

Clinical success has been dncumented in civilian patients

patients whe underwent elective fascietemy fer CECE.

Uverall, F'fl ‘i’u ef patients remained in the military, and the subjective satisfactien rate was i’l'i’s. Level ef evidence: IV.

Many miliary patients with CECE de net return te full fit-

ness after fasciectemy. The lack ef a relatienship between intramuscular pressure and eutcnme calls inte questien the rele ef pressure in CECE. Level ef evidence: IV.

3'3. Mathis JE, Echwarts BE, LesterJD, Kim W], Watsnn JN,

Hutchinsen MR: Effect ef lewer extremity fascietemy length en intracempartmental pressure in an animal med-

el ef cempa rtment synd reme: The impertance ef achieving a minimum ef 90% fascial release. Arn Jl Sperts Med ID15;4E{I}:TE-TE.Medlinc

DUI

This study feund a streng cnrrelatinn between fascietemy length and a reductien in intracempartmcntal pressures in a swine medel. A 90% fascial release may represent a pessible watershed acme fer returning intracempartmental

pressure te its baseline. Level ef evidence: II.

3'4. Finestene AE, Neff M, Nassar Y, Meshe E, Agar G, Tamir

E: Management ef chrenic exertienal cempartment syn-

dreme and fascial hernias in the anterier lewer leg with the ferefeet rise test and limited fascietemy. Feet Ankle Int 1014;351:31235—191. Medlitte

DUI

Selected patients with CECE were feund re benefit frem a limited fascietemy. Level ef evidence: IV.

T5. Packer JD, Day ME, Nguyen JT, Hebart E], Hanuafin JA, Metal JD: Functienal eutcemcs and patient satisfactien after fascietemy fer chrenic exertienal cempartment syndreme. An: ] Sperts Med 2013;41i2}:43D-436. Medline DUI

Age yeunger than 23 years and iselatetl anterier cempart-

ment release were facters asseciated with impreved subjective functien and satisfactien after fascietemy. Lateral release sheuld be aveided unless symptems er pestestertien

cempartment pressures clearly indicate lateral cempartment invelvement. Level ef evidence: III.

T6. Pillai J, Levien L], Haagensen M, Candy '3, Clever MD,

Velier MG: Assessment ef the medial head ef the gastrecnemius muscle in functienal cempressien cf the pepliteal artery. }' Vase Enrg Eilfifly-IEIEHIRE-1196. Medline DUI

treated fer CECE, but surgical treatment in military

Eb Iiilii American Academy ef flrdtepaedic Eurgeena

Drrhepaedic Knewledge Update: Eperrs Medicine .5

1.4.} FT. :5

re re a: 3

El.

E

Sectien 3:1I'inee andLeg

T1 Alttan Iltia EA, Ucerler H, nur E: Anatnmic variaticns

nf pcpliteal artery that may be a reascn for entrapment.

3mg Radial Anal 20 0953ll9}:595-?Dfl. Medline

DUI

Anemaleus anatemic relatie-nships between muscle and arteries in the pepliteal fessa were fennd re lead te arterial cnmpressinn. TE. Pelitane AD, Bhamiclipati CM, Tracci MC, Upchurch GR Jr, Cherry K]: Anatnmic pnpliteal entrapment syndrnme

is c-ften a difficult diagncsis. 1Vase Endevascalar Burg 2012;46l?l:542-545. Medline

DUI

In the diagnestic algerithm fer feur patients with PAES, angingraphy with forced plantar flexinn against resistance was useful fnr eliciting pathngnnmnnic images nf arterial ucclusien. Level of evidence: IV. 7’9. Turnipseed WI): Functicmal pnpliteal artery entrapment syndmme: A pearly understand and eften missed diagncsis that is frequently mistreated] 1Vase Sarg 2fl09:49{5}:11391195. Medline DUI PAEE and CECE nccur in the same pnpulatinns and have

similar symptnms, but they require different treatments.

El}. Emil G, Tay KH, Hnwe TC, Tan BS: Dynamic cnmputed tnmngraphy angingraphy: Rnle in the evaluatinn nf pnp— liteal artery entrapment syndreme. Cardieeasc Interveat Radial 2fl11;34[2}:259-2?fl. Medline DUI Dynamic CT angingraphy is a useful tcnl fer diagnnsing

PRES.

31. t-ng H, Gan J, Zhacr Y, et al: Rule crf CT angingraphy in the diagnnsis and treattnent cf pcrpliteal vascular entrapment syndreme. AJR Am ] Reenrgenei 2fl11:19?{fil:W114?-W1154.Medline D01 Digital snbtractien angiegraphy was fen nd te have limited value in the evaluaticn nf PAES and has been replaced by nnninvasive imaging techniques such as apler snnng-

raphy, CT angingraphy, MRI, and magnetic resenance angiegraphy.

El. Lane R, Nguyen T, lfluxailla M, Unmens D, Mehabbat W, Haaelten 5: Functicnal pepliteal entrapment syndrnme in the spnrtspersnn. Eur ] 1lifasc Endnnasc Snrg

2fl11543{1]:31-fi?.Medline em

PAEE can be characterised by prnvncative nnninvasive clinical tests, particularly hnpping. A pnsitive clinical cutccme ef surgery can be predicted by abnermal pre— surgical nltrasenic findings and cenfirmed by a similar nnrmal pnstsurgical study. 1While standing, patients may have cnncnmitant venous cnmpressitm related rc- muscle

hypertrephy. Level of evidence: IV.

33. Ziind G, Brunner U: Surgical aspects cf pnpliteal artery entrapment syndreme: 26 years cf experience with 26 legs. Vasa 1995:24l1):29-33. Medline

34. Isner—Herebeti ME, Muff G, Masat J, Daussin JL, Dufeur 5P, Lecccq J: Entulinum tnxin as a treatment fer functic-nal pnpliteal artery entrapment syndrnme. Med Sci Sprints

Exerc amswrreeuaa—nax Medline ntn

Betulinnm tcxin treatment cculd be an alternative tc sur— gery fer patients with in nctienal PAES. Betulinum tcxin ctmld reduce functional ccmpressinn and cnnsequently reduce exercise-induced pain by decreasing gastrncnemius muscle velume. Level nf evidence: IV. 3.5. Him 511’, Min SK, Ahn 5, Min 51, Ha], Kim 5]: Lung-term cutcemes after revascularieaticn fer advanced pepliteal artery entrapment synd reme with segmental arterial ccclusinn. ] 1lirasc 3mg 2012;55l1}:9fl-91 Medline DUI After surgery fnr advanced PAES, a relatively lnng arterial

bypass with superficial femeral artery inflew had peer

lcng—term graft patency. Graft patency was excellent in patients with pnpliteal artery ncclusinn nnly after pnpliteal interpcsitinn graft with a reversed saphennus vein. A

lcnger bypass extending heyend the pcplitcal artery may

be indicated in patients with critical limb ischemia c-nly if the extent {if disease dues net allnw a shnrt interpc-sititm graft. Level cf evidence: IV. 36. Yamamntn S, Heshina K, Hnsalta A, fihigematsu K, Watanabe T: Lang—term nutcemes cf surgical treatment in patients with pepliteal artery entrapment synd reme. 1.i'ascedar 2.014 New 1? [Epub ahead cf print]. Medline BID] The lfl-year cumulative patency cf 13 limbs treated with bypass fer PAEE was 100%, althc-ugh 2 cf these limbs had

an ecclusien that eccurred 12 nr 13 years after surgery. Level cf evidence: IV.

DI

m

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T:

E m m Ill-1 : a:

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flrrhnpaedie Knnwledge Update: fipnrrs Medicine 5

El ll] 16 American AcadMy ef Drrhnpaedie Surge-ens

Chapter 22

Ankle and Foot Injuries and Other Disorders

Thomas {1 Clanton, MD

Norman E. 1i'llhldrop III. MD

Nicholas 5. Iohnson, lD

Scott 11. 1Flull'iitlow, MD

Abstract

players in the National Football League Scouting Com-

The most common foot and ankle injuries and ether

the most common of which were lateral ankle sprain

heel pain, Lisfranc injuries, turf toe, stress fractures,

findings have led to increased interest in the diagnosis, treatment, and rehabilitation of these injuries. Acute

conditions in athletes are ankle sprains, syndesmosis injuries, osteochondral injuries, ankle impingement, and Achilles tendon disorders. The diagnostic and

treatment recommendations are based on a review of the current research.

Keywords: Achilles tendon; ankle: ankle sprain:r

ankle impingement; foot; heel pain: Lisfranc injury: osteochondral lesion; sesamoid: stress fracture:

syndesmosis: turf toe Introduction

The foot and ankle are the most commonly injured body parts in athletics, and these injuries often result in loss

of playing time."2 A study of intercollegiate football

Dr. Clanton or an immediate family member is a member

of a spealrers‘r bureau or has made paid presentations on behalf of Arthrex, Small Bone lnnova tions, Strylrei; and

Wright Medical Technology: serves as a paid consultant

to Arthrea. Small Bone innovations, Strykei: and Wright Medical Technology; has received research or institution-

al support from Arthrer; and serves as a board member. owner. officer; or committee member of the American Orthopaedic Foot and Ankle Society Dr: Waldrop or an

immediate family member is a member ofa speakers“ human

or has made paid presentations on behalf of Arthrer and Wright Medical Technology and serves as a paid consultant

to Arthreir. Neither of the following authors nor any imme-

bine found that T2.% had a history of foot or ankle injury, {40%}, syndesmosis sprain {1?%}, metatarsophalangeal {MTP} joint injury {13%}, and fibula fracture {9%)} Such

traumatic and chronic overuse athletic injuries can often

be treated nonsurgically, though many of these disorders

are often challenging for both the athlete and physician.

Nevertheless, it is imperative for the physician to quick-

ly recognize a pathology or circumstance that requires surgical intervention. Ankle. Injuries

The incidence of ankle sprains in the United States was

reported as 2.15 per 1,000 person-years.‘* Almost half

of all sprains occurred during athletic activity; basket-

ball {41.1%}, football {9.3%}, and soccer {19%} were

responsible for the most ankle sprains. In contrast, a similar study found an ankle sprain rate of 53.4 per 1,000

personuyears; 64.1% of the sprains occurred during an athletic activity, most commonly men’s rugby, women’s cheerleading, men’s andlor women’s basketball, soccer, and lacrosse.E Lateral ankle sprains account for 35% of

ankle sprains, syndesmosis sprains account for 10%, and medial sprains account for 5%.5

Ankle stability is a function of extrinsic elements such

1.4,:

of each element varies with the load level, the direction

on or cu 3

as ligaments and tendons and intrinsic elements such as the geometry of the articular surface. The contribution in which force is applied, and the integrity of the liga— ments. In general, the ankle is most stable in dorsiflestion

and when loaded and is least stable in plantar fleaion and when unloaded. When the ankle is loaded, articular

diate family member has received anything of value from or has stock or stock options held in a commercial company

geometry provides 100% of translational stability and

this chapter: Dr. Johnson and Dr. Whitiow.

relies on the ligaments. Between ?0% and 30% of anterior stability is provided by the lateral ligaments, 50% to 80%

or institution related directly or indirectly to the subject of

@ 1016 American Academy of Drthopaedic Surgeons

60% of rotational stability. The unloaded ankle, however,

Orthopaedic Knowledge Update: Sports Medicine 5

F. :ii

El.

:5

Secticn 3: Knee and Leg

Figure 1

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

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

Lateral Ankle Injury

The lateral ligamentuus cnmplert cf the ankle jnint includes the anterinr talnfibular ligament (ATFLJ, the calcanecfibular ligament {EFL}, and the pusterinr talcifihular

ligament {PTFL} {Figure 1}. Relatively recent anatcimic

research pruvided impnrta nt infnrmatinn an the qualita— tive and quantitative characteristics at these ligaments? The ATFL, which is the primary restraint tn inversiun

in plantar flea-{inn and has the least strength cf the lateral ligaments (133.9 N], resists anterinr translatinn and internal rntatic-n cf the talus in the mcIrtise“ {Figure 2]. 1When

: ‘ eral

the ankle is in neutral pnsitinn nr dnrsiflercinn, the lEFL

talar prucess

is the primary restraint tn inversicin; its average strength is 345.? bl“ {Figure 3}. The CFL spans the tibic-talar and

subtalar jciints, thereby restraining subtalar inversinn. The PTFL, which is the largest cf the lateral ligaments, DI

er

._I

T:

I: in tu Iii-1 I: as

H

rarely is injured.I 9 Radingraphic parameters have been

defined tn quantitatively describe these anatnmic nrigins and insertinns ed the lateral ankle ligaments.” Injury tn the lateral ankle ligaments typically fiEEUTS

during plantar fleetinn and supinatinn, which cumbine inversic-n and addnctic-n. In this type nf injury, the anternlateral jnint capsule tears first, fcllcwed by rupture cf the

ATFL and EFL as the farce pf injury progresses laterally. The ATFL is injured in 35% ed lateral ankle sprains,

and the CFL is injured in was tn 40%. A grade I lateral

ankle injury invnlves stretching pf the ATFL with mild

tenderness, nn evidence nf mechanical instability, and

flrrhnpaedic Knnwledge Update: Sparta Medicine 5

Figure 2

Schematic drawing shews the erigln and insertiun sites of a twin—ha nd anterinr talcifibular ligament in a right ankle. with the

distances frcrn landmarks. [Repreduced with permissinn frnm Elantnn TD, Campbell ltJ,

Wilsun it]. et al: Qualitative and quantitative

anatcirnic investigation at the lateral ankle ligaments fur surgical recn nstructinn precedures. J Bane Jaint Surg' Am 2fl14;95[12]:e93.l

ability tn bear weight with minimal discemfert. A grade

II injury is a cnmplete tear cf the ATFL, usually accumpanied by a partial injury cf the CPL. A grade III injury

El 1016 American Academ~y nf Drrhnpaedjc Surge-ans

Chapter 22: Ankle and at Injuries and Either Disnrders

is cnmplete rupture cf the ATFL and CFL. Symptnms

nf severe tenderness and pain are cnnunnn, and weight

bearing is difficult} In an effnrt tn reduce the incidence and severity cf lat-

eral ankle sprains, numernus studies nf varying quality

have fncused nn identifying the risk factnrs. A level II study identified age, sex, race, and athletic invnlvement as risk factnrs.‘l The highest risk nf ankle sprains was if]

tn 14 years nld in females and 15 tn 19 years nld in males. Bnys and men age 15 tn 24 years had a higher incidence nf lateral ankle injury than their female cnunterparts. a-

en age 3i] tn 9? years had a higher incidence than men in that age range. Athletic invnlvement was respnnsihle fnr

45% tn 50% nf ankle sprains. The same database shnwed

a race-based disparity; the incidence was substantially higher amnng thnse identified as black nr white than

amnng thnse identified as Hispanic. Several factnrs may

be related tn the race-based differences in injury rate, including nbesity, eapnsure tn high-risk athletic activity,

cnnnnctive tissue prnperties, and skeletal fnnt mntphnlngy

{specifically as related tn the cavnvarus fnnt}. Additinnal risk factnrs assumed tn be irnpnrtant include strength,

prnprinceptinn, range nf mntinn, and balance, but there is

an high—quality evidence tn suppnrt these assumptinus.” The best evidence suppnrts the belief that an earlier ankle injury is a significant risk factnr fnr a secnnd ankle sprain

in the same nr the cnntralateral ankle.11 Extrinsic risk factnrs are related tn specific spurt participatinn, level nf cnmpetitiveness, playing surface, and

shne wear. Accnrding tn level II evidence, sports injury tn

Schematic drawing shnvvs the calca nenfi bular ligament nrigin and insertinn sites in a right ankle, with the distances frnm landmarks.

{Fieprnduced with permissinn frnrn Clantnn TU. Campbell it]. Wilsnn Ki. et al: Qualitative and quantitative anatnmic investigatinn cf the lateral ankle ligaments fnr su rgical

recn nstructinn prncedures. J Bone .lnint Surg

Am 2014:96I12]:e93.]

whn underwent surgery had a mere rapid return tn ath-

letic activity.” Only level V evidence suggests that surgical

the lateral ankle is mnst cnmmnn during wall climbing,

treatment is preferable fnr prnfessinnal nr elite athletes.llEi In patients whn received nnnsurgical treatment fer a

cheerleading, and field spnrts such as rugby, snccer, lap crnsse, and American fnntball. Game cnmpetitinn places

aatinn fnr 1i] days than after use nf a rigid stirrup brace nr walking bnnt.” lDrher evidence-based treatments nf ankle

rnck climbing, indnnr vnlleyball, basketball, wnrnen‘s an athlete at greater risk fnr an ankle sprain than practice

participatinnF'" Meta-analyses have evaluated the nptimal treatment nf

severe sprain, the nutcnme was better after cast immnbili-

sprains include supervised early exercise, unsupervised

balance—bnard training, NSAIDs, and the traditinnal

acute lateral ankle sprains.”*” llCIurrent npininn, practice

rest-ice-cnmpressinn-eievatinn prngram.“ bin scientific evidence suppnrts the use nf ultrasnund, laser therapy,

lateral ankle sprains. This cnnclusinn is well suppnrted

nr platelet-rich plasma {PEP}.“ Evidence exists tn sup-

1.4,:

Acute surgical repair nf a lateral ligament rupture nf

re re tn 3

patterns, and research studies suppnrt functinnal nnnsur— gical management as the preferred methncl nf treating all for grade I and II sprains, but many variables can affect the nutcnme and nest-benefit ratin fnr a severe grade III

sprain. Surgery fnr a severe sprain leads tn a slightly better

functinnal nutcnme than nnnsurgical treatment. Hnwev— er, surgery is mnre cnstly and has a higher cnmplicatinn rate than nnnsurgical treatment, with a slightly higher risk

nf nstenarthritic change nn MRI. Functinnal nnnsurgical treatment leads tn a higher incidence nf reinjury; hnwever,

rates nf return tn preinjury status are similar after surgical nr nnnsurgical treatment.“ Nnnsurgical treatment was

unsuccessful in 10% nf japanese athletes, and athletes

El Ifllii American Academy nf Urthnpaedic Surgenns

electrntherapy, manual mnbilisatinn, estracnrpnreal shnck wave therapy {ESWT}, hyperharic nxygenatinn, pnrt bracing nr taping during the pnstinjury perind until rehabilitatinn is cnmplete.”

the ankle is nnt always cnntrnversiai. The indicatinns include an npen injury, a large av ulsinn, nr annther assnci-

ated pathnlngy such as dislncated pernncal tendnn, nstenchnndral fracture, nr hima llenlar fracture variant with a

cnmplete tear nf the medial and lateral ligaments. Even an avulsinn fracture cf the distal fibula heals readily withnut late instability cnmpared with a purely iigamentnus injury.” Snme evidence suppnrts surgical treatment nf a

Drthnpaedic Knnwledge Update: Spnrns Medicine 5

FT. :5

El.

E

Sectinn 3:1Cnee andLeg

Tibi- -:leaneal liga - :

I

Pnstarin, ‘ distal

tibintal. .Igament De- pnsterinr. tibir larllgame

anterinr

“bl-I'm. inament Deep l! tibintalar

' _--=

A Schematic drawings shnvv superficial {A} and deep {B} ligaments nf the medial ankle.

severe lateral ankle sprain, particularly in an elite athlete

nr a patient whn dncs haeardnus wnrk and cannnt risk persistent instability nr reinjury.“*~15

are used fnt treating recurrent instability. The standard treatment nf chrnnic lateral ankle instability has been the

that the use nf lace~up ankle braces reduces the incidence but nnt the severity nf acute ankle sprains in basketball

an anatnmic recnnstructinn nf the ATFL and IEFL that has had gnnd lung-term results.El This prncedure has lim-

Evidence frnrn high-level randnmiaed studies can firms

and fnntball players.”"*m Evidence alsn suppnrts the val—

ue nf neurnmuscular educatinn and balance training in reducing the incidence nf recurrent ankle sprains."~”

cnmplen and challenging prncess requiring a histnry and physical enaminatinn as well as stress radingraphy, CT,

immnbiliaatinn fnr an adequate perind nf time befnre aggressive rehabilitatinn.15'3"

A disability resulting frnm instability must be identi— fied as functic-nal nr mechanical. Functinnal instability

Medial Ankle Injury The deltnid ligament cm the medial side at the ankle is

instability and the sensatinn nf jnint instability due tn the cnntributinns nf any neurnmuscular deficits?“ The

ligament cnnsists nf a maximum nf sin bands, nf which nnly the tibinnavicular ligament, tibinspring ligament,

MRI, nr ankle arthrnscnpy.

has been defined as “the nccurrence nf recurrent jnint

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T:

I: re a: III-1 I: s:

H

itatinns related tn pnnr tissue quality, hyperflenibility, the

present in 32% tn THEE nf patients.5~“'” The disability usually is in the fnrm nf residual swelling, pain, andl'nr instability. Elucidating the cause nf disability can be a

a:

Gnuld mndificatinn nf the Brnstrcim prncedure, which is

stresses impnsed by large nr elite athletes, and aggressive early rehabilitatinn.” Several mndificatinns nr recnmmendatinns shnuld be cnnsidered when the Brnstrnm—Gnuld prncedure is used, such as the use nf an augmentatinn methnd fnr reinfnrcemeat and prntectinn, anatnmic al-

Residual disability after ankle sprain is repnrted tn be

DI

Bnth anatnmic and nnnanatnmic surgical techniques

primary cause is injury tn the jnint mechannreceptnrs and

afferent nerves resulting in impaired balance, reduced jnint pnsitinn sense, slnwed firing nf the pernneal muscles in respnnse tn inversinn stress, slnwed nerve cnnductinn

lngraft recnnstructinn if lncal tissue is inadequate, and

cnmpnsed nf distinct superficial and deep layers. The and deep pnsterinr tibintalar ligament are cnnstant. The

superficial layer is a brnad, band-like structure that nrig~ inates frnm the anterinr cnlliculus and fans nut tn insert intn the navicular, neck nf the talus, sustentaculum tali,

vein-city, impaired cutanenus sensatinn, strength deficits, and decreased ankle dnrsiflestinn. Functienal instability

and pnsternmedial talar tubercle {Figure 4}. The deep pnrtinn nf the deltnid is the primary medial stabilizer nf

bilitatinn prngram. Mechanical instability, hnwever, is “laxity nf a jnint due tn structural damage tn ligamentnus

pnrtinn is nrganiaed intn twn shnrt, thick, discrete bands: the deep anterinr tibintalar ligament and deep pnsterinr

typically imprnves in respnnse tn a well-designed reha-

tissues which suppnrt the jnint"?l Mechanical instability can lead tn altered jnint kinematics and arthritic changes,

which nften require surgical cnrrectinnFE-l‘

flrdtnpaeclic Knnwledge Update: Sparta Medicine 5

the ankle jnint. Unlike the superficial pnrtinn, the deep tibintalar ligament, which are intra-articular but estra-

synnvial. The deep pnsterinr tibintalar ligament is the largest band at the deltnid cnmplex.“

El ll] 16 American Acadenw nf Drthnpaedic Surge-ans

Chapter 22: Ankle and Foot Injuries and Ether Disorders

The primary function of the deltnid ligament as a

modality of choice for defining injury to the deltnid lig-

neal ligaments, is to prohibit eversinn and abduction. The deep deltnid, primarily the deep posterior tibiotalar

Most deltnid ligament injuries can be treated nonsurgically. Treatment is dictated by the associated injuries.

dorsiflexed, and it is responsible for the greatest restraint against lateral translation. Valgus tilting of the talus

stabilizes the ankle and allows the deltnid ligament to

whole, and specifically the tibinspting and tibiocalca-

ligament, also resists external rotation when the foot is

within the mortise requires complete rupture of both

the superficial and deep deltnid. As a multicomponent ligament, the deltnid requires considerable force for disruption. The deep deltnid ligament was found to have a greater load to failure $13.3 hi [:I: 69.3 NH than the

lateral collateral ligamentsf“E The dominant mode of failure of the deep deltnid ligament is an intrasubstance

aments and associated structures?5

Usually there is no need to repair the injured deltnid ligament because stabilisation of the concomitant injuries heal. Functional management of grade I and most grade II

isolated deltnid sprains with a pneumatic brace, a walking boot, or rarely, a walking cast is sufficient for adequate healing, although the delay before return to sports usually

is greater than after a lateral ankle sprain. A grade II or III medial sprain does not require surgery if an anatomic reduction can be maintained by immobilization in a cast

or walking boot.“ After the repair of an associated injury, such as fibula

rupture near the talar insertion; the superficial deltnid ligament most commonly fails at its insertion into the anterior colliculusfi'3 Rupture of the deltnid ligament is rare in the absence of lateral ligamentous or fibula injury. In all patients, the

casionally reveals persistent medial instability. Primary repair of the deltnid ligament is warranted in this cir-

sis injury, lateral ligamentous injury, or fibula fracture {including high fibula fracture or proximal tibiofibular

of the ankle.

physical examination must exclude associated syndesmo—

joint injury}. The posterior tibial, flexor digitnrum longus,

fracture or syndesmosis rupture, stress flunrnscnpy oc-

cumstance. The use of suture anchors or a suturednnly construct often is sufficient to stabilize the medial side

and flexor hallucis longus tendons also must be evaluated. Any associated neurologic pathology such as tibial or

Syndesmosis Injury The ankle syndesmosis is continuous with the interosse-

Anterior and posterior translation, medial and lateral translation, internal and external rotational instability,

the tibial plafond. In most patients, the ankle syndesmosis forms a synovium-lined joint space. Several recent studies

saphennus nerve injury should be noted.

nus membrane proximally and is located at the level of

and varus—valgus instability should be carefully evalu—

clarified the important anatomic features of this region

be certain the patient is fully relaxed. Comparison with

reconstructinn.33'“ Although the distal fibula and tibia

ated. The patient can be seated, supine, or prone, but it is beneficial to test in more than one position and to the normal contralateral extremity is key to appreciating subtle differences. The criteria for the diagnosis of medial instability are medial ankle joint pain, a subjective feeling

of giving way, and a valgus or pronation deformity that is correctable with posterior tibial muscle activation:H

The diagnosis is reinforced by an examination indicating

excess motion in external rotation, eversion, valgus, or

posterior translation. Radiographs may suggest deltnid ligament injury, espe-

of the ankle and provided valuable information related to injury interpretation, method of treatment, and anatomic

are congruent, most of the stability in the syndesmosis comes from its ligamentous support, which includes three welludefined ligaments: the anteroinferinr tibiofibular ligament [AITFLL the posteroinferior tibiofibular ligament,

and the interosseons tibiofibular ligament {Figure 5}. The motion that occurs between the distal tibia and distal fibula is limited but includes an increase in the intermalleolar distance of approximately 1.5 mm as the ankle moves from plantar flexion tn dorsiflexion, rotational

to

fibula. 1When a force overstresses these limits of motion,

m m tn 3

cially if there is an associated syndesmosis injury or fibula fracture. The presence of small av ulsion fragments at the

movement in the horizontal plane of approximately 12" to 1?“, and an average 1.4 mm of distal migration of the

in association with the history and physical examination findings. In a complete deltnid ligament injury, a valgus

ligaments tear andfor the bone fractures. Several mechanisms can produce such an injury, the most common of

tip of the medial mallenlus may indicate an acute injury AP stress radiograph shows a talar tilt. i'viost such injuries

which is internal rotation of the leg and body on a foot

medial ankle instability is stress radiography.” A gravity

The wide spectrum of injuries to the syndesmosis

are incomplete, and standard radio-graphs appear normal. As a result, the traditional gold standard for evaluating stress radiograph may be useful in the office setting for detecting an acute injury. MRI increasingly is the imaging

Eb Ifllti American Academy of flrdiopaedic Surgeons

that is firmly planted, causing an external rotatory force on the fibula.

complex ranges from subtle sprain to complete diastasis and instability {Figure 6}. Local swelling and tenderness

Drthopaedic Knowledge Update: Sports Medicine 5

FT. :5

El.

E

Sectien 3:1Cnee andLeg

Grceve ter tlbliaiis pesterier and Heater digiterum Iengus

Interesseeus

Anterelateral tihi-

'rrernhrane

tubercle

Fresnel

('l'tllautt-Chstput

.

ridge

DiEt-al EEUEESUW

' _

r— .

Welltmann} __

—

:e‘ band [Bassett ligament} F

- ' .

Peeierelateral tibial tubercle

Pereneal

aceeseery band Primary band{s}

Capsular

.;.

membrane —

lnteresesttue

3 .,

AITFL

“‘ Antaremedial fibular

I

iur tip

_ -_

fiatemln—R.

allaclus

_ {Wagetafie} tubercle

CFL’

1

Deep PITFL “‘1 {Interier transverse ligament}

..---r' .

" sTFL

It...“

A Figure 5

Schematic drawings shew the ligaments ef the ankle syndesmesis in the anterelateral {A} and pesterier {I} views. AITFL = antereinferler tibie'fibular ligament. ATFL - anterier tale'fihular ligament. lEFL = calcanee'libular ligament. PITFL = pestereinferier tibiefibular liga ment. PTFL = pesterier talefibular ligament. {Repred uced with perrnissien

trem Williams BT, Ahrberg AB, Geldsmith MT. et al: An ltle syndesntesis: A qualitative and quantitative anatemic analysis. Am J Sparts Med 2015;43l1lflfle51}

after the acute injury quickly give way te diffuse signs

and symptems that make the diagnesis less ebvieus. The

Cetten, prettimal fibular squeeze, external retatien stress, hep, weighted retatien, and cressed-leg gravity stress

tests specifically are designed tci detect syndesmesis injury

and instability, but neither these tests ner the standard imaging methedelegies {plain and stress radiegraphs,

CT, ultraseund, and MRI} are cempletely reliable. Mere

than iii mm ef widening ef the tibiefibulat clear space an the AP radiegraph indicates a syndesmesis injury, but significant injury can be present in the absence ef this

finding. MRI has beceme the preferred diagnestic study fer a suspected syndesmesis injury in a prefessienal er DI

cu

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T:

I: a: tu ill I: a:

H

cellegiate athlete in the United States.“1 MRI is useful fer

cerrelating physical esaminatien findings with syndesmesis injury and predicting time missed frem spurts based en the severity ef findings.“

Neusurgical treatment is preferred fer a stable syndes—

mesis injury. Rest, immebiliaatien, NSAIDs, and ice are

used. PEP was feund te be a useful additienal treatment fer stable injuries.“3 A syndesmesis injury requires almest twice as much time hefere return te play as a severe lateral ankle sprain. A systematic review ef the literature

feund that time last from spurts after a syndesmesis sprain ranged frem {i te 13? days and that die average

flrdtepaedic Knewiedge Update: Sperts Medicine 5

Figure 6

AP anltle racliegraph shews a type W 51; ndesmesls injury. {Hep reduced with permissien frem Clanten TD, Waldrep ME; Athletic injuries te the raft tissu as at the feet and ankle. in Eeughlin Mi. Saltzman i:L, Andersen RB, eds: Mann‘s Surgery ef the

Feet andAnlcle, ed 9. Philadelphia, PA. Meshy Elsevier, 20'“.- pp 1531-1681}

El ll] 16 American AcadMy ef Ctrrhepaedie Surge-ens

Chapter 12: Ankle and at Injuries and Either Disnrders

Figure B

Arthrnscnpic phntngraph shnws an

nstenchnndral lesinn nf the lateral talar dnme after a shearing injury tn the rig ht anltle.

Figure I

Ftadingra phic mnrtise view shnws titanium buttnn stabilizatinn nf a type l"v" synd esmnsis injury. {Her-reduced with permissinn irnm Clantnn TD. 1tl'li'altlrnp HE: Athletic injuries

In the snft tissues nf the tent and ankle, in

Cnughlin Ml. Saltzman L'L. Andersen HE. eds: Mann’s Surgery nt the at and Ankle, ed El. Philadelphia, PA, Mnsby Elsevier, It'll 4, pp 1531163?.)

lnss ranged frnm 1i] tn 52. days.“ Residual symptnms are

diagnnsis and treatment.

nstenchnndral Lesinns at the Talus and Distal Tibia

An nstenchnndral lesinn nf the talus {0LT} is a cnmmnn

injury that is challenging tn treat because nf the peer

healing capability nf articular cartilage and the difficulty nf access tn all areas nf the ankle jnint {Figure 3). Talar

cartilage is thinner than articular cartilage in the hip and knee (“H.353 mm thick, cnmpared with 23], 3.33, nr 2.92

nnt uncnmmnn. Dne smdy fnund gnnd tn excellent ankle functinn in 36% nf patients at an average 4T-n1nnth fel-

mm thick fnr the femur, patella, nr tibial plateau, respectively”).“” The mechanical prnperties nf talar articular

and nne-fnurth had mild activity-related pain.“ Surgical treatment is indicated fnr patients whn have

including develnpment nf stiffness and nstenarthritis, in cnmparisnn with hip nr knee cartilage.51

lnw-up, althnugh nneuthird nf patients had mild stiffness nbvinus diastasis nn plain nr stress radingraphs nr whn

cartilage make it mnre resistant tn the effects nf aging,

The characteristic finding in an {3LT is pain aggravated

have undergnne unsuccessful rehabilitatinn. Highvlevel athletes with subtle diastasis andinr an MRI-cnnfirtned

by weightrbearing exertinn. A histnry nf print injury is cnmntnn in the diagnnsis nf I.ClLT. It is impnrtant tn define

stabilizatinu, although this treatment is cnntrnversial. Ankle arthrnscnpy usually is warranted tn inspect the

tnry and physical examinatinu, diagnnstic imaging, and nccasinnally an anesthetic injectinn tn the ankle jnint.”

tear nf syndesmntic ligaments may benefit frnm surgical

jnint and evaluate it fnr cartilage lesinns. After the jnint is déhrided, it is sta biliaed with a screw nr a sutttre—buttnn

cnnstruct. There is mnunting evidence that suture-huttnn stabilizatinn is mnre beneficial than screw fixatinn‘mi‘” {Figure 3"}. A screw typically is remnved .3 tn 4 mnnths after implantatinn, althnugh the need fnr screw remnval

the BLT as the snurce nf the pain thrnugh a thnrnugh hisStaging nf the lesinn is helpful in determining the treat-

pg

type II is a partially detached nstenchnndral fragment,

re re tn 3

ment. The Berndt—Hardy-Lnnmer radingraphic system is cnmmnnly used.“ 55 Type I is suhchnndral cnmpressinn,

type III is cnmpletely detached, type IV is a cnmpletely detached and displaced nstenchnndral fragment, and type

has been questinned by recent studiesfhii Nevertheless,

V is a cystic lesinn.“+55 CT— and MRI-based elassifieatinn

cnnsiderahle research related tn syndestnnsis injury and

the extent nf the BLT. CT dnes nnt define snft-tissue

screw remnval has been shnwn tn imprnve a malreduced syndesntnsis and imprnve pain and functinn.-“"l-Jil Despite

treatment, significant cnntrnversy remains, and there is a lack nf high-level evidence nn nptimal methnds fnr

El Ifllti American Academy nf flrflinpaedic Surgenna

systems alsn have been described. MRI is helpful in identifying additinnal pathnlngy, but it tends tn exaggerate pathnlngy but prnvides an accurate picture nf the struc-

tural character nf the IZZ'IILT and any cystic dimensinns.53

Drrhnpaedic Knnwledge Update: Sperrs Medicine .5

F. :5

El.

3

Section 3:1i'2nee ancg

The arthroscopic classification of ULTs follows the system established by the International Cartilage Research

Society.‘IE1 The combined use of radiographs, CT andi'or MRI, and arthroscopy is essential for optimal treatment of these lesions.

Articular cartilage injuries are common in both se—

vere sprains {acute or chronic} and fractures of the ankle. The incidence of articular cartilage injuries ranged from 63% to 95% in studies of both acute and chronic lateral

ankle sprains and was as high as 30% in unstable an-

kle fractures.5”3 If an 0LT is left untreated, the risk of

posttraumatic ankle osteoarthritis increases significa ntly: approximately 50% of untreated |IIIiLTs were found to

have later degenerative changes within the ankle joint-m”

Nonsurgicsl treatment of l[ZILTs is successful in fewer than 50% of patients, and this factor as well as the risk of significant long—term effects requires an effective surgical

treatment strategy.‘1

Video 22.1: Autologous Ch rond rocyte Implantation. Richard D. Ferkel, MD, and Kyle David Stuart, MD {13 min}

Figure 9

Arthroscopic photograph shows microfra cture treatment of an osteochondral lesion of the talar clome.

a 26% success rate. Bone marrow stimulation was rec-

ommended as the first-line treatment because of its high Video 22.2: Conventional Treatment Debridement Abrasion Microfracture

Drilling. Mark Glaze-brook. MD {4 min)

Video 22.3: OATS Procedure. Laszlo

Hangody, MD, PhD, D5: {10 min)

Arthroscopic drilling or curettage, bone marrow stimulation using microfracture, mosaicplasty, osteo-

chondral autograft or allograft transplantation, and

autologous chondrocyte implantation have been used

._I

I: in to Iii-1 I: s:

American firthopaedic Foot and Ankle Society hiudfoot score.“ Corettage had a ??% success rate, and drilling had an approximately 66% success rate for the treatment

of DLTs. In addition, 13 studies reported that 35% of patients had an excellent outcome after bone marrow stimulation. Usteochondral autologous transplantation

had a good to excellent outcome in approximately ST'h': of patients, and autologous chondrocyte implantation had

28-1

come, as indicated by an American Drthopaedic Foot and

Ankle Society score lower than 3D.“ The location of the lesion as well as the patient‘s age, sex, body mass index,

history of trauma, and duration of symptoms also can

simultaneous bone graft, autologous osteochondral transplantation with single or multiple plugs, or fresh

and fixation. The primary outcome measure was the

H

Several factors may have a role in the success of treat-

ment for lIZIILT. Talar defects larger than 15l} mm1 were found to be relatively unlikely to have a satisfactory out-

drilling, osteochondral autologous transplantation, au— tologous chondrocyte implantation, retrograde drilling,

{microfractnre}, autogenons bone graft, transmalleolar

T:

or mesenchymal stem cells had better results than bone marrow stimulation aloneff'fii'

treatment, excision, curettage, bone marrow stimulation

ular cartilage lesions of the talus including nonsurgical to

cosupplementation, PEP, micronised cartilage allograft,

affect the clinical outcome, but discrepancies in results have made it difficult to confirm other predictors of the success or failure of BLT treatment!“I A large lesion, including a lesion with a large cystic area, typically requires complex treatment such as

to treat C'ILTs'E'l“53 {Figure 9}. A systematic review of 52 studies compared the outcomes of treatments of artic-

UI

success rate, low morbidity rate, and relatively low cost. Supplementation of bone marrow stimulation with vis-

flrthopaedic Knowledge Update: Sports Medicine 5

autologous chondrocyte implantation with or without talar osteochondral allograft53 l[Figure 1'3}. Treating an

DLT after unsuccessful bone marrow stimulation can be challenging, but autologous chondrocyte implantation

was mported to be successful in 23 of 2.9 patients at a

mean 3.3-year follow—up, and osteochondral autologous transplantation was effective in 13 of 22 patients who

had undergone earlier treatment of an ULTF": 7" Dou-

ble-plug osteochondral autologous transplantation and mosaicplasty were found to be effective for large lesions,

El 2016 American Academ1r of Urthopaedie Surgeons

Chapter 21: Ankle and Foot Injuries and flther Disorders

Figure 1D

Coronal [A1 and sagittal {5} CT images of a large osteochond ral lesion of the talar dome.

in comparison with fresh talar ostcochondral allograft,

which often leads to osteolysis, subchondral cysts, and degenerative changes?1 Tibial osteochondral lesions are much less common than talar lesions; only one tibial lesion occurs for every 14 to El] talar lesionsfi’3 No single area of the plafond is

to the anteromedial tibia occurred in Tfi'il'fn.” A cadaver study found that the anterior capsule attaches to the distal tibia on average 6 mm proximal to the anterior cartilage rim rather than near the spurring at the distalmost tibia.“

Lateral radiographs of the ankle reveal osteophytes

a particularly common site for these lesions?“ The lim—

on the anterior tibia and talar neck, often described as kissing lesions, although CT studies found that these

those used for the talus are effective.F3 Many patients in

dorsiflexion.” Chronic changes in the talar surface can

ited available reports suggest that techniques similar to the study had a concomitant procedure such as removal of soft tissue or osseous anterior impingement without a substantial reported change in outcome. Ankle lmpingement Syndromes

Anterior Bony lmpingement Anterior ankle impingement is a common source of pain in athletes and is related to osteophytes on the dorsome-

dial aspect of the talar neck and the anterolateral aspect

of the distal tibia. Athletes often have a palpable spur of bone that is painful to palpation and interferes with

osteophytes usually do not contact one another during be caused by osteophytes. A divot sign of the talar neck

and a tram track fissure of the talar dome articular cartilage surface were found to correspond to the offending spursfit The ScrantonuMcDermott classification of ankle

bony impingement is based on the radiographic size and location of the spurs, and the van Dijk classification is based on the extent of osteoarthritis.” MRI can be used to define additional pathology, articular cartilage injury, intra-articular effusion, and bone contusions. Q

Video 21.4: Anterior Ankle Impingement.

J. Chris Coetzee, MD l? min)

performance, particularly during cutting, push-off, and

maximum dorsiflexion, which can be critical in sports such as alpine skiing. It is believed that bony impingement in the anterior ankle is a consequence of athletic activity

that consistently places the ankle in extreme positions over a long period of time. A laboratory study of 15D

kicking actions by 15 elite football players found that

maximal plantar flexion and stretching of the capsule occurred in only 39% of the kicks but that direct trauma

El Ifllti American Academy of Urthopaedic Surgeons

1.4,: FT. :5

m m tn 3

El.

The treatment includes rest, ice, range-of-motion exercises, and corticosteroid injections for van Dijk grade I impingement {osteophytes without joint space narrowing}.

If nonsurgical measures are unsuccessful, arthroscopic débridement of the ankle is recommended. According to

one study, 90% of patients without joint space narrowing (van Dijk grade I, l], or III} and T3% of patients with pain

Drrhopaedic Knowledge Update: Sports Medicine 5

E

Section 3:1Cnee andLeg

of less than 1 years’ duration improved significantly.EIJI

procedure involves open excision of the trigonal process

kles and therefore have a good response to arthroscopic

approach. Although open surgery has been successful, arthroscopic excision and decompression of the poste-

These patients typically do not have osteoarthritic an—

treatment with spur excision. However, the presence of other symptoms, such as those from an 0LT, can affect

and is as successful as open surgery. All 16 patients who underwent posterior ankle arthroscopy had good to ex-

chondral lesion.El Although osteophyte lesions commonly recur, the improvement in function remains."l

come scores at a mean 32-month follow-up, and 93% had returned to their preinjury athletic level.“E High-level

Posterior Bony Ankle lmpingement Posterior ankle impingement is caused by irritation of

scale scores, with an average return to the preinjury level

46.9 days after arthroscopic decompression surgery.”

of compression in maximum plantar flexion. The bony impingement may involve the posterior malleolus, the

Soft-Tissue lmpingement of the Ankle Inflammation within the ankle joint is common after

an os trigonum, the posterior subtalar joint, or the posterior calcaneal tuberosity. The os trigonum, which is an

injury. Recurrent ankle sprains can cause repeated hem-

orrhage into the joint, leading to synovitis and subsequent

talus, and the posterolateral tubercle are most commonly involved in the impingement syndrome.“

impingement in the ankle. Although impingement lesions most commonly are found in the anterior ankle, they can

sively use the extreme plantarflexed position, as is com~ mon in dance as well as kicking and jumping sports.

Ankle impingement most commonly is anterolateral. Thickening of the ATFL or the inferiormost portion of

tendon during specific activities such as jumping, kicking, or a push-off maneuver. A traumatic incident can he an

common cause. The Bassett ligament, a well~described accessory band of the AITFL, and the extensor tendons

the posterior structures of the ankle, usually as a result posterolateral talar process {trigonal or Stieda process},

ununited lateral tubercle of the posterior process of the

Posterior impingement is seen in athletes who exten-

The athlete reports a deep pain anterior to the Achilles inciting event, as in fracture of the os trigonum or poste—

rior talar process, but usually the symptoms are caused by overuse. The initial diagnosis is based on the patient history and physical examination. The standard workup

includes radiographs, which may reveal the presence of an

os trigonum or posterior talar process. MRI can detect the soft-tissue and bony edema that commonly occurs

with posterior ankle impingement. Q'

to

._I

Video 22.5: Posterior Ankle Arthroscopy -

H

cellent health-related quality of life and functional out‘ athletes had a significant decrease in visual analog pain

injury and often becomes chronic as a result of repeated

scarring of the ligaments. This often leads to soft-tissue occur in almost any part of the ankle.

the AITFL and the surrounding soft tissues is the most can be the source of soft—tissue impingement in the ante‘

rior ankle. Posterior soft—tissue impingement results from repeated plantar flexion that traps the tissue between

the calcaneus and the tibia. Stenosing tenosynovitis of

the flexor hallucis longus, hypertrophy of the posterior capsule, and enlargement of the posterior intermalleolar ligament also are common causes of softbtissue impinge-

ment in the posterior ankle. Medial impingement is less common but was found to affect athletes.“ The patient

history and physical examination play an important role

Impingement Us Trigonum FHL Tenosynovitis. Johannes J. WIEQEFIHEk, M5c, PhD; Peter de Leeuw, MD; and C. Niel: van Dijk, MD {3 min]

in the diagnosis of softrtissue impingement. Patients re~ port a history of chronic injury to the ankle or partici-

The treatment of posterior ankle impingement begins with rest, ice, HSAIDs, and avoidance of extreme plan—

gutter or the inferior aspect of the AITFL. In posteri-

T:

I: ll'.'l to III-1 I: a:

rior ankle has become popular during the past decade

long-term outcome. The outcome most commonly is related to the age of the patient, sire of the osteophyte, ankle morphology, or an associated condition such as a

UI

or os trigonum through a posteromedial or posterolateral

tar flexion. Physical therapy can be useful, as can selective posterior injections to calm the local inflammation.

Nonsurgical treatment was successful in sex. of patients with posterior impingement symptoms, and 35% of pa-

tients who received an injection reported pain relief.“

“5 Surgical treatment is indicated after 3 to 6 months of unsuccessful nonsurgical treatment. The traditional

flrdtopaedic Knowledge Update: Sports Medicine 5

pation in a sport that predisposes them to impingement,

such as basketball, volleyball, or gymnastics. Typically, there is tenderness to palpation along the anterolateral

or impingement, maximum plantar flexion reproduces the symptoms. Radiographs are necessary to rule out

bony pathology but rarely reveal positive findings. MRI

is more useful than radiographs for detecting soft-tissue

impingement. Nonsurgical treatment is unlikely to be successful in athletes. A regimen of rest, ice, and NSAIDs is the start-

ing point, but immobilization with a controlled ankle

El 1016 American AcadMy of Cirrhopaedic Surgeons

Chapter 12: Ankle and Fuut Injuries and Either Disnrders

muvement walking bunt can be used tn prevent the ex-

tremes nf mntinn that elicit symptums. lntra-articular

steruid injectiuns alsn can pruvide relief. After nnsnccessfui ucnsurgical treatment, arthrcscupy is the surgical treatment nf chuice.

-_ Differential Diagnnsis fur Plantar Fasciitis Skeletal Disorders Calcaneal cyst

Calcaneal epiphysitis Funt Disurders

Heel Pain and Plantar Fasciitis

Calcaneal stress fracture Infectiun

The plantar fascia is dense cnnnective tissue that suppul'ts the arch uf the funt. The medial and lateral bands, the

Subtalar usteuarthritis

MTP juints and the base nf the prnximal phalanges. This

Heurulugic Disurders

twn main bands uf the plantar fascia, run frum the calcaneal tuberusity and insert en the plantar plates cf the strung band uf tissue pruvides stabilizatiun fur the plantar arch cf the funt as well as the first MTP juint thruugh the

windlass mechanism. The apuneurusis functinns frum

heel strike tn tne-uff in the nurmal gait cycle tn achieve hindfcnt inversiun, tibial external rutatinu, and transverse tarsal jnint stabilizatiun.

ln athletes, the plantar fascia is susceptible tn injury primarily thruugh nveruse. Lung-distance running and prulunged training regimens can lead tn repetitive, chrnn-

ic trauma that can damage the plantar fascia. Acute injury alsn is pussible and results in a partial cr cumplete tear cf the plantar fascia that can lead tn chrnnic iniury. Patients

typically repnrt murning ur activity~related pain specific tn the plantartnedial aspect uf the heel at the nrigin cf the medial band nf the plantar fascia. Pain is aggravated by

direct palpatinn ur by initial weight bearing and stretch— ing cf the plantar arch.

Cavuvarus funt defurmity and Achilles tendun cnnu

tractnre are believed tn have a rule in the pathnlngy uf plantar fasciitis. Dbesity and wurlc-related weight bearing

were fuund tn be independent variables cnntributing tn

plantar fasciitis.” In evaluating a patient with heel pain, it is impnrtant tn keep in mind the numeruus cnnditinns

that must be cnnsidered in the differential diagnusis {Ta-

ble 1}. Calcaneal stress fracture and tarsal tunnel synr drume are the cnnditinns must likely tn mimic plantar fasciitis. A calcaneal stress fracture shnuld be suspected

with an acute exacerbatiun uf heel pain nr pain elicited by cumpressiun cf the heel. The diagnusis is cunfirmed by heel radiugraphs un which the classic findings uf a stress

fracture can be seen after several weeks. A bune scan ur MRI nften is indicated tn rule nut stress fracture and help in determining the severity cf plantar fasciitis.

Tarsal tunnel syndrnme nr nerve entrapment cf the first branch cf the lateral plantar nerve alsn shnuld be

ruled nut. Patients with tarsal tunnel syndrnme repnrt

radiating pain and paresthesia, and they nften have a pnsitive Tinel sign. The must cummunly invnlved nerve

Eb Iflld American Academy uf Urthupaedic Surgenns

Systemic arthritis (lupus, psuriatic, rheumatuid}

Abductur digiti quinti nerve entrapment Lumbar spine pathnlngy Heurupathy Tarsal tunnel syndrnme Soft-Tissue Disurelers Fat pad atruphy Fleitur hallucis brevis tear Heel pacl atruphy Plantar fascia rupture Hetrucalcaneal bursitis Dther Disurslers Euut

fisteumalacia Paget disease Tumur

1si'ascular disurd er

is the Ba Itfil’ nerve {the first branch cf the lateral plantar nerve], which is a mixed mutur and sensury nerve tn the

abductur digiti quinti and the lateral burder uf the plantar surface cf the fnnt. Must cummunly, the nerve becnmes

1.4.}

electrnmyngraphic ur nerve cnnductinn velucity studies

re in en a

entrapped between the deep fascia cf the abductur hallucis and the quadratns plantae. The wurkup typically invulves

tn cunfirm the diagnusis. Nunsurgical treatment is the mainstay fur almust all

furms uf heel pain. The treatment cf plantar fasciitis fucnses un HSAIDs, activity mudificatiun, and a dedicated

stretching prugram uf the plantar fascia and Achilles tendun cumpleit. A custum-made nr nff-the-shelf cushiuned in—shne urthnsis is used tn cuntrul heel mutiun and prevent splaying uf the heel pad, alung with a dursiflesciun night

Drthnpaedic linuwledge Update: Sparta Medicine 5

F. :i

El.

E

Sectien 3:1Cnee andLeg

splint. lviere invasive treatments include ientepheresis, certicnsternid nr PEP injectinns, and ESWT. High—quality

tn an avulsinn fracture but usually are net the types nf

a night splint.9"'95 ESWT, cnrticnsternid injectinn, and

spectrum nf sprains in athletes ranges frnm a stable sprain

but little suppert was feund fer the leng-term use ef an

ebvieus widening bets-teen the base ef the first and secend

studies have suppnrted use nf NSAIDs, plantar fascia stretching witheut weight bearing, calcaneal taping, and PRP injectinn alsn were supperted by research evidence, nrthnsis in treating plantar fasciitis.“'99

Medial plantar fascintnmy typically is recnmmended

after unsuccessful nensurgical treatment. The medial

third nf the plantar fascia is excised, with maintenance cf

the lateral band tn prevent cnllapse nf the arch. The ben'

because it has better nutcnmes than traditinnal fascintnrnyJ“ lviest evidence supperting the efficacy ef surgical

than 5 mm and evidence nf less nf arch nn weight-bearing radiegraphs. The cemmen radingraphic appearance

nn randnmized cnntrnlled study results are available. Rupture ef the plantar fascia repertedly eccurs after

lnngitudinal, depending nn whether the Lisfra nc ligament is tern and whether the Patbelegy extends heriaentally

typically is painful. Patients repnrt a lnud, painful pnp~ ping sensatien in the arch ef the feet. Little evidence is

space and perhaps thrnugh the naviculncnneifnrm jnintJf" Injuries tn the TlT jeint efteu are misdiagnesed, and

available tn guide treatment, altheugh the injury usually

is managed nnnsurgically. Twn tn 3 weeks nf immnbili~ eatien with a nen—weight-bearing cast er beet with arch suppert allews the inflammatinn and pain tn subside.

nf the misalignment can be classified as transverse nr acrnss the MTP jnints nr vertically intn the intercu neifnrm

therefnre a high index nf suspicinn is required. The diag—

nnsis nf a severe injury with displacement usually is nbvi~ eus, but a ligamenteus injury with minimal displacement

is likely tn be missed. Pain with weight bearing shnuld

were treated with this regimen sustained reinjury, had pnstinjury sequelae, nr needed surgery!“

nr supinatinn—adductinn stress usually is painful. The physical examinatinn shnuld include evaluatinn nf the

Lisfranc Fracture-Dislecatinn

well as assessment fer a fnnt cnmpartment syndrnme in severe Lisfranc fracture-dislncatinn. Predispnsing factnrs

ticulatinn between the base nf the five metatarsals and the three cuneiforms and cubeid. Stability primarily is prnvided by the heme and ligament anatemy. There is nn ligament between the bases nf the first and secend

metatarsals, and stability in this area mnstly depends en

the recessed base nf the secend metatarsal, the aan arch wedged shape cf the midfnnt arch, and the strnng

Lisfranc ligament, which cennects the medial cuneifnrm tn the base nf the secend metatarsal.

Injuries tn the TlT jeint are caused by indirect er

athlete has difficulty pushing nff. Prnnatinn~abductinn dnrsalis pedis pulse and deep pernneal nerve functinn as fnr Lisfranc injury include a ratin nf secend metatarsal

length tn fnnt length nf less than 29% and a greater secnnd metatarsal length relative tn the depth nf the mnrtise fnrmed by the cuneifnrms.”5

Diagnnstic imaging nf a feet with a suspected Lisfranc fracture-dislncatinn begins with AP weight-bearing ra-

dingraphs as well as nblique and lateral views [Figure 11}.

Cnmparisnn with a weight—hes ring AP rad ingraph nf the uninjured fnnt nften is helpful. Ten cemmen radingraphic findings are indicative ef midfeet injuryIlls {Table 2}.

direct forces. The indirect fnrces invnlve axial leading nr twisting en a plantarflexed feet, and direct injury nc-

If a Lisfranc injury is suspected and plain radingraphs are net diagnnstic, CT nr MRI is useful. If rnutine ra-

Lisfranc injury cnmmnniy nccnrs in athletes as an injury tn the ligaments nf the TMT jnints that may extend tn

dingraphs taken with the patient under anesthesia may

cnrs when a lead is applied tn the midfeet. Ligamenteus

283

injury has first tn secend metatarsal diastases nf mere

be the first sign if it is accnmpanied by lncal swelling and tenderness at the midfeet. Even with a mild injury, the

The Lisfranc nr tarsnmetatarsal {TMT} jnint is the at-

H

MRI findings may be negative. A stage II injury has first tn

Gradual weight bearing is initiated with a return tn ac— tivity as pain and swelling allew. One study feund that

nene nf the '13 patients with a plantar fascia rupture whn

I: re re III-1 I: a:

In a stage I injury, the patient is unable tn participate in

secend metatarsal diastases nf 1 tn 5 mm but nn evidence ef less ef arch en weight-bearing radiegraphs. Stage III

sudden acceleratinn during an athletic activity. This injury

._I

metatarsals nr further intn the midfn-nt. A classificatinn system described in a 21102 study has been feund tn be useful in treating athletes with a relatively mild injury.‘”3

recnvery time and lnwer assnciated mnrbiditydfl'" Recently, ether surgeens have beceme prepenents ef gastrecnemius

treatment nf plantar fasciitis is nf nnly fair quality, and

T:

withnut radingraphic displacement tn a severe sprain with

efits ef epen and endescepic release have been debated,

recessinn alnne as a treatment nf chrnnic plantar fasciitis

a:

fractures nr dislncatinns that nccur in high-energy injury frem a meter vehicle crash er a fall frem a height. The

spnrts because nf pain in the Lisfranc jnint; weight-bearing radingraphs shew ne displacement, and bene scan er

but snme surgenns prefer endnscnpic surgery tn decrease

DI

the intertarsal jnints. These injuries range frem a sprain

flrthepaedic Knnwledge Update: Sperts Medicine 5

dingraphs are net diagnnstic in a mild injury, stress ra-

be helpful.

El 1016 American deadeniy nf Drtbnpaedic Surge-ens

Chapter 11: Ankle and Foot Injuries and flther Disorders

g

B

Figure 11

WEI

Hon-welght-bea rlng {A} and weig ht-bea ring {Bl AP radiog raphs show a subtle Lisfranc injury {arrow}. {Reproduced with permission from Haytmanelt CT. Ela nton Tfl: Ligamentous Lisfanc injuries in the athlete. flper Tech Sports“ Med 2014;21j4]:313-32fl.}

‘ Radiographic Findings Indicative of Midfoot Injury

Diastasis of first and second metatarsal bones First and second cuneiform diastasis Widening between second and third metatarsals Widening between middle and lateral cuneiforms Avulsion fracture at the base of the second

metatarsal on CT or other advanced imaging {Fleck

sign). representing Lisfranc ligament avulsion

Misalign ment of ta rsometata rsal joints on lateral images Misalignment of second metatarsal medial border to align with medial border of middle cuneiform Misalignment of fourth metatarsal medial border to

align with medial edge of cuboid Loss of congruity of metatarsal bases Compression fracture of the lateral edge of the

cuboid

Anatomic reduction is the key to a good outcome in

a Lisfranc injury. A short leg non-weight-hearing cast

is effective in patients with a truly nondisplaced, stable Lisfranc sprain until tenderness resolves at approximately

El Ifllfi American Academy of flrfliopaedic Surgeons

6 weeks, with subsequent functional rehabilitation. If displacement is present, rigid internal fixation is recommended for the first through third Tl'vlT joints as neces-

sary for stability. Temporary stabilization in an anatomic alignment is preferable for the fourth and fifth TMT joints

to preserve their mobility. There is little debate about

the need to perform an arthrodesis in TMT joints with significant articular damage or preexisting arthritis, but

controversy remains as to the treatment of young athletes

with purely ligamentous injury to the Lisfranc joint (Figure 12}. At least two high-quality studies suggested that arthrodesis is preferable for purely ligamentous Lisfranc

injuries, but a systematic review of studies including 193 patients found no statistical difference in outcomes after open reduction and internal fixation or arthrodesis.‘”?'1"9

1.4.}

the timing or necessity of hardware removal. Lisfranc

re m to 3

Other points of discussion in the treatment of Lisfranc fracture-dislocations relate to methods of fixation and fracture—dislocations traditionally have been rigidly fixed with transarticular screws, but bridge plating to immobi-

line the TMT joints is gaining favor because the articular

cartilage is preserved. The standard method for restabiliaing the first and second TMT joints is the placement of a so~called Lisfranc screw between the medial cuneiform and the base of the second MT. The newer use of a suture button device has had good results, may provide a more

Drrhopaedic Knowledge Update: Sports Medicine .5

F. :5

El.

E

Sectien 3:1Enee and Leg

A Figure 12

Radiographs shew a severe Lisfranc injury with articular damage hefere {A} and after (Bl arthreclesis. {Rec-reduced with permissien frem Haytma neit CT, Clenten TD: Liga menteus Lisfa nc injuries in the athlete. Dper Tech Sperts Med 2fl14:22[4]:313-32fl.]

physielegic fixatien than screw fiaatien, and dees net ne-

cessitate remeyal."” Regardless ef ether facters, heweyer, it appears that the must impertant negatiye pregnestic

facters in these injuries are severe seft—tissue injury and nenanatemic reductien. Turf Tee Turf tee eriginally was described as a hyperesttensien

injury tn the first MTP jeint caused by wearing fleeti— ble shees en hard artificial surfaces, but the definitien has eyelycd te encempass almest any injury te the first

MTP jeint caused by spurts participatien. The primary injury inyelyes the plantar plate, er capsuleligamenteus DI

as

._I

T:

I: es tu Iii-1 I: a:

H

cemplett ef the first MTP jeint, which typically is injured

in skill—pesitien feetball players whe axially lead their

heels when the ferefeet is listed en the turf!” 1F«liarus and yalgus ferces alse can centribute te a turf tee injury,

further destabilizing the jeint with less ef integrity ef the cellateral ligaments. Afte: an acute injury, the athlete has pain, swelling, ecchymesis, and stiffness at the first MTP jeint, which

with the centralateral nermal side te detect any retractien.

An ayulsien fracture, sesameid fracture, er diastasis ef

bipartite sesameids alse may be feund. MRI is reliable

fer assessing the extent ef seft-tissue injuryr113 {Figure 13}. Eiemechanical studies feund that stress fluerescepy is

reliable fer diagnesing an unstable injury. Injury te at least three ef the feur ligaments is indicated by a 3-mm

difference in sesameid excursien cempared with the un-

injured side en stress dersiflc‘sien fluerescepy.”" Nensu rgical treatment ef a turf tee injury begins with

the rest-ice-cempressien-eleyatien pretecel. Immebili-

satien is used te centrel acute swelling and rest the tee. Heweyer, early jeint mebilizatien is essential because

stiffness is a cemmen sequels ef this injury. Further

treatment includes restricting dersifletsien ef the first MTP jeint by stiffening the shee er using carben fiber er graphite inserts te reduce the ameunt ef energy trans-

fer frem the feet during push—eff. Taping ef the hallust alse is useful. As seen as symptems allew, the rehabilitatien pregrant

are classified by their severity111 [Table 3}. The initial

begins with actiye and passive nen—wcight—bearing and weight-bearing range-ef-metien exercises fer the feet

yiews ef the feet, which eften appear nermal. The radie— graphic pesitien ef the sesameids sheuld be cempared

symptems and functien. The use ef anesthetics er stereid injectiens te allew the athlete te return te play is net

radiegraphs are standing weight-hearing AP and lateral

flrfltepaetlic Knewledge Update: Sperts Medicine 5

and ankle. The ability te return te play is dictated by

El 1016 American Acadenw ef Cirthepaerlic Surge-ens

Chapter 12: Ankle and Foot Injuries and Either Disorders

Table 3

,

Classification of Turf Toe Injury Grade |

Dbjective Findings

Activity Level

Pathology

Treatment

Local plantar or medial tenderness

Continued athletic participation

Stretching of capsuloligamentous

Symptomatic

Loss of S to 14 days

Partial tear of

Walking boot

Minimal swelling

CDmPIEI

No ecchymosis II

More diffuse, intense

tenderness

Mild to moderate swelling

of playing time

Mild to moderate ecchymosis Severe, diffuse tenderness

Marked swelling

Moderate to severe ecchymosis Extremely painful, limited range of motion

complex

“'3 articular injury

Painful, restricted range of motion ||I

capsuloligamentous

Loss of 2 to 5

weelrs of playing

Complete tear of

time

capsuloliga mentous complex

and cmtches as "field?“

Long-term

boot or cast

Immobilization or surgical repair

Adapted from Elanton TD. Butler E, Eggert A: Injuries to the metatarsophalangeal joints in athletes. Foot Ankle tEEfifllSiflliZ-li'fi: Eoughlin ME: Biomedianics efthe foot and anlrle linkage in DeLee it; Dre: D .Ir, eds: Drtbopaedic Sports Medicine. Philadelphia, PA, WE Saunders, 1994, p

1552: Rodeo SA. Warren HF. O'Brien 5]. et al: Diastasls of bipartite sesamoids of the first metatarsophala ngeal joint. Foot Ankle 1593;14:425—434.

recommended because of the potential for further joint deterioration or injury. If the injury is severe, first MTP joint stability is com—

promised. iii. complete plantar plate tear, sesamoid retrac— tion, sesamoid fracture or diastasis, traumatic bunion,

progressive halluir valgus or varus, or dislocation of the

MTP joint can indicate instability that requires surgical intervention. The joint is stabilized by repairing the pa-

thology, including associated chondral lesions, fractures,

and torn ligaments as well as removal of loose bodies. lDuly limited evidence is available on the outcomes of surgical treatment of these injuries.

Sesamoid Disorders

The sesamoids of the great toe, which are part of the

plantar plate complex, often are involved in acute trau— matic and over use injuries. These two small bones under-

go considerable force with weight bearing and can be a

source of pain from traumatic fracture with displacement,

Figure 13

Sagittal MFtl shows a planter plate tear. {Courtesy of Jena Ieeiin. MD, Ath erton, CM

FT. :5

Stress reaction or fracture, sesamoiditis, osteonecrosis,

or osteoarthritis. Radiographs, including weight-bearing

AP comparison views, should be obtained and can be useful in acute injury. A dedicated bone scan and MRI

and can provide the patient with significant relief. These modifications are used with NSAIDs, physical therapy,

extent of the injury. Treatment of a sesamoid disorder can be difficult.

significant pain relief. If necessary, immobilization with a controlled ankle movement walking hoot or toe spica

can confirm the diagnosis and determine the site and Activity and shoe wear modifications are used, with an

orthosis if necessary. Shock—absorbing shoes with dancer pads can be used to offload the stresses on the sesamoids

Eb Ifllti American Academy of flrdiopaedic Surgeons

pg

and perhaps anesthetic and steroid injections to provide cast can he used.“ Surgery is the last resort, although

satisfactory outcomes have been reported, especially among athletes!”

Drrhopaedie Knowledge Update: Sports Medicine S

re re tn 3

El.

E

Section 3:1Cnee audLeg

are similar.”“~ ‘31 Proximal fifth metatarsal stress fractures

are most common in athletes who participate in a sport

such as basketball, football, or soccer. The patient has

worsening activity-related pain along the lateral aspect

of the midfoot over a period of several weeks. Physical

examination may reveal point tenderness over the base of the fifth metatarsal as well as pain with passive inversion of the foot. The fracture often is apparent on radiographs Figure 14

The classification of fifth metatarsal fractures

by zones. zone 1 = lateral tuberosity {avulsion

fracture}. acme 2 = metaphysis or metaphysealclia physeal junction (1 ones-type fracture}, zone 3 = proximal diaphysis lfiacturel.

Stress Fractures

and are a common overuse foot and ankle injury in ath—

surgical fixation include minimising the risk of nonunion

use of a hard playing or running surface. Pain is generally

union l[Torg type II or III], surgical fixation generally is

be maintained so the injury can be diagnosed and treated in a timely fashion.

The challenges of intramedullary screw fixation pri-

weight-bearing limitations. Three specific stress frac-

tures are particularly problematic: stress fracture of the proximal fifth metatarsal [a Jones fracture}, the tarsal navicnlar, and the medial malleolns. These areas are considered to be highurisk stress fractures that often

progress to complete fracture, leading to delayed union or nonunion, and occurring along the tension side of the bone. These injuries necessitate aggressive treatment in

the form of surgery or strict non—weight hearing?“ A delay in diagnosis can exacerbate the risks associated with these fractures.

._I

H

and refracture as well as allowing a more rapid return to sport. If there is evidence of delayed union or nonrecognized as the standard of care with selective open débridement and bone grafting. Fixation usually is done

Stress fractures have been described in most bones of the foot and ankle, and most heal with rest and

I: m cu III-1 I: a:

margins and no sclerosis), many active individuals and elite athletes opt for surgical fixation. The goals of early

insidious at onset and can be vague or point specific in the location of the stress fracture. Initial radiographs often are negative, and a high index of suspicion should

T:

in a short leg cast for 6 to 3 weeks is an option for a Torg

type I fracture [an acute fracture with sharp fracture line

letes.“"' These injuries typically occur after a change in footwear or training {such as an increase in intensity} or

cu

patient’s goals and athletic participation.112 Although nonsurgical management with strict non-weight bearing

Stress fractures are considered to be the result of “exces— sive, repetitive, submaximal leads on bones that cause

an imbalance between bone resorption and formation“

DI

and can be classified based on appearance as an acute traumatic fracture, stress-related fracture, delayed union, or nonunion.1‘11 Treatment selection often is guided by the Torg classification of fractures in zones 2 and 3 as well as by the

Fifth Metatarsal Fracture Fractures of the base of the fifth metatarsal are classified by xone119 {Figure 14}. Zone 1 represents an avulsion fracture of the lateral tuberosity, zone 2 is a Jones-type fracture of the metaphysis or the metaphyseal-diaphyseal

junction, and zone 3 is a proximal diaphyseal fracture.

with an intramedullary screw and has a good to excellent result {Figure 15). marily are related to the shape and contour of the bone

itself. A recent radiographic study examined the fifth metatarsal in great detail using three-dimensional CT of 119 patients.113 The average straight~segment length was

found to be 52 mm, which was 63% of the overall length of the metatarsal from the proximal end; the medullary

canal was found to be elliptical; the average coronal canal diameter at the isthmus was 5 mm; and in 31% of

men the diameter was greater than 4.5 mm. The use of a

solid, partially threaded screw with a 4.5-, 5.5-, or 6.5-

mm diameter was recommended. The partially threaded configuration was found to provide compression across the fracture site. Headed screws were recommended over headless screws because of their superior pullout strength and easier removal. The so-called plantar gap is a possible prognostic in-

dicator, according to a study that found a significantly increased time to bony union in fractures with at least 1 mm of fracture margin separation, regardless of Torg

A stress fracture can occur in zone 2 or 3, and some

classification.114 A recent systematic review of surgical and nonsurgical treatment of high-risk stress fractures

they carry a similar risk of delayed union or nonunion and refracture, and the surgical treatment and outcomes

research on fifth-metatarsal base fractures would be of great use in treatment decision making.1M In addition,

experts recommend combining these two zones because

flrrltopaedic Knowledge Update: Sports Medicine 5

of the lower leg concluded that additional prospective

El ll] 16 American AcadMy of Urrhopaedic Surgeons

Chapter 12: Ankle and Feet Injuries and IEither Diserders

A

Figure 15

it

B

AP {A} and lateral {I} radiegraphs shew intramedullary screw tisatien et a fifth metatarsal fracture.

the review feund a weighted mean return te spert ef 14

indes: ef suspicien as well as MRI, CT, er bene scanning

surgical treatment.

The traditienal treatment ef a stress fracture ef the navicular is nen—weight-bearing cast immebiliaatien fer

weeks after surgical treatment and 19 weeks after nen-

Tarsal Navicular Fracture Stress fractures ef the navicular are mest cemmen in par tients whe participate in estplesive running and jumping activities, as in basketball er track and field. Menuspetts

related facters that may play a rele in the develepment ef navicular stress fracture include the presence ef a leng secend metatarsal er a shert first metatarsal, anteriet ankle

impingement, er decreased ankle metien. The symptems are similar te these ef ether stress fractures; the pain eften

is vague, insidieus in enset, exacerbated by activity, and

relieved with rest. Altheugh the usual lecatien ef the pain is at the dersal aspect ef the midfeetflI the patient may describe ankle pain and this may be tender te palpatien

during physical erraminatien. The relatively avascnlar central third ef the navicular bene predispeses it re stress fracture and subsequent nenunien er esteenecresis. The

use ef a lecal vasculariaed pedicle bene graft fer fractures

with evidence ef delayed unien, nenunien, er esteenecresis has had enceuraging results.125 Negative initial

radiegraphs and vague initial symptems were reperted te lead te a 1- te T—menth delay in diagnesisJ“ A high

El Ifllti American Academy ef Urthepaedie Surgeena

is useful in the diagnesis {Figure 16}.

6 tn 3 weeks. Attempts at limited weight bearing and

sherter perieds ef immebiliaatien have led an persistent pain and inability te return te activity.”” The thresheld fer surgical treatment has decreased in the hepe ef allew-

ing a mere rapid return te play, especially in highvlevel athletes. Unfertunately, ne high-quality studies have in-

vestigated the treatment ef navicular stress fractures. A

CTvbased study reperted that 3 ef ID surgically treated fractures went en te beny unien and that cemplete, dis-

placed fractures had an increased risk ef nenunien. ”T A

1.4.}

ne statistically significant differences related te time te

re re tn 3

meta—analysis ef surgical and nensurgical treatment ef cemplete, nendisplaced navicular stress fractures feund return te activity er successful eutceme rates, but the likeliheed ef a successful result was decreased after early

weight hearing!” The methedelegic flaws ef this analysis were painted eat in a mere recent systematic review ef

navicular stress fractures that used the ZT-item Preferred Reperting Items for Systematic Reviews checklist fer the centent ef a systematic review er meta—analysis.‘3” A systematic review ef surgical and nensurgical treatment

Drthepaedic Knewledge Update: Sparta Medicine .5

F. :l

El.

s

Secticm 3:1Enee and Leg

Figure 15

Advanced imaging fer navicular fracture. A. MRI shcirt tau inversicn reccwergn,r sequence shc-ws increased signal in

the navicula r. E, Eercinal CT image shnws fracture ncinuninn crl‘ the dnrsal navicular extending intn the bndy.

nf high-risk stress fractures nf the lnwer leg cnnclndecl

that nn strnng recemmendatinns cnnld be made fer the

treatment nf navicular stress fractures based cm the liter-

ature!” The weighted mean return tn spurt was 16 weeks

after surgical treatment and 22 weeks after nonsurgical management‘“ Medial Mallenlus Fracture Stress fractures cf the medial mallenlus represent nnly

._I

I: in as III-1 I: as:

H

treatment methnd is clearly preferred. Several factnrs

sheuld be cnnsidered in deciding whether nnnsurgical

cir surgical treatment is preferable: the presence of a

fracture line, cyst, nr lncal nstenpenia nn radingraphs; fracture displacement; level nf athletic participatinn;

as track and field cir gymnastics. Several intrinsic factnrs

prngressive weight bearing and a gradual return tci activity. Surgical treatment cnnsists nf cnmpressinn screw

ing the presence of a narrnw tibia, increased external hip rntatinn, fnrefnnt varus, snbtalar varus, limb-length

T:

the relative rarity nf medial mallenlar stress fracture, nn

and the timing nf injury {in seasnn nr tiff seasnnl.”1

are believed tn predispnse individuals tn medial mallenlar stress fracture {althnugh nnne have been prnved} includ-

as

a medial mallenlar stress fracture. Because nf the paucity nf high-quality research and

fl.6% tn 4.0% cif all lnwer extremity stress fractures.131

These injuries mnst nften nccnr in athletes whn participate in a running, jumping, nr high-impact spnrt such

DI

recnmmended early MRI whenever there is suspicinn nf

Nnnsnrgical management nften cnnsists nf 6 weeks nf nnn-weight-bearing cast immnbiliaaticin fellnwed by fiscatinn perpendicular acrnss the fracture as well as re-

mnval nf any anternmedial nstenphytes. A recent liter-

discrepancy, tibial varus, pes cavus, and anternmedial

atnre review included studies that recnnnnended b-nth nnnsurgical and surgical management. A study that cem-

during activity. The nnset nf pain is gradual, but the pain may acutely wnrsen after a pericid nf chrnnic medial an-

these whn were surgically treated had an earlier return tn spurt [4.5 weeks versus 7' weeks} and mere rapid uninn

nstenphytesfii- Patients ciften repnrt medial ankle pain

kle pain. Physical examinatinn may reveal an effusinn

as well as pain nn palpatinn alnng the anternmedial tib— ial plafnnd. Diagnnsis can be challenging; cmly 30% of stress fractures ef the medial mallenlus are identified an initial radingraphs, and CT, MRI, er a bnne scan may he helpfulfiii A study nf medial mallenlar stress fracture diagnnsis and surgical treatment found that initial radiu-

graphs were negative in all 10 patients.”i MRI did reveal the fracture line in all patients, hnwever, and the study

flrdtnpaeclic Knnwledge Update: Sparta Medicine 5

pared nnnsta ndardised grnups nf patients suggested that

{4.2 mnnths versus 6.? mnnths} than these whn were

nnnsurgically treated!“

Achilles Tenclcin Diserclers

As the largest tendnn arising frnm buth the snleus and gastrncnemius muscles, the Achilles tendcm can be affected by pathnlngy ranging frnm acute or chrnnic rupture tn nveruse injury nr insertinnal tendinnpathy. Any cif these

El 1016 American Acadenw cif Drthnpaedic Surge-ens

Chapter 12: Ankle and Foot Injuries and flthcr Disorders

conditions can result in create serious athletic limitation and loss of playing time. Acute Rupture Despite considerable published research, there is little

consensus on the optimal treatment of Achilles tendon ruptures. The injury is most common in men who are so—called weekend warrior athletes in their third through

fifth decades of life, but it can affect individuals regardless of age, sex, or level of athletic participation {including nonparticipation}.

The mechanism of injury most commonly involves a sharp dorsiflexion force onto a tensioned tendon, which

typically creates a rupture through an area of preexisting

degenerative change in the watershed area between 2 cm and 6 cm from its insertion.”5 The diagnosis of acute rupture was missed in 24% of patients, many of whom were

elderly or had a high body mass indexfli'fi 1ii'iii'ith a careful

history and physical examination findings including an abnormal Thompson test, decreased resting tension, and a

palpable gap within the tendon, the diagnosis can reliably he made without the need for more sophisticated studies”? {Figure 1?]. Ultrasound and MRI can be useful in patients

who have ambiguous examination findings, a chronic rupture, or a need for objective continuation of the injury. The treatment of acute rupture of the Achilles tendon

is controversial. A meta~analysis found a significant de— crease in the rerupture rate after surgical repair of the

Figure 1'.-'

tEi'ISlfli'i.

Achilles tendon, whether open or pcrcutaneous {4.4%

compared with 1fl.6% after nonsurgical treatment}.‘-35

The rate of complications was higher after open surgery than after nonsurgical treatment {2?% versus 5%}. Peru

cutaneous fixation had a lower risk of infection than open repair {relative risk = 9.32} but carried a 1.1% risk

Photograph shows an Achilles tendon rupture with a palpable gap (arrow) and loss of resting

Q

Video 22.6: Hagluncl Deformity. Achilles Problems. Johannes J. Wiegerincit, MSc,

PhD; Peter de Leeuw, MD; and C. Niel: van Dijk, MD {3 min}

of sural nerve injury. No solid conclusions about func-

tional outcomes could be reached because of the studies”

varied scoring tools, inconsistent definitions, and incomplete data acquisition, all of which highlighted the need

Dveruse Injuries flverusc injuries related to the Achilles tendon are com-

for greater standardisation in future studies!“ A secr ond meta-analysis found similar rerupture rates among

mon and include tendinosis, paratenonitis, superficial and retrocalcaneal bu rsitis, and insertional Achilles tendinop-

and early range-of-motion exercises and patients treated surgically”? A Swedish study that compared surgical

that involves intratendinous degeneration and atrophy, initially is asymptomatic, and results from repetitive mi-

patients treated nonsurgically using functional bracing treatment with nonsurgical treatment using functional

bracing also reported similar rerupture rates but found a significant improvement in single heel rise test and calf circumference in surgically treated patients.““1 Nonsur-

gical treatment with innnediate weight hearing, which improves the patient‘s quality of life during the healing process, and dynamic rehabilitation can be recommended

without concern for increasing the risk of rerupture or functional outcome deficits?"-

Eb Ifllti American Academy of Urthopaedic Surgeons

athy. Achilles tendinosis is a noninflammatory condition

1.4,:

crotrauma or aging. Pain may represent partial tearing in

m in tn 3

an area of degenerative tendon and warrants evaluation and initiation of nonsurgical management consisting of rest, the use of a small heel lift or Achilles tendon heel pad,

correction of hindfoot misalignment, physical therapy, and correction of training errors. Ultrasound and MRI can he used to evaluate the extent of tendon involvement. Eccentric training was found to be effective in reducing pain in male patients but may be significantly less effective

Drthopaedic Knowledge Update: Sports Medicine 5

FT. :5

El.

E

Sectinn 3:1Enee and Leg

Figure 19

Figure 13

MRI shnws insertinnal Achilles tendinnpathy.

in wnmenJ“ Surgical management invnlves debridement althnugh the central tendnn-splitting apprnach has gained favnr as a mere direct access tn the pathnlngy. Invnlve-

en, thnse whn are nverweight, sedentary nr have multiple medical cnmnrbidities. Nnnsurgical management shnuld

age necessitated augmentatinn with a fleanr hallucis lnn~

shnw calcificatinn at the Achilles tendnn insertinn nr a

meut nf mnre than SUSS nf the tendnn nr advanced patient

in patients whn were nlder than 44 years and relatively inactive.”

the success nf nnnsurgical treatment tn be predicted {Figure 131.1“ ES'WT is mnre beneficial than nther nnnsurgical

in mnst patients can be successfully treated with the measures used fnr tendinnsis. Surgery is cnnsidered after 3 tn

is cnnsidered."”*”3 Surgical treatment usually is success~ ful, althnugh nn single methnd nr apprnach appears tn

6 mnuths nf unsuccessful nnnsurgical treatment. Dpeu

nr endnscnpic débridement and lysis nf adhesinns are the prncedures nf chnice.

Superficial bursitis nften is assnciated with a pnetern-

lateral bony prnminence at the lateral calcaneal ridge, which nften is called Haglund deformity and may be mistaken fur ._I

I: in ca III-1 I: at

H

be attempted but nfteu is unsuccessful. Radingraphs may

pnsternsuperinr calcaneal prnminence. MRI is valuable

Pa ratennuitis is an in flammatinn nf the parateunn that

T:

years whn are recreatinnal runners as well as elderly wnm-

gus tendnn transfer, which led tn significant imprnvement in Achilles tendnn functinn, physical functinn, and pain

cu

lnsertiunal Achilles Tendinnpamy

Insertinnal Achilles tendinupathy appears as pain at the bnne-tendnn junctinn and is cnmmnn in men age 35 tn 45

nf diseased tissue thrnugh a medial nr lateral apprnach,

DI

Ph c-tugraph shows the central Achilles tendnnsplitting surgical apprnach.

insertinnal Achilles tendinupathy.144 Retrncalcaneal bursitis

fnr evaluating the extent nf diseased tendnn and allnws

treatments and shnuld be used befnre surgical treatment be mnre beneficial than nthers.143 Hnwever, the central

tendnn—splitting apprnach has gained pnpularity because nf its direct apprnach tn the area nf pathnlngy {Figure 19}. Sum merryr

Injuries and disnrders nf the inert and anlrle are cnm-

is characterised by tenderness bnth medially and laterally anterinr tn the Achilles insertinn but nnt directly at the bnne-teudnn interface. Bnth fnrms nf bursitis can nccur iu assnciatinn with insertinnal Achilles tendinupathy but are separate entities that can be treated nnnsurgically with

nther subtle injuries will ntten nccur. These can nften

and activity mndificatinn. In snme patients, immnbilisatinn in a shnrt leg cast nr endnscnpic surgical excisinn may be

in diagnnsis when cnmbined with a thnrnngh clinical enaminatinn. Many nf these cnnditinns can be treated

mnre satisfied after endnscnpic excisinn nf the retrncalca— neal bursa than after an npen prncedure.WT

indicated. 1With the apprnpriate treatments nutlined in this chapter, gnnd nutcnmes can be achieved.

rest, shne wear mndificatinn, HSAIDs, physical therapy,

necessary. A systematic review fnund that patients were

flrfltnpaedic Knnwledge Update: Spnrts Medicine 5

mnn amnng athletes and active individuals. Althnugh bnth lateral and medial ankle sprains are mnst cnmmnn, be challenging tn diagunse and treat. Clinicians must be vigilant and perfnrm a thnrnngh histnry and physical est-

aminatinn. The use nf advanced imaging is nften helpful nnnnperatively, thnugh surgical management is snmetimes

El 1016 American AcadMy nf Drthnpaedic Surge-ens

Chapter .12: Ankle and Foot Injuries and Dther Disorders Hey Study Points

1' Ankle sprains represent one of the most common

athletic injuries. Good evidence from high-level studies is available to guide management and treatment decision making.

Dsteoehondral lesions of the ankle respond poorly

to nonsurgical management, and surgical treatment

continues to evolve. The surgical options have different indications. The causes and locations of ankle impingement are

numerous, and both open and arthroscopic proce-

dures are used. Plantar fasciitis can be mimicked by calcaneal stress fracture or tarsal tunnel syndrome.

were in basketball, football, and soccer players. Level of evidence: II. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC: Persistent disability associated with ankle sprains: A prospective examination of an athletic population. .Foot Article Int 1990;19l10j:653-600. Medline DUI Watanabe K, Kitaoka HE, Eerglund L], Zhao ED,

Kaufman KR, An EN: The role of ankle ligaments and

articular geometry in stabilizing the ankle. Cine Biomecb (Bristol, Avon) 2012:2?{2j:139-195. Medline DDI The contributions of the lateral ligaments, the deltoid ligament, and articular geometry in ankle stabilization were investigated. In the unloaded state, the lateral ligaments accounted for T0943 to 80% of anterior stability and the deltoid ligament accounted for 50% to 30% of

posterior stability. Both ligaments contributed 50% to

achieving a good outcome after a Lisfranc injury.

00% of rotational stability. In the loaded state, articular geometry accounted for 100% of translation and 60% of rotational stability.

diagnose a high-risk stress fracture of the foot or

Clanton TD, Campbell K], Wilson K}, et al: Qualitative

Anatomic reduction is the most important factor in A high index of suspicion should be maintained to

ankle. A prolonged recovery and delayed union or nonunion are common after these injuries.

Annotated References 1. Fernandez WE, Yard EE, Comstock RD: Epidemiology of lower extremity injuries among 0.5. high school athletes.

Acad Emerg Med 200?:14{?}:E41-645. Medline DUI

. Waterman BR, Belmont P] Jr, Cameron KL, Deberardino TM, IZirwens ED: Epidemiology of ankle sprain at the United States Military Academy. Arr: ,l Sports Med 2010;33i4}:?9?—003.Medline DDI

Among military cadets, 614 new ankle sprains were re—

ported during 10,511 person-years {53.4 per 1,000 person-years}. Level of evidence: II.

. Kaplan LD, Jost PW, Honkamp N, Horwig J, West R, Bradley JP: Incidence and variance of foot and ankle injuries in elite college football players. Am I Orthop (Belle Mead N]; 2011;40{1}:40-44. Medline

and quantitative anatomic investigation of the lateral ankle

ligaments for surgical reconstruction procedures. I Bone joint Sarg Ara: 2014:96l1ljm90. Medline DD]

Anatomic study of the lateral ligaments of the ankle and subtalar joint found that the ATFL can be found as one to three bands, with the single band originating an average 13.3 mm above the inferior tip of the lateral malleolus on the anterior fibular border and attaching along the anterior border of the talar lateral articular facet an average 1'13

mm superior to the apex of the lateral talar process. The

EFL originates from the fibula an average 5.3 mm anterior to the inferior tip of the lateral malleolus and courses posteroinferior to insert on the calcaneus an average 16.3

mm from the posterior point of the peroneal tubercle.

Attarian DE, McCrackin H], Devito DP, McElhaney JH,

Garrett 1ll'i’Ejr: A biomechanical study of human lateral

ankle ligaments and autogenous reconstructive grafts. An:

} Sports Med 1935;13l6}:3??—331. Medline

DUI

Reed ME, Feibel JB, Dooley BIG, Gina E: Athletic ankle injuries, in Kibler WE, ed: Drtbopaedic Knowiedge Update: Sports Medicine, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010, pp 159-214. This chapter discusses various topics related to athletic ankle injuries and provides further insight inm management of these conditions.

A study of 320 intercollegiate football players found that 231 grass} had a history of foot or ankle injury {1.24 injuries per injured player). Lateral ankle sprains were most common, followed by syndesmosis sprain, MTP dislocation, and fibula fracture.

10. Haytmanek CT, Williams ET, James EW, et al: Radiographic identification of the primary lateral ankle struc-

. Waterman BR, Dwens ED, Davey S, Eacchilli MA, Bel— mont P] Jr: The epidemiology of ankle sprains in the United States. I Horse Joint Surg Am 2010;92l’13j:22?9-2234.

An anatomic study quantitatively described the anatomic attachments sites of the ATFL, |EFL, and PTFL in relation to reproducible osseous landmarks.

The estimated incidence of ankle sprains was 1.15 per

11. Kerkhoffs GM, van den Bekerom M, Elders LA, et al: Diagnosis, treatment and prevention of ankle sprains:

Medline

DUI

1,000 person—years in the United States, and the peak incidence was at age 15 to 15' years. Most ankle sprains

+0 1016 American Academy of Drthopaedie Surgeons

tures. Am1 Sports Med emswsnprs-sr. Medline no:

Drrhopaedic Knowledge Update: Sports Medicine 5

Pr' FT. :5

re a: e: 3

El.

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Sectien 3:1Cnee audLeg

An evidence-based clinical guideline. Br J Spares Med 2fl12;46{11}:354-Efifl.Medline DUI A literature review previded an evidence-based guideline fer the preventien, predictien, diagnesis, surgical treat— ment, and pregnesis ef lateral ankle injury. 11. Kefetelis ND, Kellis E, 1v'iachepeules 5P: Ankle sprain injuries and risk facters in amateur seccer players during a 2-year perind. Am J Sperts Med lflfl?;35[3}:453-466. DUI 13. Petersen W, Rembitzki IV, Keppenburg AG, et al: Treat-

ment ef acute ankle ligament injuries: A systematic review. Arch Urrhep Trauma Serg 2013;133j3}:1129-1141. Medline DUI

Analysis ef I? randnmized centrelled studies and three meta—analyses feund that must grade I, II, and III lateral ankle ligament ruptures can be managed witheut surgery. A semirigid brace sheuld be used, altheugh grade III injuries may benefit frnm shnrt-term immebiliaatieu befere brace use. Level ef evidence: I. 14. Pihlajamsiki H, Hietaniemi K, Paavela M, Visuri T, Mattila 1v"M: Surgical versus functienal treatment fer acute ruptures ef the lateral ligament cemplert ef the ankle in ynung men: A randemiaed centrelled trial. ,1 lines jeirrt SurgArr: 2U1D;92(14}:136?-23T4. Medline

DUI

All .51 active Finnish men with an acute grade III lateral

ligament rupture repertedly returned te previeus activity

level after surgical er functienal nensurgical treatment. There was ne significant difference in ankle sceres, theugh the prevalence nf reinjury was higher after functienal treatment. Level ef evidence: I. 1.5. Takae M, Miyamete W, Matsui K, Sasahara J, Matsushita T: Functienal treatment after surgical repair fer acute lateral ligament disruptien ef the ankle in athletes. Am

J Spur-rs Med 1011;40j2}:44?—45 1. Medline DUI

After P3 feet were treated nnnsurgically and 54 were treated with primary surgical repair fellewed by nensurgical treatment, 3 nensurgically treated feet {10.3%} had a fair te peer result, and all surgically treated feet had a gee-d te excellent result. Level ef evidence: III. 16. van den Bekerem MP, Kerkheffs GM, McCeIlum GA, Calder JD, van Dijk UN: Management ef acute lateral

ankle ligament injury in the athlete. Knee Sarg Sperts

DI

a:

Trauma-rel Arrhresc 2fl13:21{6]:1390-1395. DUI

._I

T:

I: m a: III-1 I: :c

H

1?. Lamb 5E, Marsh JL, Hutten JL, Na kash R, Ueeke MW: |Eellals-erative Ankle Suppert Trial [CAST Greup}: Mechanical suppnrts for acute, severe ankle sprain: A pragmatic, multicentre, randnmised centrnlled trial. Lancet 2fl09;3?3{9653]:5?5-531. Medline DUI A randemised trial ef 534 subjects with severe ankle sprain shewed that primary eutceme was functien at 3 mnnths with Feet and Ankle Scere {PAS}. Patients whe

received the belew—knee cast had a mere rapid recevery

than these treated with the tubular cempressien bandage.

Urthepaeclie Knewledge Update: Sperts Medicine 5 ® ,

13. Haraguchi N, Tega H, Shiba N, Kate F: Avulsieu fracture

ef the lateral ankle ligament cemplmt in severe inversinn

injury: Incidence and clinical eutceme. Am } Spear-ts Med

200?;35i?]:1144-1152.Medline DUI

19. McGuine TA, Ereeks A, Hetsel 5: The effect ef lace-up aukle braces en injury rates in high scheel basketball players. Arr: j Sperts Med 2011;39i9}:134 ill-1343. Medline

DUI

After 1,4Ei} high scheel basketball players with ankle

injury were randemly assigned te a lace-up ankle brace

er a centrel greup, lace-up ankle braces were feund te reduce the incidence but net the severity ef acute ankle injuries. Level ef evidence: I.

ll}. McGuine TA, Hetael 5, Wilsen J, Ereeks A: The effect ef lace-up ankle braces en injury rates in high scheel feetball players. Am }' Sperrs Med 1fl12;4fl{1}l:49-5?.

Medline DUI

After 2,031 high scheel feetball players with ankle injury were randemly assigned tn a lace-up ankle brace er a centre] greup, lace—up ankle braces were feund te reduce the incidence but net the severity ef acute ankle injuries.

Level ef evidence: I.

21. Besien WE, Staple US, Russell 5W: Residual disability fellewing acute ankle sprains. I Herve Jere: Snrg Am. 1955;3T:113T—1143.

23. Jacksen DW, Ashley EL, Pewell JW: Ankle sprains in ynung athletes: Relatinn ef severity and disability. Cffrs

Urrhep Refer Res 19?4;1fl1:1i]1-215.

23. Lentell (3, Has E, Lupe: D, McGuire L, Barrels M, Snyder F: The centrihutiens ef preprieceptive deficits, muscle functien, and anatemic laxity te functienal instability ef the ankle. J Urtfaep Spnrts Pfrys Ther 1995;11:2llfi-215. DUI 24. Hertel J: Functinnal instability fnlle-wing lateral ankle sprain. Spnrts Med Zflflflfififi 1:361—3T'1. Medline DUI 25. Clantnn TU, 1lllli'aldrnp NE: Athletic injuries tn the snft

tissues ef the feet and ankle, in Genghlin M], Saltaman

CL, Andersen RE, eds: Mann’s Surgery ef the Feet and Ankle, ed ELPhiladelphia, PA, Mushy Elsevier, 2fl14, pp 1531-1631 25. Capute AM, Lee JY, Spritzer CE, et al: In vive kinematics ef the tibietalar jniut after lateral ankle instability. Am } Sperts Med 10H?;3?{111:2141-2243. Medline DUI

Nine ankles with unilateral ATFL injuries were bieme

chanically studied and cempared as they stepped en a level surface. A statistically significant increase in internal retatien, anterinr translatinn, and superinr translatinn nf the talus was measured in ATFL~deficieM ankles cempared with the intact centralateral centrels. 2?. Maffulli H, Del Euene A, Maffulli {312}, et al: Iselated anterier talefibular ligament Brestrem repair fer chrenic lateral ankle instability: 9-year fellnw-up. Am J Sperts

Med 1013:41{4J:8ss-sss. Medline net

El 1016 American AcadMy ef Urthnpaedie Surge-ens

Chapter 22: Ankle and Feet Injuries and Either Disurders Lung—term uutcnmes were repurted far 33 nf 42 patients whn underwent Ernstrfim ATFL repair. Twenty-twn patients {53%} returned tn their preinjury activity level, 5 {16%} were at a luwer activity level but still active, and 10 {26%} abandnned active sperts but were still physically active. Level nf evidence: IV.

34. Feminn JE, 1|liaseennn T, Phisitkul P, chigi 1’, Andersen DD, Amendnla A: Varus external rntatinn stress test fc-r radingraphic detectinn nf deep deltnid ligament disruptinn

23. 1i'l'iaIdrnp HE III, 1|I'fli'ijdicks CA, Janssun KS, LaPrade RF, Clantnn TD: Anatomic suture anchnr versus the Brnstriim technique fur anterinr talc-fibular ligament repair: a binmechanical cumpariscm. An: ,1 Sparta Med 2fl12;4fl{11}:259fl-2596. Medline DUI

at the medial gutter and cm AP and mnrtise radingraphs cf the deep deltnid ligament. This finding may imprnve

A cadaver smdy cf 24 fresh-fresen ankles revealed significantly lnwer strength and stiffness in all three repair

gruupe cumpared with the native, intact ATFL. It was determined that repairs must be sufficiently prutected tn avnid premature failure.

23'. Viens Na, 1Wijdicks Ca, Campbell K], Laprade RF, Clantnn TC}: Anterinr talnfibular ligament ruptures: Part 1. Binmechanical cnmparisnn nf augmented Brnstrfim repair

techniques with the intact anterinr talufibular ligament.

Am J Sparta Med 2fl14;42{2}:4fl5-411. Medline

DUI

A cadaver study cf 13 fresh-fruten ankles cnmpared ankles with an intact fiTFL tn thnse with suture tape augmentatinn nr Ernstrfim repair with suture tape augrnentatinn. Strength and stiffness were greater after Ernstriim repair with suture tape augmentatinn in cumparisnn tn the intact ATFL nr the Ernstriim alnne. 3f}. Clantnn TD. Viens NA, Campbell K], Laprade RF, Wijdicks CA: Anterinr talnfibular ligament ruptures. Part 2.

Eiumechanical cemparisnn nf anterinr talnfibular ligament

with and withuut syndesmntic disruptinn: A cadaveric study. FuutAn-ftie int 2fl13;34{21:251 -26fl. Medline

DUI

Varus external rntatiun stress was mc-re effective than valgus external rntatinn stress displacement nf markers detection nf assnciated pathnlngy and instability.

33. Heals TC, Crim J, Hickisch F: Deltnid ligament injuries in athletes: Techniques nf repair and recnnstructiun. Dper

Tech Sports and salnnsmni-ia nnI

Deltnid ligament injuries are a snurce nf valgus and In-

tatiunal ankle instability and uften cccur as a result nf

athletic injury. The anatnmy nf the medial ankle ligament cnmple}: was reviewed, with emphasis nn pertinent radiulngic findings.

36. Chhabra A, Suhhawnng TK, II'Sarrinun JA: MR imaging nf deltnid ligament pathnlngic findings and assnciated impingement syndrumes. Radiogrepbica 2431 fl;3fl{3l:?51T61. Medline DUI MRI technique fur the deltnid ligament was reviewed, with the nnrmal and ahnnrmal appearances nf its cnmpnnents. 37. Savage-Elliott I, Murawski CD, Smyth NA, Gnland P, Kennedy JG: The deltnid ligament: An in-depth review {if anatnmy, functinn, and treatment strategies. Knee Snrg Sparta Tranmetci Artbruaa 2fl13gllifijfl3lfi—1321 Medliue DUI

reccnstructiun using semitendinusus alIc-grafts with the intact ligament. Am J Sports Med lfl14;41{2}:412-416.

The anatnmy and binlngy of the medial ankle ligament cnmplek and treatment strategies were reviewed.

Mlngraft recnnstructinn nf the ATFL led tcr nn significant difference in strength ur stiffness cumpared with the intact ATFL.

33. Gnlanr’i P, Vega J, de Leeuw PA, et al: Anatnmy cf the ankle ligaments: A pictnrial essay. Knee Snrg Sparta Trantnntnf Artbrnac lfllG;lS{S]:SST—SSS. Medline DC}!

31. Eamphell K], Michalski MP, 1Eli'ilscm K], et al: The lig-

This article is an illustrative review uf ankle ligament anatnmy. Several annntated phntngraphs and diagrams nf ankle ligaments in varinus views are presented.

A cadaver anatnmic study detailed the specific cumpunents

35‘. Williams ET, Ahrherg AB, Gnldsmith MT, et al: Ankle syndesmnsis: A qualitative and quantitative anatnmic analysis. Am J Sports Med 1fl15543[11:33-9?. Medline DUI

Medline

DUI

ament anatnmy cf the deltnid cc-mplea cf the ankle: A qualitative and quantitative anatnmical study. J EnneJnfnt Snrg Arn 1f] 14:96l3}:e62. Medline Dfll cf the deltnid ligament cumpler-t, their prevalence, and their relatinnships tn nearby anatnmic structures.

32. Attarian DE, McCrackin H], DeVitn DP, McElhaney JH, Garrett WE Jr: Binmechanical characteristics nf human ankle ligaments. .a-t Ankle 1935;6{1j:54-53. Medline DUI 33. Jenng MS, Chni TS, Kim Y], Kim J5, 1Ii’nung KW, Jung TY:

Deltuid ligament in acute ankle injury: MR imaging anal—

ysis. Skeletal Radial 3&14;43{5 }:655- 563. Medline DUI An MRI study cf 36 patients with acute deltnid injury detailed patterns nf deltnid injury fur the superficial and

deep deltnid and hnw they related tc- cnncnmitant assn-ci-

The anteruinferiur, pusteruinferinr, and intercsseuus tibinfibular ligaments were described in relatinn tn nsseuus landmarks. 40. Williams GIN, Juries MH. Amendnla a: Syndesmutic ankle sprains in athletes. Am J Sparta Med EUDTflSlTlfllFT110?. Medline

DUI

41. Clantnn TU, Her CF, Williams ET, et al: Magnetic resunance imaging characterisatinn nf individual ankle syndesmnsis structures in asymptnmatic and surgically treated cnhnrts. Hnee Sam-g Sparta Trenmatni Artist-sac Ellis; Nev 15. [Published nnline ahead nf print] Medline DUI

ated ankle pathnlngies.

Eb Ifllii American Academy nf Urthnpaedie Surgenns

Drrhnpaedic Knnwledge Update: Spnrts Medicine 3

1.4.} 5'": :5

re en tn 3

El.

3

seasonasnssanateg Preeperative 3—Tesla MRI had excellent accuracy in the diagnesis ef syndesmetic ligament tears and allowed visualizatien ef relevant individual syndesmesis structures.

Asseciatcd ligament iniuries ceuld be readily identified.

4-1. Sikka RS, Fetaer GE, Sugarman E, et al: Cerrelating MRI findings with disability in syndesmetic sprains ef NFL players. Feet Ankle In: 2012:3136 1:3?1-STS. Mcdlinc DUI

MRI findings censistent with increasing grade ef injury

can helped predict number ef games missed in Natienal Feetball League players. Level ef evidence: IV.

43. Laver L, Garment MR, McCen key MID, et al: Plasma rich

in grewth facters {PRGF} as a treatment fer high ankle

sprain in elite athletes: A randemised centrel trial. Knee Snrg Sparta Tranmatel Artistes-r [published enline ahead ef print June 13, 2014]. Medline

DUI

Sixteen elite athletes with an AITFL tear and dynamic syndesmesis instability were randemly assigned te a PRP treatment er a centrel greup. The treated patients returned te play at MILE days cempared with 59.6 days fer these in the centrel greup, and they had significantly less residual pain upen return te activity. Level ef evidence: II.

44.

Jenes MH, Amendela A: Syndesmesis sprains ef the ankle: A systematic review. Cffrt Urtfaep Refet Res

ZflflTHSSHSSHfli-US.Mcdlinc DUI

4-5. Degreet H, Al-Umari AA, El |Ghaaaly SA: Uuteemes ef

suture butten repair ef the distal tibiefibular syndesmesis. DUI

Titanium butten fixatien ef the syndesmesis was effective in maintaining reductien in 1D patients threugheut an almest 2-year fellew—up peried. Device remeval was mere cemmen than anticipated. Level ef evidence: IV.

4?. Haqvi GA, Cunningham P, Lynch E, Galvin R, Awan N: Fixatien ef ankle syndesmetic injuries: lIL'Jemparisen ef tightrepe fixatien and syndesmetic screw fixatien fer accuracy ef syndesmetic reductien. Am ] Sperts Med

2fl11;4fl[12}:2323—1335.Medline ee:

S

'U E I'D Ill I1! I: be:

H

49. Manjee A, Sanders DW, Tiesaer C, MacLeed MD: Functienal and radiegraphic results ef patients with syndesmetic screw fisatien: Implicatiens fer screw remeval. I Gather: Trauma Efllfl:24(1]:2-E. Medline DUI A tetal ef T6 patients underwent functienal testing and radiegraphic review after syndesmesis screw fixatien. Pa-

tients with a fractured, leesened, er remeved screw had a better functienal eutceme than these with an intact screw. Level ef evidence: III.

SD. Sung D], Lanei JT, Greth AT, et al: The effect ef syndesmesis screw remeval en the reductien ef the distal

tibiefibular ieint: A prespective radiegraphic study. Feet Andria Int Efl14:35{fil:543 543. Medline

DUI

Syndesmesis screw remeval can lead te the spentaneeus reductien ef a malreduced syndesmesis. Almest Hfl‘ifz- ef the malreduced ankles were spentaneeusly reduced with

screw remeval. Level ef evidence: IV.

.51. Miller AN, Barei DP, Iaquinte JM, Ledeus WE, Beingcssner DM: Iatregenic syndesmesis malreductien via clamp and screw placement. ] Urtfrep Trauma EDISflT’iEHflU-

1136. Medline DDI

A cadaver study ef 14 dissected legs with cempletc syndes-

45. Tayler DC, Englehardt DL, Eassctt FH III: Syudesmesis sprains ef the ankle: The influence ef heteretepic essificatien. Art: I Sperts Med 1992;.‘Efli21fl46-150. Mcdline DUI

Feet Arr-He fret lflll;32[3]l:25fl—ESS. Medline

screw greup, and 85.3!) in the remeved screw greup {P = {13466}. Ne difference in clinical eutceme ef patients with intact er remeved syndesmetic screws was feund.

mesis disruptien cencluded intraeperative clamping and fixatien ceuld cause statistically significant syndesmesis malreductien.

52. Mitchell ME, Giza E, Sullivan MR: Cartilage transplantatien techniques fer talar cartilage lesiens. ,7 Am Acad Drtbep Surg 2009:1?[?}:4D?—414. Medlinc This review article discusses the anatemy ef talar cartilage and surgical treatment eptiens. The article fecuses especially en autelegeus chendrecyte implantatien and matrix—induced autelegeus chendrecyte implantatien.

53. Easley ME, Latt LD, Santangele JR, Merian-Uenast M,

Nunley ]A II: flsteechendral lesiens ef the talus. I Am. Acad Gil-thee Serg EUIDflSllOkEIE-ESU. Medline A review ef management ef ULTs included indicatiens and centraindicatiens, preeperative evaluatien, arthrescepic precedurcs ldéhridcment, drilling, micrefracturc, and

hene grafting}. medial and lateral epen appreaches, epen

A study cf 46 patients included 23 whe received tightrepe fixatien and 23 whe received syndesmesis screw fixatien. Level ef evidence: II.

chendrecyte implantatien, structural allegra ft transplan—

4-3. Hamid N, Leeffler E], Eraddy W, Kellam JF, Cehen BE, Hesse M]: Uutceme after fixatien ef ankle fractures with an injury tn the syndesmesis: The effect ef the syndesme-

54. Berndt AL, Harry M: Transchendral fractures {estee— chendritis dissecans} ef the talus. ] Barre Jefet Sat-erg Am.

sis screw. j Berra jeint 5mg Br Zflfl9:91{S}:lflES-1fl?3.

Mcdlinc

DUI

The authers present a cnmparative study ef syndesmesis

screws after ankle fracture with asseciated syndesmetic in-

jury. American |[l’vrthepaedic Feet and Ankle Seciety scere was 33.11}? in the intact screw greup, 91.413 in the hreken

firthepaedic Knewledge Update: Sperts Medicine 5

precedures {esteechendral autegraft transfer, autelegeus tatien}, and cemplicatiens and results.

1959;40:115-120.

55. Leemer F... Fisher C, Lleyd-Smith R, Sisler J, Ceeney J: Usteechendral lesiens ef the talus. Am ] Sperts Med

1993:11[IJ:13-19. DUI

fl lfllfi American Academy ef Orthepaedic Surge-ens

Chapter 11: Aulde and Fear Injuries and lEither Disarders SS. Brinberg M, Aglierti P, lEamhardella R, et a1: ICES Carri; lage Injury Evaluatian Package. Third 1633 Sympasium, Gateharg, Sweden, April 23, 2011!]. Available at httpa'iIr www.cartilage.arg. 5?. Hiutertuann B, Regaezaui P, Lampert C, Stute G, Giichter

A: Arthrascapic findings in acute fractures af the ankle.

j’ Eunejainr Snrg Er 2303:32l3}:34§-351. Medliuc

DDI

53. Sugiruata K, Takakura T, Ukahashi K, Samara H, Kawate K, Iwai M: Chandra] injuries af the ankle with recurrent lateral instability: An arthrascapic study. ] Bane faint Snrg Arn 2339;91{1}:99-106. Medline DDI The authars presented a crass-sectianal study af 93 patients undergaing ankle arthrascapy far recurrent instahility. The relatianship herweeu chandral damage, patient factars, injury patterns, alignment, and ether variables was studied. 59. McGahan P], Piuney S]: Current eaucept review: Dsteachandral lesiaus af the talus. Paar Ankle i'nr 1310;31{I}:5i}-

131. Medline DUI

The etialagy, clinical presentatian, imaging, and classifieatian af DLTs as well as treatment with hane marraw stimulatiau, asteachaudral autagrafts, asteachaudral allagrafts, autalagaus chandracyte implantatiau, and autageuaus hane grafting were reviewed. Si}. Stufkens SA, Knapp M, Harisherger M, Lampert C, Hiutermauu E: Cartilage lesiaus and the develupmeut af

astcaarthritis after internal fixatian af ankle fractures: A

praspective study. J Bane Iain: Snrg Arn 2013;933:331??236. Medline

DUI

At lung-term fullaw—up af 139 patients wha underwent

surgical treatment af an ankle fracture, initial cartilage

damage seen during arthrascapy was an independent pre— dictar af pasttraumatic asteaarthritis. Lew] af evidence: I].

SI. Tal JL, Struijs PA, Bassuyt PM, Verhagen RA, van Dijk CH: Treatment strategies in asteachaudral defects af the talar dame: A systematic review. Faut Ankfe Int 2003;! 1 [2} : I 1 9-1 2 S. Medlint': 62. Deal PP, lfluttica D], Smith ”WE, Berlet GE: Dsteachundral lesiaus af the talus: Sire, age, and predictars af autcames. Fact Ankle Cir'n 2313:13i11:13-34. Medline DUI The histarical perspective, predictars af autcames, and uausurgical and surgical treatment aptiaus were presented far asteachaudral lesiaus af the talus. Lesian size, presence af edema an MRI, and patient age were discussed as factars in patient care and autcumes. SS. Yushimura I, Kauaeawa K, Takeyama A, et a]: Arthruseupic haue marraw stimulatiau techniques fur asteachaudral

lesiaus af the talus: Pregnaetic factars far small lesiaus. An: I Sparta Med 2313;4ll3}:523-534. Medline

DUI

iFifty patients with DLTs smaller than 15!] mm1 underwent arthrascapic haue marraw stimulatiau. Deep lesiaus and

lesiaus in patients alder than 40 years had inferiar clinical

autcames. Level af evidence: IV.

I3! 2316 American Academy af Drthapaedic Surgeans

64. Eeugerink M, Struiis PA, Tal JL, vau Diik CN: Treatment af asteachaudral lesiaus af the talus: A systematic review. Knee Snrg Sparta Tremnera! Artbrasc 2013:13IZ}:233246. Medline DGI A systematic review uf treatment strategies for DLTs faund success rates af STS‘J: far asteachaudral autalagaus transplantatian, 35% far bane marraw stimulatiau, P1536 far autalugaus chandracyte implautatiau, 33% far retragrade

drilling, and 33% far fixatian. Because af its relatively law cast and marhidity, bane marraw stimulatiau was identified as the treatment af chaice far primary ULTs.

I55. IElantan TIC}, Jahnsan HS, Matheny LM: Use af cartilage extracellular matrix and h-aue marraw aspirate cauceutrate in treatment uf asteachaudral lesiuns af the talus. Tech Faat Anieie Snrg 2014;13{4}I:212-223. DDI Surgical technique and preliminary results were presented far the use af micrauized cartilage allagraft extracellular matrix and haue marraw aspirate cauceutrate as a saurce

af meseuchymal stem cells ta augment standard micrafracture technique.

66. Daral MN, Bilge D, Eatmae G, et al: Treatment af asteachaudral lesiaus cf the talus with micrafracture technique and pustaperative Hyaluranan injectiun. Knee Snrg Spar-rs Treamerai Arthrasc 2311;Zfl[?}:1393 4433. Medline DID] A praspective randamired study cf 16 patients wha received déhridement and micrafracture alaue and 41 patients wha received déhridemeut and micrafracture as well as a pastaperativc intra-articular hyaluranan injectian faund a significant increase fram preaperative ta pastaperative scares amaug thase wha received injectiun. Level af evidence: I. 5?. Guney A, Akar M, Karaman I, Duet M, Guney E: Clinical autcamcs af platelet rich plasma {PRP} as an adjunct ta micrafracture surgery in asteachaudral lesiaus cf the talus. Knee Snrg Sparta Trenrnutaf Arthrasc 2314; Nev

33 [published auline ahead af print]. Medline DDI

In a study af 16 patients wha underwent micrafracture alane and 19 wha underwent micrafracture plus PEP, thuse whu received PRP had significantly better functiuual scares. Level af evidence: II.

63. Kim TS, Lee H], IEhai Y], Kim YI, Kah YE: Dues an injec-

tian af a stramal vascular fractian cantaiuing adipasc-dc-

rived meseuchymal stem cells influence the autcames af marraw stimulatiau in asteachaudral lesiuns af the talus? A clinical and magnetic resaua nee imaging study. An:

H

MRI af 26 ankles after bane marraw stimulatiau alane

:11 D.

} Sparta Med 1314;42{101:2424-1434. Medline ear

and 24 after hane marraw stimulatiau plus stramal vascular fractiuu injectiau cantaiuing meseuchymal stem cells

revealed significantly better clinical autcamcs in the latter

graup af ankles. Invel af evidence: III.

SS. Chai W], Park EH, Kim 35, Lee JW: Dstcachandral lesian cf the talus: Is there a critical defect sire far paar aurcamei' Am J Sparta Med 23 [19:3 Tilfljfl HIM-1933. Medline DflI

Drrhapaedic Knawledge Update: Sparrs Medicine S

F:

5 m :1: tu-

e

SectiunS:Kneeand1eg This cahart study af Ilfl ankles eza mined asteachandral Iesiun size an the talus and clinical autcame fulluwing arthruscapic marraw stimulatian. Initial defect size was

7’5. Tal JL, Slim E, van Saest AJ, van Dijk CH: The relatianship cf the kicking actian in succer and anteriur ankle impingement syndrame: A biumechanical analysis. Arn I Sparta Med lflfll;30{1}:45-SD. Medline

'P'fl. Kwak SK, Kern ES, Ferkel RD, lIl'llian KW, Kasraeian S, Applcgate GE: Auralagaus chandracyte implantatian af the ankle: E— ta I'D-year results. Ann ,I Sparta Med 2fl14;42{9}:1156-2164. Medline DUI

7’6. Tul IL, van Dijk CH: Etiulugy uf the anteriur ankle impingement syndrame: A descriptive anatamical study. Faat

At lung-term fallaw-up, 29 uf 32 patients whu underwent autalagaus ehandracyte implantatian aI the talus had significant impravement in autcames scares. Lew] uf evidence: IV.

72'7“. Elias I, Zaga AC, Marrisan WE, Besser I'vIP, Schweitzer .l'v'IE, Raikin SM: Usteuchundral lesiuns uf the talus:

faund ta he an impartant praguastie factar.

TI. Yuan HS, Park ‘1’], Lee M, Chai W], Lee JW: Usteachundral autulugaus transplantatian is superiur ta: repeat

arthrasecrpy far the treatment af asteachaudral lesians at

the talus after failed primary arthrascapic treatment. Am 1 Sparta Med 2D14;4l{3]:1396-1903. Medline DUI

After unsuccessful bane marruw stimulatian, 22 patients underwent asteachandral autulaguus transplantatian and 22. underwent repeat arthraseapy. At a mean Sfl-manth fulluw-up, results were better in the patients wha underwent usteachunclral autulugaus transplantatiun. Level uf evidence: III. ?2. Haleern AM, Russ KA, Smyth NA, et al: Duuhle-plug autalagaus asteachandral transplantatian shaws equal functianal autcames campared with single-plug precedures in lesiuns uf the talar dame: A minimum 5-year

clinical fallaw—up. Arn j Sparts Med 2U14;41[3J:1333— 1395. Medline DUI

Faurteen patients with a large ULT treated with dauhle-plug autuluguus asteuchundral transplantatiun were cumpared with 23 patients treated with single-plug autalagaus asteachandral transplantatian. Na statistically significant differences were nuted in uutcumes scures at a mean BS-manth falluw-up. Level af evidence: III. T3. Russ KA, Hannun CF, Deyer TW, et al: Functional and

MRI uutcumes after arthrascupic micrufracture fur treatment af asteachaudral lesiuns at the distal tibial plafand. J Bane ,Iar'nt Snrg Am 2014;96{2fl}:l?flS-I?15. Medline DUI After 31 usteuchundral lesiuns cf the distal tibia were treated with mierafraeture, patient autcarues were im-

praved hut MRI revealed increased lesian size. Level af

E

'U E I'D Ill I1! I: I

H

evidence: IV.

?4. Elias I, Eaikin SM, Schweitzer ME, Besser MP, Marrisan WE, Zuga AC: |[listecz-chandral lesiuns of the distal tibial

Ankfe Int Zflfld-tlilfilrd HE 336.

Lucalizatiun and murphulugic data from 414 patients

using a navel anatamical grid scheme. Faat Ankle Int Zflfl?;23{2]:154-161.Medline DUI 7S. Kim SH, Ha KI, Ahn JH: Tram track lesian af the talar dame. Arifhrue.-:-clli'r_1.I 1999;15{2}:1fl3-206. DUI ?9. van Dijk EN, Verhagen RA, Tal JL: Arthrascapy far pruhlems after ankle fracture. I Bane juirrt Srrrg Br 199?;?9{2}:13fl—134.Medline DUI SD. van Dijk CN, Tul JL, Verheyen CC: A pruspective study uf pragnastic Iactars cancerning the autcame at arthrasaapic surgery far anteriar ankle impingement. Arn I Spares Med 199?;25i6}:?3?—?45.Medline DUI 31. Parma A, Euda R, 1|:iannini F, et a1: Arthrascapic treatment af ankle anteriur bany impingement: The lung-term clinical autcame. Faat Ankle Int 2fi14;35{1}:143-1SS.

Medline DUI

A new classificatian af ankle impingement has lung-term predictive value far the success uf arthruscupic déhride-

ment. Assaciated pathulugy {including chandral lesiuns],

advanced age, ankle marphalagy, and previaus trauma were relevant pragnastic factars. Leml af evidence: IV. 32. Walsh SJ, Twaddle EC, Rasenfeldt MP, ale M]: Arthruscupic treatment af anteriur ankle impingement: A

pruspective study cf 46 patients with 5-year fullaw—up.

Arn ] Sparta Med lflld;42{11}:2?12-2?26. Medline DUI Functianal autcames af 46 patients with arthrascapie anteriur ankle decampressian remained high at 5-year fullaw-up despite radiagraphic recurrence cf the lesiuns. Level af evidence: IV.

B3. Giannini S, Euda R, Masca M, Parma A, Di |lilapriu F: Pus-

teriar ankle impingement. Feat Ankle Int lfllfigfidfiirdfl-

455. Medline DUI

plafand: Lacalizatian and marphalagic characteristics

Treatment algarithms far pasteriar saft-tissue and hany impingement were presented, including warkup and treatment aptians.

Using a nine-zune grid system fur the articular surface uf

34. Hedrick MR, McEryde AM: Pasteriur ankle impingement. Fuut Ankie Int 1954;IS(1}:2-E. DUI

with an anatamical grid. Paar Ankle Int lflflflfiflifilfild529. Medline DUI

the distal tibia, MRI scans item 33 patients were reviewed

and lacatians were assigned far asteachandral lesiuns cf the distal tihial plafund. Na lucatiun had a preduminant incidence, and su-called kissing lesiuns were rare. Level

af evidence: II.

Urthnpaeclic Knawledge Update: Sparta Medicine S

35. Mauhsine E, Crevaisier I, Leyvraz PF, Akiki A, Dutait

M, Uarafala E: Past~traumatic averlaad ar acute syndrume cf the us trigunum: A pussihle cause of pusteriur ankle impingement. Knee Srrrg Sparts Trenrnatai Arthrasc lfifl4;12{3}:250-253.Medline DUI

U lfllfi American Academy af Urthupaedic Surge-ans

Chapter 1.1: Anlde and Fear lniuries and Uther Disardera

36. Willits K, Sanneveld H, flmendala PL, Giffin JR, Griffin

5, Fawler P]: Uuteame af pesteriar ankle arthrnscapy far hindfaat impingement. Arthrascapy 2D flS;24[2]I:196 4102. Medline

DUI

is mare effective in relieving heel pain than the use af fnat artheses alane.

3?. Ldpea 1ivi'aleria V, Seijaa R, Alvarez P, et a1: Endaacapic

96. 1|Wang C], 1|Wang F5, Tang KD, Weng LI-I, Kn J‘I’: Langterm results af eatracarpareal shackwave treatment far plantar fasciitis. Am ] Sparta Med 2DGfi;34{4}:592-59E.

triganum in saecer players. Faat Ankle Iat 1015;36{1}:7flP4. Medline DUI

9?. Parter MD, Shadhalt B: Intralesianal carticasteraid injec-

The pesterinr impingement synd tame assnciated with an as triganum was described. Twenty saccer players un-

tar fasciapathy. Gift: I Spa-rt Med 3005;15{3};119-134,

repair nf pasterinr ankle impingement syndrame due ta as

derwent pasteriar anltle arthrascapy with exeisian af the

as trigannm. Pain scares significantly decreased 1 manth after surgery, and patients returned ta preinjury levels 46.9

days after surgery. Level uf evidence: IV.

33. Murawslti CD, Kennedy JG: Anteramedial impingement

in the ankle iaint: Uuteames fallawing arthraseapy. Am

I Sparta Med Zfllflfiflflfllflflfirlflld. Medline DUI

39. Lareau CR, Sawyer GA, 1Wang JH, DiGiavanni CW:

Plantar and medial heel pain: Diagnasis and management. ] Am Acad Urtfaap Surg 2014;12ffi}:3?2-330. Medline DUI

Anatamy, etialag‘fr': treatment aptians, and auteames af plantar fasciitis were reviewed.

Medline

DUI

tian versus extracnrp-areal shack wave therapy far plan-

Medline DUI

9E. Manta RR: Platelet-rich plasma efficacy versus carticasteraid injectian treatment for chrnnic severe plantar fasciitis. Pant Ankle fut 2014;35i4}:313-313. Medline DUI

Party patients with plantar fasciitis were randamly as-

signed ta carticasteraid injectian at PEP injectian. These wha received the PRP iniectian had a mare durable and effective respanse than thase wha received the steraid

injectian. Level af evidence: I.

99. Landarf KB, Keenan AM, Herbert RD: Effectiveness af faat arthases ta treat plantar fasciitis: A randamiaed trial. Arch Intern Med EflflfitlfififllltflflS-ldlfl. Mediiue

DUI

9!}. Danley EU, Maare T, Sferra J, Gaedanavic J, Smith R:

100. Eader L, Parlt K, Eu Y, U'Malley M]: Punctianal autcame af endascapic plantar fasciatamy. Faat Pinkie Int 2012:33i1}:3?—43.Medline DUI

randamieed, praspeetive, placeba-eantralled study. Feat

Patients had rapid impravement in chranic sytnptams with law marhidity after undergaing endascapic plantar fascintamy. Lavel nf evidence: IV.

91. Digiavanni BF, Hawaczenslti DA, Malay DP, et al: Piantar fascia-specific stretching exercise impraves autcames in patients with chranic plantar fasciitis: A praspective clinical trial with twn-year fallaw—up. }' Bane jat'ut Surg Am 2Dflfi;33{3l:1??5—1?31. Medline DUI

101. Manteaguda M, Maceira E, Garcia-Vina V, Canasa R: Chrnnic plantar fasciitis: Plantar fascintamy versus gastracnemius recessian. Int Urtfaap 1fl13;3?{9]:1345-1350. Medlinc DUI

The efficacy af era] nansteraidal anti-inflammatary medicatian {NSAID} in the treatment af plantar fasciitis: Pl. Pinkie Irtt EflflTtlflil}:ZD-23. Medline

DUI

91. Radfard 1A, Landarf KB, Euchhinder EL, lElaalt C: Ef—

fectiveness af calf muscle stretching far the shart-term treatment af plantar heel pain: A raudumised trial. EMU Muscufaskefet Disard lflfl?;fl:36. Medline DUI

93. Hyland MR, Wehher- l[Saffney A, Cahen L, Lichtman PT:

Randamieed cautralled trial af calcaneal taping, sham

taping, and plantar fascia stretching far the shart—term management af plantar heel pain. I Urtfrap Sparta Phys

Ther aeesastsyssv-svi. Medline ual

ZUUSflflUDUUUdIE. Medliue

9.5. Lee WC, Wang WY, Hung E, Leung AK: Effectiveness of

adjustable darsiflevtian night splint in camhinatian with accamrna-dative fact arthasis an plantar fasciitis. J Refrafrff DUI

The use af darsifleatian night splints in canjunctian with

feet arthases far the treatment af chtanic plantar fasciitis

IE! lfllfi American Academy af Urthapaedic Surgeans

fasciatamy campared with 95% after preaimal medial gas-

tracnemius release. Patients in the gastracnemius release graup had much-impraved functianal and pain autcame scares and fewer camplicatians. Level af evidence: I'v'. 101. Saxena Pt, Fullern E: Plantar fascia ruptures in athletes.

Am I Sparta Med 2904;32{3J:EEE-665. Medline DUI

IDS. Nunley JA, 1'v"ertulla C]: Classificatian, investigatian, and

94. Crawfard F, Thnmsan C: Interventians far treating plantar heel pain. Cnchrarve Database Syat Rea

Res Dev lflll;49[1l]}:lSST-1 SE4. Mctllinc

Thirty patients underwent partial plantar fasciatamy, and 3'!) underwent praatimal medial gastracnemius release. The result was satisfactary in Efl'if. after partial plantar

management af midfaat sprains: Lisfranc iniuries in the athlete. Am } Sparta Med lflfll;3flifi}:BTI-ETE. Medline

104. Hear 5, Femina J, Marag ‘1’: Lisfranc jaint displacement fallawing sequential ligament sectianing. ] Bane faint Sarg Am lflfl?:fl9ilfl}:2215u1231. Medline DUI 105. Gallagher SM, Rndriguea NA, Andersen CR, Uranherry WM, Panchhhavi VK: Anatamic predispaaitian ta ligamentaus Lisfranc injury: A matched case-central study. ] Barre faint Sttrg Am 2013;95illltlfi43-2fl41 Medline DUI

Urthapaedic Knnwledge Update: Sparta Medicme 5

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Sectinndflfneeentlleg A retrnspective case—central study cf 26 patients with Iigamentnus Lisfranc injury and 52. cnntrc-l subjects fnund that the patients with Lisfranc injury had a significantly

smaller ratic: nf seccnd metatarsal length tn fcnt length.

Level nf evidence: III.

106. I-Iaytmanelr CT, Clantnn TC}: Ligamentnus Lisfranc injuries in the athlete. Dper Teck Sperts Med Efl14:32{4j:31332f]. DUI Mechanism nf injury, clinical decisinn making, radiugraphic evaluatinn, treatment nptinns, and surgical apprnach were reviewed far liga mentnus Lisfranc injuries. 111?. Henning JA, jnnes CE, Sietsema DL, Enhay DR, Andersen JG: Dpen reductinn internal fixatinn versus primary arthrndesis fnr Lisfranc injuries: A prnspective randc-mised study. Pent Ankle Int lflDH;3fi{1flj:913-911. Medline DUI A prnspective randnmiaed trial nf surgical treatment cptinns fur Lisfranc injuries is presented. Fnrty patients underwent nip-en reductirm and internal fixatinn nr pritnary arthrndesis. Arth redesis was asseciated with significantly fewer secnndary surgeries. There was up difference in SEE-Item Shnrt Fnrm nr Shnrt Fnrm Musculnslreletal Func-

tinnal Assessment scares between cnhnrts.

lflfl. Ly TV, Cnetaee JC: Treatment nf primarily ligamentnus Lisfra nc jnint injuries: Primary arthrndesis cnmpared with npen reducrinn and internal fixatinn. A prnspective, randnmized study. ] Ennejnfnt Snrg Am lflfldflflfljrfi14-51fl. Medline DUI 1139. Sheibani-Rad S, Cnetzee JC, Giveans MR, DiGinvanni C: Arthrndesis versus DRIP fc-r Lisfranc fractures. Drrknperft'cs 2012;35lfi}:e363-e3?3. Medline DD] A systematic review pertaining tn primary arthrndesis and

npen reductinn and internal fixatinn nf Lisfranc fractures fcund that bcth prncedures prnvided equivalent satisfac-

tnry results, althnugh clinical nutcnmes may be slightly better after primary arthrndesis.

111]. Marsland D, Bell-ruff SM, Snlan MC: Binmechanical analysis nf endnbuttnn versus screw fiJ-ratinn after Lis-

franc ligament cnmples. sectiening. Feet Ankle Snrg 2fl13;19j4}:EET-2?2.Medline

f

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In a cadaver study, 24 fresh-frnaen feet were assigned tn titanium butt-n cI-r screw iii-ratinn and subsequently were lnaded tn 343 H and subjected tn 1l],IIDlI cycles. After initial leading, Li] tnm cf diastasis was nbserved in the buttnn grnup cnmpared with nn diastasis in the screw grnup. After cyclic Inading, diastasis in the buttnn grnup

decreased tn IL? mm, and the screw grnup was unchanged.

111. lflenrge E, Harris AH, DragnnjL, Hunt K]: Incidence and tislr factnrs fnr turf tne injuries in intercnllegiate fnntball: Data frnm the Natinnal |lillnllegiate Athletic Assnciatinn injury surveillance system. Punt Ankfe Int 2014;35{21:111311.5. Medline DUI

Turf tee is a cnmmnn fnntball injury that usually affects skill-pnsitinn players. Apprnpriate acute and lung-term management is required. Level bf evidence: IV. 111. Clantnn TU, Butler JE, Eggerl: A: Injuries tn fl1e metatarsaphalangeal jnints in athletes. Fun: Ankr'e 1936;?[3]:1611T6. Mcdlinc

1131-

DUI

Crain JM, Phancau JP, Stidham K: MR. imaging cf turf

tee. Megn Reece Imaging Clin N Am 2DGS;16{1}:53-Ii}3,

vi. Medline

DUI

114. Waldrnp NE III, Eirlrer CA, 1|liii'ijdiclrs EA, Laprade RF, Clantcrn TD: Radingraphic evaluatinn nf plantar plate

injury: An in virus binmechanical study. Feet Ankle Int 2313;34j3}:4fl3—4fl3.Medline

DUI

Histnrical evaluatinn cf turf tc-c injury has been qualitalive. This study prnvided quantifiable data an the severity nf plantar plate injuries, which may prnvide guidance tn

physicians. Three millimeters nf difference in excursic-n frnm the intact state indicated a three-ligament injury.

115. lIEnhen BE: Hallur-r sesame-id disnrders. Feet Ankle Elise Eflfl9;14{1}:flI-lfl4.Merlline

DUI

This review article {if hallux sesamnid disnrders nutlined treatment nf several sesamnid pathnlngiee, including acute fractures, stress fractures, nnnuninns, estennecresis, and chnndrnmalacia. 116. Bichara DA, Henn RF III, Thendnre GH: Sesamnidectnmy fnr hallus: sesamnid fractures. Pent Ankfe Int

1012;33j9}:?fl4-?fl6.Medline nnI

Sesamnid resectinn is a gnnd nptitm after unsuccessful

nnnsurgical treatment. Twenty-twn cf 24 patients returned tn full activity at a mean 11.6 weeks after surgery. Hallus valgus nccurred in nne patient. Pain levels significantly

improved as patients returned tn full activity. Level c-f evidence: IV. 11?. Maquirriain ], Ghisi JP: The incidence and distributien

nf stress fractures in elite tennis players. H:- j Spnrts Meal EDI] fi;4l}{5 1:454 455', discussinn 455'. Medline DUI

113. Haeding CC, Spindler KP, Amendnla A: Management nf trnublesnme stress fractures. Instr Currrse Leer

lflfl4;53:455-469. Mcdline

119. Lawrence 5], Butte M]: jnnes’ fractures and related fractures cf the prnsrimal fifth metatarsal. Pent Ankle 1993:14j6}:353-365.Medline D-EIII Ill]. lIEarreira D5, Sandilands SM: Radiegraphic factnrs and effect nf fifth metatarsal Juries and diaphyseal stress fractures cm participatinn in the NFL. Punt Ankfe Int 2D13;34[4}:513-521. Mcdline DUI A study cf the effect cf prnirimal fifth metatarsal fractures an the number nf games played, numhm nf games started, and number nf years played in the Natinnal at-

ball League fcund nu statistically significant differences

Drthnpaedic Knnwledge Update: Spnrts Medicine 5

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Chapter 1.1:An1de and Foot Iniuries and Uther Disorders

between players with a fracture and those in the control

dorsal fragmentation or esostosis at the graft site occurred

111. Chuckpaiwong E, Queen RM, Easley ME, Nunley JA:

11?. McCormick JJ, Bray EB, Davis WH, Cohen BE, Jones CP III, Anderson RE: Clinical and computed tomography evaluation of surgical outcomes in tarsal navicular stress fractures. Am J Sports Med ED11;39{S}:1?41-1?4S. Medline DUI

group. Level of evidence: 1'11.

Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. ln Urtlrop Relut Res lflflfl;466{fl}:1SEE-19?fl.Medline DUI

122. Torg J'S, Balduini FC, Eellto RR, Pavlov H, Peff TC, Das M: Fractures of the base of the fifth metatarsal distal to the tuberosity: ISlassification and guidelines for non-surv gical and surgical management. J Bone Joint Sttrg Ant 1934:66llififlfl-214. Medline 123. Uchenjele G, Ho E, Switaj PJ, Fuchs D, Goyal N, Kadaltia

AR: Radiographic study of the fifth metatarsal for opti‘

in four patients. Level of evidence: IV.

Healing and bony union of navicular stress fractures were evaluated with CT in 10 patients an average 42.4 months after surgery. Eight had bony union, of whom

6 had residual lucency of 1 to 2 mm, although it proved

clinically insignificant. Both patients with nonunion had a complete, displaced fracture on preoperative imaging. Level of evidence: IV.

mal intramedulla ry screw fixation of Jones fracture. Foot Anltle Int 2015;36{3}:293-3fl1. Medline DUI

123. Khan KM, Fuller PJ, Brukner PD, Kearney C, Hurry

In a retrospective review, 119 patients underwent three-di-

of navicular stress fracture in athletes: Eighty~sis cases proven with computerized tomography. Am J Sports Med 1991;2fll6}:65?—SSS.MedIine DUI

mensional CT of the foot tn determine measurements of the fifth metatarsal.

HE: Uutcome of conservative and surgical management

124. Lee KT, Park TU, Young KW, Kim JS, Kim JR: The plantar gap: Another prognostic factor for fifth metatarsal stress fracture. Am J Sports Med 2011:39i1fl}:22fl6-2211. Medline DUI

129. Torg JS, Moyer J, |Graughan JP, Boden BP: Management

In T5 patients with fifth metatarsal stress fracture treated with tension-band wiring, factors such as the plantar gap may help guide treatment, especially in patients at high risk for nonunion. Level of evidence: III.

A meta-a nalysis included 313 tarsal navicular stress frac-

12.5. Mallee TH, Wee] H, van Dijlt CH, van Tulder MW,

Kerkhoffs GM, Lin CW: Surgical versus conservative

treatment for high-risk stress fractures of the lower leg

{anterior tibial corteit, navicular and fifth metatarsal base}: A systematic review. BrJ Sports Med 1015;49{63:3Tfl -376. Medline DUI

A systematic review of the literature pertaining to three

stress fractures of the lower extremity included eight studies {246 fractures} on proximal fifth metatarsal stress fracture. Pooled results produced a weighted mean time to return to sport of 13.3 weeks after surgical treatment and 19.2 weeks after nonsurgical treatment. For navicular stress fracture, eight studies {Elli} fractures} had a weighted mean time to return to sport of 16.4 weeks after surgical treatment and 21.? weeks after nonsurgical treatment. Because of the low-quality evidence and high risk of bias, recommendations for standard of care could not he made. Level of evidence: 11".

126. Fishman FG, Adams SB, Easley ME, blunley JA II: Vase cularited pedicle hone grafting for nonunions of the tarsal navicular. Foot Ankle Int 2012:33i9]:?34-?39. Medline DUI The limited blood supply of the navicular and difficulty in treating nonunion or osteonecrosis led to a technique using vascularieed bone graft from the cuboid, second cuneiform, or third cuneiform to aid navicular healing. In seven patients with a mean 41] -month radiographic follow-up, no cystic change or collapse was noted, although

of tarsal navicular stress fractures: conservative versus

surgical treatment: A meta—analysis. Am J Sports Merl 2fl10;33{5 1:1fl4S-1fl53. Medline DUI

tures from 13 different reports. No statistically significant difference was noted in terms of successful outcome and time to return to sport between non-weight-bearing nonsurgical management and surgical fixation. Nonsurgical

management with weight hearing was statistically inferior to non-weight—bearing management.

130. Moher D, Liberati A, Tetalaff J, Altman DG; PRISMA

Group: Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Int J Surg 2010;3[5]:33E—34I.Medline DUI

A review and guidelines statement for conducting ethical

and highwquality systematic reviews is presented. The article specifically reviews the history of UUURUM and its subsequent evolution to PRISMA.

131. IGross CE, Nunley JA: Medial-sided stress fractures: Me-

dial malleolus and navicular stress fractures. Uper Tesla Sports Med 2fl14:22{4}:256—3fl4. DUI

This article reviews the diagnosis and treatment of medial-sided stress fractures of the foot and ankle, as well as specific surgical techniques. 132. Caesar BC, McCollum GA, Elliot R, Williams A, Calder

JD: Stress fractures of the tibia and medial malleolus. Foot Ankle Clln lfllSflSlZIflSS-SSS. Medline

The incidence, pathophysiology, clinical presentation, diagnosis, and treatment options for stress fractures of the medial malleolus and tibia were reviewed. 133. Steinbronn DJ, Bennett GL, Kay DE: The use of magnetic

resonance imaging in the diagnosis of stress fractures of

the foot and ankle: Four case reports. Foot Ankle Int 1994;15[2}:3[l-33.Medline

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erative treatment. Strand ] 3mg 1fl11;101{4}:261-264.

135'. Sure-ceann A, Sidhwa F, Aarahi 5, Kaufman A, Glasebrnclr. M: Surgical versus nunsurgical treatment of acute Achilles tendon rupture: A meta-analysis cf randnmize-d

In a retrnspective review nf medial mallenlar stress frac— ture in If] patients, 5 patients initially were managed with pain-free limited weight bearing, thnugh all .5 pruceeded tn

A meta-a nalysis cf 1!} smdies cumparing surgical and nunsurgical treatment {if acute Achilles tendnn rupture found

134. Lempainen L, Liimatainen E, Heikkilsi J, et al: Medial mallenlar stress fracture in athletes: Diagnusis and up-

Medline DUI

surgical fixatinn after nu radiugraphic signs cf healing 4 tn

6 mnnths after diagnnsis. Five patients underwent surgical fixaticn because uf small diastasis an MRI nr lung-standing symptcms. In all 10 patients, nn fracture was visible an initial plain radiugraphs althuugh subsequent MRI revealed the fracture and discnntinuity cf the cnrteir. All 1|]| fractures were clinically healed 3 [D 4 mnnths after

surgery. Level uf evidence: IV.

135. Maffulli H, Lungn UG, Maffulli GD, Rabitti C, Khan-

na A, Denarc V: Marked pathulngical changes prmri-

mal and distal tn the site nf rupture in acute Achilles tendtm ruptures. Knee 5mg Sparts Tranmatnf AHA-rust: 2fl11,19[4}:6fifl—63?.Medline DUI

Micruscupic analysis cf the histupathulugic features c-f

tendun tissue samples frnm 29 patients with an Achilles tendun rupture and 11 central subjects when had died c-f cardiuvascular causes fuund that patients with a rupture had prufnund histupathulngic changes th rnughuut the ten— dnn and the central su bjects had little pathnlngic change.

136. Raikin 5M, Garras DH, Krapchev PU: Achilles tendnn injuries in a United States pnpulatiun. .Fnert Ankle Int 2fl13;34{4}:4?5-43i}.Medline DUI A retruspective review nf 436 patients with Achilles tend-an rupture fuund that 215 ruptures {63%} were the result cf spurts activity. The most cummunly invnlved spurt was basketball. Injuries in patients nlder than .55 years and

patients with a high hudy mass index were mere likely tn

nccur in nunspnrts activities, and the diagnnsis was more likely tn be initially unrecngnised. Level nf evidence: II. 13?. Garras DIN, Rail-:in 5M, Bhat SE, Taweel H, Karanjia H: MRI is unnecessary fur diagntising acute Achilles tendnn ruptures: Clinical diagnnstic criteria. Gift: flrthup Relat Res 2012;4TfllfllfllfiS-filfi. Medline DUI A retruspective cnmparisen nf Eli patients with a surgically c-anfirmed acute Achilles tendnn rupture cm ME] and 66 patients withuut a prenperative MRI fc-uncl that three

clinical findings {an abnurmal Thumpsun test, decreased

E

'U E I'D Ill I1! I: he:

H

resting tension, and palpable defect) were present in all patients and were Illll'ifi sensitive. MRI was less sensitive

and was read as inconclusive in twu patients. Level nf evidence: II. 133. Juries I'vIP, Khan R], Carey Smith RL: Surgical interventinns fur treating acute achilles tendnn rupture: Key findings frnm a recent Cnchrane review. J Bone faint Surg Am

2011;94f11}:e33.Med|ine um

A Iflirtehrane review cf 14 studies ccmpared surgical and

nunsurgical treatment nf acute Achilles tendnn rupture. The results supp-titted surgical treatment, althuugh it was assnciated with mere infecticrns than nensurgical treatment. The risk was reduced with percutaneuus techniques.

®

firthnpaedic Knnwledge Update: Spurn: Medicine 5

trials. ,7 Bane Irvin: Snug Am 2012;94[231:21 35-2143. Medline DflI

that functiunal rehabilitatiun with early range-uf—mutic-n

exercises decreased the risk nf rerupture tn cle-se te- that uf surgery, with fewer cumplicatinns. Level of evidence: I. 1413'. Eergkvist D, Astrtim I,]nsefssnn PD, Dahlherg LE: Acute Achilles tendcn rupture: A questinnnaire fullnw-up nf 415i?r patients. I Butte faint 3mg Ant 2011,94[13}:1229-1133.

Medline DUI

A recurds review cf 43? patients with an acute Achilles tendc-n rupture fuund that the rerupture rate was 3% after

surgical treatment cumpared with 6.6% after functic-nal

nunsurgical treatment. Level nf evidence: III.

141. Barfnd KW, Benclte J, Lauridsen HE, Ban 1, Ebsltcv L, Truelsen A: Hnnnperative dynamic treatment nf acute Achilles tendnn rupture: The influence uf early weight-bearing crn clinical nutcc-me. A blinded, randumizecl cnntrulled trial. _,I Barre Joint Surg Am lflI4;96{13}:I49?-15f13.

Medline

DflI

Patients received nensurgical functic-nal treatment fer acute Achilles tendtm rupture based nn full weight bearing {29 patients} ur nun—weight hearing [2? patients}. There were nu hetween~grunp heel~rise test nr mean scare differences. The patients when were weight bearing had a better

health-related quality nf life. Level cf evidence: I.

142. Enable-ch K, Schreibmueller L, Kraemer R, Jag-Ddsinslti M, Vugt PM, Redeker J: lBender and eccentric training in Achilles mid-pnrtinn tendinnpathy. Knee Sutg Spur-ts Tranmatul Arthtnsc lfllfl;13{5}:E4S-555. Medline DUI In 53 patients whu underwent eccentric training fc-r treatment nf midpc-rticrn Achilles tendinnpathy, men with symptums had significantly better reductinn in pain and imprnvement in scares than wc-men with symptnms at 11-week fnllcrw-up. Level nf evidence: III. 143. Schun LC, Shcrres JL, Fart: FD, 1|lift-ta AM, Camire LM, Guytcun GP: Flexnr hallucis Icrngus tendctn transfer in treatment nf Achilles tendinusis. j Bane faint Sat-g Am 2013;95l1]:54-60.Medline DUI A study cf 46 sedentary patients {average age, 54 years} whn underwent Hester hallucis lungus tendun transfer fur

treatment uf insertic-nal nr midsubstance Achilles tendinc-

sis fnund significant imprnvement in Achilles tendnn functitm, physical functinn, and pain intensityr at 24-mnnth fnllciw-up. Level of evidence: IV. 144. van Dijk EN, van Sterlcenbnrg MN, Wiegerinclt JI, Karis-

snn _|, Maffulli N: Terminulugy fur Achilles tendc-n re—

lated disnrders. Knee Sarg Spain‘s Tranmatcf Arthrnsc 2fl11;19{5}:335-fl41. Medline DID] Inctmsistencies in terminulugy used fur Achilles tendtm

pathnlngy were nutlined. The preferred terminals-g}.T and

fl 211115 American Academy nf Urthnpaedic Surge-ans

Chapter 1.2: Amide and Feet lniuries and lEither Diserders

classificatiens ef Achilles tenden and related diserders were presented.

145. Wiegerinclt JI, Eel: AC1, van Dijlt CN: Surgical treat-

ment ef chrenic retrecalcaneal bursitis. Arthrescepy 2012;23{2}:233-293.Medline

DUI

A systematic review [if surgical treatment uf chrnnic

A systematic review ef surgical and nensutgical treattnent

ef insertienal Achilles tendinepathy reperted en 451 pre-

cedures in 433 patients. Patient satisfactien was high in all surgical studies, ESWT appeared effective in nencalcific

insertienal tendinepathy, and fleer-level eccentric exercis-

es had higher patient satisfactien than full range-ef-metien eccentric exercises. Level ef evidence: III.

retrecalcaneal bursitis reperted en 54‘? precedures in

461 patients. Patient satisfactien and centplicatien rates favered endescepic surgery ever epen surgery. Level ef evidence: IV. 145. Nichelsun CW, Berlet GE, Lee TH: Predictien ef the

success ef neneperative treatment ef insertienal Achilles

tmdinesis based en MRI. Feet rink is Int 200?;23f4}:412-

42?. Medline DUI

14?. Mashhad H, Simen JV: The effectiveness ef extracerper real sheclt wave therapy en chrenic Achilles tendinupathy: A systematic review. Feet Ankle Int 2fl13;34[1]:33-41. Medline

A repert ef feur randemired centrelled studies cencluded there was satisfactery evidence fer the effectiveness ef lew-energy ESWT at a minimum 3-menth fullew-up. fl.

cemhinatien ef ESWT and eccentric leading had superier

results. Level ef evidence: I.

143. Wiegerinclt JI, Kerkheffs GM, van Sterltenhurg MN, Sierevelt IN, van Dijk EN: Treatment fer insertienal Achilles tendinupathy: A systematic review. Knee Surg Sperts Treneretef Arthresc 2013:21f6}:1345—1355. Medline DUI

Vida-e References 22.1: Ferltel RD, Stuart KI}: Antefegens Chmndrecyte Inepi'errtesien [videe excerpt]. Van Huys, CPL, 2fl11. 22.2.: Glaaehrunlt l'vl: Cunventienal Treatment - Dehridement

Abrasien Micrefracture Drilling [videe excerpt]. Halifax, Neva Scetia, 2011.

12.3: Hangedy L: BA TS Precedere [videe excerpt]. Budapest, Hungary, 1011. 22.4: Cectsee JG: Aeterier Ankle fmpingemeet [videe excerpt]. Edina, MN, 2011. 22.5: Wiegerinck 11, de Leeuw PA, van Dijk EN: Pesterier Arnhfe Arthrescepy - fmpingemerst Us Trigennm FHL Tenesynerritis [videe excerpt]. Amsterdam, Netherlands, 2D11. 22.6: Wiegerinclt JI, de Leeuw PA, van Dijlt CN: Hegfrrrtd

Defermity, Achilles Prefrfems. [videe excerpt]. Amsterdam, Netherlands, 2011.

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Drthepeedic Knewledge Update: Sperrs Mediums 5

Rehabilitation '

a. ECTIDN EDITURS

Chapter 23

Current Concepts 1n

Rehabilitation of Rotator Cuff Pathology: Nonsurgical and Postoperative Considerations George I. Davies, M D, DPT, h-‘IEd, PT, SCS, ATC. LAT, CSCS, PES, F151 PTA

Abstract

Rehabilitation of the patient with rotator cuff pathology

requires a comprehensive physical examination and evidence-based rehabilitation focusing on restoring

normal joint motion, scapular stabilization, and ro-

tator cuff strength. Many patients with rotator cuff tendinitis, impingement, and partial- and full-thickness tears can return to full activity by means of a complete

rehabilitation program. Patients who ultimately undergo rotator cuff repair benefit from early range of motion

and progression of rehabilitation exercises to treat both

range of motion and strength deficiencies.

Keywords: shoulder: rotator cuff; rehabilitation Introduction

Shoulder pain and conditions comprise one of the more common musculoskeletal problems that occur and can

affect 16% to 11% of the population.1 Rotator cuff pap thology can comprise up to Efl‘h’s of all shoulder condi-

tions. Although several mechanisms have been reported

to produce rotator cuff injury, one of the more commonly described mechanisms is shoulder impingement, or

Several types of shoulder impingement have been defined in the literature, including primary, secondary, and internal impingement syndromes. The history, mechanism

of injury, subjective comments by the patient, examina-

tion, and imaging studies all are used to identify the specific condition, and most important, the causative factors

of the impingement.2 Primary impingement usually results from three major causes: encroachment of the rotator cuff in the subacromial space because of swelling or scarring

of the pain-generating structures, acromial morphologies {type II or type III acromion], or a selective hypomobility

of noncontractile tissues such as the capsule, capsular

ligaments, and fascia] tissue. Secondary impingement

usually results from microinstahility of the glenohumeral

joint, often because of acquired ligamentous laxity, in-

adequate dynamic muscular stabilixation, and scapular dysfunction.J Internal impingement is commonly involved in overhead athletes or when the arm is used in an abducted, externally rotated, and horizontally extended position.‘ In addition to the listed conditions that can

cause impingement, most patients will also have neuro-

muscular dynamic stability deficits of the scapulothoracic and glenohumeral musculature. Nonsurgical Treatment

compression.

1"i'Ili'hc-n treating patients with subacromial impingement

Dr. Eilenbecker or an immediate family member serves as

dalities, postural exercises, stretching for tight contractile

an unpaid consuitant to Them-Band Hygenic. Neither Dr.

Davies nor any immediate family member has received anything of value from or has stock or stock options held

in a commercial‘ company or institution reiateri directiy or indirectiy to the subject of this chapter.

@ lflld American Academy of Drthopaedic Surgeons

syndrome, a multimodal approach is usually performed that includes, but is not limited to, physical therapy momusculotendinous units, mobilization for tight noncon~

tractile tissue, taping techniques, movement reedueation of the entire kinematic chain, and strengthening of the

entire kinematic chain including legs, core, scapulothoracic, and glenohumeral links. This includes rotator cuff,

Orthopaedic Knowledge Update: Sports Medicine 5

uoneuucjeuau :1;

Todd S. Ellenbecl-ter, DPT, MS, SCS, DCS. |CECE

Section 4: Rehabilitation

scapular, and total arm strengthening, neuromuscular dynamic stabilization exercises, and advanced functional specificity exercises:l Clinicians have an ethical obligation to do everything appropriate to help the patient recover

After training, functional test outcomes increased during

modal approach and the potential interaction of various

provements in these functional outcome measurements. One conclusion from these studies is that performing

indicates the best practice pattern during the early phases of rehabilitation, many of the aforementioned treatment

es can still improve multiple-joint functional movement

and return to activity. However, because of this multi—

interventions, it is not clear which are most effective and which may be unnecessary. Because no high—level evidence interventions that customize specific interventions to the

patient and the cause of the problem can be applied. The section of this chapter discussing nonsurgical E

.E 4.! I'll .1: :5

I15 .E d? fl'.’ E

both a closed kinetic chain {weight hearing} test and an

open kinetic chain {throwing} test. This study found that subjects who never performed functional multiple-joint movement activity during training demonstrated im— isolated shoulder exercises without multiple—joint exercis-

activities.

Exercise to Treat Rotator Cuff Pathology

treatment primarily focuses on the application of ther—

The current review of literature supports the use of ex—

neuromuscular dynamic stability deficits of the scapu—

{1} muscle activatioul'motor learningl'motor control, {2}

apeutic exercises including neuromuscular dynamic stability and outcomes related to treating patients with

lothoracic andfor rotator cuff muscles. These also have exceptional application for postoperative rotator cuff re-

habilitation. Numerous studies,‘"" systematic reviews,”‘”‘

and meta-analyses'i'i13 demonstrate the effectiveness of exercise for patients with subscromial impingement syndrome. Most of these studies demonstrated decreased pain, increased strength, improved movement patterns, and improved functional outcomes in patients following therapeutic exercise for shoulder impingement. Authors

of a 20 Ellil study performed a systematic review of 12,423 articles and identified only 11 that had good methodol-

ogy.” Exercise strongly decreased the patients’ symp—

toms and led to significant improvements in functional measures. However, one conclusion of the analysis was

ercise to treat rotator cuff pathology. A therapeutic exercise program usually progresses through four stages: muscle strengtheningfpowerfendurance, {3] neuromus-

cular dynamic stability exercises, and {4} functional specificity exercises. Despite the forthcoming focus on

rotator cuff and scapular exercise training, total-body training, including the legs and core muscles, should be

performed and is recommended during a comprehensive

rehabilitation program. Many training techniques can be used for these areas, but these are beyond the scope of this

chapter. The authors of this chapter recommend working

each link in the kinematic chain first to establish a good

foundation with each muscle group and add the advanced neuromuscular dynamic stability and functional exercises

after establishing the r"basics.”

the lack of consensus on an ideal treatment program for

Scapulnthnracic Exercises

on patients with shoulder dysfunction.” Another men

ment patterns appropriate for patients with rotator cuff

patients with rotator cuff disease. A EDI 1 meta-analysis demonstrated the effectiveness of therapeutic exercises ta—analysis of the effectiveness of therapeutic exercises for treatment of painful shoulder conditions evaluated

The following scapulothoracic exercises are supported by electromyographic [EMS] research and involve movepathology.”15

19 articles, 1? of which had a rating of 6 or better on the

Scapular Plane Elevation

however, subsequent research is necessary for translation

couple with the upper trapezius, lower trapezius, and

PEDro scale.” Therapeutic exercise had a greater positive effect on pain and function than all other interventions; to clinical practice. Therapeutic exercises are usually performed as a com-

bination of isolated and multiple-joint exercises. Most

clinicians think that multiple-joint exercises must be per— formed because they are functional to improve perfor-

mance. However, other studies have demonstrated that

isolated rotator cuff exercises carry over to improving functional movements such as throwing and serving.”11

A group of healthy, uninjured subjects in a training

study performed isolated shoulder rehabilitation exer— cises for each muscle group in the shoulder complex.ll

flrfltopaodie Knowledge Update: Sports Medicine 5

Scapular plane elevation {scaption with the thumb pointing up} creates a functional strengthening of the force serratus anterior. In most patients with shoulder dysfunction, the upper trapezius is hypertonic and does not

need isolated strengthening. Consequently, this exercise

activates both the upper trapezius in the scapula and the glenohumeral muscles. The patient moves through

the range of motion {RUM} appropriate to his or her

particular shoulder condition [typically limited to less than 9B” of elevation to minimize the effects of sub-

acromial contact}. Alternating arm motions to prevent

compensation and recruit core stabilisation are also recommended“ {Figure l}.

El 1016 American AcadMy of Unhopaedic Surgeons

uvsvnuavuas :1:-

lIIZhapter 13: Current Concepts in Rehabilitation of Rotator Eufi Padlologj': Nonsurgical and Postoperative Considerations

Figure 2 Figure 1

Photograph demonstrates press-down exercise.

Photograph demonstrates scapular plane

elevation in the "thumb up" position using weights.

Press DownfUp

Mauv muscle groups are recruited, but the lower trape—

aius muscles and scapular depressors are substantiallv activated {Figure I].

Push-Up With Plus Position and Protraction

The push-up with the plus position is designed to recruit

the serratus anterior muscle using the “plus” position, which encourages maximal scapular protraction. If a

Figure El

Photog ra ph demonstrates the pu shop with the

plus position exercise.

“hug motion" is used, such as in the dynamic hug ext

Rowing Motions and Scapular Retraction The rowing motions activate the middle and lower trape-

internal rotation at the end of the plus maneuver. If the

exercises {Figure 6} use retraction to activate the mus-

ercisefi" patients are recommended to have their palms face each other {thumbs pointed to the ceiling} to prevent

hands internally rotate, it causes the greater tuberositv to compress the pain generators in the subacromial space and can iatrogenicallv result in problems or continue

aggravating the condition (Figures 3 and 4).

IE! lfllii American Academy of flrthopaedic Surgeons

aius muscles as well as the rhomboids. Scapular retraction exercises such as the robbery {Figure 5 l and lawnmower clesfifl‘i i'ltdditionallv,r exercises with elastic resistance such as external rotation with retraction” {Figure T") combine the movements of external rotation with scap-

ular retraction, and EMG research has shown the lower

Drtbopaedic Knowledge Update: Sports Medicine 5

Section 4: Rehabilitation

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A Figure 4

A and B. Photographs demonstrate dynamic hug using an elastic band.

trapezius is recruited at a 3.3‘fold greater rate than the

exercises for several reasons. Using 3H“ of abduction pre-

reviewing EMG research of scapular stabilisation exer-

to increase the oxygen and nutrients to the tendon, and

upper trapezius, forming a favorable lower trapezius— to-upper trapezius ratio. This ratio is important when cises because many exercise movement patterns produce abnormally high upper trapezius muscle activity, which

vents the wringing-out effect on the rotator cuff, speeds the healing process by means of increased blood flow

decreases the strain on the rotator cuff tendon.3"~35 Using

is unwanted and can result in abnormal motor patterns

3E1“ of scapular plane elevation stress shields the ammoinferior capsule and prestretches the posterior shoulder

that scapular exercises using a lower resistance level {Borg

improve power.M In the 3080130 position, a bolster is

the rehabilitation of shoulder pathology.“

the arm and adducting the muscles to hold the bolster in place creates a synergistic overflow {cocontractionif

and recruitment strategies.“ A lflll study demonstrated

scale 3 versus Borg scale 3) produce higher lower trape— zius—to—upper trapezius ratios, which are beneficial for filenohumeral Exercises for the Rotator Cuff Internal and External Rotation Glenohumeral exercises include internal and external

rotation exercises starting at 30° abductionflfl“ forward

flexion into scaptionflfl" diagonal movement, also called

the 3flf3flflfl position {Figures 8 and 9}, and progressing the patient to the 90:90 position in the scapular plane {Figure 10}, if appropriatefilall The 3flf3flf3fl position is the

initial starting position for the rotator cuff strengthening

firthnpaedic Knowledge Update: Sports Medicine 5

muscles, which increases their length-tension ratio to

placed under the arm for the aforementioned reasons, but also for research-based reasons. Placing a bolster under irradiation} to the posterior muscle groupsxud" These are the weakest muscles in the shoulder complex, and

using the bolster enhances the muscles’ ability to generate more power. Moreover, using the bolster and adducting the arm with 15 N of force increased the subacromial space in all arm positions: 3i)“, 6H”, 9i)“, 120“, and 150“

of abductionfifls” Because this area of the shoulder is the

most vulnerable to impingement, this technique can help

minimize subacromial contact stress in this area.

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 13: Current lEtuuaepts in Rehabilitaliun uf Retatur Cuff Pathulegj': Hullsurgieal anid Pastuperafive Cuneitlerafiuns

lube Exercises

Prune herizental abductien {Figure 11}, prune extensien

{Figure 12}, and prune external rcntaticrn with 90" Df ab—

ducticnn [Figure 13], ccnn‘u'nunljrr referred tn as Jebe exercis-

es, have been studied extensivelyF since their intreduetinn in 1.932.” Extensive EMS and research analysis have been performed c-n these movement patterns {exercises}, the exact pnsitien hi the extremity {thumb peinted eutif in and su furth}, and their inherent activatitin levels bf the

rc-tatcir cuff and surrciunding musculaturefiL‘I'“ These exercises celleedvelv repnrt high levels ef EMG aetivatinn

in the retatur cuff including the supraspinatus while de— creasing the level cif activatinn ef the surrounding delteid

ueueuuqeuaa :1:-

and upper trapezius t minimize fll' quiet cumpensaticln.

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

Additienal Cencepts ef Exercise for Retater Cuff Pathelugy

The ll] upper extremity,r exercises described fer rehabil-

itatinn exercises ef the shnulder enmplex should be per-

farmed using the fulluwing guidelines tn establish the fuundaticm bv wurlcing each link in the kinematic chain.

h; J

The American Enllege ef Sperts Medicine and ethers“

previde guidelines for designing exercise pregra ms based cm mere than Tflflr references. The American |Crsllege ef

Figure 5

Fhetegraph clemnnstrates rubbery exercise.

a Figure ti

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

IE! lfllfi American Academyr ef flrthepaeclic Surgeens

Drthepeedic Knuwledge Update: Sperts Medichie 5

®

Seeticin 4: Rehabilitation

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

Figure B

i-tegraph demonstrates standing external retaticm using an elastic band with a tbwel rclll placed under the arm.

Sperts Medicine and anthers“? recpmmend training 3 tn

Figure 9

F'hntcrg raph demnnstrates sidelying external

ratatien with a hand held weight while lying en the left side.

4 days per week with a day at rest and reccwerjr between resistance training wnrkeuts. Patients whe are untrained

the exercise pregram pregresses, the specificityr bf 1Irctlume at training {the specific needs and functienal demands cf

trained sheuld perfcrrm three sets tn bptimiae gains in tetal werlr, peak terqne, and average pnwer.“

retatcrr cuff muscles are prednminantl},r fast-twitch muscle fibers; therefnre, it is impertant tn exercise the muscles

shbnld perfc-rm ene set c-f exercises; patients when are

Ten repetitiens per set is the eptimnm number tn in—

crease strength in the beginning bf an exercise pregram. As

firthnpaedic Knewledge Update: Sparta Medicine 5

the patient} determines the number pf repetitiens. The

when apprepriate based en clinical cenditiens. Te recruit the fast-twitch fibers, bne must exercise at least 50% at

fl lflld American Academy at Cirrhepaedic Surge-ens

Chapter 13: Current Concepts in Rehahflitafiun crf Retater Cufi Pamelugy: Hensurgieal and Pastuperafive Censiclerafiens

Figure 11 Phategraph demenstrates external retaticln with Bu“ ef alscluctic-n in the scapular plane using an elastic band.

Figure 12

Phetegraph demenstrates prc-ne herizc-ntal abducticsn with a handheld weight.

Phatagraphs demenstrate prene extensictn with a handheld weight.

the maximal veliticmal centracticm er repetitien maxi— mum.” The resistance sheuld be established at 60% re BITE;- ef the subject’s ace-repetitian maximal centractien,

allewing the subject ta cemplete the exercises threugh full range at matic-n {RUM} witheut deviating frem cc-rrect

technique. The UMHI-Resistauce Exercise Scale can he

used as a guideline fer the patientsii'r“ {Figure 14}. The patients sheuld use a superset farmer in which the agenist

muscle is trained fuller-wed immediately by the antagenist

muscle. Supersets were used to impreve muscle balance, save time in the clinic, and previcle the muscle with recevery time ta achieve efficiency ef werkuuts.

After the basic exercises are performed to establish a selid foundaticm, the advanced neurumuscular dynamic

stability and functienal exercises are perfermed. Numer— eus descriptive articles exist in the literature; hewever,

IE! lfllfi American Academy at flrthepaedic Surgeens

Figure 13

Photograph clemenstrates prune external retaticrn with 9d“ at abductien with a hand— held weight.

limited studies demtmstrate the effectiveness ef the pre-

grams in a pruspective, systematic manner. Based an

Drthepaedic Knuwledge Update: Sperrs Medichse 5

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Sectien 4: Rehabiflmfiuu

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a Elli)? systematic review, limited high-level evidence supperts the effectiveness ef sente ef these advanced interventiens in rehabilitatien with patients.51 Plyemet-

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ric exercises have been indicated in threwing athletes

te increase threwing velecity and beth cencentric and eccentric strength;53 A recent EMG study“ quantified the muscular activity ef plyemetric sheulder exercises

perfernted in 90" ef abductien that are cetnntenly used in high-level rehabilitatien pregrams.” Finally, the use

ef isekinetic test results and training in sheulder reha-

bilitatien is supperted in the literature. An extensive review en this tepic eutlined evidence-based training paradigms, pepulatien-specific descriptive data, and ere

ercise pregressiens.55

Festeperative Cements

Figure 15

Fhetegreph demenstrates the stemach rub

exercise.

RUM, specifically eutlining the nieventent‘s jeint excur-

siens and capsular lengthening that previde safe inherent mnsiens in the repaired tenden. A 1001 cadaver medel ef repaired 1 a l—crn supraspinatus tears studied the effects

A 2012 research study cempared the increase in reta-

ef humeral retatien RUM en the tensien in the supraspinatus in 30“ cf elevatien in the cerenal, scapular, and

identified natienal trends, including the increased num-

neutral retatien, external retatien ef 3D“ and till“ actually

ter cuff repairs perferrned between 1995 and lflflfi and ber ef tetal retater cuff repairs as well as these that are

perfernted arthrescepicaliy (a EDD‘ih increase frem 1995 re Eflflfil.“ Pesteperative rehabilitatien cencepts {Figures 15 and 16} used by the anthers ef this chapter fellevving arthrescepic retater cuff repair are listed in Table 1. RUM Cencepts

Initial pestsurgical rehabilitatien fecuses en RUM te prevent capsular adltesien while pretecting the surgically

sagittal pla nes.” lIEentpared with tensien in a pesitien ef resulted in decreased tensien within the supraspinatus rnusculetendineus unit. In centrast, 3D" and 60" ef in— ternal retatien resulted in increased tensien within the supraspinatus tenden. Because mest patients are placed

in pesitiens ef internal retatien feiiewing surgery during the immebilizatien peried, intents] sheulder retatien is perferrned despite the increased tensien. In additien, the

tensile lead in the repaired supraspinatus tenden was cempared in the cerenal, scapular, and sagittal planes

during humeral retatien simulatien. Substantially higher

repaired tissues. Seme pestsurgical pretecels have specific ROM limitatiens that are applied during the first 6 weeks

leading was present in the supraspinatus tenden during humeral retatien in the sagittal plane cempared with

ratienale fer the safe applicatien ef glenehurneral jeint

passive ROM sheuld be perfernted in the directiens ef

ef rehabilitatien. Several basic science studies previde a

firthepaedic Knewledge Update: Sperts Medicine 5

beth the frental and scapular planes. Therefere, early

fl lfllfi American Academy ef Urthepaedic Surge-ens

lIIZhapter 13: {Jul-rent Enncepts in Rehabilitatinn nf Rntatnr Cuff Pathnlngy: Nunsurgical and Pnstnperafive Cnnsiderafinns

stages nf rehabilitatinn fnllnwing arthrnscnpic rntatnr cuff repair. Snme disagreement amnng clinicians exists regarding the amnunt nf muscular activatinn nccurring

during activities cnmmnnly used fnr rehabilitatinn. A

1993 study clearly delineated the degree nf muscular activatinn nf the supraspinatus during supine assisted RUM

and seated elevatinn with the use nf a pulley.” Althnugh

bnth activities prnduce lnw levels nf inherent muscular

activatinn in the supraspinatus, the upright pulley activity prnduces substantially mnre muscular activity than the supine activities. The delay in upright pulley nr active-as-

RUM in the initial 6—week perind fnllnwing surgery.Efl Tn

truly minimise muscle activatinn, RUM pcrfnrmed by

a physical therapist with the patient supine is indicated based en the results nf the 1993 study.”

The levels nf muscular activatinn during the IUndman pendulum exercise have been quantified in a study that shnws minimal levels nf muscular activatinn in the rnta-

tnr cuff musculature.“ Hnwever, the exercise cannnt he cnnsidered passive because the musculature is truly acti-

vated, especially in individuals with shnulder pathnlngy. In additinn, althnugh many therapists dn nnt recnmmend bnlding a weight in the hand during pendulum exercises tn

Figure 1E

Phntngraph demnnstrates the sewing exercise.

avnid pntential anterinr tra nslatinn, activity in the rntatnr cuff musculature was nnt changed between performing the pendulum exercise with nr withnut a handheld weight.

bnth external and internal humeral rntatinn using the scapular plane pnsitinn tn minimize tensile leading in

A mnre recent study measured supraspinatus and in— fraspinatus EMG activity in patients perfnrming a series

The effects nf passive mntinn nn tensile leading nf the supraspinatus tendnn were alsn studied in lflflfi.“ Nn sub-

decnmpressinn and distal clavicular resectinn.f1 These exercises included therapist-assisted external rntatinn and

the repaired tendnn.

stantial increases in strain were fnund during the mnve-

ment nf crnss-arm adductinn in either the supraspinatus

nr infraspinatus tendnns at till“ nf elevatinn. Hnwever, internal rntatinn perfnrmcd at 3C!“ and 60" nf elevatinn

placed increased tensinn in the inferinrmnst pnrtinn nf the

infraspinatus tendnn nver the resting nr neutral pnsitinn.

This study demnnstrated the impnrtance nf lcnnwing the degree nf tendnn invnlvement and repair because pesterinrly based rntatnr cuff repairs {thnse invnlving the infraspinatus and teres minnr} can be subjected tn increased

tensile lnads if early internal rntatinn is applied during

pnstnperative rehabilitatinn. Cnmmunicatinn between the

surgenn and treating therapist is nf vital impnrtance tn ensure that nptima] RUM is perfnrmed fnllnwing repair. Passive Versus Active—Assisted RUM

The prngressinn frnm passive RUM applicatinns tn ac—

tive-assisted and active RUM is impnrtant in the early

IE! Ellie? American Academy nf Urthnpaedic Snrgenns

nf early rehabilitatinn exercises fnllnwing subacrnmial

elevatinn perfnrmed in the supine pnsitinn, patient-assist-

ed external rntatinn and elevatinn perfnrmed in the supine

pnsitinn, as well as pulleys, table flexinn, and scapular retractinn exercises. EMU activity during these early re-

habilitatinn exercises was cnmpared with baseline levels [standing at rest} in the infraspinatus and supraspinatus

muscles. The findings shnwed nn difference between therapist-assisted external rntatinn and elevatinn and baseline

activity in the supraspinatus and infraspinatus. Pendulum

exercises were alsn nnt different frnm baseline EMG levels in thnse muscles. This study suppnrted therapist-assisted

external rntatinn and elevatinn fnr patients fnllnwing

shnulder surgery because the level nf muscular activity inherent in these maneuvers facilitates early jnint mutinn and mnbilixatinn withnut mu sculntendinnus unit activatinn abnve baseline {standing pnsture} levels. Rehabilitatinn in the first 2 tn 4 weeks fnllnwing rntatnr cuff repair typically cnnsists nf truly passive and

several minimally active nr active-assisted exercises fnr the

Urthnpnedic Knnwledge Update: Spnrts Medicine 5

uvsexuqvuas :v

sisted elevatinn exercises is present in several prnminent rehabilitatinn prntncnls that inherently use nnly passive

Section 4: Rehabilitation

-— Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair of a Medium-Size Tear General Guidelines

Progression of resistance exercise and ROM depends on patient tolerance. Resistance exercise should not he performed with specific shoulder joint pain or pain over the incision site.

A sling is provided for support as needed with daily activities and to wear at night. The patient should be weaned from the sling as tolerated and under the direction of the referring surgeon. Early home exercises given to the patient following surgery should include stomach rubs {Figure 15}. sawing {Figure 15}, and distal gripping activity. Progression to assisted Hfllvl against gravity and duration of sling use is determined by the size of the rotator cuff tear and the quality of the tissue and fixation. i: .E 4.!

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Postoperative Weeks 1 and 1

Early postoperative Rfllvl to patient tolerance during the first 4 to 6 weelcs Flexion

Scapular and coronal plane abduction IHIER with 9D“ to 45" abduction as tolerated

Mobilization of the glenohumeral joint and scapulothoracicjoint. Passive stretching of elbow. forearm. and wrist to terminal ranges.

Side-lying scapular protractionlretraction resistance to encourage early serratus anterior and lower trapezius activation and endurance.

Home exercise instruction:

Postoperative and active-assisted HUM exercises with T-har, pullfiyfi. or opposite-arm assistance in sUpine position using HUM to patient tolerance. Weight-bearing {closed chain} Codman exercise over a ball or countertoprtable Therapeutic putty for grip strength maintenance Postoperative Week 3 Continue above-shoulder ROM and add isometric strength program (IRIEH in neutral} to patient tolerance. Begin active scapular strengthening exercises and continue side-lying manual scapular stabilization exercise: Scapular retraction Scapular retraction with depression Begin submaximal rhythmic stabilization using the balance point position {9W to 1'30" elevation} in supine position to initiate dynamic stabilization. Ell = external rotation. In = intee rotation. HUM = range of motion.

rotator cuff such as active-assisted elevation and pendulum exercises. The balance point position [9'3“ of shoulder

serratus anterior muscular activation, are recommended.

also used: the patient is queued to perform small active motions of flexionfextension from the El)“ starting posi-

chain exercise such as weight shifting on a rocker

These exercises, coupled with early scapular stabilization via manual resistance techniques emphasizing direct hand

highlighted as well as several exercises such as robbery and the low row, which produce low to moderate levels

elevation in the scapular plane} in the supine position is

Early scapular stabilization exercises have also been

advocated using EMG quantification of low-level closed

tion to recruit rotator cuff and scapular muscular activity.

boardfiiri‘3 The low levels {a 10%} of activation of the rotator cuff ancl scapular musculature during application were

contact on the scapula to bypass force application to

of scapular stabilizer activation while not placing the

the rotator cuff and optimize trapezius, rhomboid, and

firthopaedic Knowledge Update: Sports Medicine 5

shoulder with a repaired rotator cuff in harmful positions.

fl lflld American Academy of Orthopaedic Surgeons

lIIZhapter 13: {Jul-rent Concepts in Rehabilitation of Rotator Cufi Padlology: Nonsurgieal and Postoperative Considerations

Table 1 rrr

—

Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair of a Medium-Size Tear Postoperative Weeks 5 and E Initiate isometric and isotonic resistance exercise focusing on the following movements: Standing IRIEP. isometric step-outs with elastic resistance Sidelying EH Prone extension Prone horizontal abduction [range limited to 45'; 3 weeks postoperative}

Side-lying flexion to SD“

Progression to full postoperative and assisted RDM in all planes including ER and IR in neutral adduction, progressing from the 91]“ abducted position used initially postoperatively. EH oscillation [resisted ER with a towel roll under axilla and a body blade or flexion bar} Home exercise program for strengthening the rotator cuff and scapular musculature with isotonic weights andfor elastic tubing. Postoperative Week 111 Begin closed chain step-ups and quadruped rhythmic stabilization exercise. Initiate upper extremity plyometric chest passes and functional two-hand rotation tennis groundstroke or golf swing simulation using small exercise ball progressing to light medicine ball as tolerated. Postoperative Week 12 Initiation of submaximal isokinetic exercise for IHrER in the modified neutral position. Criterion for progression to isokinetic exercise: Patient has IRrER REM greater than that used during the isokinetic exercise. Patient can complete isotonic exercise program pain—free with a 2- to 3-lb weight or medium resistance surgical tubing or elastic band. Progression to 90" abducted rotational training in patients returning to overhead work or sport. Prone EH Standing EHIIH with Sfi‘ abduction in the scapular plane Statue of Liberty {El-l oscillation in the SDISD position} Reevaluation of strength with isometric IHIEH strength [at sidE}. goniometric HUM {active and passive ROM], and functional outcome measures Postoperative Week 15 Progression to maximal isokinetics in IHrEH and isokinetic test results to assess strength in modified base SWEDISH position. Formal documentation of assisted RUM, postoperative REM, and shoulder rating scales. Begin interval return programs if following criteria have been met: IHIEH strength at minimum of 35% of contralateral extremity t'lfl ratio is 50% or higher Pain-free RUM Negative impingement and instability signs during clinical examination Preparation for discharge from formal physical therapy to home program phase EH - external rotation. In - internal rotation. HUM - range of motion.

IE! Eillfi American Academy of flrthopaedic Surgeons

Drtbopaedic Knowledge Update: Sports Medicine S

uarlesrqeuaa :1:-

A. low-resistancei'high-repetition {for example, 30 repetitions} format is recommended initially using no resistance {such as the weight of the arm}.

Section 4: Rehabilitation

Resistance Exercise

The progression to resistance exercise for strengthening

the rotator cuff and scapular musculature typically occurs in an interval of approximately 6 weeks following surgery. The time for initiation of resistance exercise varies substantially'i'l“ and is based on several factors including, but not limited to, tear size, tear type, tendon retraction,

tissue quality, fatty infiltration, concomitant surgical procedures, patient health status, and age. Communication between the referring surgeon and physical therapist is

critical to ensure information is shared regarding fixation i: .E 4.!

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by scapular internal rotation and anterior tilt theoretically decrease the subacromial space and could compromise the

ability to perform repetitive movement patterns required

to improve strength during shoulder rehabilitation. Progression to Functional Activities

The patient evaluation used to determine return to func-

tional and recreational activities requires reexamination

of clinical test results, objective determination of RUM

and muscular strength, and the ability to simulate func-

tional movement patterns without symptoms or unwant-

limitations, tissue challenges, andfor other concomitant relative factors that would limit the progression of posts

ed compensatory movement deviations. Progression to advanced strengthening exercises, including isolcinetic

this critical stage of rehabilitation should be guided by

loading and faster angular joint movements inherent in

surgical rehabilitation. The clinical application of resistance exercise during

training, emphasizes the movement of internal and external rotation, which prepares the patient for the increased

both the literature detailing the level of muscular activity within the individual muscles of the rotator cuff and scap-

most functional activities.-"5 The contralateral extremity is used as the baseline for most patients and allows a

toleranee.31~“~3?~‘"~”~54 The application of low resistance levels used in a repetitive format are recommended both

cular strength. Although the goal is a full return of both

ular stabilizers and the patient’s demonstrated exercise

meaningful comparison of postsurgical ROM and mus—

passive and active RDM as well as muscular strength

described in several training studies to improve muscu— lar strength in the rotator cuff and scapular stabilizing

and endurance, these indices cannot always be measured during the initial length of many rehabilitation programs. Formal rehabilitation should restore 35% to MW: of cotational strength compared with that of the contralateral uninjured extremity, as well as muscular balance repre-

arms and maintain the glcnohumcral joint in positions less than 9d“ of elevation and anterior to the coronal plane

recommending the patient return to functional activities

for safety and relative protection of the repaired tissues

as well as to improve local muscular endurance. Multiple

sets of 15 to 20 repetitions have been recommended and

musculature.”EH Exercise patterns that use shorter lever of the body {such as the scapular plane} are theorized to

reduce the risks of both compressive irritation and capsular loadingfattenoation.“ In addition, early focus on the rotator cuff and scapular stabilizers without emphasis on

larger, primary muscles such as the deltoid, pectorals, and

sented via an externali'internal rotation strength ratio of at least 60% {65% to 735% is the preferred ratio}, before such as upper extremity sports and aggressive activities

of daily living. In addition, clinical impingement and

instability signs should also be eliminated before higher level activities can be recommended. Short-term follow-up of patients for 12 weeks follow-

upper trapezius are recommended to minimize joint shear and inappropriate arthrolcincmatics as well as optimizing

ing both mini-openfij and arthroscopic“1 rotator cuff repair shows the return of almost full active and passive

fine specific exercise that has been described extensively

1G% to EME- in internal and extemal rotation compared

externali'internal rotation muscle balance.”

ROM, with deficits in muscular strength ranging from

in the literature is the empty can exercise: scapular plane elevation with an internally rotated {thumb pointed down}

with the uninjured extremity. Greater deficits following both mini-open and arthroscopic rotator cuff repair have

levels of supraspinatus activation during the empty can

tor musclcsj despite emphasis placed on these structures during postsurgical rehabilitation.

arm position. Although EMG studies have shown high

exercise,“~m*“ the combined movements of elevation and internal rotation have produced clinically disappointing

results in practical application as well as common patterns of substitution and improper biomechanical execution. A 2'306 study quantified these compensations objectively

and showed increases in scapular internal rotation and anterior tilting when comparing the empty can and full can [scapular plane elevation with external rotation) exercises

using motion analysis.41 Movement patterns characterized

firthopaedic Knowledge Update: Sports Medich'ie 5

been reported in the posterior rotator cuff {external rota-

Early lv‘ersus Delayed Hfll‘v'l: Effect on Dutcome

Early versus delayed RUM is likely one of the areas

of greatest controversy and variation in rehabilitation following rotator cuff repair. Given the increase in the numbers of arthroscopic rotator cuff repairs being per— formed, rehabilitation professionals and surgeons have

fl lflld American Academy of Orthopaedic Surgeons

Chapter 13: Current Ueneepts in Rehabilitaliee ef Retater {Sufi Pamelegy: Heesurgieal and Pusteperative Censideratiens

retater cuff repair rehabilitation.“ Five randemised centrelled trials {RCTs} have been

published cemparing early passive RUM te sling immebilisatien fellewing arthrescepic retater cuff repair?“-Til PL meta—analysis identified the impertant findings frem these RCTs fer clinical applicatien.” Advecates ef early passive RUM fellewing surgery cite the must cemmen

cemplicatien fellewing arthrescepic retater cuff repair {pesteperative stiffness} as the primary ratienale fer early mebilisatien and mevement;fulfil eppenents cite the high

incidence ef re-tearff-HE' The meta-analysis” shews that early pesteperative passive RUM results in substantial

increases in sheulder flexien at 3, 6. and 12 menths after

surgery cempared with immebilisatien. External retatien RUM alse increased acress the early passive RUM greups;

hewever, this increase was enly significant at 3 menths after surgery. Perhaps mest impertant, early passive RUM

did net result in increased retater cuff re-tear rates at a

minimum fellew—up ef 1 year. The studies included in this analysis excluded massive retater cuff tears. A Hill study alse excluded retracted tears and these that extended heyend a single tenden.“ These results indicate that early passive RUM is net a risk facter fer increased re-tear rates fellewing arthrescepic retater cuff repairs. The early metien perfermed in these studies included pendulum exercises and manual passive RUM perfermed by a physical therapist. A 2fl13

study shewed that therapist-assisted passive RUM dees net preduce EMG activity in the supraspinatus and infraspinatus abeve baseline levels {pestural standing at rest}.fl

This finding, ceupled with the results ef increased RUM in elevatien and external retatien in the meta-analysis.”

It is imperta nt te review the current cencepts and evidence

regarding key elements ef rehabilitatien fer retater cuff pathelegy. The benefits and indicatiens fer RUM and retater cuff and scapular strengthening ferm the primary

fecus ef rehabilitatien efferts presently recemmended

and supperted in the current literature. Further research

is always needed and is indeed ferthceming regarding greater delineatien ef the specific parameters and char-

acteristics ef exercise interventiens as well as additienal randemised clinical trials te develep eptimal pretecels fer

rehabilitatien ef the patient with retater cuff pathelegy. Hey Study Feints

I Retater cuff rehabilitatien invelvcs specific applicatien ef Exercise interventiuns that activate the

retater cuff and scapular musculature at high levels witheut placing the cuff in pesitiens er mevement patterns that premete impingement er instability.

I It is imperative that beth nensurgical and pesteperative retater cuff rehabilitatien begin with a

key feundatien ef scapular stabilisatien exercises. 1iWeakness er dykinesis ef the scapula is a cemmen

clinical finding in patients with retater cuff diser-

ders, and early rehabilitatien and emphasis en the

serratus anterier and lewer trapezius ferce ceuple

is recem mended. e Pesteperative retater cuff rehabilitatien begins with

early passive range ef metien te pretect the repair

while preventing the develepment ef pesteperative stiffness, fellewed by scapular stabilizatien exercise and finally retater cuff strengthening te restere full active metien, muscular strength, and endurance.

supperts the use ef early passive RUM fellewing retater

cuff repair.

A 2-311 study applied a medified early RUM pretecel

in “F9 patients with identified risk facters fer stiffness fellewing arthrescepic retater cuff repair.“I These risk facters included calcific tendinitis. partial articular supra-

spinatus tenden avulsien lesiens, cencemitant superier

labrum anterier te pesterier repairs, preeperative adhe-

shaneHsHEHflsefenences 1. Picavet HS, Scheuten J5: Musculeskeletal pain in the Netherlands: Prevalences, censequences and risk grenps. the DMCifil-study. Pat's! lflfl3flflll1—2hllfT-1T'fl. Medline

DUI

sive capsulitis, and singleutenden retater cuff repairs. The

2. Davies G], Geuld ], Larsen R: Functienal examinatien ef the sheulder girdle. Phys Spertsmed 1931;9{6}:32-1G4.

in a seated pesitien next te a table tep. Ne patient ex—

3. Jebe PW, Kvitne RS, Giangarra CE: Sheulder pain in the

pretecel included patient—directed RUM with a polyvinyl chleride bar as well as the use ef table slides perfermed

perienced any pesteperative stiffness with the medified treatment pretecel fellewing retater cuff repair, and an early metien pretecel is advecated fer patients fellewing retater cuff repair.

IE! lfllfi American Academy ef Urthepaeclic Snrgeens

everhand er threwing athlete. The relatienship ef anterier

instability and retater cuff impingement. Urthep Rev

emphases-sta. Merliine

Urthepaedic Knewledge Update: Sperts Medicine 5

usssaussuaa:s

been investigating this particular issue fer seme time. A systematic review in 2009” feund insufficient evidence te previde an evidence—based cenclusien er recemmendatien regarding immebilisatien versus early passive RUM fer

Section 4: Rehabilitation

4. 1Which G, Eoileau P, Noel E, Donell ST: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elliott! Surg 1992;1[5]:233-245. Medline DUI Tate AR, McClure PW, 1't"oung IA, Salvatori R, Michener LA: Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: A case series. I Urtlrop Sports Plays Ther 2fl10;4fl{3}:4?4—493. Medline DUI

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impingement syndrome: A systematic review. J Hand TlJEt‘

lflfl4;1T{1}:151-164.Medline nor

13. Kuhn JE: Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evi-

dence-based rehabilitation protocol. J Shoulder Elbow SHt‘g lflfl9;13{1]:133-16fl. Mcdline

DUI

This review of 11 RCTs focused on the effect of exercise for patients with subacromial impingement. The results of the studies showed that exercise had a substantial effect

on improving pain and function but not directly on ROM

This case series reviewed the use of manual therapy, exer— cise, and thrust and nonthrust manipulations for patients with subacromial impingement. At 12 weeks, SD93 of patients had a successful outcome {Sfl‘i‘h improvement in the Disabilities of the Arm, Shoulder and Hand score). This study supports the use of exercise and manual therapy for patients with subacromial impingement. Level of

14. Desmeules F, care CH, FnEntont P: Therapeutic exercise and orthopedic manual therapy for impingement syndrome: A systematic review. Clin J Sport Med lflfl3513{3}:1?6-132.Medline DUI

Ainsworth II, Lewis J5: Exercise therapy for the conservarive management of full thickness tears of the rotator cuff:

15. Grant H], Arthur A, Pichora DR: Evaluation of interventions for rotator cuff pathology: A systematic review. J Hand Ther Zflfl4;1?i2]:1?4-399. Medline DUI

evidence: IV.

A systematic review. Br J Sports Med 200?;41i4]:2{lO-21fl.

Medline DUI

Bang MD, Deyle GD: Comparison of supervised exercise

with and without manual physical therapy for patients

with shoulder impingement syndrome. J Urtlrop Sports Phys Ther EflflflflflfllfllE-idl Medline DUI

Haahr JP, fistergaard 5, Dalsgaard J, et al: Exercises versus arthroscopic decompression in patients with subacromial impingement: A randomised, controlled study in 190 cases with a one year follow up. Ann Rheum Dis 2Ufl5;64i5}:?6fl-?64. Medline DUI

Ketola 5, Lehtinen J, Arnala I, et al: Does arthroscopic

acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: A two-year

randomised controlled trial. J Bone Joint Surg Br 20139;? 1-

Ellfl}:1325-1334.Medline

DUI

One hundred forty patients were randomized into groups undergoing either arthroscopic acromioplasty and post-

and increasing strength.

16. lL‘lreen 5, Euchbinder R, Herrick S: Physiotherapy intervEntions for shoulder pain. Cochrane Database Syst Rev lflfl3;2:CDfl{l=-12.SS. Medline 1?. Erudvig TJ, Kullcarni H, Shah S: The effect of therapeutic exercise and mobilisation on patients with shoulder dysfunction : A systematic review with meta—analysis. ,l Urtlrop Sports Plays Thar 2fl11;41{1fllt?34-T43. Medline DUI

Seven RGTs were identified that used therapeutic exercise

and manual therapy for patients with shoulder disorders. Manual therapy did not provide an additional benefit scientifically to exercise in patients with rotator cuff pa-

thology. Level of evidence: 1a.

13. Marinlco LN, Chaclco JM, Dalton D, Ghaclco EC: The effectiveness of therapeutic exercise for painful shoul— der conditions: A meta-analysis. J Shoulder Elbow Surg 1fl11;2i}{fl}:1351-1359.Medline DUI

operative exercise or exercise alone. Analysis of the vi-

This meta-analysis of 19 articles specific to the use of

impingement.

cise made a positive contribution to pain reduction and the improvement of function in patients with shoulder conditions. Level of evidence: 1a.

sual analog scale pain ratings showed that arthroscopic acromioplasty did not provide an additional benefit over exercise rehabilitation alone in patients with subacromial

exercise in shoulder rehabilitation concluded that exer—

1D. McClure PW, Eialker J, Neff bl, Williams G, Karduna A: Shoulder function and 3-dimensional kinematics in people with shoulder impingement syndrome before and after a Iii-week exercise program. Plays Thar 2U D4;S4I{9}:331-S4S. Medline

15". Ellenbeclcer TS, Davies G], Rowinsl-ti M]: Concentric versus eccentric isokinetic strengthening of the rotator cuff. Ubjective data versus functional test. Am J Sports Med 1938;16i11m4-59. Medline DUI

11. Senbursa G, Baltaci G, Atay A: lComparison of conservarive treatment with and without manual physical thera— py for patients with shoulder impingement syndrome: A prospective, randomized clinical trial. Knee Sarg Sports Traumetol Arthrosc 100?;1 511?}:915-921. Medline DUI 12. Michener LA, Walsworth MK, Burner EN: Effectiveness of rehabilitation for patients with subacromial

Drthopaedic Knowledge Update: Sports Medicine 5

ED. Mont MA, llilohen DB, Campbell HR, Gravare K, Mathur SK: Isokinetic concentric versus eccentric training of

shoulder rotators with functional evaluation of perfor-

mance enhancement in elite tennis players. Am J Sports Med 1994;23i4}:513-51?. Medline DUI 21. Treiber FA, Lott J, Duncan J, Slavens G, Davis H: Effects of Theraband and lightweight dumbbell training on

D 211115 American Academy of Orthopaedic Surgeons

Chapter 13: Current fleecepts in Rehabilitalien ef Retatur Cuff Patbelegy: Nunsurgical and Pustuperalive Censiderafieus

sheulder retstieu terque and serve perfertuance in cellege tennis players. Am I Sperts Med 1953;36{4}:510-515. Medline

30. Ellenbeclter TS, Ceels A: Rehabilitatien ef sheulder impingement syndreme and retater cuff injuries: An evidence-based review. Br J Sperts Medr 2D1fl:44{5):319-321

22. Byrnes E, Simpsen L, Stephens G, Riemann EL, Davies G]: Cempatisen ef tandem vs blecl-ced ptetecel design fet upper extremity rehabilitatien: a prespective randemized

This paper reviews evidence fer the treatment ef retater

award]. Graduate Student Research Presentatiens, HASH, Savannah, Gill, flptil, 1?, 2i] ll? {MS Thesis, 2110?}. 23. Meseley JE JI', Jebe PW, Pink M, Perry I, Tibene J: EM’G analysis ef the scapular muscles during a sheulder rehabilitatien pregram. An: __l Sperts Med 1992:2fl{2]:123-134.

Medline DDI

24. Eltstrem RA, Denatelli Rd, Sederherg GL: Surface elec-

DUI

cuff pathelegy. Detailed reviews ef therapeutic exercise,

manual therapy including retater cuff strengthening, and scapular stabilisatien are previded. Exercises that premete activatien ef the lewer trapezius and serratus anterier in

additien te retater cuff activatien are recem mended and summarized. Level ef evidence: V.

31. Andersen CH, Zebis MK, Saervell C, et al: Scapular muscle activity ftem selected strengthening exercises per-

fermed at lew and high intensities. I Strength Cend Res

2011;26f9]:24fl3-2415.Medline eel

tremyegraphic analysis ef exercises fer the trapeeius and serratus anterier muscles. I Drthep Sperts Phys Ther lflflfl:33{5}:24?—253. Medline DDI

This study analyzed EMG activity between the upper and lewer trapezius musculature under Berg scale 3 and E cenditiens. Increased lewer trapeeius activatien and

25. Kibler WE, Sciascia AD, Uhl TL, Tambay H, Cunningham T: Electremyegraphic analysis ef specific exercises fer scapular centre] in early phases ef sheulder rehabilitatien. Am I Seer-rs Med 2fl03;36i9i:l?89-l?93. Medline DUI

intensity exercises fer scapular stabilisatien {Berg scale 3} cempared with higher intensity exercise. This study has impertant clinical applicatien fer therapists designing eptimal ptegrams fer patients with sheulder pathelegy. Level ef evidence: Centrelled laheratery study.

26. Will: KE, Yenchalc A], Attige CA, findtews jE: The Advanced Threwets Ten Exercise Pregram: :5: new exercise series fer enhanced dynamic sheulder central in the everhead threwing athlete. Phys Sperrsmed 2011:39i4i:9fl-9?. Medline DUI This cemmentaty included advanced sheulder exercises

fecusing en bilateral upper extremity perfermance and

use ef a physie hall te impreve sheulder activatien and previde a training stimulus te ptegtessively impteve sheulder strength and endurance. The exercises previded can be incerperated inte advanced rehabilitatien pregrams fer patients with sheulder pathelegy. Level ef evidence: V. 3?. Decker M], Hintermeister RA, Faber K], Hawkins R]: Settatus anterier muscle activity during selected rehabilitatien exercises. Am I Sperts Med 1999;1Ti6}:?34-?91. Medline 23. Tsuruilce M, Ellenbeclter TS: Setratus anterier and lewer trapezius muscle activities during multi-jeint isetenic scapular exercises and isemetric centractiens. ] ms: Tree: 2015;50{2}:199-21fl.Medline DUI This study previded EMG analysis ef several key scapular exercises used in rehabilitatien ef sheulder patients including a quadrupecl arm elevatien, rehhery, and lawnmewet exercises. The interactiens ef exercise intensity

reduced upper traperius activatien was feund with lewer

32.. Reineld MM, Will: KE, Fleisig GS, et a1: Electremyegraphic analysis ef the retater cuff and delteid mus-

culature during cemmen sheulder external retatien exercises. J Drthep Sperts Phys Ther 2DM;34{?}:335—354.

Medline DDI

33. Hintenneister RA, Lange 5W, Schultheis JM, Bey M], Hawkins R]: Electtemyegtaphic activity and applied lead during sheulder rehabilitatien exercises using elastic resistance. Am I Sperts Med 1 993;26{2J:210-220. Medline 34. Rathbun JB, Macnah I: The micrevascular pattern ef the retater cuff. ,i Bese Jeinr Surg Br 19?fl;52[3}:54fl-553. Medline 35. Biberthaler P, 1liiii'iedemann E, Nerlich a, et al: Micrecirculatien asseciated with degenerative retater cuff lesiens. In vive assessment with erthegenal pelarixatieu spectral imaging during arth rescepy ef the sheulder. ] Herve jer'ut Surg Am Eff-[13:35 -fi{3}:4?5 "430. Medline 36. Saha AK: The classic. Mechanism ef sheulder mevements and a plea fer the recegnitien ef “zete pesitien" ef glenehumeral jeint. Cffrr Urtfsep Ref-st Res 1933;1T3:3-1fl. Medline

with external leading and muscle activatien ef the serratus

anterier and lewer trapezius are previded in this clinically applicable study. Level ef evidence: lIEtess-sectienal laberatery study.

3?. Reineld MM, Macrina LC, Will: KE, et al: Electremyegraphic analysis ef the suptaspinatus and delteid muscles during 3 cemmen tehabilitatien exercises. I Ash-f Tfflffl Zflfl?;42{4}:464a469. Medline

29. McCabe RA, Dtishime KP, McHugh MP, Nichelas 5]:

33. Ilflraichen H, Hinterwimmer E, ven Eisenhart-Rethe R,

muscle during exercises perfermed helew ninety degrees ef sheulder elevatien in healthy subjects. N Am I Sperts Phys Ther lfifl?;2(1):34-43. Medline

adducting muscle activity en glenehumeral translatien, scapular kinematics and suhacremial space width in vive. J Biemeef: 2005;33H}:T55-T6fl. Medline DIDI

Surface electremygtaphic analysis ef the lewer trapezius

ID EDIE American Academy ef Drthepaeclic Surgeens

1|lifegl T, Englmeier KH, Eclcstein F: Effect ef abducting and

Drthepeedic Knewledge Update: Sperrs Medicine 5

usesuuavues :1:-

centrelled training study [Henerable mentien financial

Medline

Sectien 4: Rehabilillutiuu

3.9. Hinterwimmer 5, Men Eisenhart-Rethe R, Siebert M, et

al: Influence ef adducting and abducting muscle furces en the subacremial space width. Med Sci Sperts Eaters Eflfl3;35{11k2f155-2fl59.Medline DUI

4|]. Jebe PW, Meynes DR: Delineatien ef diagnestic criteria and a rebabilitatien pregram fer retater cuff injuries. An: I Sperts Med 1932:1fl{51:336-339. Medline

DUI

41. Tewnsend I-I,]ehe FW, Pink M, Perry]: Electremyegraphic analysis ef the glenehumeral muscles during a baseball rebabilitatien pregram. Ant ] Sperts Med 1991,11 9f3]:164EFL Mfidllnc

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41. Thigpen CA, Padua DA, Mergan bl, Kreps E, Karas EU: Scapular kinematics during supraspinatus rehabilitatien exercise: fl cemparisen ef full-can versus empty-can techniques. Ant ] Sperts Med 1DDE;34{4}:644»551. Medline DUI 43. Takeda Y, Kasbiwaguchi S, Ende K, Matsuura T, Sasa T: The mest effective exercise fer strengthening the supraspinarus muscle: Evaluatien by magnetic resena nce imaging. Am I Sperts Med lflfl1;3l}{3}l:3?4-331. Medline

44.

Balla ntyne ET, U‘Hare S], PaschallJL, et al: Electremyegraphic activity ef selected sheulder muscles in cemmenly used therapeutic exercises. Phys Ther- 1 993;?3{1fl]:663-

EFT, discussien GIFT-632. Medline

45. Alpert 5W, Pink MM, Jebe PW, McMahen P], Mathiyakem W: Electremyegraphic analysis ef delteid and retater

cuff functien under varying leads and speeds. }' Shenfder Efbew Snrg lflfl U;9I{I}:4?—53. Medline

DUI

4E. Bitter HL, Clisby EF, Jenes MA, Magarey ME, Jaber— aadeh 5, Sandew M]: Relative centributiens ef infraspinatus and delteid during external retatien in healthy sheulders. I Shenfder Efbew Snrg EDDT;IE{S}:d-563. Medliue DUI 47-". llilarrell T], Abernethy P], Legan PA, Barber M, McEniery MT: Resistance training frequency: Strength and myesin heavy chain respenses te twe and three heuts per week. Eur 1 App! Pbysfef Uccup Pbysfef 1993;?3l3}:2?fl-2TS. Medline DUI 43. Durrall C, Hermsen D, Demutb C: Systemic review ef single-set versus multiple-set resistance— training randemiaed centrelled trials: Irnplicatiens fer reha bilitatien. Crit Rev Plays Refrebff Med Efl06;13f2}:IDT-IIE. DUI

49. Levering RM, Russ DW: Fiber type cempesitien ef cadaveric human retater cuff muscles. I Urtfaep Sperts Phys Ther lflfl3;33{11}:ET4-6flfl. Medline

DUI

5t}. Celade JC, Garcia-Masse H, Triplett TN, Flandes J, Eurreani 5, Tella V: Eencurrent validatien ef the UMI‘ILresistauce exercise scale ef perceived exertien with Theta-band resistance bands. I Strengtil'lI [Tend Res 1fl11;16{11]:3fl13Sill-4. Medline DUI

Urthepaedic Knewledge Update: Sperta Medichie S

This study validated using the DMNI—Resistance Exercise Scale te ebjectively evaluate exercise intensity using a visual scale. This allews clinicians te accurately under-

stand the exercise intensity free: the patient fer eptimal

resistance exercise pregressien and strength develepment.

51. Eelade JC, lI'.'.iarcia-I'vfasse K, Triplett NT, et al: Censtruct and cencurrent validatien ef a new resistance intensity scale fer exercise with theta-bandlfil elastic bands. I Sperts Sci Med 2014513I41:?53-?66. Medline This study fecused en the use ef elastic resistance using a validated pregressien ef celer-based elastic bands and cencemitant exercise intensity. 52. Zech A, Hubscher M, Vegt L, Bearer W, Hansel F, Pfeifer K: Neuremuscular training fer rebabilitatien ef

spurts injuries: A systematic review. Med Sci Sperts Exerc lflfl9:41{10}:1331-134I.Medline DUI

This systematic review identi fied 2U RCTs that supperted the use ef balance training and preprieceptive training te impreve neuremuscular centre] in patients with erthepaedic injuries. This study supperts the current use ef preprieceptive exercise interventiens and prevides key ebjective evidence fer its inclusien in rebabilitatien pregrams. Level ef evidence: Systematic review. 53. Carter RB, Kaminski TW, Deuex AT Jr, Knight CA, Richards JG: Effects ef high velume upper extremity plyemetric training en threwing velecity and functienal strength raties ef the sheulder retaters in cellegiate base-

ball players. ] Strength Cend Res lOfl?;21(1}:2fl3—115. Medline

DUI

S4. Ellenb-edcer TS, Sueyesbi T, Baille D5: Muscular activatien during plyemetric exercises in 9D” ef glenehumeral jeint abductien. Sperts Heuftf: EDIS;?{1}:?5-TR Medline DUI This study analyzed the EMU results ef [we plyemetric ex-

ercises perfermed in 913" cf glenehumeral feiut abductien,

which had high activatien levels ef the infraspinatus, lewer trapezius, and serratus anterier. [LS- and l-kg exercise leads were used. These exercises are recemmended fer clinical use te increase retater cuff and scapular strength. Leml ef evidence: |I'.'.‘entrelln.=:d laberatery study. .55. Ellenhecker T5, Davies (3]: The applicatien ef isekinetics in testing and rebabilitatien ef the sheulder cemplex. j Athf Train Iflfll};35{3}:33fl—SSD. Medline DUI 56. Celvin AC, Egereva N, Harrisen Ali, Meskewits A, Fla-

tew EL: Hatienal trends in retater cuff repair. I Benejetnt

Snrg Ant Eflllgfl‘llfikllilfl.

This study analysed the number ef retater cuff repairs between 1996 and lflllfi. A 141% increase was feund in

the number ef retater cuff repairs and a 600% increase in the repairs perfermed arthrescepically were reperted.

5?. Hata keyama 't', Itei E, Urayama M, Pradban RL, Sate If:

Effect ef superier capsule and ceracehumeral ligament release en strain in the repaired retater cuff tenden. A cadaveric study. An: I Sperts Med lflfll;29{5}:633-64ll. Medliue

D lflld American Academy ef Urrhepaedic Surge-ens

Chapter 13: Current Concepts in Rehabilitation of Rotator Cuff Padaology: Nonsurgical and Postoperative Considerations

S: The effect of arm position on stretching of the supraspinatus, infraspinatus, and posterior portion of deltoid muscles: .f'i. cadaveric study. Clin Biomeeb (Bristol, Arron)

lflfld;11{5}:4?4-4Sfl.Medline nor

59. McCann PD, 1illfootten ME, Kadaba MP, Bigliani LU: A

kinematic and electromyographic study of shoulder rehabilitation exercises. Cltn Grtbop Rer'nt Res 1993:ESS:ITS133. Medline

Si}. Koo SS, Parsley BK, Eurkhart SS, Schoolfield JD: Reduction of postoperative stiffness after arthroscopic rotator cuff repair: Results of a customized physical therapy regimen based on risk factors for stiffness. Arthroscopy 2fl11;2?{2}:ISS-ISD.Medline DUI This case series studied 152 patients {152} who underwent

rotator cuff repair; T9 were at high risk for stiffness. Pa-

tients in this subgroup were given a table slide exercise in addition to a standardised rehabilitation program. The

patients in this group did not develop stiffness and the

authors recommend this exercise for patients who are at risk for stiffness following rotator cuff repair. ISL Ellsworth Ah, Mulla ney M, Tyler TF, McHugh M, Hichv olas S: Electromyography of selected shoulder musculature during un-weighted and weighted pendulum exercises. N

Ant ,1 Sports Phys Ther Iflflti;1{2}:?S-TS. Medline

62. Murphy CH, McDermott W], Petersen RH, johnson SE, Baxter SA: Electromyographic analysis of the rotator cuff in postoperative shoulder patients during passive rehabilitation exercises. ] Shoulder Elbow Strrg 1fl13;12(1}:1i}1lfl'F. Medline DUI

This study examined 14 passive shoulder rehabilitation

exercises and compared them with baseline activity in the shoulder 4 days following shoulder surgery using fine wire electrodes. Exercises such as therapist-assisted supine ROM and external rotation, pendulum exercises, and isometric internal rotation created supraspinatus activity level similar tn baseline. Actual levels were nut reported

but were measured relative to baseline activity. This infor-

mation provides key evidence for clinicians on early muscle activation during passive exercises used following rotator

cuff repair. Level of evidence: EMG laboratory study.

63. Hibler WE, Livingston E, Bruce E: Current concepts in

shoulder rehabilitation, in Advances in Upsratr‘ee Orthopaedics .St Louis, Mushy, 1995, pp 249-293 vol 3.

I54. Wilk FEE, hrrigo C: lIL'Iurrent concepts in the rehabilitation of the athletic shoulder. J Drtfrop Sports Phys Timer 1993;13(1i:3SS-3?S.Medline DUI

individuals. I Strength Bond Res lflfilflfitlflelvflfl. Medline

6?. 1|Wang CH, McClure P, Pratt HE, Hobilini R: Stretching and strengthening exercises: Their effect on three-dimensional scapular kinematics. Arch Plays Med Rehabil' 1999;BD[3}:913-919.Medli11e

DUI

63. IEiannakopoulos K, Beneka A, Malliou P, Godolias G: Isolated vs. complex exercise in strengthening the rotator cuff muscle group. J Strength Cond Res lflfldflflilhfld-

143. Medline

65'. Lee SH, An RN: Dynamic glenobumeral stability provided by three heads of the deltoid muscle. Clin Urthop Relat Res 1Dfl1;4flfl:4fl—4?. Medline DUI Ft}. Malanga GA, Jenp TN, Growney ES, Pin KN: EMG analy-

sis of shoulder positioning in testing and strengthening the supraspinatus. Med Sci Sports Exere 1996;23lfil:fifil-664.

Medline

DUI

3’1. Kelly ET, Kadrmas WR, Speer HP: The manual muscle examination for rotator cuff strength. Pin electroluyo-

graphic investigation. Ant I Sports Med 1996;14iSlt531SSS. Medline DUI

"Tit. . Ellenbecker TS, Fischer DJ, Eeman D: Glenohumeral joint range of motion, rotational isokinetie strength, and functional self-report measures following All-Arthroscopic

rotator cuff repair.[flbstract]. } Urtbop Sports Phys Ther 2i] fltifi sueass.

T3. Baumgarten RM, Vidal AF, Wright REF: Rotator cuff repair rehabilitation. A level I and II systematic review. Sports Health ZflflftflillfllS-ISD. Medline

DUI

This systematic review of rotator cuff repair rehabilitation

studies noted a paucity of evidence identified in high-level

studies. The use of continuous passive motion was not supported by the literature by one study included in this review. Level of evidence: I. “F4. Arndt J, Clavert P, Mielcarek P, Eouchaib J, Meyer N, Kempf JF; French Society for Shoulder Sc Elbow {SUFEC}: Immediate passive motion versus immobilization after endoscopic supra spinatus tendon repair: A prospective randomised study. Urtlrop Trnrrrnrttol Srrrg Res lflllflfllfi,

Suppl}:5131-5133.Medline DUI

This study analysed the effects of immediate passive RUM following rotator cuff repair with complete immobilisetion for 6 weeks following surgery. Improved functional results were found in the early passive RUM group without decreases in healing. This study supports early passive RUM following rotator cuff repair. Level of evidence: I.

SS. Ellenbecker TS, Elmore E, Bailie D5: Descriptive report of shoulder range of motion and rotational strength :5 and 12 weeks following rotator cuff repair using a mini—open deltoid splitting technique. ] Urtirop Sports Phys Ther 20G6;36{Si:326-335.Medline DUI

3’5. Cuff D], Pupello DR: Prospective randomized study of arthroscopic rotator cuff repair using an early versus de-

66. Moncrief sa, Lau JD, Gale JR, Scott Sn: Effect of rota-

This prospective, randomized controlled trial studied S3 patients who either started physical therapy on

tor cuff exercise on humeral rotation torque in healthy

IE! Eillti American Academy of firthopaedic Surgeons

layed postoperative physical therapy protocol. }' Shorrfder Effiote' Sttt‘g 2G13;21{11]:145fl-14SS. Medline DUI

Unbopaedic Knowledge Update: Sports Medicine S

uneasiness-vs :r-

SS. Mural-ti T, Aoki M, Uchiyama E, Murakami G, Miyamoto

Sectinn 4: Rehabilillatitln

pnstnperative day 2 at were immnbilited and had RUM initiated after *5 weeks. Nu significant difference was repnrted between grnups in RUM, re-tear rates, and patient

?9. Eibnh JCS, Garrigues GE: Early passive mntinn versus immnbilizatinn after arthrnscnpic rntatcrr cuff repair. Arthroscnpy 2fl14;3fl{3}:99‘F—Iflfl5. Medline III-[III

Kim vs, Chung sw, Kim yr, D}: JH, Park 1, cs: JH: Is

This meta—analysis identified five RCTs nf early passive REM fullnwing arthrnscnpic retatnr cuff repair. Imprnved flexinn ROM was mated at 3 mnuths, E mnnths, and 12

satisfactinn at 1 year. Level nf evidence: 1. 5'6.

early passive metinn exercise necessary after arthrnscnpic rntatnr cuff repair? AmJSpni-ts Med lflll:40{4}:315-321. Medline DUI In this study, 1135 patients underwent arthrnscnpic rntatnr

cuff repair [excluding large and massive tears} and were

:: .E 4.!

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randnmised intn either an early RUM grnup with mntinn three In four times per day while wearing an immnbiliaer, nr iutc: a delayed mntinn grnup with up mntinn far 4 tn 5 weeks. RUM and VHS pain ratings were cnmpared at 1-year fnllnw-up and several either intervals and nu substantial differences were fnund between the twn grnups.

Early passive pcrstnpcrative RUM did nut prcducc greater RUM but alsn did net increase re-tear rates. T1 Lee BIG, Che- NS, Rhee TE: Effect nf twn rehabilitatinn prntncnls cm range nf mntinn and healing rates after arthrnscnpic rntatnr cuff repair: Aggressive versus limit-

ed early passive exercises. Arthrnscnpy 2012;23i1}:34—42. Medline DD]

In this study, 64 patients were assigned tn either an aggressive early mntinn and unlimited self-stretching grnup nr a limited passive exercise grnup fnllnwing arthrnscnpic rntatnr cu ff repair. Patients in the early mntinn grnup shnwecl an early increase in shnulder ROM nver the limited passive mntinn grnup. bin substantial difference was fnuncl

in RUM at 1—year fullnw up. He substantial difference in restear rates was fnuncl berween the twc- grnups.

T3. KeenerJD, Galata Ll'vI, Stabbs—Eucchi G, Patten R, Yamaguchi K: Reha bilitatinn fnllnwing arthrnscnpic rntatnr cuff repair: A prnspecn've randcrmized trial nf immnhiliaa-

tinn campared with early mntinn. } Enuefnint Snag Am

2fl14:9fifIJ:II'19. Medline

DflI

In this study, 122 patients ynunger than 65 years underwent arthrnscnpic rntatnr cuff repair and either underwent a traditinnal rehabilitatinn prngram with early passive

ROM at were immnbilised far 6 weeks with us mntinn.

Nu lung-term differences were fnund in functinnal return, REM, and strength between grnups and ma difference in

rntatnr cuff healing was seen between the two grnups. Level nf evidence: I.

firthnpaedic Knnwledge Update: Spnrts Medicine 5

months pnstnperatively. External rntatinn was nnly identi-

fied as superinr with early mntinn at 3 months. He differ-

ence was nnted in re—tear rates between early and delayed passive RUM. Level nf evidence: II. 3f}. Brislin K], Field LI}, Eavnie FH III: Cnmplicatinns after arthrnscnpic rntatnr cuff repair. Arthrnscnpy

lflfl?,23{11:114-113.Medline nca

31. Namdari S, Green Ft: Range nf mntinn limitatinn after rt:-

tatc-r cuff repair. I Shnafder tnw Sarg 2fl10;19{l}:19fl296. Medline DUI

In this review nf 345 patients whn underwent rntatnr cuff repair, mean active fnrward flexinn was 90%, external rntatinn was E3253, and internal rntatinu was 30% nf the cnntralateral side at 3—mnnth fullnw-up. Patients with restricted prenperative RUM were mnre likely tn have limited RUM pnstnperative that was significant. |fil'nly 3 nf 4? patients whn had stiffness at 1 year required cap— sular release. 32. Galatt LI'vI, Ball CM, cfey 5.5L, Middletnn WEI, Tamas guchi K: The nutcnme and repair integrity nf cnmpleteIy arthrcrscnpically repaired large and massive rntatnr

cuff tears. j Base faint Snrg An: lflfl4:EE—A(2}:119—214. Medline

33. Tashjian RE, Hnllins AM, Kim HM, et al: Factnrs affect— ing healing rates after arthrnscnpic dnuble-rnw rntatnr cuff repair. Am I Sparta Mad EflIfl;33{IZ}:2435-2442. Medline [ll-DI

In this study, 49 shnuldcrs with full-thick ness rcrtatnr cuff

tears underwent arthrnscnpic dnu ble-rnw repair and were evaluated fur tend-an healing at a minimum fi-mcmth fullnw—np: at ultrasnnngraphic evaluatitm, 51% nf tendnns were healed, tiF'if- nf single—tenders tears she-wed cnmplete healing, and 36% nf multiple-tendnn tears shnwed healing. Increased age and [anger fnllnw-up time were significant

factnrs fer healing Iimitatinns in this study.

fl lfllfi American Academy nf Urthnpaedic Surge-nus

Chapter 24

Nonsurgical and Postoperative Rehabilitation for Injuries of

the Overhead Athlete’s Elbow

Todd R. Hooks. PT. ATE. {DC-5. 5C5. NREMT—l. CECE. CMTPT. FAADMPT

Abstract

fiverhead athletes are subject to injuries at the elbow

introduction

Elbow injuries are common in the overhead athlete

joint as a result of high levels of forces imparted onto the elbow during the throwing motion. Injuries can

because of the repetitive nature of overhead sporting activities. Elbow injuries have been reported to repre-

result of repetitive overuse. It is imperative that the restoration of elbow function is achieved to allow the

jor League Baseball.“ The elbow extends at more than

be acute to the point of tissue failure, or chronic as a

sent approximately 22% to 25% of all injuries in Ma-

elbow to return to its prior level of function. Systematic

23flflils during overhead throwing, which produces a medial shear force of 300 H and a compressive force of

overstressing healing tissues. The treatment programs

during the acceleration phase of throwing, which exceeds

and endurance, and restore neuromuscular control. Multiphased rehabilitation programs are designed to restore function in the overhead athlete’s elbow and

ment (UCL).

and progressive rehabilitation programs can help avoid are designed to restore full motion, muscular strength,

include both nonsurgical and specific postoperative pathologies of the overhead athlete. Keywords: overhead athlete: ulnar collateral ligament: elbow: rehabilitation

9th] H} These fumes impart a valgus stress of E4 I'll-mi

the ultimate tensile strength of the ulnar collateral liga-

Throughout the throwing motion, several forces con-

verge at the elbow.3 During the acceleration phase of throwing, valgus stresses at the elbow create tension across the medial elbow, whereas compression forces are

applied to the lateral aspect of the elbow during this phase of throwing.3 During the acceleration and deceleration

phases of throwing, the posterior compartment is subject

to valgus extension overload as a result of tensile, compressive, and torsional forces that can cause osteophyte

formation, stress fractures of the olecranon, or physeal

injury.”

The rehabilitation program described in this chapter

or. Will: or an immediate family member serves as a paid consultant to LiteCure Medical. intelliSlrin, and Zetrfla; serves as an unpaid consultant to Alter-‘3: has received research or institutional support from lntelllsizin; and has received nonincome support {such as equipment orservices},

commercially derived honoraria. or other non-research-

related funding {such as paid travel} from Educational Grant, Bauerfeind. and ERMl. Neither lvh'. Hooks nor any immediate family member has received anything of value from or has steel: or steel: options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

fl acne American Academy of Drrhopaedic Surgeons

uses a multiphased approach focused on returning the athlete to the prior level of function via a systematic pro-

cess. This program is divided into four phases that are

designed to follow a gradual progression of exercises and stresses applied methodically to restore strength, dynamic

stability, and neuromuscular control. The key to a success-

ful and effective treatment program is the identification of each athlete’s causative factors, facilitating the design

of a specific treatment program to address these factors.

Guidelines for rehabilitation following elbow injury {Table 1} and elbow arthroscopy {Table 2} are presented. The postoperative rehabilitation programs for specific

pathologies and for surgical intervention also are included.

Drthopaeclic Knowledge Update: Sports Medicine 5

uvsomqvuas :v

Iiievin E. Willi. PT. DPT. FAPTa

Section 4: Rehabilitation

-— Nonsurgical Rehabilitation Program for Elbow Injuries

Nonsurgical Rehabilitation Program for Elbow Injuries

I. Acute Phase {Week 1]

Weeks 4-5

Goals: To improve motion, diminish pain and inflammation, retard muscle atrophy

1. Continue daily strengthening exercises, endurance

1. Stretches for wrist, elbow, and shoulderjoint

drills. and flexibility exercises. 2. Continue Thrower's Ten Program. 3. Progress plyometric drills.

2. Strengthening exercises; isometrics for wrist,

4. Emphasize maintenance program based on

Exercises

elbow. and shoulder musculature 3. Pain and inflammation control: cryotherapy. HUGS. i: .E 4.!

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as.“ .-.......-.—..s..;. _

ultrasound. and whirlpool

II. Intermediate Phase [Weeks 1-4)

Goals: To normalize motion; improve muscular strength, power, and endurance Week 2

1. Initiate isotonic strengthening for wrist and elbow muscles.

2. Initiate exercise tubing exercises for shoulder. 3. Continue using cryotherapy and other pain-control modalities. M1 1. Initiate rhythmic stabilization drills for elbow and shoulder joint. 2. Progress isotonic strengthening for entire upper extremity.

3. Initiate isokinetic strengthening exercises for elbow flexio nfextension.

flecks! 1. Initiate Thrower's Ten Program. 2. Emphasize work on eccentric biceps. concentric triceps, and wrist flexor. 3. Progress endurance training. 4. Initiate light plyometric drills. 5. Initiate swinging drills. lll. Advanced Strengthening Phase [Weeks 4-3} Goals: To prepare athlete for return to functional activities

Criteria: To progress to advanced phase 1. Full nonpainful HCIM

2. hlo pain or tenderness 3. Satisfactory isokinetic test 4. Satisfactory clinical examination

pathology.

5. Progress swinging drills [for example. hitting}. W 1. Initiate interval sport program as determined by physician. 2. Begin Phase I program. IV. Heturn-to—Activity Phase [Weeks 5-9} Return to play depends on the athlete's condition

and progress: physician determines when it is safe. 1. Continue strengthening program and Thrower's Ten Program.

2. Continue flexibility program. 3. Progress functional drills to unrestricted play. HG'v'S - high-voltage galvanic stimulation, HUM - range of motion. Data from lll'll'ilk ltE. Fleinhold MM. Andrews IR: Heha bllitatlon ofthe

thrower‘s elbow. Tech Hand Up Extrem Surg remainder-sis.

Nonsurgical Rehabilitation Phase I: Acute Phase

The first phase of the elbow rehabilitation program is

designed to reduce pain and inflammation, normalize range of motion {REM} and muscle balance, correct postural adaptations, and re-establish baseline dynamic joint stability. During this phase, the athlete may be

prescribed NSAIDs andfor local injections. In addition,

the clinician can use local therapeutic modalities such as

ice, iontophoresis, phonophoresis, and electrical stimu— lation to reduce pain and inflammation. The athlete also is educated about activity avoidance and activity modi-

fication during throwing, exercise, and other strenuous activities. Following the initial acute inflammation phase,

the clinician can use moist heat, a warm whirlpool, and.If or ultrasound to increase local circulation and soft~tissue

extensibility to increase the pliability of the joint capsule and musculotendinous tissues.

RUM activities are initiated in the acute phase of treatment to ensure the normalization of motion. All aspects of elbow mobility should be assessed, but it is common for

the overhead athlete to display a loss of elbow extension

firthopaedic Knowledge Update: Sports lviedich'ie 5

fl lflld American Academy of Orthopaedic Surgeons

Chapter 24: Nousurgital and Postoperative Rehabilitation for Injuries of die Overhead Athlete’s Elbow

Table 2 (ritiir'rifntievii')

Postoperative Rehabilitation Protocol

for Elbow Arthroscopy

for Elbow Arthroscopy

I. Initial Phase {Week 1}

Week 3

Goals: Full wrist and elbow REM, swelling and pain

reduction. retardation of muscle atrophy

Day of surgery

Begin gently moving elbow in bulky dressing. Postoperative days I and 2 Replace bulky dressing with elastic bandages. Immediate postoperative hand, wrist. and elbow exercises Puttyigrip strengthening Wrist flexor stretches Wrist exten sor stretches Wrist curls Reverse wrist curls Neutral wrist curls Pronationr'supination ARDM elbow extensioniflexion Postoperative days 3 through ? PROM elbow extensioniflexion {motion to tolerance]

Begin PRE exercises with 1-lb weight. Wrist curls

Reverse wrist curls Neutral wrist curls

Pronationisupination

Broomstick roll-up

II. Intermediate Phase [Weeks 2-4}

Goal: To improve muscular strength and endurance. normalize joint arth roltine matics

Week 2 RUM exercises {overpressure into extension} Add biceps curl and triceps extension. Continue to progress PHE weight and repetitions as tolerable. Supraspinatus

Scapulothora cic strengthening

Initiate biceps eccentric exercise program. Initiate shoulder exercise program. External rotators

Internal rotators Deltoid

Supraspinatus Scapulothoracic strengthening Ill. Advanced Phase [Weeks 4-H} Goal:_ To prepare athlete for return to functional

activities

Criteria to progress to advanced phase Full nonpainful ROM Absence of pain or tenderness

Isoltinetic test that fulfills criteria to throw Satisfactory clinical examination Weeks at through 6 Continue maintenance program. emphasizing muscular strength, endurance, flexibility. Initiate interval throwing program phase HUM - range of motion. AHDM = active range of motion. FROM passive range of motion, FEE - progressive resistance exercise.

contractures because of the intimate congruency of the joint articulations, the tightness of the joint capsule, and

the tendency of the anterior capsule to develop adhesions following injury.”r Furthermore, the brachialis muscle at-

taches to the anterior joint capsule as it crosses the elbow

joint, and injury to the elbow joint can create excessive scar tissue formation of the brachialis muscle, causing

functional splinting of the elbowf Therefore, ROM ac-

tivities should be performed for all planes of elbow and

wrist motions to prevent the formation of scar tissue and adhesions by providing nourishment to the articular cartilage and assisting in the synthesis, alignment, and

organization of collagen tissue-“"91 Restoring full elbow extension or preinjury REM is the primary goal of early

RGM activities, to minimize the occurrence of elbow

flexion contractures.”r Determining the athlete’s preinjury ROM helps to guide the clinician in restoring motion. The

in particular. The authors of a 2flfl6 study evaluated 33

athlete also can be queried whether full elbow extension

mean loss of elbow flexion of 5.5", compared with the

occurrence of joint contractures and improve joint mou

professional baseball players during the preseason and determined a mean loss of elbow extension of 7'“ and a contralateral elbow.‘l5 The elbow is predisposed to flexion

IE! lfllfi American Academy of flrthopaedic Surgeons

was present before injury. Joint mobilization may be performed to minimize the bility. Grade I and II mobilisations are used initially and

Drthopaedic Knowledge Update: Sports Medicine 5

ussexlrssvaa :1:-

— _ Postoperative Rehabilitation Protocol

Section 4: Rehabilitation

are progressed to grade III and IV mnbiliaatinns during the later stages of rehabilitation, as symptoms subside. Grade I and II mobilization techniques also may be used

external rotation stretching.

articular receptors. Posterior glides of the humeroulnar jnint are performed at end range of joint mobility to assist

can implement a low—load, long duration {LLLD} stretch

to neurnmndulate pain by stimulating type I and type II

in the regaining of full elbow extension {Figure 1}. In addition, the clinician may perform mobilization for the radiocapitellar and radinulnar joints. The aggressiveness of the stretching and mobilization

techniques is determined by the healing constraints of

the involved tissues, the specific pathology or surgery, and the amount of motion and end feel. If the patient i: .E 4.!

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is beneficial to be aggressive with glennhumeral rehabilitation to improve 11t through internal rotation and

presents with a reduction in motion and a hard end feel

without pain, aggressive stretching and mobilization techniques may be used. Conversely, a patient who exhibits

pain before resistance or an empty end feel should be

progressed slowly with gentle stretching. In addition, it

Clccasinnally, patients may continue to have difficulty achieving full elbov.r extension. In such cases, the clinician

to produce deformation nr creep of the collagen tissue,

which results in tissue elongation. Clinically, this stretch

can be performed by having the patient lie supine with a towel rnll placed under the distal humerus to act as a cushion and fulcrum. Light resistance exercise tubing is

applied to the patient’s wrist and secured to the table or to a dumbbell on the ground {Figure 2, A} as the patient is instructed to relax for the duration of 10 to 15 minutes of LLLEI treatment. The amount of resistance applied should be of low magnitude to enable the patient to perform the stretch for the entire duration without pain or muscle

spasm; this technique should impart a low-load but a long-duration stretch. Patients are instructed to perform

the LLLD stretches several times per day, equaling at least

ED minutes of total end range time. This type of program has been referred to as the total end range time program.11 The program has been extremely beneficial for patients with a stiff elbow. In some patients, it may be beneficial to use spliuting and bracing to create the LLLD stretch {Figure 2, B}.

Figure 1

Photograph shows pnste rinr mobilization of the ulna to improve elbow extension.

The early phase of rehabilitation also focuses on the voluntary activation of muscle and the retardation of muscular atrophy. Pain—free submaximal isnmetrics are performed initially for the elbow flexors and extensors,

wrist flexnrs and extensors, as well as the forearm pro—

natnrs and supinatnrs. Shoulder isnmetrics also may be

.3“.

Figure 1

Photographs demonstrate the low-load. long duration lLLLDl stretch to increase elbow extension. A. The stretch is performed using light resistance while the sh oulcler is placed in internal rotation, with the forearm pronated to minimize compensation and best isolate the stretch on the elbow joint. B, Splinting and bracing using a

commercial device also can be used to create the LLLD stretch and perform elbow extension range of motion as part of a home exercise program.

@

firthopaedic Knowledge Update: Sports Medicine 5

fl ants American Academy of Orthopaedic Surgeons

Chapter 24: Nousurgiml and Postoperative Rehabilitation for Injuries of line Dyerbead Athlete’s Elbow

performed during this phase, with caution against internal rotation and external rotation exercises if they

-_ Exercises for the Scapular Musculature

adduction as well as shoulder internal rotation and ex-

I Seated scapular neuromuscular control with manual resistance

ternal rotation are performed. Elbow flexion, extension,

supination, and pronation also are performed to begin

reestablishing proprioception and neuromuscular con-

trol of the upper extremity. Furthermore, the patient’s shoulder joint RUM may be addressed during this phase using a stretching program to improve internal rotation and horizontal adduction.

Phase II: lntennediate Phase Phase II is initiated when the patient has achieved full RUM, experiences minimal pain and tenderness, and has

a good HIS} score with manual muscle testing of the elbow

flexor and extensor musculature. The goals of this phase of treatment are to progress the strengthening program,

maintain normal physiologic flexibility, mobility, and RUM of the elbow, and enhance neuromuscular control. Stretching and ROM exercises of the elbow, shoulder, and trunk are progressed throughout this phase of

rehabilitation. Joint mobilization techniques may be pro-

gressed to grades III and IV to apply a stretch to the joint

capsule and improve joint mobility. Flexibility exercises

are continued for the wrist flexors, extensors, pronators, and supinators, with increased emphasis on improving

elbow extension and forearm pronation flexibility. Shoulder mobility and flexibility should be assessed,

because it is common for the overhead athlete to lose internal rotation and horizontal adduction. The loss of in-

ternal rotation commonly is described as a glenohumeral

- Sidelying scapular neuromuscular control with

manual resistance

- Prone horizontal abduction {prone T's} on table or stability ball I Prone full can {prone T’s] on table or stability ball I Prone rowing into external rotation {prone W's} on table or stability ball I Prone extensions {prone l's} on table or stability ball I Seated modified robbery movement for lower

trapezius

.- Wall circles .- Corner stretch for pectoralls minor

placed on the entire elbow and forearm musculature, the clinician should incorporate strengthening exercises for the glenohumeral and scapulothoracic musculature as well. The Thrower’s Ten Program,” which is based on electromyography {EMS} data to ensure the restoration of muscle balance in the treatment of the overhead ath— lete, can be used."‘-‘~IT Because the external rotators are commonly weak, particular focus is placed on this muscle

group by the inclusion of sidelying shoulder external rotation and prone rowing into shoulder external rotation exercises, because these movements have been shown to

have high EMG activity of the posterior rotator cuff.13 The scapula is critical for optimal arm function, be-

internal rotation deficit {GIRD}. An 13" loss of internal

cause it provides the proximal stability needed for effi-

adaptations, posterior rotator cuff tightness, posterior

well described by numerous authorsflg-‘ED The scapular

rotation in the throwing shoulder has been implicated in elbow injuries.” GIRD has been attributed to osseous capsule tightness, and an anteriorlyr tilted scapulaJI'“ A

proper clinical assessment to differentiate between altered

scapula positioning, posterior capsule tightness, andfor posterior shoulder tightness is essential for the clinician to direct the appropriate treatment program. Shoulder external rotation also should be assessed, because a loss of motion can result in increased strain on the medial aspect of the elbow du ring the throwing motion. Shoulder

flexibility exercises in all planes of movement also are continued during this phase. The clinician may assess for the total arc of motion and compare the motion to the contralateral shoulder.

Strengthening exercises are progressed to include iso-

tonic exercises, beginning with concentric activities and

progressing to eccentric activities. Although emphasis is

IE! lfllfi American Academy of flrchopaedic Surgeons

cient distal arm mobility. The importance of the scapular muscles in facilitating optimal shoulder function has been retractors, protractors, and depressors are emphasized

because of their commonly noted weakness. Specific exercises (Table 3} have been developed, designed to normalize

the force couples of the scapular musculature and enhance

proprioceptive and kinesthetic awareness to facilitate neu-

romuscular control of the scapulothoracic joint.“

Closed kinetic chain exercises are advanced to include proprioceptive drills such as table pushuups on a tilt board

or ball (Figure 3}. These drills have been shown to generate increased upper and middle trapezius and serratus

anterior activity compared with a standard push—up exa

erciser'iI Rhythmic stabilization drills can be performed by having the athlete place a ha ad on a small ball against a wall as the clinician performs perturbation drills to the athlete’s arm {Figure 4}. Additionally, neuromuscular

Drtbopaedic Knowledge Update: Sports Medicine 5

usilealiseuaa :1:-

are painful. Alternating rhythmic stabilization drills for shoulder flexion, extension, horizontal abduction, and

Seerien 4: Rehabilitation

i: .E 4.!

I'll

: E

I'fl

.: Ill ac Iii:

.-.-'I_'. .

at. 'i' - .'-

Figure 4 l

Figure 3

Fhetegraph depicts a push—up en an unstable surface with manual rhythmic stabilizatie ns te facilitate dynamic stability fer the shoulder and cere musculature.

F'hetegraph demenstrates dynamic stability training with the patient's hand placed ente a ball against a wall. The arm is in the scapular plane te preyide cemp ressiye ferces inte the glenehumeral jeint as the clinician preyides rhythmic stabilizatlens.

Phase III: Advanced Strengthening Phase Phase III is designed te initiate aggressive strengthening exercises, pregress functienal drills, enhance pewer and endurance, and impreye neuremuscular centrel re pre-

pare fer a gradual return te spert. Befere advancing re this

phase, the athlete sheuld exhibit full nenpainful RUM, have ne pain er tenderness, and demenstrate strength that

is Tfl‘i'v‘i. ef that ef the centralateral extremity. Muscle fatigue has been sbewn re decrease neure-

muscular centrel and diminish preprieceptiye sense.fl

Therefere, the athlete is pregressed with strengthening activities using the Advanced Threwer’s Ten Exercise Pregram, which incerperates high—level endurance and

alternating meyement patterns re further challenge neu-

remuscular centrel and restere muscle balance and symmetry in the threwing athlete.14 The incerperatien ef

sustained helds challenges the athlete re maintain a set

pesirien while the eppesire extremity perferms iserenic

Figure 5

Fheteg ra pb shews manual preprieceptiye neuremuscular facilitatien using cencehtric and eccentric resistance with rhythmic sta bilizatiens.

centrel exercises can be perfermed fer the upper extremity, including preprieceptiye neuremuscular facilirarien exercises with rhythmic stabilizatiens and manual resis— tance drills {Figure 5}.

firthepaedic Knewledge Update: Sperrs Medicb'ie 5

exercises. Three sets are incerperated inte each exercise, each fellewing a sequential pregressien that integrates bilateral iserenic meyemenr and unilateral iserenic merement with a centralateral sustained held and alternating iserenici'susrained-held sequencing. The athlete can be instructed te perferm these exercises en a stability ball

re further challenge the cere. Manual resistance drills can be added re increase muscle excirarien and premere endurance. Manual resistance prexided by the clinician is

applied re seared stability ball exercises re augment muscle

excirarien and impreee the endurance ef the sbeulcler and

cere musculature {Figure 6].

Elbew flexjen exercises are pregressed te emphasise

fl lfllfi American Academy ef Cirrhepaedic Surge-ens

Figure ti

Photograph demonstrates manual resistance

external rotation using tubing performed on a stability ball to incorporate proximal and core stabilization.

eccentric control. The biceps muscle is an important stabilizer during the follow-through phase of overhead throw-

Figure 3'

Fri otog raph depicts external rotation at 911‘ of abduction using exercise tubing. The clinician provides rnanual resistance and rhythmlc sta bilizations.

plyometric exercises with conventional isotonic train-

ing, because it eccentrically controls the deceleration of the elbow and therefore prevents pathologic abutment

ing, an increase of shoulder internal rotation power and throwing distance was reported.“ Plyometric exercises

be performed with elastic tubing to emphasis slow— and fast-speed concentric and eccentric contractions. Manual

stimulates the muscle spindle, followed by the amortization phase, which marks the time between the eccentric and concentric phase. To allow an effective transfer of energy and prevent the beneficial neurologic effects of the

of the olecranon within the fossa.” Elbow flexion can

resistance can be applied for concentric and eccentric

contractions of the elbow flexors. The triceps are exercised primarily with a concentric contraction because of the

acceleration {muscle shortening] activity of this muscle

begin with a rapid prestretch eccentric contraction that

prestretch from being dissipated as beat, this phase should

be as short as possible. The athlete is instructed to coor-

during the acceleration phase of throwing. Aggressive strengthening exercises with weight machines also are

dinate the trunk and lower extremity to most efficiently facilitate the transfer of energy into the upper extremity

commonly begin with bench presses, seated rowing, and front latissirnus dorsi pulldowns.

been described that systematically introduces stresses on

incorporated during this phase. These exercises most

during the plyometric drills. A plyometric program has

Neuromuscular control exercises are progressed to in—

the healing tissues, beginning with two-hand drills such as the chest pass, side—to—side throws, side throws, and

Concentric and eccentric external rotation are performed

these two-hand drills, the athlete can progress to one-

clude sidelying external rotation with manual resistance.

against the clinician’s resistance, with the addition of rhythmic stabilization at end range. This manual resis-

overhead soccer throws.” fin successful completion of

tance exercise may be progressed to standing external

haud drills, including standing one-hand throws, wall dribbles, and plyometric step-and-throw exercises. Specific plyometric drills for the forearm musculature include

{Figure ff}.

important components of an elbow rehabilitation pro-

rotation with exercise tubing at El" and finally at 90” Plyometric exercises are initiated to further enhance

wrist flexion {Figure fl} and extension flips, which are gram that emphasise the forearm and hand musculature.

dynamic stability and proprioception and to introduce and gradually increase functional stresses to the shoulder

Muscle fatigue has been shown to diminish proprioceptive sense and alter biomechanics; therefore,

well as decreased time for peak torque generation were seen following 6 weeks of single-arm plyonietric tosses performed at 9B“ of shoulder abduction as demonstrated with isokinetic testing.“ In a comparison of 3 weeks of

habilitation program for overhead athletes.”r Kinematic and kinetic motion analysis reported in a 1001 study showed that shoulder external rotation and ball veloc~ ity declined along with lead knee flexion and shoulder

joint. Enhanced joint position sense and lcinesthesia as

IE! lfllii American Academy of flrthopaedic Surgeons

muscle endurance training should be included in any re-

Drthopoedic Knowledge Update: Sports Medicine 5

uessalissuaa :s

Chapter 24: Nousurgioal and Pbsboperative Rehabilitation for Injuries of the Overhead Athlete’s Elbow

Seeders 4: Rehabilitatinn

Phntngraph shnws an athlete perfnrming a prnne hall drnp and catch, with the shnulder in hnriznntal abductinn fnr lncal muscular

endurance. i: .E 4.!

thrnwing with a slight arc fnr each prescribed distance.

I'll

:I: E

It is necessary tn implement a slight arc {versus thrnwing

I'fl

.: Ill n: Iii:

Figure B

ttng ra ph sh nws a plyn metric wrist flip using

a E-Ih medicine ball tn strengthen the wrist

flexnrs.

adductinn tnrque after a thrnwer became fatigued.” En-

durance training perfnrnied by the athlete includes wall

dribbles with a medicine ball, prnne ball drnps {Figure 9) wall arm circles, the upper-bndy cycle, and Advanced Thrnvver‘s Ten Prngram exercises.

en a line} in the lnng-tnss prngram as a way tn regulate the intensity nf each thrnw and ensure that the athlete is net thrnwing harder than needed fnr each distance.

During the lnng-tnss prngram, as intensity and distance

increase, the stresses alsn increase en the patient’s medial elbnw and anterinr shnuldcr jnint. A 2011 study repnrted

that the lnnger thrnwing distances substantially increased

these threes.31 The lnng-tnss prngram is designed tn grad-

ually intrnduce leads and strains and shnuld be cnmpleted successfully before thrnwing frnm the mnund is allnwed.

Pnsitinn players additinnally can begin a prngressive hit-

ting prngram that begins with swinging a light bat and

Phase W: Return-tn-Activity Phase

prngresses tn hitting nff a tee, snft-tnss hitting, and finally,

tn cnntinue prngressing with activities that allnw a return tn full cnmpetitinn. This phase includes an interval thrnw-

Fnllnwing the cnmpletinn nf a lnng-tnss prngram, pitchers prngress tn phase II nf the thrnwing prngram,

absence nf pain nr tenderness, a satisfactnry isnltinetic test

ber nf thrnws, the intensity, and the type nf pitch are prngressed tn gradually increase stress nn the elbnw and

testing is perfnrmed at 13fl°fs and 3fl0‘b's. Data indicate

intensity and gradually prngresses tn T593, 9D%, and

Phase IV nf the rehabilitatinn prngram enables the athlete

ing prngram {ITP}. The criteria required tn begin phase IV nf treatment include the achievement nf full REM, the

result, and a satisfactnry clinical examinatinn. Isnkinetic

that the bilateml cnmparisnn at 130% fnr the thrnwing

arm‘s elbnw flexinn is 10% re 2fl% strnnger and the dnm— inant extensnrs are typically 5% tn 15% strnnger than

batting practice.

thrnwing nff a mnund [Table 6}. In phase II, the num-

shnuldcr jnints. Generally, the pitcher begins at 5fl% nf

113034;. nver a 4-week tn 6-week perind. Breaking balls

are initiated after the pitcher can thrnw 4|} tn SCI pitches at least at 30% nf intensity withnut symptnms. During

these nf the nnnthrnwing arm?

this phase, pnsitinn players will be prngressed with pnsi-

tn facilitate the restnratinn nf nnrmal thrnwing mntinns.

described exercises and drills tn maintain and imprnve

The ITP was develnped tn gradually intrnduce the quantity, distance, intensity, and types nf thrnws needed

tinn-specific fielding drills and functinnal drills. The athlete is instructed tn cnntinue with all previnusly

The ITP is divided intn twn phases. Phase I is a lnng—tnss prngram {Table 4 and Table 5} that is initiated at 45 feet

upper extremity, cnre, and lnwer extremity strength, pnwer, and endurance during this phase nf rehabilitatinn.

vnlume nf thrnws. Phase II is a mnund thrnwing prngram used fnr pitchers. During phase I, the athlete is instructed

cnnditinning prngram, including the perindiaatinn nf thrnwing and strength-training activities, tn help prevent

synchrnniaatinn nf the trunk and lnwer extremities, while

alsn tn prepare for the upcnming seasnn. A 1992 study

[15 m} and is prngressed with increased distances and

tn use a crnw—hnp methnd nf thrnwing, tn incnrpnrate

firthnpaedic Knnwledge Update: Spnrrs Medicine 5

It is alsn impnrtant tn teach the athlete a year-rnund nvertraining and thrnwing when pnnrly cnnditinned and

fl lfllfi American Academy nf Cirrhnpaedic Surge-ens

Chapter 24: Nousurgitall and Postoperative Rehabilitation for Injuries of dse Overhead Athlete’s Elbow

_—

Table 4 (titsr'rffntre'rifl

Interval Throwing Program for Baseball Positional Players

Interval Throwing Program for Baseball Positional Players

45-Feet Phase

fill-Feet Phase

Step 1

Step 9

A} We rm-up throwing El} 45 feet {25 throws} C} Rest 5-10 min

D} Warm-up throwing E} 45 feet {25 throws}

A} Warm -up throwing B} 150 feet {25 throws} C} Rest 3-5 min

D} We rm-up throwing E} 151] feet {25 throws}

Step 15

Step 2 A} We rm-up throwing El} 45 feet {25 throws}

C} Rest 5-10 min

D} Warm-up throwing

E} 45 feet {25 throws} F} Rest 5—11] min

A} Warm-up throwing B} 151] feet {25 throws}

H} 45 feet (25 throws}

D} Warm—up throwing

G} Warm-up throwing

E} Rest 3-5 min

Eli-Feet Phase

1Bfl-Feet Phase

Step 3

Step 11

A} We rm-up throwing

5} Eli feet [25 throws} C} Rest 5-11.} min

D} Warm-up throwing

E} 60 feet {25 throws}

Step 4

E} 151] feet {25 throws} F} Rest 3—5 min

E} Warm-up throwing

H} 15D feet [25 throws}

h g, %

D'

ET:

A} Warm-up throwing

R} 135 feet (25 throws} E} Rest 5-5 min

D} We rm-up throwing

E} 135 feet (25 throws}

DJ

E”

1'

Step 12

A} We rm-up throwing 5} 55 feet [25 throws} C} Rest 5-11] min D} We rm-up throwing

E} 5D feet {25 throws} F} Rest 5-10 min G} Warm-up throwing H} so feet (25 throws}

A} Warm-up throwing B} 130 feet {25 throws} C} Rest 3-5 min D} Warm-up throwing

Elli-Feet Phase

Step 15

Step 5

A} Warm-up throwing

a} so feet [as throws}

E} Rest 5-10 min 5t 5 ep A} Warm—up throwing C} Rest 5—10 min D} WE rm-IJIJ thrDWIng

E} as feet [as throws} E} 55 feet [25 throws} G} We rm—up throwing

H} St} feet (25 th rows}

1104;531: Phase

51 Rest 3-5 "1|"

D} Warm-up throwing E} 150 feet {25 throws} F} Rest 3-5 min

E} 130 feet (25 throws} F} Rest 3-5 min E} Warm-up throwing H} 15f} feet {25 throws} G} We rm-up throwing

'1 Rest 3-5 "1'"

J} Warm-up throwing R} 15 throws progressing from 120 feet to 5D feet to so feet

All throws should be on an arc with a crow—hop. Warm—up throws

consist of ll;I to 25 throws at approximately 51: feet. The throwing program should be performed every other day, 3 times per weelr.I unless otherwise specified by the physician or rehabilitation

Step 1"

A} Werm-up throwing

B} 12f] feet [25 throws} _

-

D} Warm-up throwing

E} 120 feet {25 throws}

C} REF" 5 10 mm Step 3

A} We rm-up throwing B} 120 feet [25 throws} C} Rest 5-10 min D} Warm-up throwing

specialist. Each step is performed ___ times before progressing to

the "an it”

Date eda pted from Will: RE, Reinhold MM. Andrews JR:

Rehe bilitation of the thrower‘s elbow. Sports Med Arthrosc Rev

lflfl3;11{1}:?5-95, and Ellenbeclter TS, Willc RE, Reinhold MM. MurphyI TM, Paine RM: Use of interval return prog re ms for shoulder

E} 120 feet {25 throws} F} Rest 5-11] min

G} Warm-up throwing H} 125 feet {25 throws}

showed that a dynamic variable resistance exercise program significantly increased throwing velocity.32 Similar— ly, the throwing velocity in high school baseball players

ID 2fl15 American Academy of flrthopaedic Surgeons

rehabilitation. in Ellenbeclter T5: Shoulder Rehebiiita tion: Non-

fiperative Treatment. New vars, av. Thieme, sass. pp 139-155.

was increased using a program that includes a variety of resistance exercises, including plyometric training and a

Thrower’s Ten training program.”

Drthopaedic Knowledge Update: Sports Medicine 5

a

Section. 4: Rehabilitation

Table 5 {cr:;nntirrued}

Interval Throwing Program for Baseball

Interval Throwing Program for Baseball

45- Feet Phase

Flat Throwing

Step 1

Step 9

Pitchers: Phase I

A} Wa rm-up throwing B} 45 feet [25 throws} E} Rest 3-5 min

D} Wa nn-up throwing E} 45 feet [25 throws}

E .E 4.! :: E

tin-Feet Phase

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I'D

.: I} ac if

E} 45 feet [25 throws}

F} Rest 3-5 min I5} Warm-up throwing

H} 45 feet {25 throws}

E} El} feet {25 th rows}

C} Rest 3-5 min

E} 6i} feet {25 throws}

Step 4 A} Wa rm-up throwing 5} 5i} feet {25 throws}

C} Rest 3-5 min D} Warm-up throwing

E} 6i} feet [25 throws} F} Rest 3-5 min G} Warm-up throwing H} so feet {25 throws}

Step 5 E} 5i} feet {2D throws}

D} 5i} feet {10 throws} E} 9i} feet {2i} throws}

C} Rest 5—5 min

D} iii} feet (3’ throws}

E} 50 feet {15 throws} F} Rest 3-5 min E} El} feet {1 throws} H} 51'} feet {13 throws}

tau-Feet Phase

A} 60 feet (5-? th rows}

E} 60 feet (5-? throws}

B} 91] feet (5-? throws}

F} 90 feet {S-ir' throws}

C} 124 feet [15 throws}

G} 120 feet {15 throws}

D} Rest 3-5 min

Throwing program should be performed every}I other day. with one day of rest between stepsr unless otherwise specified by the

physician. Each step is performed 2 times before progressing to the next Etep.

elbow. Sports Med Arthrosr: Rev 2Dfl3;11{1}:?5v55.

UCL Injury}r

Nonsurgical treatment is attempted for partial tears and

sprains of the UCL, although surgical reconstruction

may be warranted for complete tears or if nonsurgical treatment is unsuccessful. A nonsurgical rehabilitation used to restrict RUM and prevent valgus stresses from

limiting movement so additional adverse stresses on the UCL can be avoided. RUM nsnallv is permitted, although

in a nonpainful are of motion, typicallv from 1D” to 1m} “',

to allow inflarmnation to subside and collagen tissue to align. Isometric exercises are performed for the shoulder,

Step 3

C} 120 feet [15 throws} D} Rest 5-5 min

ground} using pitching mechanics {20-30 throws}

program is outlined in Table 1 Initially, a brace can be

Step ?

A} 56 feet {5 throws} 5} 5|} feet iii] throws}

pitching mechanics {2t} throws}

Specific Nonsurgital Rehabilitation Guidelines

Step 5 E} 5i} feet {15 throws}

D} Th row 5i} feet {flat

ground} using

Will: RE. Reinhold MM. Andrews .IR: Rehabilitation of the thrower's

E} Rest 5-5 min A} so feet {If throws}

C} Throw 120 feet iii}| throws}

E} Rest 3—5 min F} Throw 60-99 feet {1i}15 throws} G} Throw Efl feet [flat

Data from Willt ICE, Reinhold MM, Andrews JR: Rehabilitation of the thrower's elbow. Tech Hand Up Extra-m Surg 2443:?{4}:15?—215. and

Bil-Feet Phase A} Go feet {1 [I throws}

A} Throw 60 feet (1 [1-15 throws} throws}

D} We rm-up throwing

C} Throw 120 feet {10 throws} D} Throw ED feet [flat ground} using pitching mechanics {ED-3i} throws}

Step 10

5} Th row 50 feet {it}

Step 3 A} We rm-up throwing

A} Throw SCI feet [113-15 throws] E} Th row 50 feet [1D throws}

Step 2

A} We rm-up throwing B} 45 feet [25 throws} C} Rest 3-5 min D} Warm-up throwing

Pitchers: Phase I

E} 60 feet [5 throws} F} 50 feet {it} throws} G} 12D feet {15 throws}

elbow, and wrist to prevent muscular atrophy. Ice and

anti—inflammatory medications are prescribed to control pain and inflammation. Elbow flexion and extension

RUM is increased gradually,F by 5” to 1D“ per week during

the second phase of rehabilitation or as tolerated, with

full RUM achieved bv at least 3 to 4 weeks. The clini-

cian should ensure the restoration of full shoulder RUM by incorporating manual stretches, RUM exercises, and

Drthopaedic Knowledge Update: Sports Medicine 5

D lflld American Academy of Orthopaedic Surgeons

|Chapter 24: Hensurgital and lbstepetafive Rehabilitatien fer Injuries ef the Dyerhead Athlete’s Elbew

Threwing f the Meund Stage I: Fastball: lilnlyl Step 1: Interval threwing

15 threw: eff meund at 50%”

Step 2: Interval threwing 30 threw: eff meund at 50%

Step 3: Interval threwing 45 threw: eff meund at 50%

Step 4: Interval threwing

50 threw: eff meund at 50% Step 5: Interval threvving 10 threw: eff meund at 50%

Step 5: 45 threw: eff meund at 50%

50 threw: eff meund at 15%

Step 1: 30 threw: eff meund at 50% 45 threw: eff meund at 15% Step 5: 10 threw: eff meund at 50% 55 threw: eff meund at 15% Stage II: Fastball: tilnlyr Step 9: 50 threw: eff meund at 15% 15 threw: in batting practice

Step 10: 50-50 threw: eff meund at 15% SD threw: in batting practice Step 11: 45-50 threw: eff meund at 5% 45 threw: in batting practice

mebilisatien techniques. Altheugh all aspects ef sheultier Rfllvi sheuld he addressed, glenehumeral internal retatien sheuld be emphasized, because a less ef internal

retatien RUM has been implemented in elbew injuries}1 Rhythmic stabilizatien exercise: are initiated as telerated in the acute stage: ef rehabilitatien te develep dynamic stabilisatien and neuremuseular centre] ef the upper extremity. A: dynamic stability is advanced,

isetenic exercises are incerperated fer the entire upper extremity. The flexer carpi ulnaris and flexer digiternm superficialis everlay the UCL; therefere, strengthening exercises fer these muscle: can assist the UCL in resisting valgus stresses at the elbew.“ In additien, pesterier retater cuff and scapular strengthening exercises are per

fermed te restere preximal stabilisatien. The advanced strengthening phase usually is initiated at 5 te 1' weeks af-

ter injury, with valgus leading menitered threugheut the

rehabilitatien pregram. An interval return-te-threwing pregram is initiated after the athlete regains full metien, adequate strength, and dynamic stability ef the elbew.

The athlete is allewed te return te cempetitien fellewing the asymptematic cempletien ef the interval spert pre-

gram. If symptems recur during the interval threwing pregram, they typically present when threwing at lenger

distances er with greater intensity er during threwing

frem the meund. If symptems persist, the athlete is reassessed and surgical interventien is censidered.

Medial Epicendyl'rtis and Flexer—Prenater Tendinitis Medial epicendylitis eccurs because ef changes within

Stage III

the musculetendineus flexer—prenater unit, character-

Step 12: 30 threw: eff meund at 15% warm-up 15 threw: eff meund at 50%; begin breaking balls 45-50 threw: in batting practice {fastball enly]

the medial epicendyle. lDyerhead threwers whe exhibit

Step 13: 30 threw: eff meund at 15% 30 breaking balls at 15%

50 threw: in batting practice

Step 14: 30 threw: eff meund at 15% 50-90 threw: in batting practice [gradually increase breaking balls]

Step 15: Simulated game; pregress by 15 threw: per werlteut (pitch ceunt}

All direwing eff the meund sheuld he dene in the presence ef the pitching ceach er spert hiemethanist te stress preper th revving

mechanics. Use speed gun te aid in effert centrel.

' Fer steps 1 thrnugh 5, use the interval threwing at 110 feet {35.5 m} phase as a warm-up.

" Percentage ef effert. Data frem near M, Willi ItE: Heneperat'rve treatment efthe elbew in

threvvers. Oper Tech Spares Med 1595:412131-95.

ized by micrescepic er macrescepic tearing within the flexer carpi radialis er prenater teres near the erigin en

flexer-prenater tendinitis alse may have UCL pathelegy that create: this secendary pathelegy due te the underlying increased laxity. Furthermere, it may be beneficial te

determine the number ef episedes and the chrenicity ef medial epicendylar symptems. Patients with lung histeries

ef medial epicendylitis may exhibit a chrenic degeneratien knewn as tendinesis er tendinepathy, net true tendinitis. The treatment ef tendinepathy is based en a careful examinatien te determine the exact pathelegy present. Uften, patients in whem tendinitis has been diagnesed enly later discever that the tenden had undergene a de-

generative precess referred te as tendinesis.35-3“ The differential diagnesis ef tendinesis may be made using MRI, ultrasenegraphy, er tissue biepsy.

The treatment ef tendinitis typically fecuses en reducing inflammatien and pain. This geal is accemplished

threugh the reductien ef activities, stereid injectiens, an-

ti—inflammatery medicatiens, cryetherapy, ientepheresis,

ID 2015 American Academy ef flrthepaedic Surgeens

Drthepeedic Knewledge Update: Sperts Medichse S

uvuemqsvaa :-

-_ Interval Threwing Program: Phase II,

Section 4: Rehabilitation

—— Nonsurgical Treatment Following Ulnar Collateral ligament Sprains of the Elbow Immediate Motion Phase

lnterrnediate Phase

Advanced Phase

Heturn-to-Activity Phase

Weeks {1 through 2

Weeks 3 through 6

Weeks 6 through 12

Weeks 12 through 14

Criteria to progress: Full RUM, no pain or

Criteria to progress to return to throwing: Full nonpainful RUM,

NA

NA

tenderness, no increase

in laxity. strength #5 of elbow flexio niextension

no increase in laxity.

fulfillment of isokinetic test criteria, successful clinical examination

c .E 4.!

I'll

::

Goals: To increase HUM, promote healing of UCL, retard muscular atrophy, reduce pain and inflammation

Goals: To increase ROM,

RUM: Brace (optional) for nonpainful RUM {Eat-ED“), AARDM, PROM elbow and wrist {nonpainful ROM 1

ROM: lGradually increase motion III" to 135‘I increase 11] per week

HUM: Progress to full elbow HUM

Maintain full elbow REM and elbow and forearm

Exercises: Isometrics

Exercises: Initiate isotonic exercises: wrist curls, wrist

Exercises: Initiate exercise tubing, shoulder

Exercises: Initiate interval throwing, continue

improve strength and endurance, reduce pain and inflammation,

promote stability

E I'fl

.: flil ac if

for wrist and elbow musculature: shoulder strengthening {no EH: strengthening}

Modalities: Ice. compression

extensions, pronationiIr supination, bicepslr triceps; dumbbells: glenohumeral ER and IR, deltoid, supraspinatus, rhom boids

Modalities: Ice. compression

Goals: To increase

strength, power and

endurance: improve neuromuscular control;

initiate high-speed

Goals: Maintain strength,

power, and endurance gains. Maintain REM and flexibility.

exercise drills

program: Thrower's Ten program. biceps! triceps program, supinationl'pronation,

muscle flexibility

Thrower's Ten Program. continue plyometrics

wrist extensionfflexion. plyometrics, throwing drills

Modalities: Moist hot pack pretreatment; ice FDSttI'Et'IEI'I'l:

Modalities: Moist hot pack pretreatment; ice posttreatment

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

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

light exercise, and stretching. Conversely, the treatment of tendinosis focuses on increasing the circulation to promote collagen synthesis and collagen organisation. Such treatment would include heat, stretching, eccentric exercises, laser therapy, transverse massage, and soft-tissue

mobilisation. These therapies are performed to increase the circulation and promote tissue healing. Dry needling has been advocated for this pathology to promote tendon

healing.“ Platelet-rich plasma {PEP} therapy is a promising in-

that it is minimally invasive, provokes a local response

only, and avoids an inflammatory response. Disadvan-

tages can include the cost of treatment, a laclc of sup— porting evidence, and increased staff time to withdraw

and centrifuge the blood, and then reinject it into the site

of pathology. Early research on the clinical application of PEP to promote healing and an adaptive response is

promisingfifldg Substantial benefits of PRP were shown in

blood is separated and the platelet-rich layer is injected into the site of injury. The proposed mechanism delivers

patients with chronic lateral epicondylitis.” Basic science and controlled studies have yet to report the efficacy of such a treatment. The nonsurgical approach [Table 3} for the treatment of epicondylitis {tendinitis andior paratendinitisl focus-

a healing response. Either advantages of PEP therapy are

gradually improving muscular strength. The primary

tervention in which a small sample of the patient’s own humoral mediators and growth factors locally to induce

flrdsopaedic Knowledge Update: Sports Medich'le 5

es on diminishing the pain and inflammation and then

fl lflld American Academy of Orthopaedic Surgeons

|Chapter 24: Nonsozgieal and Pbstuperative Rehabilitation for Injuries of tile Overhead Athlete’s Elbow

—_ Epicondylitis Rehabilitation Protocol Phase I: Acute Phase

Phase II: Suhacute Phase

Phase III: Chronic Phase

Goals: To reduce inflammation.

Goals: To improve flexibility. increase muscular strength»Ir endurance. increase functional activities. promote return to function

Goals: To improve muscular strength and endurance. maintaini'enha nce flexibility.

Exercises: Emphasize concentricfeccentric

Exercises: Continue strengthening exercises

Concentrate on involved muscle group 1ii'v'rist extensioni'flexion Forearm pronationfsupination Elbow flexioni'extension

Continue to emphasize deficiencies in shoulder and elbow strength Continue flexibility exercises Gradually decrease use of counterforce brace Use cryotherapy as needed Gradually return to sport activity Modify equipment {grip size. string tension. playing surface} Emphasize maintenance program

Therapies and exercises: Cryotherapy Whirlpool Stretching to increase flexibility: wrist extensionrflexion. elbow extensioniflexion. forearm supinationipronation Isometrics: wrist extensioniflexion. elbow extensioniflexion. forearm su pinationipro nation High-voltage galvanic stimulation Phonophoresis Friction massage

lontophoresis {with anti-

inflammatory drug. eg. dexa met hason e] Avoidance of painful movements

lea. gripping}

strengthening

Initiate shoulder strengthening {if deficiencies are noted} Continue flexibility exercises May use counterforce brace

Continue using cryotherapy after

gradually return to sport and high—level activities

I{emphasize eccentrici‘concentricl

exerciseffunction Gradually return to stressful activities Gradually reinitiate formerly painful movements

Data from Will: HE. Macrina LC: Rehabilitation for elbow instability: Emphasis on the throwing athlete. in Sklrven TM. Cisterman AL Fedorczylt J. Arnadio PC: Rehabiiitation of the Hand and Upper Extremity-r. Philadelphia. PA. Elsevier. 2U“. PP 1143-1155.

goals of rehabilitation are to control the applied loads

30° to 45". A gradual progression through plyometric

and create an environment for healing. The initial treatment consists of warm whirlpool baths, iontophoresis,

and throwing activities precedes the initiation of the ITP.

stimulate a repair response. Therapeutic modalities often

Ulnar nerve changes can result from tensile forces, com-

using these modalities in isolation. Common modalities

by an acute onset of radicular symptoms. During the

stretching exercises, and light strengthening exercises to

are used by rehabilitation specialists to reduce inflammation and promote healing. Very limited evidence supports

Ulnar Heuropathy

pressive forces, or nerve instability. Ulnar neuropathy occurs in three stages."'3 The first stage is characterized

can include massage. cold laser therapy, iontophoresis,

second stage, a recurrence of symptoms occurs as the

other modalities, however, studies have shown improved

changes. If the athlete presents in the third stage of injury,

ultrasound, nitric oxide, and extracorporeal shock wave therapy. When used in combination with exercise or with tissue quality and ontcomes.“‘5"“1 Conversely, patients with tendinosis are treated with transverse friction massage, forceful stretching, a focus on eccentric strengthening

athlete attempts to return to competition. The third stage is distinguished by persistent motor weakness and sensory nonsurgical management may not be effective. A leading mechanism for tensile force on the ulnar nerve is valgus stress. This mechanism may be coupled

with gradually progressing loads, and warm modalities to promote tendon regeneration.

with an external rotation supination stress overload mechanism. The traction forces are magnified further when

gressive stretching and strengthening program featuring high loads and low repetitions that emphasizes eccentric contractions is initiated. 1Wrist flexion and extension activ— ities should be performed, initially with the elbow flexed

Ulnar neuropathy is often a secondary pathology of UCL insufficiency. Compression of the ulnar nerve is often

After the patient’s symptoms have subsided, an ag—

IE! lfllfi American Academy of Cirrhopaedic Surgeons

underlying valgus instability from UCL injury is present.

due to hypertrophy of the surrounding soft tissues or the

presence of scar tissue. The nerve also may be trapped

Urthopoedic Knowledge Update: Sports Medicine 5

uyuexuaeuas :1:-

promote tissue healing. retard muscular atrophy

Section 4: Rehabilitation

between the two heads of the flexor carpi ulna ris. Repetitive flexion and extension of the elbow with an unstable

or removal of the loose bodies, is indicated.” Long-term follow-up studies regarding the outcome of patients un-

nerve may subluxate or rest on the medial epicondyle, rendering it vulnerable to direct trauma.

reported favorable results, suggesting that prevention and early detection of symptoms may be the best form of treatment.“

nerve can irritate or inflame the nerve. Additionally, the The nonsurgical treatment of ulnar neuropathy focuses

on reducing ulnar nerve irritation, enhancing dynamic

medial joint stability, and returning the athlete to com-

petition gradually. Using a night splint with the elbow flexed to 45“ can help to restrict movement and prevent

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IJttle Lesguer's Elhow

During the arm~cocking and acceleration phases of throwing, the medial epicondyle physis is subject to repetitive

ulnar nerve irritation. HSAIDs can be prescribed as well

tensile and valgus forces that can lead to a spectrum of

activities for at least 4 weeks, depending on the severity

the medial epicondyle through the apophysis. Pain in the

over 4 to 5 weeks, with emphasis on eccentric and dy—

with potential fragmentation, hypertrophy, separation

as an iontophoresis dispensable patch and cryotherapy. Throwing athletes are instructed to discontinue throwing c .E 4.!

dergoing surgery to drill or reattach the lesions have not

and chronicity of symptoms. They will be progressed through the immediate motion and intermediate phases namic stabilization drills. Plyometric exercises are used

to facilitate further dynamic stabilization of the medial

elbow. The athlete is allowed to begin an ITP when full

pain-free RDM and muscle performance are achieved without neurologic symptoms.

flsteochondritis Dissecans Dsteochondritis dissecaus (0CD) of the elbow eau develop as a result of the valgus strain on the elbow joint, which produces not only medial tension but also a lateral

injuries to the medial epicondylar apophysis, ranging from microtrauma to the physis to fracture and displacement of

medial elbow is common is adolescent throwers. These forces can result in microtraumatic injury to the physis, of the epiphysis, or avulsion of the medial epicondyle. In the absence of an avulsion, a nonsurgical rehabilita-

tion program similar to that used for the UCL is initiated.

Initial emphasis is placed on the reduction of pain and inflammation and the restoration of motion and strength. Strengthening exercises are performed in a gradual fash— ion. First, isometrics are performed, then, light isotonic strengthening exercises are initiated. Young throwing ath-

letes often exhibit poor core and scapular control, along

compressive force.“ This is observed as the capitellum

with weakness of the shoulder musculature, therefore, core, leg, and shoulder strengthening are emphasized.

valgus stress. Classification of the pathologic progress

and horizontal adduction. No heavy lifting is permitted

of the humerus is compressed against the radial head. Patients often report lateral elbow pain on palpation and

sion of DIED has been described in three stages.“ Stage I describes patients without evidence of subchondral displacement or fracture, whereas stage II refers to lesions

showing evidence of subchondral detachment or articular cartilage fracture. Stage III lesions involve detached osteochondral fragments, resulting in intra—articular loose

bodies. Nonsurgical treatment is attempted for stage 1

patients only and consists of relative rest and immobili-

zation until elbow symptoms have resolved. Honsurgical treatment includes 3 to 6 weeks of im-

mobilization at 90" of elbow flexion. RUM activities for the shoulder, elbow, and wrist are performed three to

four times a day. As symptoms resolve, a strengthening program is initiated with isometric exercises. Isotonic ex~

In addition, stretching exercises are performed to nor— malize shoulder REM, especially into internal rotation for 12 to 14 weeks. An ITIJ is initiated as tolerated when symptoms subside.

In the presence of a nondisplaced or minimally dis-

placed avulsion, a brief period of immobilization for approximately 7’ days is encouraged, followed by a gradual

progression of RUM, flexibility, and strength. An ITP usu—

ally is allowed at week 6 to B. If the av ulsion is displaced, open reduction and internal fixation may he required. Specific Postoperative Rehabilitation Guidelines

LICL Reconstruction

Su rgica] reconstruction of the UCL attempts to restore the stabilizing functions of the anterior bundle of the UCL.”

ercises are added after approximately 1 week of isometric exercise. Aggressive high-speed, eccentric, and plyometric

Several types of surgical procedures are available to reconstruct the UCLJM‘W The modified Jobe procedure

for the start of an ITP. If nonsurgical treatment fails or evidence of loose

source is obtained and passed in a figure-of-S pattern through drill holes in the sublime tubercle of the ulna

exercises are included progressively to prepare the athlete

bodies exists, surgical intervention, including arthro—

scopic abrading and drilling of the lesion with fixation

firthnpaedie Knowledge Update: Sports Mediehie 5

can be used, in which the palmaris longus or gracilis graft and the medial epicondyle.” A subcutaneous ulnar nerve

transposition is performed at the time of reconstruction.

fl lflld American Academy of Orthopaedic Surgeons

Chapter 24: Nonsurgiml and Postoperative Rehabilitation for Injuries of die Overhead Aflflete’s Elbow

Postoperative Rehabilitation Protocol

Table '3 {contoured}

Postoperative Rehabilitation Protocol

Following Ulnar Collateral Ligament Reconstruction Using Antogenous Palmaris

Following Ulnar Collateral Ligament Reconstruction Using Antogenous Palmaris

Immediate Postoperative Phase {ti-3 Weeks}

Inten-necllate Phase [Weeks ill-1}

Goals: To protect healing tissue. reduce pain and inflammation, retard muscular atrophy, protect graft site to allow healing

Goals: Gradual increase to full ROM, promote healing of repaired tissue, regain and improve muscular strength, restore full function of graft site

Week 'i

Week If

Brace: Posterior splint at BB“ elbow flexion

Brace: Elbow BUM Elf-135", motion to tolerance

ROM: Wrist ABDM extensioniflexion immediately after surgery

Exercises: Begin light resistance exercises for arm

Longus Graft {Accelerated RUM]

Elbow: Postoperative compression dressing 5-? days 1llla‘rist {graft site) compression dressing 1-1131 days as needed Exercises: Gripping exercises, wrist ROM, shoulder isometrics {no shoulder ER}, biceps isometrics

Longus Graft [Accelerated RUM}

{1 lb]: wrist curls, extension. pronation, supination: elbow extensionfflexion

Progress shoulder program emphasize rotator cuff and scapular strengthening Initiate shoulder strengthening with light dumbbells Week 5

Cryotherapy to elbow joint and to graft site at wrist

REM: Elbow BGM {if-135’

Week 2

Discontinue brace

Brace: Elbow BUM 15‘-1l]5° or as tolerated

Maintain full ROM

Motion to tolerance

Continue all exercises; progress all shoulder and

Exercises: Continue all exercises listed above Elbow BUM in brace Elf-105' Initiate elbow extension isometrics Continue wrist ROM exercises

Initiate light scar mobilization over distal incision

{strait}

Cryotherapy: Continue ice to elbow and graft site

Week 3 Brace: Elbow HUM 5"1'10“ to 115°l'120“, motion to tolerance

Exercises: Continue all exercises listed above Elbow BUM in brace

upper extremity exercises {progress weight 1 lb}

Week 6

ABGIM: {if-145“ without brace or full HUM

Exercises: Initiate Thrower's Ten Program, progress

elbow strengthening exercises, initiate shoulder Eli strengthening, progress shoulder program

Week 3’ Progress Th rower‘s Ten Program (prog ress weig hts}

Initiate PNF diagonal patterns {light} Advanced Strengthening Phase [Week B44] Goals: To increase strength, power, endurance;

maintain full elbow REM; gradually initiate sporting activities

Initiate ABUM wrist and elbow [No resistance]

Week 3

Initiate light wrist flexion stretching

Exercises: Initiate eccentric elbow flexioniextension,

Initiate ABDM shoulder Full can Lateral raises ERIIR tubing Elbow flexio nfextension Initiate light scapular strengthening exercises May incorporate bicycle for lower extremity strength, endurance

continue isotonic program: forearm and wrist, continue shoulder program (Thrower's Ten Program}, manual resistance diagonal patterns, initiate plyometric exercise program (two-hand plyometrics close to body only), chest pass, side

throw close to body, continue stretching calf and hamstrings

Week id

Exercises: Continue all exercises listed above: program plyometrics to two-hand drills away from

body: side-to-side throws, soccer throws, side

throws

IE! tots American Academy of flrthopaedic Surgeons

Drthopaedic Knowledge Update: Sports Medicine 5

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Section 4: Rehabilitation

Table 9 {continued}

Postoperative Rehabilitation Protocol

Following Ulnar Collateral Ligament Reconstruction Using Autogenous Palmaris Longus Graft [Accelerated RflM} Weeks 12-14

Continue all exercises: initiate isotonic machines strengthening exercises {if desired}: bench press {seated}. lat pull down; initiate golf. swimming; initiate interval hitting program

lteturn-to Activity Phase {Weeks 14-31]

Goals: Continue to increase strength. power. r: .E 4.!

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endurance of upper extremity musculature; gradually return to sport activities

Week 14

Exercises: lContinue strengthening program; emphasize elbow and wrist strengthening and flexibility exercises: maintain full elbow RUM: initiate one-hand plyometric throwing [stationary throws); initiate one-hand wall dribble; initiate one-hand baseball throws into wall Week 16

Exercises: Initiate interval throwing program

{phase I. long-toss program]; continue Thrower's Ten Program and plyometrics; continue stretching

before and after throwing

Weeks 22-24

Exercises: Progress to phase II throwing (after phase I successfully completed]. Weeks 313-3.?

Passive RUM activities are initiated immediately to reduce pain and slowly stress the healing tissues. Initially,

the focus of the rehabilitation is on obtaining full elbow

extension while gradually progressing flexion. Elbow

extension is encouraged early, to at least 15‘“, but full extension is allowed if the patient can comfortably achieve

it as long as no discomfort is present. a recent study

demonstrated that passive ROM of the elbow produced

3% or less strain in both bands of the reconstructed liga— ment and approximately 1% strain for the anterior band of the UCL.“ Therefore, it has been determined that in the immediate postoperative period, full elbow extension is safe and does not place excessive stress on the healing

graft. Conversely, elbow flexion to 100“ is allowed and

should be progressed at about 10” per week until full RDM is achieved by 4 to 6 weeks postoperatively. Isometric exercises are progressed to include light resis-

tance isotonic exercises at week 4 and the full Thrower’s Ten Program by week 6. Progressive resistance exercises

are incorporated at week 3 to 9. Again, focus is placed

on developing dynamic stabilization of the medial elbow.

Because of the anatomic orientation of the flexor carpi

ulnaris and the flexor digitorum superficialis overlying

the UCL, isotonic and stabilization activities for these muscles can assist the UCL in stabilizing valgus stress at the medial elbow.“ Thus, concentric and eccentric

strengthening of these muscles is performed.

Aggressive exercises involving eccentric and plyometric

contractions are included in the advanced phase, usually weeks 11 through 16. The Advanced Thrower‘s Ten Exercise Program is initiated at week 12 after surgery.

Exercises: Gradually progress to competitive throwingl'sports.

Two-hand plyometric drills are performed at week 12,

HUM = range of motion, AHDM = active range of motion, Elil I

allowed at postoperative week 15. Progression to throw‘

external rotation. IF. = internal rotation. PHF = proprioceptive

neuromustular facilitation.

Data from Willl'. ltE, Arrigo EA. Andrews .llll. Azar FM: Fleha bilitation following elbow surgery in the throwing athlete. Dper Tech Sports Med mementos-132.

and one-hand drills are executed at week 14. An ITP is

ing from a mound may occur within 4 to 6 weeks follow-

ing the initiation of an ITP, and a return to competitive throwing may cormnence at approximately 9 months

following surgery.

a Edit) study reported the outcomes of UCL recon-

The rehabilitation program in current use following UCL reconstruction is outlined in Table 9. The athlete‘s arm is placed in a posterior splint with the elbow immobilized at 9H“ of flexion for the first T days postoperatively to allow early healing of the UCL graft and fascial slings

struction of the elbow in T43 athletes during a 2—year minimum follow-up.“ The authors stated that UCL reconstruction with subcutaneous ulnar nerve transposition was

found to be effective in correcting valgus elbow instability in the overhead athlete and that the procedure allowed most athletes {fl 3%, 616 patients} to return to the previous

involved in the nerve transposition. The patient is allowed to perform wrist ROM and gripping and submaximal

or a higher level of competition in less than 1 year. Major complications were noted in only 4% {30 patients].

gressed from the posterior splint to a hinged elbow ROM brace to protect the healing tissues from valgus stresses that can be detrimental. The brace is discontinued at the beginning of week 5.

Ulnar Herve Transposition

isometrics for the wrist and elbow. The patient is pro—

firthopaedic Knowledge Update: Sports Medicine 5

An ulnar nerve transposition can be performed in a subcu-

taneous fashion using fascial slings. The clinician should

use caution to avoid overstressing the soft-tissue structures

fl lflld American Academy of Orthopaedic Surgeons

|Chapter 24: Nonsnrgieal and Pbstpperative Rehabilitation for Injuries of tile Overhead Aflflete’s Elbow

Postoperative Rehabilitation Following Ulnar Nerve Transposition Phase I: Immediate

Phase W:

Phase III: Advanced

Heturn-to-Activlty

Postoperative Phase

Phase II: lntennediate Phase

Week 0-2

Weeks 3-?

Weeks 3-12

Weeks 12-16

Goals: To allow soft— tissue healing of

Goals: To restore full pain—free REM; improve strength. power, endurance of upper-extremity

Goals: To increase strength, power,

Goal: To gradually return to sporting

relocated nerve,

reduce pain and inflammation,

retard muscular

Strengthening Phase

musculature: graduallyr increase

functional demands

endurance;

gradually initiate

Phase

activities

sporting activities

Week 1

Posterior splint at 9G“ elbow flexion with wrist free for motion (sling for comfort}; compression

dressing; exercises such as gripping exercises, wrist HUM, shoulder isometrics Week 2

Remove posterior splint for exercise and bathing; progress elbow HUM {PRGM 15" 420“}; initiate elbow and wrist

Week 3

Discontinue posterior splint; progress elbow REM and emphasize full extension; initiate flexibility exercise for wrist extensionl'flexion, forearm supinationl‘pronation, and elbow extensionl'flexion;

initiate strengthening exercises for wrist extensionfflexion, forearm supinationr'pronation, elbow extensorsrflexors, and a shoulder program

Week 8

Wee-It 12

Initiate eccentric exercise program;

Return to competitive throwing; continue

begin plyometric

exercise drills; continue shoulder and elbow strengthening and flexibility exercises; initiate interval throwing program NA

Week 6

Thrower's Ten program

NA

Continue all exercises listed above; initiate light sports activities

isometrics; continue

shoulder isometrics

HDM - range of motion, PROM - passive range of motion, HA - not applicable.

involved in relocating the nerve while soft—tissue healing

occurs.“ The rehabilitation guidelines following an ulnar

Posterior Dlecranon Dsteophyte Excision

Surgical excision of posterior olecranon osteophytes is

nerve transposition are outlined in Table 10. A posterior

performed arthroscopically using an osteotome or mo-

operative weelc to prevent excessive extension RUM and tension on the nerve. The splint is discontinued at the

the coronoicl, olecranon tip, and fossa to prevent further

splint at 90° of elbow flexion is used for the first post— beginning of week 2, and light RUM activities are initiated. Full RUM usually is restored by weeks 3 to 4. |Gentle

torised burr. Approximately 5 to ll] mm of the olecranon tip is removed, and a motorised burr is used to contour impingement during extreme flexion and extension.fl The rehabilitation program following arthroscopic

isotonic strengthening is begun during week 3 to 4 and

posterior olecranon osteophyte excision is slightly more

eccentric training, the Advanced Thrower’s Ten Exercise

tient‘s tolerance, but by 1|] days after surgery, the patient should exhibit at least 15“ to 10591 If!” of RUM, and 5“-

progressed to the full Thrower’s Ten Program by 4 to 6 weeks after surgery. Aggressive strengthening, including Program, and plyometric training, is incorporated at week, 3 and an [TP is begun at week 3 to 9 if all previously outlined criteria are met. A return to competition usually

occurs between weeks 12 and 16 postoperatively.

IE! Elllli American Academy of flrthopaedic Surgeons

conservative in restoring full elbow extension secondary to postsurgical pain. RUM is progressed within the pa-

10” to 115* by day 14. Full ROM ll)” to 145“} typically is

restored by day 20 to 25 after surgery. The rate of RUM

progression most often is limited by osseous pain and

Drthopaedic Knowledge Update: Sports Medicine 5

uvsvxllssuas :v

atrophy

Section 4: Rehabilitation

synovial joint inflammation, usually located at the top of the olecrauon.

The strengthening program is similar to the previously

discussed progression. Isometric exercises are performed for the first 10 to 14 days, and isotonic strengthening is performed from weeks 2 to I5. During the first 2 weeks fol—

lowing surgery, forceful triceps contractions can produce

posterior elbow pain; therefore, the clinician should avoid

initiating or reducing the force produced by the triceps muscle. The full Thrower’s Ten Program is initiated by

week 6. An ITP is included by week lfl to week 12. Em-

phasis again is placed on eccentric control of the elbow flexors and dynamic stabilisation of the medial elbow. c .E 4.!

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Hie-y Study Points

- Multiphased rehabilitation programs allow individualised progression of the athlete as determined by

successful completion of each phase.

II A complete and thorough evaluation allows the re-

habilitation specialist to properly design an effective treatment program for each athlete. I The rehabilitation programs are designed to gradually introduce functional forces and stresses through functional and sport—specific drills to prepare for a return to prior level of function.

The outcomes of elbow surgery in T2 professional based

ball players have been reported.” Elf these athletes, 4? exhibited a posterior olecranon osteophyte, and 13 of the athletes who underwent an isolated olecranon excision later required a UCL reconstruction.” These findings suggest that subtle medial instability can accelerate osteophyte formation.

The elbow joint is a common site of injury in athletes,

especially in the overhead athlete, because of the repet-

itive forces occurring at the elbow that create repetitive microtraumatic injuries. |Conversely, in athletes playing in collision spurts such as football, wrestling, soccer,

and gymnastics, elbow injury often results from mace rotraumatic forces to the elbow, leading to fractures,

dislocations, and ligamentous injuries. Rehabilitation of

the elbow, whether after injury or surgery, must follow a progressive and sequential order to ensure that the healing tissues are not overstressed. The rehabilitation program

should limit immobilization and achieve full ROM ear-

ly, especially elbow-ar extension RCM. Furthermore, the rehabilitation program should restore strength and neu—

romuscular control progressively and should incorporate

sport-specific activities gradually to successfully return

the athlete to his or her previous level of competition as quickly and safely as possible. Additionally, the rehabilitation of the elbow must include the entire kinetic chain

[the scapula, shoulder, hand, corei'hips, and legs} to ensure

the athlete’s return to high-level sports participation.

Annotated References 1. Conte S, Requa ELK, Garrick JG: Disability days in major league baseball. Am ] Sports Med 1001;19{4}:431-436. Medline Z. Posner M, Cameron KL, Wolf Jl'vl, Belmont P] Jr, lCwens BI}: Epidemiology of Major League Baseball injuries. Am I Sports Med 2011;39{S}:16?S-163ll. Medline DDI

The authors analysed the Major League Baseball disabled

list from Eilfll to IDES. They examined the differences in injuries between seasons and occurring on a monthly basis during the season. These injuries were categorized

by anatomic regions. Injuries also were categorised for

position and pitchers.

3. Fleisig CS, Escamilla RF: Biomechanics of the elbow in the throwing athlete. C'per TeslaI Sports Med 1996:4[2ht52-63. DUI 4. Andrews JR, Craven WM: Lesions of the posterior compartment of the elbow. Cffrr Sports Med 1991;1fli3}:63?651. Medline 5. Wilson FD, Andrews JR, Blackburn TA, McCluskey G: Valgus extension overload in the pitching elbow. An: J7 Sports Med 1933:1Hl}:33-SS. Medline DH] 6. Wright 11W, Steger—lvlay K, Wasserlauf BL, C’Neal ME, Weinberg BW, Paletta GA: Elbow range of motion in professional baseball pitchers. Am I Sports Med lDflE;34{2,‘I:l 90—193. Medline DCII 7’. Will: KE, Arrigo C, Andrews JR: Rehabilitation of the elbow in the throwing athlete. I Crrbop Sports Phys Tiler 1993;1?{6]:3fl5 -31?. Medline DUI S. Salter RE, Hamilton HW, Wedge jH, et al: Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: A preliminary report of a feasibility study. I Crtbop Res 1534;“31:325342. Medline DUI

Clrthopaedic Knowledge Update: Sports Medicine S

C lfllfi American Academy of Orthopaedic Surgeons

Chapter 24: Noosorgiml and Ibstoperafive Rehabilitation for Injuries of the Overhead Athlete’s Elbow

the rabbit. j Bone Joint Surg Am 19Sfl:SZ{S):1131-1 231. Medline

1'3. IGreen DP, McCoy H: Turnbuckle orthotic correction of elbow-fiexion contractures after acute injuries. ] Bone Joint Surg Am 19?9:61{?}:1fl92-1fl95. Medline 11. McClure PW, Blackburn LG, Dusold C: The use of splints in the treatment of joint stiffness: Biologic rationale and

an algorithm for making clinical decisions. Phys Ther 1994;?4{12}:11fl1-11l]?. Medlilte

12. Dines J5, Frank JE, Akennan M, Yocum LA: Glenohu-

meral internal rotation deficits in baseball players with ulnar collateral ligament insufficiency. Arr: J Sports Med lflfl9;3?{3j:SSE-S?fl.Medline D0]

The authors demographically matched 19 baseball players with UCL insufficiency to a control group of baseball players with no history of shoulder, elbow, or cervical injuries and measure passive glenohumeral internal and external rotation, elbow flexion and extension, and fore— arm pronation and supination. The authors reported a significant difference between players with UCL injury

versus control patients for dominant arm internal rotation, internal rotation deficit, and total RUM. The authors concluded that pathologic glenohumeral internal rotation deficit can be associated with elbow valgus instability.

Level of evidence: Ill.

13. Crockett HC, IGross LB, Wilk FEE, et al: Dsseous ad— aptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Merl

lflfl2530{1}:20-16. Medliue

14. Thomas S], Swanilc CE, Higgiuson JS, et al: A bilateral

comparison of posterior capsule thickness and its cor-

relation with glenohu metal range of motion and scapular upward rotation in collegiate baseball players. J Shoulder Elhotu Sstrgr lflllglfljS]:TflS-TIS. Medliuc DCII The authors measured the posterior capsule thickness

{PCT} using a lfl-MI-Is transducer to determine the cor-

relation with glenohumeral internal rotation, external rotation, and scapular upward rotation. The authors re-

ported that PCT was greater on the dominant shoulder

than on the nondominant shoulder. A negative correlation was noted between PCT and internal rotation. A positive correlation was found between PCT and external rota— tion and between PCT and scapular upward rotation at ED”, 9S”, and 120” of glenohumeral abduction. Level of evidence: III. 1.5. Will-t HE, Andrews JR, Arrigo C: Preventive sud Rehehilitutitre Exercises for the Shoulder and Elliott! ,od 6'. Birmingham, AL, American Sports Medicine Institute,

2001.

16. Moseley JB Jr, Jobe PW, Pink M, Perry J, Tibone J: EM’G analysis of the scapular muscles during a shoulder

IE! lfllfi American Academy of Cirrhopaedlc Surgeons

rehabilitation program. Am J Sports Med 1992;10j1}:123-

134. Medline D01

1?. Townsend H, Jobe PW, Pink M, Perry J: Electromyograph— ic analysis of the glenohumeral muscles during a baseball rehabilitation program. Am] Sports Med 1991;19I[3]:1I‘542T2. Medliue

DUI

13. Reinold MM, Will: KE, Fleisig '35, et al: Electromyo-

graphic analysis of the rotator cuff and deltoid mus-

culature during common shoulder external rotation exercises. J C'lrthojilI Sports Phys Ther 20M;34{T}:SSS-394. Mcdliuc DUI

19. Kibler WE: The role of the scapula in athletic shoulder function. Am J" Sports Med 199 SflfijljfllS-SST. Modliue ID. Paine RM: The role of the scapula in the shoulder, in Andrews JR, Wilk HE, eds: The Athlete’s Shoulder .Hew York, Churchill Livingstone, 1994, pp 495-512.

21. Wilk KE, Arrigo CA: An integrated approach to upper extremity exercises. Gil-shop Phys Ther Cliu North Am 1992;1:33T—36fl. 22.. Tucker WS, Armstrong CW, Gribble PA, Timmons MK, Yeasting RA: Scapular muscle activity in overhead ath-

letes with symptoms of secondary shoulder impingement

during closed chain exercises. Arch Phys Med Rehabil 2fl10;91{4}:55D-556.Medline DUI Using EMG data, this controlled laboratory study was

performed to compare the scapular muscle activation pat—

terns in 15 overhead athletes having symptoms of shoulder impingement with the patterns of 15 overhead athletes

with no shoulder pathology. The authors noted altered

muscle activation of the middle trapesius, and the serratus

anterior and upper trapesius had similar muscle activation.

23. Carpenter JE, Blaster RB, Pellizzon GIG: The effects of muscle fatigue on shoulder joint position sense. Am

J Sports Med tsssuststosssss. Medline

14. Will: KE, Yenchak A], Arrigo CA, Andrews JR: The Advanced Throwers Ten Exercise Program: A new exercise series for enhanced dynamic shoulder control in the overhead throwing athlete. Phys Sportsmed 2011:39l4}:9fl-9 1 Mcdliuc DUI The authors describe the Advanced Thrower’s Ten Exer-

cise Program.

IS. Andrews JR, Jobe FW: 1|slalgus extension overload in the pitching elbow, in Andrews JR, Zarins E, Carson WE, eds: Injuries to the Throwing Arm .Philadelphis, Saunders,

lass, pp ass-ass.

16. Swanilt EA, Lephart SM, Swanik CE, Lephart SP, Stone

DA, Pu PH: The effects of shoulder plyometric training

on proprioception and selected muscle performance characteristics. J Shoulder Elbow Surg 2fl02:11{6}:5?9-SSS. Mcdliuc DUI

Drthopaedic Knowledge Update: Sports Medichie S

meanness-as :t-

Salter RE, Simmonds DP, Malcolm EW, Rumble E], MacMichael D, Clements ND: The biological effect of continuv ous passive motion on the healing of full-thickness defects in articular cartilage. An experimental investigation in

Secfinn 4: Rehabilillatiuu

2?. Fertun CM. Davies G]. Kernuack TW: The effects cf plynmet‘ric training nu the shnulder internal rntaturs. Phys

Tat-r isssnsisnssa

13. 1iiiiilk HE. Vuight ML. Keirns MA. Gambetta V. Andrews

JR. Dillman CJ: Stretch—shnrtening drills fur the upper

36. Hirsch] BF. Ashman E5: Tennis elbcw tendinnsis {epicendylitis}. Instr Cnnrse Leet 2U D4:53:53 3-593. Medline

3?. Suresh 5P. Ali KB. Jenes H. Ccnnell DA: Medial epicendylitis: Is ultrasnund guided autulnguus bin-Dd injectinn an

effective treatment? Br] Spnrts Med anssssnnssssss.

extremities: Thenry and clinical applicatien. j Drtbnp Spurts Phys Titer 1993:1315 1:225-239. Medline

DUI

29. Vuight ML. HardinJA. Blackburn TA. Tippett 3. l[Banner GC: The effects nf muscle fatigue an and the relatinnship

nf arm dnminance tn shnulder prnprinceptinn. J Drtfrnp Spurts Phys Ther 1996:23ifij:343—331. Medline

D01

3B. Murrayr TA. Cnuk TD. 1|Ii‘Ii-ierner 5L. Schlegel TF. Hawkins c .E 4.!

I'll

:I: E

I'fl

.c fill n: if

R]: The effects nf extended play nn prnfessinnal baseball pitchers. Am J Spurts Med Eflfll;Z9{Z}fl3T-l42. Medliue

31. Fleisig GB. Belt B. Fertenbaugh D. 1iiii'ilk BEE. Andrews JR: Einmechanical cnmparisnn c-f baseball pitching and lung-

tnss: Implicatinns for training and rehabilitatinn. J Drtbnp

Spurts Phys Ther 2fl11;41{5}|:29fi-3fl3. Mcdlinc DID]

This kinematic and kinetic analysis examined the differences between pitching frnm a mnund and lnng-tnss pitching in 1'? healthy cullege pitchers. The results indicated that hurianntal flat thrnws prncluced binmechanical patterns similar tn pitching. whereas maximum-distance thrnws had increased tnrques cnmpared with mnund pitching.

discussinn 939. Merliine

33. de Mus M. van der Windt AE. Jahr H. et a1: Can platelet-rich plasma enhance tendcn repairi' A cell culture study. Ara.r Spnrts Med 2fl08;36i6}:11?1-11?B. Medline DD]

39. Mishra A. Pavelkn T: Treannent cf chrnnic elbnw tendinnsis with buffered platelet-rich plasma. Am J Spurts Med 1906;34f11}:1??4-1??3.Medline D'DI 4f]. Gum 5L. Reddy GK. Stehnn-Bittel L. Euwemeka C5: Cumbinetl ultrasuund. electrical sti mulatic-n. and laser prnmc-te cuilagen synthesis with mnderate changes in tendnn binmechanics. Am J Phys Med Rebufaif 199?;Tfii4iflflfl-29E. Medline DUI 41. Reddy GK. lGum 5. Stehnn-Bittel L. Enwemeka C5: Ein-

chemistry and biuruechanics of healing tendcn: Part II.

Effects cf cembined laser therapy and electrical stimulatinn. Med Sci Sparts Exerc 1993;3flifih'3'94-Bflfl. Medliue

RA. Bjnrdal jM: Effects uf luw—level laser therapy and eccentric exercises in the treannent cf recreatinnal ath-

letes with chrnnic achilles tendiunpathy. Am J Spurts Med lflflfl;3£{5}:331-33?.Medline Dfll

un thrcwiug velucity and shuulder muscle perfermance

43. Alley RM. Pappas AM: Acute and performance related

injuries cf the elbnw. in Pappas AM. ed: Upper Extremity

33. Escamilla RF. Innne M. deMahy M5. et al: Cemparisnn uf three baseball-specific 6-week training prngrams nu

threwing velucity in high schccl baseball players. ] Strength Cured Res ZBIEQEWMTET-ITBI. Medline DIDI

The authc-rs cnmpared thrnwing velncity fullnwing a 6-week training prngram in 63 high schnnl baseball players. The subjects were divided intn three training grcups {the Th mwer’s Ten. Keiser Pneumatic [Kciser]. and Plynmetric} and a centre] grnup. |Ccimplared with pretest thrnwing velncity values. pusttest velncity values were

significantly greater in the Thruwer's Ten grcup {1.3%}.

the Keiset Pneumatic {1.3%}. and the Plynmetric {23%} grnups than in the cuntrnl gruup. with ma significant dif-

ference in the cnntrnl gruup. Level crf evidence: II.

34. Davidsnn PA. Pink M. Perry J. ae PW: Functinnal anat-

DD]

42. Sterginulas A. Sterginula M. Aarskng R. aes-Martius

32. Wursden MJ. Greenfield l3. Jnhansnn M. Litaelmau L. Mundrane M. Dnnatelli RA: Effects nf strength training in teenage baseball players. I Drifter: Spurts Phys Ther 1992;15i5}:223-223.Medliue DUI

DDI

injuries in the Athlete .New Turk. Churchill Livingstnne. 1995. pp 339-364.

44.

Andrews JR. 1i'ii'hitesicle JA: lIamnn elbow prnblems in the athlete. J Drtisnp Spurts Phys Ther 1993;19ffiitll39195. Medliue DD]

45. MurreyT BF: Dstenchnudritis Dessicans. in DeLee JC. Dre: D. eds: Drtbupeiiie Spurts Meriieine .Philadelphia. Saun— ders. 1994. pp 903-912.

46. Bauer M. Jnnssnn K.]nsefssnn PC}. Lindéu B: {Listenchnn—

dritis disseca ns nf the elb-nw. A lung-term fnllnw-up study. Ciia Drthnp Heist Res 1992;234:136-160. Medline

nmy cf the flexur prnnatur muscle grnup in relatinn tn the

4?. Andrews JR. Jelsma RD. Jnyce ME. Timmerman LA: Dpeu surgical prncedures fnr iniuries nf the elbnw in thrcwers. Oper Tech Sparta Med 1 996:4{2J:109—113.DDI

35. Kraushaar B3. Nirschl RP: Tendinnsis nf the elbnw (tennis elbnw]. Clinical features and findings nf histnlngical.

4B. Dines J5. ElAttrache H3. CnnwayJE. Smith W. Ahmad 1'35: Elinical nutcemes cf the DANE TJ technique tn treat ulnar cullateral ligament insufficiency cf the elbnw. Am

medial cullateral ligament cf the elbew. Am ] Spurts Med 1995;23il}:145-25i}. Medline DD]

immunnhistuchemical. and electrnn micruscnpy studies.

I Bnne Jnint Sang Am 199 9:31i2}:239-2?B. Medline

.r Spurts art-e anagssnaynsssesaa. Medliue nnI

49. Enhrbnugh JT. Altchek DW. Hyman]. Williams E] III.

Butts JD: Medial cullateral ligament recnustructinn c-f

Drthnpaedic Knnwledge Update: Spnrts Medich'ie 3

D lfllfi American Academy nf Drthnpaedic Surge-ens

Chapter 24: Nunsurginal and Ibstnpetafive Rehabilitatinu Enr Injuries nE the Dverhead Athlete’s Elbnw

5B. Bernas GA, Ruberte Thiele RA, Kinuaman FLA, Hughes

RE, Miller BE, Carpenter JE: Defining safe rehabilitatinn fnr ulnar enllateral ligament teenusttuetinn nf the elbnw: A binmeehanieal study. Am] Spurts Med Elli] 9;3?{12}:239224(10. Medline DUI This enntrnlled labnratnrv stud}r evaluated the strain nu the UCL in eight eadaver elbnws fnllnwing UCL reennstruetinu using a graeilis teudnn graft. Strain was mea-

sured with elbnw passive REM, 22.2 H isnmetrie flexinn

in 1231 athletes: Results in T43 athletes with minimum 2-vear fnllnw—up. Am I Sports Med 2U]D;3E{12}:242E2434. Medline DUI

This retrnspeetive nutenme study repnrted the nutenmes and the return tn Fla}r in athletes fnllnwing UCL reenn-

struetinn at a minimum at 2-year tellnw-up. {if all ath-

letes, 33% were able tn return tn their previnus level nf enmpetitinn nr higher. The mean time fnr the initiatinn nf thrnwing was 4.4 mnuths, and the mean time fur the return tn full enmpetitinn was 11.6 mnnths. Level nf

evidenee: IV.

and eatensinn enntraetinn. and 3.34 N -n1 varus and valgus tnrque at 91]“ fleetinn. Frnm fl“ tn 50“ flexinn, strain was less than 3%, and at 90'" fleetinn, strain was 2%. Nn substantial strain with fnrearn: rutatinn was nnted.

52.. Martin 5D. Baumgarten TE: Elbnw injuries in the threwing athlete: Diagnnsis and arthrnsenpie treatment. Utter "ll"ee.l:lI Spur-ts Med 1996;4{2}:1flfl-1fl3. DUI

51. Cain EL Jr, Andrews JR, Dugas JR, et al: Gutenme nf

get}; in prufessinnal baseball players. Am} Spnrts Med

ulnar enllateral ligament reennstruetinn at the elbnw

IE! 2fllfi American Aeadernv nt' flrthnpaedie Surgenna

53. Andrews JR, Timmerman LA: flutenme nf elbnw sur1955;23l4}:4fl?—413.Medlitlt:

DUI

Drthnpaedie Knuwledge Update: Sperts Medicine 5

uaasuuqeuaa :1:-

the elbnw using the ducking technique. Ans ,7 Spuril‘s Med 2002;30i4jfi41-543. Medline

®

Chapter 25

Hip Rehabilitation

Heelan Enseld. MS. PT. 0C5. SOS ATE. CSCS

Dave Koblrieset. DPT, - . r n

n 1....

Ashley Young, PT, DPT, CSCS

Injuries to the hip joint in athletes have recently gained increased attention. lntra-articular conditions resulting from femoroacetabular impingement and hypermobility have been of particular interest. Because evidence to support both nonsurgical and postoperative rehabilitation

Femoroacetabular Impingement

The treatment of symptomatic FM has been debated re-

cently. Although literature reporting generally positive results for the surgical treatment of PM in athletes is in-

creasing,1 the current lack of definitive evidence justifies a

protocols is relatively limited, intervention should be based on impairments and functional limitations iden-

trial of nonsurgical treatment of this population. Monaurgical rehabilitation should focus on activity modification,

teristics of specific athletes related to hip injuries should

joint functionsm Reasonable training modifications should be the initial recommendation when treating symptomatic FM. Activities that place the hip in a position of impingement

tified using structured evaluation. The known charac-

be considered when developing treatment programs.

Future emphasis should be placed on critical appraisal

of nonsurgical treatment, postoperative rehabilitation protocols, and return-to-play considerations for athletes with hip injuries.

treatment of physical impairments, and optimization of

should be minimised. Although impingement can occur

in various positions, combined positions of flexiou, adduction, and internal rotation are commonly associat-

ed with increased symptoms associated with FAI. Deep

Keywords: hip: rehabilitation: femoroacetabular impingement: hypermobility Introduction

Rehabilitation of hip injuries in the athletic population is

a rapidly growing subject of interest in the field of sports medicine. Intro-articular pathology such as acetabular

labral tears and associated underlying mechanisms such as femoroacetabular impingement {PM} and joint bypermobility have prompted innovations in surgical and nonsurgical treatment. Nonsurgical and postoperative

rehabilitation for these individuals must consider the mechanical factors of underlying injury {and associated surgery when applicable}, the demands of the athlete, and most current available evidence. None of the following authors or any immediate famiiy member has received any-“thingI of vaiue from or has stock or stock options heici in a commerciai company or institution reiated directiy or indirectiy to the subject of this chapter: Dr. Enseiri. Dr. Kohirieser; and Di: Young.

fl lflld American Academy of Drrhopaedic Surgeons

squatting, lunging, cycling, and hurdling are examples of activities that may require modification during rehabilitation. Effective training while modifying symptomatic

activities can be difficult for competitive athletes participating in sports that require frequent performance of these activities. Impaired strength has been noted in individuals with nonarthritic hip pain, including those with Fit]. Particu-

lar deficits of the abductors and external rotators of the hip have been noted.“l Uncontrolled pelvic motion in the

frontal and transverse planes can contribute to the pain

associated with FAI.‘ Strengthening exercises should be advanced to include weight-hearing activities that chal-

lenge the patient to control excessive adduction and inter-

nal rotation of the hip. Exercises that maximize gluteal recruitment and minimize use of the tensor fascia lata

should be emphasized, including the resisted clam shell (Figure l}, the resisted sidestep {Figure I], the unilateral

bridge (Figure 3}, and ouadruped hip extension exer-

cises.‘5 Exercises to strengthen the lumbopelvic muscles

should also be considered. Appropriate control can help to decrease the occurrence of excessive anterior pelvic tilt associated with impingement secondary to altered

acetabular orientation.1r

Drthopaedic Knowledge Update: Sports Medicine 5

uvnvuuqvuas :1:-

Abstract

Section 4: Rehabilitation

r

Figure 1

Photograph demonstrates the resisted clam shell ese rcises. The patient abducts and esternally rotates the hip against resistance.

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Figure 3

Photograph demonstrates the unilateral bridge. The patient lifts the pelvis off the ground using

one leg. Pelvic stabilization is emphasized.

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

tion (RflMsl associated with symptomatic impingement. Treating hip flesror tightness should he a priority. Excessive tightness of this muscle group can he associated with

anterior pelvic tilt. Anterior pelvic tilt has been correlated with the occurrence of PHI earlier in hip RUMF 1illnl'hen

prescribing stretching activities, clinicians must be cau-

tions to avoid placing the patient in positions associated with symptomatic impingement.l

Physical therapy techniques should be considered for

patients with FA]. Joint mobilisation may be indicated when the patientis examination suggests a loss of capsular mobility. Possible examination findings include loss

of passive RDM, a capsular end-feel with passive RUM

assessment, and a decrease of symptoms with manual distraction of the hip joint. Because FA] can be part of a spec—

trum of changes and a precursor to hip osteoarthritis in some individuals,3 capsular changes should he considered.

Soft—tissue mobilisation can be useful when the tissue restricts joint mobility. A loss of motion associated with

an elastic end-feel coupled with an immediate response to

manual treatment of the target tissue indicates soft-tissue mobilization as a potentially useful intervention.l Figure 2

Photograph demonstrates the resisted sidestep exercise. The patient steps laterally with a resistance band placed around the lower legs.

Patients with symptomatic PM may demonstrate impaired hip flexibility and pelvic musculature.3 Flexibility activities should treat muscle tightness that can cause

firthopaedic Knowledge Update: Sports Medicine 5

Joint Hypermoloility.r Following a diagnosis of hypermohility or structural

instability of the hip joint, patient education and counscling regarding activity modification is of primary con-

cern to protect andi'or avoid further injury in the region. It is recommended that the individuals avoid activities

fl lflld American Academy of Orthopaedic Surgeons

Chapter 25: Hip Rehabilitation

involving uncontrolled, forceful end-range extension andi'or rotation that can place repetitive strain on the passive restraints of the hip} The correction of muscular imbalances of the hip and lumbopelvie region should be emphasized in athletes with hypermobility. An individualised program should be

developed to treat impairments identified through evaluation. Flexibility exercises should he prescribed with

caution only after end—feels have been assessed and are to be discouraged in those patients with excessive RUM}

RUM measurements should be recorded and compared

strength deficits. Individuals with excessive hip external

rotation ROM have decreased strength of the hip internal

rotators, and those with excessive internal rotation ROM have decreased strength of the hip external rotators.9 The

development and maintenance of sufficient strength to limit auditor control excessive hip RUM is essential in the nonsurgical management of this population.I

Strengthening programs designed for individuals with

hip joint hypermobility should primarily focus on the hip

abductor and external rotator muscle groups because of their role in controlling lower extremity alignment during functional activities. These specific muscle groups are responsible for maintaining a level pelvis and preventing adduction and internal rotation of the lower extremity while in single-leg stance.m Decreased hip rotational sta-

bility andfor strength has also been noted in individuals with symptomatic acetabular labral tears.1 In the presence of joint hypermobility, neu romuscular

re-education including proprioceptive and perturbation training may be beneficial. Neuromuscular reeducation has had positive effects with other pathologies of the

lower extremity. Individuals with labral pathology and compromised hip stability may benefit from the inclusion

Figure 4

Photograph demonstrates the manual

perturbation exercises. In the prone position.

the patient is instructed to match randomly directed force applied by the clinician.

the joint and postoperative inflammation quickly while

protecting the repaired structures. Many complications in rehabilitation are preventable and can be avoided with

deliberate patient education regarding the postoperative re-

habilitation protocol, appropriate level of activity progression, and early activity modification strategies. Problems

can occur during this period if the patient is not compliant

with the prescribed period of limited weight bearing, par-

ticipates in forceful RUM exercises, andfor is progressed too rapidly through the rehabilitation protocol."

Procedure-specific considerations should be applied to the rehabilitation program. Prevention of postopera-

tive joint stiffness andi'or the formation of intra-articular

adhesions should be emphasised immediately after hip

of dynamic stabilisation andfor perturbation training

arthroscopy. Circumduction RGM exercises {Figure 5} are used early in the rehabilitation program. Early applica-

musculature, which can improve dynamic hip joint con-

period has been associated with a lower rate of revision

Q

the initial postoperative period by limiting hip flexion,

{Figure 4} to increase the efficiency of the surrounding trol during functional activities.1

"Idea 25.1: Manual Perturbation, Prone

and Quaduped. Keelan Enselci, MS. PT,

DES (1 min}

tion of circumduction exercises during the postoperative

procedures.” Acetabular labrum repair should be protected during

extension, and external rotation RUM. The specific motion limitations depend on the location of the repair. Hip

flexion is typically limited to 9d“ to protect posterior

Postoperative Concerns for Athletes Undergoing

Hip i'iyrthroscopyr

In the patient who has undergone hip arthroscopy, postoperative goals are similar irrespective of the specific pro—

cedure performed. The main objectives are to reduce both

IE! Ellie American Academy of flrtbopaedic Surgeons

repairs, and hip extension and external rotation are often limited to neutral to protect anterior labral repairs.

1iiiihen the anterior joint capsule is involved {plication procedures}, external rotation is often restricted for up

to 4 weeks after surgery. ROM is typically progressed over the course of '3 months. Fewer precautions are used

if labral débridement is performed."

Drthopoedic Knowledge Update: Sports Medicine 5

usssaiiqsuaa :1:-

with the contralateral limb. Individuals with rotational hip REM imbalances demonstrate specific patterns of

Section 4: Rehabilitation

diameter can significantly decrease the amount of energy required to produce a fracture.” Although rare, femoral

neck fractures can occur following arthroscopic osteoplas-

ty; therefore, weight bearing must be limited after proce-

dures that include osteoplasty. Weight-bearing precautions specific to these procedures vary, but a period of partial

weight bearing of up to 6 weeks is often recommended.”

When capsular modification procedures are performed

to treat laxity, the rehabilitation program should be ad— justed to protect the integrity of the repaired tissues. In

these cases, RUM precautions specific to the procedure

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Figure 5

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l

'

Photograph demonstrates the circumduction

range-of-motion activity. The clinician passively

circumducts the patients hip in midrange to prevent joint stiffness.

are reconunended.” If capsulectomy was performed, often to visualize a cam lesion in the peripheral compartment, extension and external rotation RUM is avoided in the early postoperative period. With anterior capsular repair, avoiding external rotation greater than 20" is often recommended during the immediate postoperative period.11

Microfracture procedures can be performed in patients with focal full-thickness cartilage lesions of appropriate

sise.“' The immature marrow clot should be protected

during rehabilitation. Recommendations support extend-

ing the protected or limited weight hearing period to 6 to

1li'ilfeight-hearing precautions vary depending on the

surgical procedures performed. In less-invasive proce-

3 weeks.“1‘3~13 In conjunction with weight—bearing precau— tions, continuous passive motion can be recommended after microfracture to avoid intra-articular adhesions

dures such as isolated labral débridement, a short pe— riod of partial weight bearing {1 weeks or less} is often

continuous passive motion be used 4 hours per day during

labral repair, protected weight bearing is maintained for an extended period. In such cases, patients typically bear

RUM should be based on patient tolerance and progressed gradually during this period."~'f

recommended.” For more involved procedures such as

weight as tolerated with an appropriate assistive device

such as axial crutches for approximatelyr 4 weeks.""“ When using crutches, patients should be encouraged to

bear partial weight through the involved lower extremity

while demonstrating a normal heel-to-toe gait pattern. This decreases the compression forces across the hip joint and can decrease potential iliopsoas irritation that can

and scar formation. It is commonly recommended that

the first 1 to 4 weeks, with ROM set between 3C!” and W“.

Sport—Specific Rehabilitation Concerns for

Athletes With Hip Injuries

Running Hip musculature is often involved in various runningrelated injuries, including iliotibial band syndrome and

result from a sustained contraction while maintaining a

gluteal muscle strain. Previous research has demonstrated

crutches or an appropriate assistive device until the abil— ity to ambulate without deviation can be demonstrated,

response phase of running, with the gluteus medius hear— ing the greatest load, followed by the gluteus minimus,

toe-touch gait pattern."-” Patients should continue to use

that hip joint moments are greatest during the loading

even if crutch or device use persists beyond timeframes stated in postoperative guidelines. Wee hing patients from

gluteus maximus, and rectus femon' s9” increasing the step

can delay recovery by contributing to continued intra-

creased step rate has been shown to decrease gluteal and

crutches who are amhulating with compensatory patterns

articular irritation andfor overuse of accessory muscula— ture around the hip.”~”

Osteoplasty is often performed during hip arthros—

copy to treat FA]. Up to 3fl% of the diameter of the

anterolatetal femoral neck can be resected to treat carn

deformities without decreasing the load—bearing capacity of the femur.”-"5 Resection of 30% of the femoral neck

firthnpaedic Knowledge Update: Sports Medicine 5

rate has been shown to increase loading of the hamstring and gluteal muscles in late swing phase. Conversely, inpiriformis muscle loading in stance phase.11 For distance runners, the effect of step rate on specific muscles during various phases of gait should be considered.

Soccer Most severe injuries in soccer players occur in the lower extremity. Although these injuries are more common in

fl lflld American Academy of Orthopaedic Surgeons

Chapter .15: Hip Rehabilitation

ent aspects of play, including kicking, accelerating, and

changing direction. Athletes with groin pain have been

found to produce notably less torque during hip adduction tasks than those without groin pain.“ In uninjured

players, a marginal difference exists between isometric measurements of hip adduction and abduction strength

between the dominant and nondominant sides.fl When determining return-to-play criteria for soccer players,

a near-identical side-to-side measurement of isometric hip abduction and adduction strength indicates strength recovery. In cases of bilateral involvement, a ratio of 1.0 for ipsilateral hip abductors versus adductors may be

considered ideal.

Golf Most golf injuries occur at the lumbar spine; few occur at

the hip joint. However, because of the close association of

the lu mbar spine and pelvis, issues with hip rotation RflM

Return—to—Play Considerations for Athletes With Hip Injuries

A relatively small body of literature describes functional

testing and return-to-play considerations for athletes being treated nonsurgically or postoperatively following

injuries in the hip region. Currently, clinicians must use the limited available evidence combined with established functional tests and protocols for other lower extremity injuries. Variations of deep squat test results have been described for individuals with FAIR-'5 Hip abductor function has been correlated to performance on the singleleg squat and star excursion balance test. However, this association has only been studied in nonsymptomatic

individuals.” Postoperative return-to-play criteria have often been adapted from protocols described following

athletic knee injuries.l

Several patient-reported outcome measures have been validated for the younger, active population with hip injuries. The International Hip flutcome Tool liHUT—dfil has

are thought to influence spinal injuries. During the swing of right-handed female golfers, the hip joint primarily rotates in the transverse plane, with the lead leg using 50% to T594:- of available external rotation during the back-

shown reliability and validity for assessing the quality of

downswing. The lag leg rotates substantially less during a full swing, creating an asymmetric movement pattern

come measures may help the clinician assess perceived characteristics that affect an athlete’s readiness for return to sports.

swing and 34% to ”131% of internal rotation during the

at the hip.” Because golf is a weight-bearing activity, it

is reconunended that RUM be clinically assessed during weight bearing, rather than in the traditional positions

of sitting and prone. In addition, when treating hip in—

juries in golfers, obtaining full lead leg internal rotation through joint or soft tissue-mobilisation techniques must

life in young, active patients.” The Hip Outcome Score

has shown reliability and validity in patients undergoing hip arthroscopy. Additionally, the Hip Dutcome Score contains a sports subscale.“ Using patient-reported out-

5 u no me ry

Hip and groin pain can become a chronic condition in

be emphasised to minimize compensatory RUM through

athletes, potentially affecting performance and athletic participation. Recent advances in diagnostic imaging and

Ballet

these pathologies. Many factors need to be considered by

the lumbar spine.

Ballet dancers require an extreme amount of motion at the hip, which often results in compensatory soft-tissue laxity. This pronounced amount of flexion, extension,

abduction, and external rotation renders these athletes more susceptible to labral injuries, femoroacetabular subluxation, tendinopathies, and muscular imbalances.

lGenerally, dancers exhibit increased external rotation at hip at the expense of internal rotation RGM.“ External

rotation strength in dancers has not been found to be

greater than in nondancers; however, dancers generate a substantially greater angle—specific torque at extreme

ranges of external rotation.” Rehabilitation should focus on establishing external rotation strength, particularly at the extreme RDMs commonly used by dancers.

IE! lfllfi American Academy of flrthopaeclic Surgeons

improved understanding of pertinent examination findings should result in more rapid and accurate diagnosis of clinicians when implementing guidelines for nonsurgical management or a specific postoperative rehabilitation

program. To achieve the most effective results and de— sired outcomes, the rehabilitation program should be based on the most current literature, individualized to

treat impairments identified during clinical examination, and modified to consider athlete’s diagnosis, history, and

specific surgical procedure performed. A paucity of evi-

dence exists detailing objective criterion—based progression through nonsurgical or postoperative rehabilitation.

For this reason, decisions to advance exercise or activity

level should be based on the individual’s ability to demonstrate correct mechanics and appropriate dynamic con-

trol during functional activities versus advancing solely

on time-based measures. Current evidence provides a

Drrhopaedic Knowledge Update: Sports Medicine 5

uvilvaltqsuvs :s-

the knee and ankle, elite athletes often report unilateral or bilateral groin pain. Groin pain affects many differ-

Secfien 4: Rehabilitatien

theeretical feundatien en which re base rehabilitatien;

hewever. future research sheuld fecus en cemparisens

between interventiens andfer pretecels te impreve ef— fectiveness ef carc. Key Study Peints

I Treatment techniques applicable tn athletes with symptematic FAI and hyperme bility ef the hip jnint must be identified.

It The apprepriate pesteperative treatment pregres-

sien te athletes undergeing hip arthrescepy sheuld

c .E 4.!

be applied. ' Spert—specific facters affect rehabilitatien ef athletes with hip injuries.

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individuals with chrenic hip pain and centre] patients feund substantial differences exist between experimental and centrel greups. Level ef evidence: III. Austin AB. Senna RB. Meyer JL. Pewers CM: Identi-

ficatien ef abnermal hip mntinn asseciated with ac-

etabular labral pathelegy. J Uri-“hep Sperss Phys Ther Zflfl3;33{9}:553-565.Medline DUI Selltewits DM. Benecls G]. Pewers CM: 1i'ii'hich exercises target the gluteal muscles while minimizing activatien

ef the tenser fascia lata? Electremyegraphic assessment

using fine—wire electredcs. ] Urshep Sperrs Phys Ther 2013:43i2]:54-64.Medline DUI

This centrelled laberatery study used electremyegraphic data tn determine gluteal muscle activity during selected

exercises and identified specific exercises that recruit the

gluteal muscles while minimising tenser fascia lata recruitment. Level ef evidence: III. Ress JR. Nepple J]. Philippen M]. Kelly ET. Larsen EM. Hedi A: Effect ef changes in pelvic tilt en range ef me-

Annetated References l. Tranc-vich M]. Salsler M]. Ensclti KR. Wright 1|If]: A review ef femereacetabular impingement and hip arthrescepy in the athlete. Phys Spertsmed ID14;41{1}:T5-31 Medline DUI

This clinical review expleres recent evidence en the evaluatien. recegnitien. and treatment ef FAI. and discusses nensurgical management, pesteperative rehabilitatien. and treatment in the pediatric and master athlete pepu—

latiens. Level ef evidence: V.

1. Enselti It. Harris—Hayes M. White DM. et a1; Drthepaedic Sectien ef the American Physical Therapy Asseciatien: Nenarthritic hip jnint pain. I Urrhep Sperts Phys Ther 2fl14;44{6}:A1-A31.Medline DUI These guidelines develnped by the Urthepaedic Sectien ef the American Physical Therapy Asseciatien describe evidence-based physical therapy practice fer treatment ef nnnarthritic hip pain. Level ef evidence: I. 3. Yasbelt PM. Uvanessian V. Martin RL. Fultuda TY: Hensurgical treatment ef acetabnlar labrum tears: A case series. ] Urthep Sperrs Phys Ther 2011:41i5 1:346—353.

Medline DUI

This case series describes a nensurgical pregram fer these with clinical evidence ef an acetabnlar labrum tear and fen nd all patients demenstratcd decreased pain. functienal imprevement. and cerrectien ef muscular imbalances. Level ef evidence: IV. 4. Harris-Hayes M. Mueller M]. Sahrmann EA. et al: Perseus with chrenic hip jnint pain exhibit reduced hip muscle strength. I Urthep Sperts Phys Ther 2fl14;44{11}:39fl— 393. Medline DUI This centrelled laberatery cress-sectieual study assessing hip abductien and retater strength characteristics in

Urthepaedic Knewledge Update: Sperts Medicine 5

tieu te impingement and radiegraphic parameters ef ac—

etabnlar merphelegic characteristics. Am J Sperts Med 2D14;41[1fi}:24fl2-24i}9.Medline DUI This centrelled laberatery study examining the effect ef changes in pelvic tilt en terminal hip RUM and measurements ef acetabnlar vetsien feund dynamic changes in pelvic tilt substantially influence the functienal erientatien ef the acetabulum. Level ef evidence: III. Hedi A. Lynch EB. Sibilslty Enselman ER. et al: Elevatien

in circulating biemarlters ef cartilage damage and inflammatien in athletes with femereacetabular impingement.

Am I Sperts Med 2fl13:41(11}:2535-2590. Medlilte DUI This centrelled laberatery study measured biemarlters ef cartilage degradatinn and inflammatien in athletes with

FAI cemparcd with centrel patients and feund the results

were substantially higher in the experimental greup. Level ef evidence: III.

Cibull-ta MT. Strube M]. Meier D. et al: Symmetrical and asymmetrical hip retatien and its relatienship te hip retater muscle strength. Clix Eiemech {Batiste-l. Ayers}

2Dlfl:25[ll:55-62.Medline

DUI

10. Lectun DT. Ireland ML. 1ilii’illsc-n JD. Ballantyne ET.

Davis IM: ISure stability measures as risk facters fer lewer extremity injury in athletes. Med Sci Sperrs Exerc lflfl4:36{fil:926-934.Medline DUI

This study examined strength measurements in subjects

with symmetrical and asymmetrical hip retatien RUM and fennd that strength values depended en the pnsitien that the hip retater muscle is tested and the type nf hip retatien symmetry er asymmetry present. Level ef

evidence: III.

11. Spencer—Gardner L. Eischen ll. Levy BA. Sierra R]. Engasser WM. Krych A]: A cempreheusive five-phase

rehabilitatien pregramme after hip arthrescepy fer

D lfllfi American Academy ef Urrhepaedic Surge-ens

Chapter 25: Hip Rehabilitatinn

This case series describes a nensurgical pregram fer pa— tients with clinical evidence ef an acetabular labrum tear that emphasizes hip and lumbnpelvic stabilizatinn, cnrrectien ef hip muscle imbalances, biemechanical centre], and spert-speeific functienal pregressien. Level ef evidence: IV.

19. Enseki KR, Martin EL, Draevitch P, Kelly ET, Philippen

M], Schenker ML: The hip jeint: Arthrescepic precedures

and pesteperative rehabilitatien. ] Drtitep Sperts Phys Timer lflfl6;36{?}:516-525. Medline DUI 20. Schache flG, Blanch PD, Darn TW, Brawn NA, Resemend

D, Pandy MG: Effect ef running speed en lewer limb jeint

kinetics. Med Sci Sperts Exevc 2m 1;43i?}:116fi-12?1. Medline DUI

12. TN'illinten 5C, Briggs KK, Philippen M]: Intra—articular adhesiens fellewing hip arthreseepy: A risk facter analysis. Knee Sarg Sperts Trnnmetni drtbresc 2014;21{4}:322325. Medline DUI

This centrelled laberatery study evaluated the effect ef running speed en lewer limb kinetics and feund hip eit-

This case series was cenducted te evaluate the pessible risk facters fer adhesiens after hip arthrescepy and feund adhesiens fellewing hip arthrnscepy were reduced with mud-

lead when running speed pregressed reward sprinting. Level crf evidence: III.

ificatien nf rehabilitatinn pretecels. Level ef evidence: IV.

13. Enseki KR, Kahlrieser D: Rehabilitatinn fellnwing hip

arthrescepy: An evelving precess. int j Sperts Phys Ther 2D14;9{fil:755-TT3. Medline

14. Edelstein J, Ranawat A, Enseki KR, “fun It], Draevitch P: Pest-eperative guidelines fellewing hip arthrescepy. Curr Rea Mnsctdeskeiet Med 2fl12;5[1l:15-23. Medline DUI This clinical cc-mmentary details a multiphase reha-

bilitatien pretecel fellewing hip arthrescepy. Level ef evidence: V. 15. Ayeni (JR, Eedi a, Lerich DIG, Kelly ET: Femeral neck fracture after arthreseepie management ef femereaeetabnlar impingement: A case repert. I Bette Infnt Surg Am

lfll];93{9l:e4?.Mcdline net

The authers reperted a case descriptien ef a patient experi-

tenser and knee fleser muscles during terminal swing demenstrated the mest dramatic increase in bieruechanical

21. Lenhart R, Thelen D, Heiderscheit B: Hip muscle leads

during running at varieus step rates. ,i Ortbep Sperts Phys Titer Efl14;44{101:?tifi~??4. ALA-4. Medline

DUI

This cress-sectienal centrelled Study characterising hip muscle ferces and pc-wers during running and hew these measurements change with step—rate demenstrated increasing step rate and increased hamstring and gluteal muscle leading in late swing, but decreased leading ef gluteal muscles and pirifnrmis during stance-phase. Level ef evidence: III. 11. Therbnrg K, Serner A, Petersen], Madsen TM, Magnussen P, Hiilmich P: Hip adductien and abductien strength prefiles in elite seccer players: Implicatieus fer clinical evaluatinn cf hip adductnr muscle recnvery after injury.

slaw } Spetts Med lflllgfifliljflll—IZE. Medline DUI

This cress-sectienal study cemparing isemetric hip ad-

16. Mardenes RM, Genaalea C, IEheu Q, Zebita M, Kaufman KR, Trnusdale RT: Surgical treatment {if femnreacetab-

ductieu and abductieu strength between deminant and nendnminant sides demenstrated that a cemparisnn between nendeminant and deminant isnmetric hip adductien strength and ipsilateral hip adductieniabductien strength ratie sheuld be used as a guideline fer seeeer players with grein pain. Level nf evidence: III.

the resectien. f Bette. jeinct Sing Am lflfl5;3?{2}:2?3-279.

23. Gulgin H, Armstcnng C, Gribble P: 1lil'eight-hearing hip

encing fracture ef the femeral neck fellewing arthrescepic esteeplasty for PAL Level nf evidence: V.

ular impingement: Evaluatien ef the effect ef the size ef

Medline

DUI

1?. Haughem ED, Ericksen B], Rybalke D, Hellman M, Nhe 5]: Arthrescnpic acetabnlar micrnfracture with the

use ef flexible drills: A technique guide. Artbresc Teri: 2014;3{4]:e459-e463.Medline DUI

retatien range {if mntinn in female gelfers. M Art: ] Sperts Phys Ther Zfllfl;5{2}:55—52. Medline

This centrelled laberatery study measuring weight hearing hip retatien RUM in female gelfers cempared with actual hip retatien RUM eccnrring during a full swing

demenstrated that weight-bearing ROM limits were net

The anthers reperted a technical descriptien ef an arthrescepic micrnfracture technique fer the hip using a flexible micrnfracture drill. Level nf evidence: V.

exceeded during swing, but the lead hip demenstrated decreased weight-hearing internal retatien. Level nf evidence: III.

13. Ten YM, Kecher M5: Chendral lesicrns nf the hip: Mi-

24-. Weber AE, Bedi A, Tiber LM, Zalta I, Larsnn CM: The

crefracture and chendreplasty. Sparta Med Attbtesc EDIG;IS[EI:E3-39. Medline DUI

This clinical cemmentary describes chendral injuries that eccur in the hip jerint and arthrnscepic precedures tn treat

such patbnlngy. Level nf evidence: V.

hyperfleatible hip: Managing hip pain in the dancer and gymnast. Sperts Health: A Maitidiscipiinnry Appreech. 2fl14;flpril23 [Epnb ahead ef print].

25. Gupta A, Ferniheugh E, Bailey G, Bembeck P, |liIIlarke A, aper D: fin evaluatien c-f differences in hip eicternal re-

tatien strength and range ef metien between female danc-

ers and nee-dancers. Br I Sperts Med 2Dfl4;3fll[ti1:??E-i'33.

Medline DUI

IE! lfllfi American Academy ef flrrhepaedic Surgeens

Drthepeedic Knewledge Update: Sperts Medicine 5

usswqu-‘is :1:-

fcmereacetabular impingement. Knee Satrg Sperts Trans metei A-rtbresc 1014;22t4}:343-359. Medline Dfll

Sectinn 4: Rehabilitatiun

25. Kivlan ER, Martin RL: Functinnal performance testing DI the hip in athletes: A systematic review fur reliability and validity. Int }' Spnn‘s Phys Tire-r 2012:?{4l:4fl2—412.

Medline

This systematic review examining perfnrmanee tests fur the ynunger active pnpulatic-n with hip pathnlngy found

the use nf functinnal perfnrmance tests in the assessment

at hip dysfunctinn has nnt been well established in the current literature. Le:tel nf evidence: lIb.

This study describes the dcvelnpment nf a self-administered evaluative tun] tn measure healtharelated quality nf life in ynnng, active patients with hip disnrders that resulted in the develnpment nf a new quality-nf-life patient-repnrted c-utcnme measure, the Sid-item Internatinnal Hip |Clutcnme Tn-nl {iHflT—SS}. Level nf evidence: IIa.

23. Martin RL, Philippnn M]: Evidence nf reliability and respnnsiveness fur the hip nutcnme scure. Arrlrruscflpy lflflfl;24{6}:fi?fi-EEZ.Mcdlitlc DUI

2?. Mnhtadi HG, Griffin DR, Pedetsen ME, et al. Multicenter

Arthrnscepy (If the Hip Dutcnmes Research Netwurk: The develnpment and validatinn of a self-administered quality-

nf—life nutcnme measure fnr ynung, active patients with

symptnmatic hip disease: the Internatinnal Hip |[Tuner-me Tupi (MDT-33}. Arthrnsenpy 2fi12;23{511:59'5 -505.

Videe Reference

15.1: Enselti K: Viden. Manual Perturbatinm PWHE and Quadraped. Pittsburgh, PA, 2-315.

E

.E 4.! I'll .1: :5

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flrdtnpaedie Knnwledge Update: Sparta Medicine 5

El ll] 16 American Aeadem~y nf Drthnpaedie Surge-ans

Chapter 26

Current Rehabilitation Concepts Following Anterior Cruciate nament Reconstructlon

Penny Lauren Goldberg, PT, DP'I', ATE

Giorgio Zeppieri Jr, PT, SE, EGGS

Debi Iones, ' II

Abstract

results in knee instability that leads to reduced knee func-

Injuries to the anterior cruciate ligament {ACL} are common in sports. Patients usually are recommended to undergo ACL reconstruction to regain the knee stability that is necessary for resuming preinjury sports participa-

or other high-demand activities} Consequently, ACL rc-

tion. Recent evidence indicates that REL reconstruction outcomes include a low return—to—sport rate, a high incidence of second ACL injury, and the development of posttraumatic knee osteoarthritis, however; ACL

reconstruction outcomes can be improved with a com-

prehensive preoperative and postoperative rehabilitation

program that addresses knee impairments, patient expectations, psychosocial factors, and movement pattern

deviations. Deciding when to allow a patient to return to sports participation or other high-dams or] activities

is challengng and should be judicious, based on the results of a battery of objective tests. Keywords: anterior cruciate ligament: rehahllltation; return to sports Introduction

Knee ligament injuries are common musculoskeletal in-

juries that often occur during sports participation. The anterior cruciate ligament (ACLI is the knee ligament

with the highest prevalence of injury.1 ACL injury usually None of the foiiowiny authors or any immediate famiiy member has received anything of vaiue from or has stock or stock options heici in a commerciai company or institution

reiateci ti‘inactiyr or indirectly to the subject of this chapter:

Dr. Goiciberg. Ms zeppieri, Eh: Jones, and Dr. Chmieiewski.

@ lfllfi American Academy of Drthnpaedic Surgeons

tion and a lower activity level. Most patients require ACL reconstruction to regain knee stability and resume sports construction rehabilitation receives substantial attention in clinical and research settings.

It is not surprising that most patients who undergo ACL reconstruction expect to return to sports partici-

pation? flnly approximately 60% of affected patients

actually return to preinjury sports participation after ACL

reconstructiond-5 Moreover, within 2 years after ACL reconstruction, as many as sea sustain a second ACL injury to either the surgical or nonsurgical knee, with a

slightly higher risk to the nonsurgical knee.“ Within 1U years after ACL reconstruction, up to 30% show signs

of posttraumatic knee osteoarthritis,” which can reduce

knee function progressively. Clinicians should be mindful of these outcomes and should seek ways to improve ACL reconstruction rehabilitation to enhance returnutousport (RTE) rates, guard against a second injury, and protect

long-term joint health.

Patients undergoing ACL reconstruction ideally should

undergo a brief period of rehabilitation before surgery and more extensive rehabilitation after surgery. Postsurgical

ACL reconstruction rehabilitation can be divided broadly

into early rehabilitation and late rehabilitation. Early rehabilitation focuses on resolving knee impairments and reintroducing low-level functional activity, whereas late

rehabilitation focuses on preparing and transitioning the patient back to high-demand activity, including sports

participation. Although general agreement about this

approach to ACL reconstruction rehabilitation exists, consensus has not been reached on when to initiate cer-

tain exercises—especially those that impart high loads

to the graft or knee articular surfaces—or what criteria to use when progressing patients between rehabilitation

Orthopaedic Knowledge Update: Sports Medicine 5

uoneuuqeqau :11

’I‘erese L. |lilhmielewslti. PT. PhD. 5C5

Section 4: Rehabilitation

phases or back to sports participation.Em In addition, can negatively influence rehabilitation outcomes. These

is necessary, because failure to address expectations early in rehabilitation can lead to dissatisfaction and increased health care utilization and cost." Patients often have an elevated fear of reinjury follow-

reconstruction rehabilitation protocols. This chapter describes the current concepts in ACL

struction.m Fear of reinjury is high immediately after

altered psychosocial factors"=” and movement patterns13 have been identified after ACL reconstruction, which impairments are not addressed routinely in most ACL

reconstruction rehabilitation. Although the focus is ACL

ACL injury but tends to decline substantially in the first

injuries.

are improving. However, psychologic disturbances can

reconstruction rehabilitation, many of the concepts are applicable to the rehabilitation of other knee ligament

Preoperative Rehabilitation E

.E 4.! I'll .1: :5

I15 .E El fl'.’ E

ing ACL injury,” and fear of reinjury is a key reason for not returning to sports participation after ACL recon-

A primary goal of preoperative rehabilitation is to resolve

knee impairments to the greatest extent possible. Acute knee impairments resulting from ACL injury, including pain, effusion, quadriceps inhibition, and loss of motion,

month after MIL reconstruction and throughout early rehabilitation,“ at the same time as knee impairments

follow a “U“ pattern, in which disturbances are high immediately after ACL injury, improve through early

rehabilitation, and increase again on FlTS.12 Preliminary

work in this area suggests that the level of a patient’s fear of reinjury immediately after ACL injury does not

affect RTE." During the preoperative period, however, it

should be addressed because they can contribute to the

might be beneficial to assess the level of a patient’s fear of reinjury. If a high fear of reinjury is present, the patient

riceps weakness occurs in almost all patients after ACL injury, likely because of effusion and pain.” Quadriceps

reasons for the fear to begin reducing the anxiety about reinjury.“ The Tampa Scale for Kinesiophobia is a ques-

development of postoperative knee arth rofi brosis.“ Quad— muscle inhibition is common after ACL injury and can

contribute to quadriceps weakness.1 High-intensity neu~

romuscular electrical stimulation can be used to reduce

quadriceps muscle inhibition and increase strength.”*“'

Additional exercises to improve quadriceps activation

include the quad set and straight leg misc. Patients usually

adopt an antalgic gait after injury and benefit from gait

training to reestablish knee extension and symmetric

weight hearing.

A subject not addressed routinely in preoperative rehae

bilitation that could influence postoperative outcomes is patient expectations. Patients should be educated about the course of ACL reconstruction rehabilitation and need to be engaged in a discussion about their expectations of postoperative outcomes to prevent postoperative dissatisfaction?“ Practitioners should establish baseline expectations for rehabilitation milestones, create RTE criteria, and provide direction to prevent unrealistic patient expectations.” Practitioners also should be aware that the

could be engaged in a discussion about the underlying tionnaire that could be used to assess levels of a patient's

fear of reinjury.l4 A recent survey showed that Sfl‘iis of physicians discuss the fear of reinjury with their patients; this type of discussion could be done more regularly.H Early Postoperative Rehabilitation Immediate Postoperative Phase

The goals of the immediate postoperative phase are to

reduce knee effusion and pain, increase knee range of motion {RGM}, obtain good quadriceps contraction, improve proprioception, and normalize gait. Weight bearing should begin immediately after surgery to restore prop—

er gait sequencing. Patients should be transitioned from protected weight bearing with assistive devices to weight bearing without assistive devices when they can achieve

full knee extension and can effectively control pain. The immediate postoperative phase continues to focus on resolving acute knee impairments, because surgery reac-

conventional criteria used to determine success following ACL reconstruction, such as knee laxity or functional

tivates the inflammatory process. Reducing postoperative knee effusion following ACL

a successful rehabilitation outcome. Excellent clinical and functional outcomes do not always equate to patient

has been shown to negatively affect intra—articular structures, inhibit quadriceps contraction, interfere with the

expectations following ACL reconstruction are higher in younger, highly active patients without a history of previous knee su rgeryf‘ however, the influence of these factors on expectations may be unique to the individual and case.” Patient education aimed at managing expectations

long rehabilitation.”*2‘5 A failure to reduce knee effusion can lead to patellofemoral pain, increased postoperative

testing, may fail to capture the patient's definition of satisfaction.”~18 Recent evidence has shown that patient

flrrhopaedic Knowledge Update: Sports Medicine 5

reconstruction is imperative because persistent effusion recovery of knee RUM, disrupt gait mechanics, and pro-

pain, posttraumatic osteoarthritis, and an increased risk

of arthrofibrosis.”=”‘13 Strategies to reduce knee effusion include the use of compression wraps, limb elevation,

El 1016 American AcadMy of Drrhnpaedic Surgeons

Chapter 26: Current Rehabilitatinn Enncepts Fnllnwing finterinr Cruciate Ligament Recnnstructinn

mndalities such as cryntherapy and high-vnltage electrical stintulatinn, and knee RUM exercises."

Initiating knee RUM exercises and restnring knee RUM in the immediate pnstnperative phase nf rehabil-

itatinn are essential. Delaying knee mntinn can cause

cnmplicatinns, including articular cartilage degradatinn, arthrnfibrnsis, impedance nf graft remndeling, capsular cnntractures, patellnfemnral pain, gait dysfunctinn, and

scar tissue fnrmatinn in the intercnndylar nntch.”-1*‘~3“13“ Achieving knee extensinn that is symmetric tn the cnn-

directed first tnward the achievement nf symmetric full

Figure 1

Phctegraph shews a heel prep exercise. perfnrmed tn restnre full knee extensinn in the preoperative and eariy pnstnperative phase of

rehabilitatinn.

knee extensinn tn the cnntralateral side, fnllnwed by full knee flexinn.if Heel slides nr active assisted RDM exer-

tissue is increased gradually.

nf a bed can he used tn imprnve extensinn and flexinn RUM. If a patient has difficulty regaining full knee ex-

phase, but it must nnt cnmprnmise the integrity nf the graft. After the patient can elicit a visible quadriceps cnu-

ratinn stretching can be implemented, such as heel prnps {Figure 1} and prnne hangs. Patellar mnbilieatinn in the

tensinn lag, exercises tn increase quadriceps strength and endurance can be implemented. Seated knee extensinn is

cises pcrfnrmed while seated in a chair nr nn the edge tensinn, passive interventions that use lnw—lnad lnng—du— superinr directinn can assist the recnvery nf knee exten-

Quadriceps strengthening is impnrtant during this

tractinn and perfnrm a straight leg raise withnut an exan np-en kinetic chain exercise that isnlates the quadriceps

sinn by facilitating quadriceps activatinn and preventing infrapatellar fat pad cnntracture.”~15 Seft-tissue mnbiliaa-

muscle; it shnuld he pcrfnrmed frnm 9i)“ tn 4D” nf knee flexinn tn minimize anterinr tibial translatinn in ranges

pain and interfere with knee RGM and patellar mnbility.

clnsed kinetic chain multijnint exercises shnuld be perfnrmed in the range nf fl“ tn iii)“ nf knee flexinn. Exam-

namic jnint stability, the reductinn nf inint fnrces, and

(Figure 2}, squats, lunges, and fnrward nr lateral steprups. Strengthening exercises shnuld incnrpnrate cnuceutric

tinns shnuld be pcrfnrmed alnng the incisinn and pnrtal sites tn minimise the risk nf adhesinns, which can cause

Reestablishing prnprinceptinn is essential fnllnwing ACL recnnstructinn tn assist in muscle activatinn, dy—

that can be harmful tn the healing graft?“31 |E'Innversely, ples nf clnsed kinetic chain exercises include the leg press

the relearning nf mnvement patterns.” Initially, weight

and eccentric training cf the lnwer extremity. Studies

shifts can be prngressed tn single-leg standing with 5“ tn

hnpping tasks than thnse whn trained with traditinnal

shifts can be used tn prnvide snmatnsensnry input and prnmnte weight bearing nn the surgical limb. Weight 3D" nf knee flexinn.

Intermediate Pnsteperative Phase

Befnre beginning the intermediate pnstnperative phase, the patient shnuld have achieved full-extensinn RGM,

have shnwn that patients whn include eccentric training have mnre quadriceps strength and perfnrm hetter nn exercise alnnesl1 High—intensity neurnmuscular electrical stimulatinn may he cnntinued in the intermediate phase if

the patient cnntinues tn have difficulty prnducing a quad-

riceps cnntractinn, has marked weakness, nr experiences pain during npen nr clnsed kinetic chain exercises. aement pattern deviatinns during clnsed kinetic

nearly full-flexinn RUM, a nnrmaliced gait pattern, and minimal tn nn effusinn, with nn jnint line nr patellnfemr

chain exercise nr nther functinnal activities are cnmrnnn

remaining acute knee impairments, increase muscle strength and endurance, restnre neurnmuscular cnntrnl,

result frnm quadriceps weakness and cnuld he addressed

nral painJfli' The gnals nf this phase are tn resnlve any and nnrmalize mnvement patterns in lnw—demand func-

tinnal activities. A factnr that cnuld delay progress during

this phase is persistent knee effusinn, which can limit knee RUM and inhibit quadriceps cnntractinn. Functinnal

activities shnuld be prngressed tn gradually increase the

lnad nn the knee. In additinn, the graft type will deter— mine exercise prngressinn sn that the lnad nn the healing

Eb Ifllii American Academy nf Urthnpaedic Surgenns

after ACL recnnstructinn. ICine pntential deviatinn is reduced weight bearing cm the surgical side, which may

with strengthening exercises. Hnwever, many patients cnntinue tn reduce weight bearing an the surgical side

even after acquiring sufficient quadriceps strength. In such cases, patients may benefit frnm instructinn frnm the rehabilitatinn specialist and feedback frnm a fnrce measuring device {such as a fnrce plate nr scale}, nrirrnr, nr viden.

Drthnpaedic Knnwledge Update: Sperrs Medicine .5

unglflulqeqeu :1;-

tralateral knee is critical because extensinn deficit is a pntential risk factnr fer the develnpment nf nstenarthritis and knee stiffness.” Therefnre, rehabilitatinn shnuld be

Section ii: Rehabilitation

@'

Video 26.1: Perturbation Training for Neuromuscular Control and Dynamic Stability. Penny Goldberg, PTr DPT, ATE {0.13 min}

- I iiii

aI

Video 25.2: Anticipatory Strategies to Enhance Neuromuscular Control and

Proprioception. Penny Goldberg, PT, DPT.

ATE {H.1S min]

a' Figure 2 E

.E 4.! I'll .1: :5

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Photograph shows a shuttle leg press exercise, which may be used for early controlled flexion range of motion and closed chain concentric and eccentric exercise during the intermediate phase of rehabilitation. The shuttle is also useful for initiating jumping in a gravity eliminated position.

E

It is widely accepted that abnormal femoral motion has

the potential to directly affect tibiofemoral ioint mechan-

Video 25.3: Reactive Strategies to Enhance Heuromuscular Control and Proprioception. Penny Goldberg, FT, DPT. ATE {dJT min}

Tasks that train anticipatory strategies include stepping

onto unstable surfaces or moving the other extremity

outside of the base of support. Reactive strategies can be taught using catching tasks with weighted balls; the patient must react to the ball and stabilize after the catch.

ics and specifically the soft-tissue restraints that connect

Completion of the intermediate phase is marked by full, pain-free lcnee ROM, adequate quadriceps and

ment pattern deviation is media] deviation of the knee in the frontal plane secondary to hip adduction and internal

and minimal pain or effusion during activities of daily living.”~15-19 The quadriceps index, a ratio between the

tion is addressed best with strengthening exercises such as resisted clam shells, side stepping with elastic resistance,

side, is an important predictor of performance, emphasizing the role quadriceps strength plays in function and

the distal femur to the tibia.3'3 Another potential move-

rotation, resulting from hip muscle weakness. This devia— the unilateral bridge, and quadruped hip extension with

knee flexion.“ This movement pattern, often referred to as dynamic knee valgus, has been associated with ALL injury” and may continue to be present even after ACL

reconstruction if not addressed.liar If sufficient hip strength is present, this medial deviation in the frontal plane may

hamstring strength, good proprioception and balance,

strength of the involved side to that of the uninvolved performance.“ Quadriceps strength can be measured

using an isokinetic or hand—held dynamometer or by isometric strength testing or one-repetition maximum

testing. 1ii'alues ranging from 65% to 90% have been re-

ported as adequate to begin higherrlevel rehabilitation

activities-”JEJFJT-HH

be a learned movement pattern that requires instruction

and feedback. A final consideration for the intermediate phase is

Late Postoperative Rehabilitation

trunk control and core stabilization, because reduced core

The goal of the late phase of AC1. reconstruction rehabil-

control to maintain the body’s center of mass within the

and sport-specific exercises are implemented progres-

tial beneficial exercises include bridges, planks, crunches,

used to ensure that the patient is physically fit enough to

proprioception has been linked to knee injuries.“ Most high-level activities require core stabilization and trunk base of support in response to unexpected perturbations, so that potentially injurious forces are minimized. Poten-

and double—leg and single—leg dead lifts. Perturbation training using stable and unstable surfaces {Video 26.1)

as well as training anticipatory strategies [Video 26.2} and reactive balance strategies {Video 26.3} should be incor—

porated to enhance proprioception and neuromuscular control of the lower extremity [Figure 3}.

flrdtopaeciic Knowledge Update: Sports Medicine 5

itation is to initiate high—demand activities in preparation for RTS.”~"5~1” A combination of in-line running, agility,

sively to appropriately challenge the patient‘s strength and endurance. Increasing levels of intensity should be

return to full, unrestricted participation in sports. Proper movement patterns are emphasized during these activities, and neuromuscular training should play a major role in

late—phase rehabilitation to reinforce appropriate muscle firing patterns and a suitable reaction to external forces,

which contribute to proper joint biomechanics and possi-

bly help prevent knee osteoarthritis” and reduce the risk of reinjnry."'1 Strengthening and flexibility exercises are

El 2016 American AcadMy of Cirrhopaedic Surgeons

Chapter 215: Current Rehabilitatinn Euncepts Fullevving Anterier Cruciate Ligament Recunstructiuu

3”." :

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3'

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3.. U‘ 5

Figure 3

Phetegraph depicts unstable surface training in a single-leg stance tc- enhance neuremuscular

centrel ef the lewer extremity. Adding

pertu rbatiens er thruwing and catching tasks

can be used tn increase the difficulty utthe drill.

centinued and move tn a maintenance er heme exercise prugram as impairments resnlve.

Straight-plane running fur 4 tn ti weeks shuuld be

Figure 4

Fhetngraph shuvvs a ladder drill, which can be used te incerperate lateral rnevements and ready the patient fer a return te spurt during

the late phase at rehabilitation.

enccruntered by each individual athlete. Mevement pat-

terns shbuld be assessed cuntinually fur the presence bf dynamic valgus, weight-bearing asymmetries,“ and de-

perfnrmed befure the intruductinn uf lateral muvements

creased knee flexiun tn minimise the risk at ACL injury.“5

the dynamic nature cf running.” Activities that puse a

mevernent pattern deviatieus are less likely te be present.

intn the rehabilitation prngrarn tn allcnv the patient an build unilateral strength and farce generation thruugh

If weakness in the hip and quadriceps muscles has been addressed earlier in the early phase at rehabilitatiun, these

high risk bf ACL iniury include landing a jumpy41 sidestep— ping, and cutting maneuvers.“3 Duuble-leg crr single-leg

Altheugh the specific criteria fur the return te spurt—specific activities vary, the prctnculs generally use a cumbiua-

perated during this phase {Figures 4 and 5}. The chesen activities shuuld mimic the muvements must likely tu be

episudes bf instability, pain, effusicrn, and self—reperting bf functicn tn determine the achievement uf each milestune

landing tasks and ladder er cane drills sheuld be incur-

El Ifllli American Academy ef flrfliupaedjc Surgecus

tie-n cf the quadriceps strength index, RUM, knee laxity,

Drthupaedic Knewledge Update: Spurts Medicine 5

Sectien 4: Rehabilitatien

te indicate readiness fer the neat milestene.“ Cemmen

criteria used te assess readiness te begin running include

a 65% te 90%”“5353139 return ef quadriceps strength

cempared with the healthy limb, full RUM, and minimal

pain and effusien. Additienally, patients may benefit from

an understanding ef the sereness rules {Table 1] se that they may self—manage during transitien frem a supervised

te an unsupervised pregressien.” The pregressien ef activities sheuld advance frem deu-

ble—limb activities te single-limb activities. Tasks that

challenge presimal centre] ef the lewer extremity sheuld remain a fecus ef the pregram {Figure 6}. Altheugh critical fer identifying limb and weight-bearing asymmetries, success in bilateral tasks alene has been shewn te be inad-

equate in identifying ether underlying unilateral deficits

{such as strength, endurance, preprie-ceptien} even when

E

activities are biased tnward the affected limb.” Plyemetric exercise te develep neuremuscular ceerdinatien during

.E 4.! I'll .1: :5

the esplesive elements ef running and athletic activities

I15 .E El fl'.’

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

E

well as the medial and lateral hamstrings ef the deminant limb has been used te evaluate the activatien ef these

muscles during cemmen plyemetric exercises.“ Single-leg

and deuble—leg sagittal plane hurdle heps censistently

preduced mere muscle activity in the hamstrings and gluteal muscles, whereas jumping while retating the bedy 13f!“ during the flight phase preduced the least activad

tien ef these muscles. This suggests that when selecting plyemetrie exercise, the practitiener sheuld cheese these perfermed in the sagittal plane, because they may effec-

Figure 5

Phetegraph clernenstrates a cutting drill. These drills, heth tewa rd and away frem the invelved side, sheuld lee emphasized during the late

phase ef rehabilitatien.

tively reduce lead re the ESL and prevent dynamic knee valgus than these perfermed in the frental plane.

A cembinatien ef visual, verbal, and tactile feedback

may be beneficial when respending te athletes regarding gait deviatiens, limb asymmetries, and abnermal

Sereness Rules Eriterien

Action

Sereness during warm—up that

2 days eff, drep dewn 1 level

Sereness during warm-up that gees away

Stay at level that led te sereness

Sereness during warm-up that gees away but redeveleps during the sessien

2 days eff, clrep clewn 1 level

Soren ess the day after lifting {net muscle sereness]

1 day eff, de net advance pregrarn tn the nest level

He seren ess

Advance 1 level per week er as instructed by health care prefessienal

centinues

Hepre-ducecl with perrnissien frern Fees M. Decker T, Snyder-Machler L, Arte M]: Upper extremity weight-training rneelificatiens fer the injured athlete: A clinical perspective. Am J Spnrts Med 19535613535.

flrdtepaedic Knewledge Update: Sperts Medicine 5

El 1016 American Academ1r ef Drthepaedie Surge-ens

Chapter 26: Current Rehabilitatien Concepts Fellewing Anterier Cruciate Ligammt Ilecunstructiun

mevement patterns cempared with the healthy limb.“

Pregrams that target individual biemechanical cerrec-

tiens have preved te be efficient in changing mevement patterns,“ petentially leading te impreved pesteperative eutcemes. The incerperatien ef mirrers, videe feedback,

er ferce plates in additien te verbal cueing after visual assessment may impreve perfermance. Multiple stable and unstable surfaces, which replicate spert—specific demands,

sheuld he used in jumping and landing tasks. Additienally, exercises that include anticipated and unanticipated mevements will prepare the athlete te accept the varieus

athlete sheuld cemplete agility and jump training fer a

peried ef several weeks te several menths te ensure that adequate strength, endurance, and neuremuscnlar centrel are achieved befere the initiatien ef RTE testing.

Ne single test can be performed te determine the readiness fer RTS. Instead, a battery ef tests sheuld he used

te create a cemplete picture ef the athlete‘s strength and

functienal status.” Functienal perfermance tests such as hep tests can identify limb asymmetries. The mest

cemmen hep tests are the single hep fer distance, the

cressever hep fer distance, the triple hep fer distance, and the d-meter timed hep.1'5+”+3“ The limb symmetry index is cemmenly used te determine when muscle strength

and hep perfermance are nermal. Generally, hep testing is included in the RTS testing, but it has been suggested that specific criteria In be achieved befere initiating hep

testing include full RDM, a quadriceps index greater than were, and ne pain with single-leg hepping.” Similarly, a wide variety ef criteria are used te determine if a

patient is ready te begin the RTS pregressien (Table 2}.

The mest cemmen criteria are full, pain-free HUME-“~15” 3fl% te 9fl% en the quadriceps index,5'*""15*"-""+‘“5 and limb

symmetry index sceres ef 30% re 90% ef the uninvelved Sidfl_16,19,39

At the time ef RTS, the effect ef quadriceps strength

asymmetry en functienal perfermance and self—reperted functien after ACL recenstrnctien has been estab-

lished.’T Mere quadriceps weakness is asseciated with

lewer self-reported knee functien and peerer perfermance in all functienal testing. Additienally, a quadriceps index Pheteqraph shuws a deuble-leg wall jump, which is an example et an early plyemetric

exercise. These exercises can he used te identify weight—bearing and limb asymmetries ea rly in

the late phase uf reha hilitati en.

scere less than 35% negatively affected functien, whereas

patients with a quadriceps index scere ef 9fl% er greater perfermed in a manner similar te uninjured individuals.3T Fer many athletes, rehabilitatien will end with RTE,

but clinicians may cheese te centinue te meniter the patient after full RTS has eccnrred. Issues ef strength er

hiemechanics that were net reselved cempletely during

the late phase ef rehabilitatien can centinue te be addressed beth during and after RTS. Additienally, the

Eb Ifllii American Academy ef flrfltepaedic Surgeuns

Drthupaedic Knewledge Update: Spurts Medicine .5

ueglflulqeqeu :1;-

ferces mest likely te be enceuntered during spurts participatien. Depending en surgical pretecel timelines, an

Section 0: Rehabilitation

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

Criteria

van Grinsven et

I Full range of motion

Tsar

3' {201 “l"

Adams et al

(20123“

E

I15 .E El fl'.’

I Hamstrings and quadriceps strength a 95% of centralateral side I Hamstringsi'quadriceps ratio -c 15% compared with contralateral side I No increased pain or swelling with sport-specific activities I a 12 wk postoperative

I a 90% on quadriceps index

I a 90% on all hep tests I a 90% on Knee |iZlutcon'ie Survey Activities of Daily Living Scale I a 90% on global rating score of knee function

.E 4.! I'll .1: :5

I Hop tests a 35% of centralateral side

I'vlanske et al

(2012)“

I Full pain-free range of motion

I No patellofemoral irritation

I 90% quadriceps and hamstring strength I Sufficient proprioception I Physician clearance for advanced activities

E

Wilk et al

{2013315

I Satisfactory clinical examination

I Symmetric pain-free range of motion I I I I I I

Kyritsis and Egg-FEW

Quadriceps bilateral comparison a 90% Quadriceps torque-body weight ratio a 65% Hamstrings-quadriceps ratio a- 66% fer males, :4- ?5% for females Acceleration rate at 0.2 s 30% of quadriceps peak torque ltT-2000 test within 2.5 mm of centralateral leg Functional hop test a 95% of contralateral side

I No pain or swelling I lsokinetic test at 50%. 1300‘s, and 30005 :- 10% deficit in quadriceps and hamstrings I lsokinetic test at 50"l's hamstringrquadriceps ratio [ii—0.9

I Student

I Limb symmetry index a- 90% I Knee Injury and Osteoarthritis Dutcome Score :- 90 on each subscale

I Patient-Specific Functional Scale score of 9—10 for each reported activity I [in-field Sports-Specific Rehabilitation fully completed

athlete may demonstrate higher levels of kinesiophobia and may benefit from continued training to develop appropriate levels of confidence. 5 u re ma ry

reconstruction outcomes. Clinicians should cautiously progress patients from early to late rehabilitation in the

presence of persistent knee impairments because progres-

sion too quickly mayr impede RTS and contribute to the early development of posttraumatic knee osteoarthritis.

Awareness has increased about how altered psychosocial

ACL reconstruction rehabilitation continually evolves and currently is being scrutinised for ways to improve RTS rates, reduce second ACL injury rates, and minimise

factors can prevent RTS and altered movement patterns can increase the risk for a second ACL injury. Recogni-

address acute knee impairments (pain, effusion, less of

clinical guidelines for ACL reconstruction rehabilitation

the development of posttraumatic knee osteoarthritis. ACL reconstruction rehabilitation protocols commonly

motion and quadriceps weakness}, which is important because these knee impairments can adversely affect ACL

flrrhepaedic Knowledge Update: Sports Medicine 5

tion of key psychosocial factors and movement pattern

alterations as well as potential assessment methods and interventions is important. Even though standardized are not available, the concepts presented provide guidance during the decision-making process.

El 10115 American AcadMy of Cirrhopaedie Surgeons

Chapter ES: Current Rehabilitation Concepts Following Anterior Cruciate Ligament Reconstruction

1' RTE rate, the second ACI. injury rate, and the in-

cidence of posttraumatic knee osteoarthritis are important ACL reconstruction rehabilitation out-

comes that require improvement. Knee impairments (effusion, pain, loss of RCM, and quad riceps weakness] can negatively affect ACL reconstruction rcha bilitation outcomes and are the

focus of early rehabilitation. Movement patterns should be assessed for common

deviations, particularly in late rehabilitation, when sport-specific tasks imparting high forces to the

lower extremity are introduced.

Psychosocial factors {such as patient expectations,

the fear of reinjury, and self-efficacy} should he monitored throughout ACL reconstruction reha-

bilitation because they can negatively affect ACL reconstruction rehabilitation outcomes.

systematic review and meta-a nalysis including aspects of physical functioning and contextual factors. Br I Sports Med 2014;43f21}:1543-1SS£. Medliue DUI This update of a previous systematic review discusses

RTS rates following ACL reconstruction surgery. Level of evidence: III.

McCullough KA, Phelps KD, Spindler KP, et aI.Re—

turn to High School and College Level Football Following ACL Reconstruction: A MDDN Cohort Studylfl]2;4fl{11}:2523-1519. This article is a retrospective analysis of RTE rates, self-report performance and reasons for RTS, and risk factors for not returning to the same level of play in football players. Level of evidence: III. Kamath CV, Murphy T, Creighton RA, Thfiradia N, Taft TN, Epang JT: Anterior cruciate ligament injury, return

to play, and reiniury in the elite collegiate athlete: Anal-

ysis of an NCAA Division I Cohort. An: ] Sports Med 2D14;41{T}:1638-1643. Medline DUI This case series of athletes undergoing ACL reconstruction

before or during collegiate competition presents data on

graft survivorship, reoperation rates, and career length.

Leml of evidence: IV.

Annotated References 1. Nicolini AP, de Carvalho RT, Matsnda RIM, aum JF, Cohen M: Common injuries in athletes"I knee: Experience of a specialised center. Acts flrtop Bros lfll4:11{3}:12?—

131. Medline DCII

In this cross-sectional comparison of common knee injuries in various sports, it was determined that ACL injuries were most common in football, basketball, and volleyball players. Level of evidence: IV. . Hurd W], Axe M], Enyder-Mackler LA: 1fl—year prospective trial of a patient management algorithm and screening examination for highly active individuals with ACL injury: Part II. Determinants of dynamic knee stability.

Arr: } Sports Med someones—5s. Medline D01

This cohort study [diagnosis] found that neither knee laxi-

ty nor quadriceps strength differed in potential copers and noncopers. Additionally, quadriceps strength influenced hop test performance more than activity level or knee

laxity. Level of evidence: I.

. Feucht M], Cotic M, Eaier T, et a1: Patient expectations of primary and revision anterior cruciate ligament reconstruction. Knee Snrg Sports Trenrrsntof Arrhrosc 2014. [Epub ahead of print] Medline DUI

Paterno M‘v', Rauh M], Schmitt LC, Ford KR, Hewett TE: Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. An: I Sports Med 1fl14541{?}:ISSF—IS?3.Medline DC’II

This cohort study to determine the incidence of repeat ACL injury following ACL reconstruction and RTS showed that, following ACL reconstruction and RTE, patiEnts have a higher risk of suffering a second ACL injury than

those with healthy knees. Level of evidence: II.

fiiestad RE, Holrn I, Anne AK, et a]: Knee function and

prevalence of knee osteoarthritis after anterior cruciate

ligament reconstruction: A prospective study with 1|) to 15 years of follow-up. Am J Sports Med 101 fl;33{11}:22fl11210. Medline DC]

This prospective cohort examination of long-term changes

in knee function after ACL reconstruction and ACL recon-

struction with concomitant injuries found a significantly higher prevalence of osteoarthritis in those who had undergone ACL reconstruction with concomitant injuries.

Level of evidence: II.

Barber-Westin SD, Noyes FR: Factors used to determine re—

turn to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy 2 fl11;2?{12]:1697— 1TDS. Medline

DCII

This prospective study demonstrated that younger patients, patients without a history of knee surgery, and highly active patients have high expectations for RTE following ACL reconstruction. Irvel of evidence: IV.

This article is a systematic review of published criteria to explore the factors used to determine when to allow athletes to return to unrestricted sports activities after ACL reconstruction.

. Ardern CL, Taylor HF, Feller JA, Webster KE: Fifty-five per cent return to competitive sport following anterior

10. Thomee R, Kaplan Y, Kvist J, et a]: Muscle strength and hop performance criteria prior to return to sports after

cruciate ligament reconstruction surgery: An updated

Ci Ifllti American Academy of Crthopaedic Surgeons

Cirrhopaedic Knowledge Update: Sports Medicine S

uoglflulqeqeu :1;-

Key Study Points

Sectian 4: Rehabilitatian

ACL recanstructian. Knee Stirrg Sparta Trerrrrtatal Artbrasc 2G11;19{11]:1T93-1305. Medline DUI This article uses relevant literature ta present recammendatians far new muscle strength and hap perfarmance criteria m be used far RTE decisians fallawing ACL recanstructian. Level at evidence: IV. 11. Ardern CL, Taylar NF, Feller JA, Whitehead T5, Webster KE: Psychalagical respanses matter in returning ta

preinjuty level at apart after antetiar cruciate ligament re-

I'll .1: :5

I15 .E El fl'.’

DUI

This clinical perspective paper describes the rale af eapectatians in clinical autcames in individuals with musculaslceletal pain. IE. Becker R, Daring C, Deneclce A, Brass l'vI: Expectatian,

satisfactian and clinical autcame af patients after tatal

In this case-cantralled study explaring whether psychalagic factars predicted RTS at 11 manths after ACL re-

This praspective study determined that patient satisfactian carrelates with Knee Saciety Scare, Western Untaria 8c McIvIaster Universities Usteaatthtitis Index, and Shart Farm-36 Health Survey autcames in a patient's status after tatal ltnee arthraplasty. Level af evidence: II.

11. Cauppan 5, Racette EA, [{lein 5E, Ha rris—Hayes I'vI: 1ii'ari—

ables assaciated with return ta spart fallawing anteriar cruciate ligament recanstructian: A systematic review. Hr 1 Sparta Med lfll4;43{5}:356—354. Medline DUI

E

The authars present a systematic review aF the variables prapased ta be assaciated with RTE fallawing AEL tecanstructian, including RI‘IEE impairments, functian, and psychalagical status. Level at evidence: IV. 13. Risberg MA, Merl: IvI, Jenssen HR, Halm I: Design and implementatian af a neuramuscular training pragram fal-

lawing anteriar cruciate ligament recanstructian. ,i' Urtirap

Sparts Phys Ther lflfllfllfllltfilfl-ESI. Medline

DUI

14. van Urinsven S, van Cingel RE, Halla C], van Lana C]: Evidence-based rehabilitatian fallawing anteriar cruciate ligament recanstructian. Knee Surg Sparta Tranrnatal

Artbraac amusements-1144. Medline net

15‘. Hartigan EH, Lynch AD, Lagerstedt D5, |Ehmielewshi TL, Snyder-Mackler L: Kinesiaphabia after anteriar cruciate ligament rupture and recanstructian: Hancapers versus patential capers. _i Urtisap Sparta Phys Ther 2013;43i11j:321-332.Medline DUI This secanda ry analysis, langirudinal cahart study eaamining ltinesiaphabia in nancapers and patential capers

befare and after ACL reeanstructian faund that preaper—

ative kinesiaphabia was high in nancapets and patential capers and that nancapers had greater reductians in fear after surgery. 2t}. Ardern CL, Webster KE, Taylar NF, Feller JA: Return ta apart fallawing anteriar cruciate ligament recanstructian surgery: A systematic review and meta-analysis at the state at play. Br ] Sparta Med 2011:45{?]:596-Efl6. Medline DUI

This systematic review creates an evidence—based pastapetative rehabilitatian pratacal far ACL recanstructian.

This article is a systematic review af pastaperative RTE

15. Manslce RC, Ptahaslta D, Lucas E: Recent advances fali lawing antetiat cruciate ligament recansttuctian: rehabilitatian perspectives : lI'Zritical reviews in rehabilitatian medicine. Curr Ree Musculasleeiet Med 2011;5{1}:59-?1. Medline DUI

21. Chmielewslti TL, Eeppieri (3 Jr, Lents TA, et al: Langitudinal changes in psychasacial Iactats and their assaciatian with knee pain and functian after anteriar cruciate ligament recanstruetian. Phys Ther 2011:91i9]:1355-1366. Medline DUI

The authars af this critical review discuss variaus phases

This praspective, langituclinal, abservatianal campares the

autcames after ACL recanstructian.

at rehabilitatian, using the current research an the early rerurn af passive matian, early weight bearing, bracing, ltinetic chain exercises, neuramuscular electrical stimulatian, and accelerated rehabilitatian.

changes in psychasacial factars and their assaciatiaus with

15. Adams D, Lagerstedt DS, Hunter—Giardana A, Arte M], Snyder—M ackler L: Current cancepts far anteriar cruciate ligament recanstructian: A criterian-based rehabilitatian pragressian. I Urtirap Sparta Phys Tiber 2012;42{?}:6fl1614. Medline DUI

22. l'v'Iarrey MA, Stuart M], Smith AM, Wiese-Ejarnstal DM: A langitudinal examinatian af athletes’ ematianal and cagnitive respanses ta anteriar cruciate ligament injury. Elie: I Spa-rt Med 1999:9{2}:63-69. Medline DUI

This article presents an updated pastaperative rehabilitatian guideline far ACL recanstructian, including the timelines and criteria far variaus milestanes thraughaut the rehabilitatian pracess ta reflect the mast current available research. Level af evidence: ‘9’.

Urthapaedie Knawledge Update: Sparta Medicine 5 @ ,

Tirer 2010:90i9}:1345-l 355. Medline

knee arthraplasty. Knee Serg Sparta Treemetai Arrbrasc 2011:19i9}:1433-I441.Medline DUI

DUI

canstructian, several psychalagic factars were independent cantributars ta RTE. Level af evidence: III.

E

at individuals experiencing musculaslteletal pain. Phys

canstructian surgery. Am 1' Sparta Med 2fl13;41{?1:154fl-

1553. Medline

.E 4.!

1?. Bialaslty JE, Eishap MD, |Eleland JA: Individual expectatian: An avetlaaked, but pertinent, factar in the treatment

knee pain and functian fallawing AEL recanstructian. All factars changed acrass a 12-week periad and early scares were nat predictive af pain ar functian.

13. Nichalas MIC, lI'fiearge SE: Psychalagically infarmed interventians far law back pain: An update far physical therapists. Phys Tirer 2fl11;91{5}:?65-?Tfi. Medline DUI

This article discusses the applicatian af empirically

based psychalagical principles and clinical reasaning ta

assist physical therapists in managing the psychalagical

El ll] 16 American AcadMy at Unhapaedie Surge-ans

Chapter 25: lll'.h:rrent Rehabilitation Concepts Felltrwing Aurel-int- Grudate Ligament Eeennstnletieu

24. Weby 5E. Reach HE. Urmstea M. 1|Illln"atsen P]: Psychemetric preperties ef the TSll: A shertened versien ef the Tampa Scale fer Kinesinphnbia. Pair: EU [15:1 1?{1-E}:13T— 144-. Medline DGI

2.5. Mann B]. Grana WA. Indelicatn PA. D’Neill DP. Genrge 52: A survey ef sperts medicine physicians regarding psychelegical issues in patient-athletes. Arr: I Sperts Med 2DG?;35{12}:214fl-2141Medline DUI 26. Saks T: Principles ef pesteperative anterier cruciate ligament rehabilitatien. Werfdj Drtfrep 2fl14:5{4}:45fl-459. Medline DUI

This article is a review ef pesteperative brace use. early

ROM. electrical stimulatien. preprieceptien. and epen chain and clesed chain strengthening in REL recenstructien rehabilitatien. 2?. Shelbnurne KD. Urch SE. Gray T. Freeman H: Less nf nnrmal knee mntien after anterier cruciate ligament recenstructien is asseciated with radiegrsphic arthritic changes after surgery. Arr: J Sperts Mad 2fl12:4fl{1}:1fl8113. Medline DUI This prespective cnhnrt study feund that rsdiegraphic esteea rthritis is lewer in patients whe achieve nermal ROM regs rdless ef meniscsl cenditien at 5-year fellew'up after ACL recenstructien.. Level ef evidence: III. 2-3. Shelbeurne KD. Freeman H. Grsy T: Dsteesrthritis after anterier cruciate ligament recenstructinn: The imp-ertance

ef regaining and maintaining full range ef metien. Sperts Heeftb 2fl12;4{1]:?'9 -35. Medline

DUI

This literature review discusses the ssseciatien between ROM and nsteearthritis fellnwing ACL recenstructien.

29. Wilk ICE. Macrina LC. |Cain EL. Dugas JR. Andrews JR: Recent advances in the rehabilitatien ef anterier

cruciate ligament injuries. 1 Urtbep Sparta Phys Ther 2D12:42{3):153-1?1.Medline

DUI

This evidence-based cemmentary describes an accelerated rehabilitatinn pregram fellnwing ACL recnnstrnctien

with additienal censideratiens fer special pepulatiens.

including female athletes and patients with cencemitsnt knee injuries.

Si}. Shelbeurne FED. Gray T: Minimum 10-year results after anterier cruciate ligament recenstructinn: Hnw the less ef nermal knee metien cempennds ether facters related tn the develepment ef esteearthritis after surgery. Ara: I Sperts Med lflfl9:3?{3]:4?1-4Bi}. Medline DUI This prespective cehert study examining RUM lnsses feund that patients with a less ef knee extensinn cf 3'”

ta 5“ including hyperextensien had lewer subjective and

ebjective Intematienal Knee Decumentatien Gemmittee sceres at Ill-year fellnw-up frem ACL recenstructien.

Level ef evidence: ll.

IE! Elllti American Academy ef flrthepaecllc Surgeens

31. Escamilla RF. Macleed TD. Iill-fill: HE. Faules L. Andrews JR: Anterier cruciate ligament strain and tensile ferces fer weight-bearing and nen-weight-besring exercises: A guide tn exercise selectien. f Drthep Sperts Phys Ther

1012:42l3]:203-220.Medline DD]

This article is a descriptive laberatery investigatien ef the tensile and strain ferces te the AGL during several cemmen weight-bearing and nen-weight-bearing rehabilitatinn exercises. It includes a review ef similar studies

and makes recemmendatiens fer the clinical utility ef the findings. 32. Gerber JP. Marcus EL. Dibble LE. Greis FE. Burks RT. LaStaye PC: Effects nf early pregressive eccentric exercise en muscle size and functien after anterier cruciate ligament recenstructien: a 1-year fellew-up study ef a randemised clinical trial. Plays The:- lflflfltflfllljfil-SE. Medline DUI This article presents 1-year fellnw-up data re a rsndnm-

iced clinical trial that investigated the effect ef early

eccentric resistance training after AGL recenstructien. Eccentric exercise led tn increased quadriceps and gluteus maximus velume as well as quadriceps strength and hepping distance.

33. Pewers CM: The influence ef abnermal hip mechanics

en knee injury: A biemechanical perspective. J Drtfrep Sperts Phys Thar lfllt};4fl{2}:42-5 1. Medline DDI

This clinical cnmmentary focuses primarily en the peren-

tially detrimental effects that altered hip biemechanics

preduce at the knee jeint. Level ef evidence: V.

34. Selkewitr DM. Eeneck G]. Pewers CM: Which exercises

target the gluteal muscles while minimising activatien ef the tenant fascia lata? Electrnmyegraphic assessment using fine-wire electredes. } Drtbep Sperts Phys Ther 2013;43l2]:54-64.Medline DUI

This centrelled laberatery study used a repeated-measures design tn determine which exercises activate gluteal muscles while simultanenusly minimizing tenser fascia lata {TFLJ activity. Five exercises scered greater than er equal te 50 en the gluteal-te-TFL index. a ratie ef gluteal activity tn TFL activatien. 35. Hewett TE. Myer GD. Ferd KR. et s1: Eiemechanicsl

measures ef neuremuscular central and valgus leading cf the knee predict anterier cruciate ligament injury risk

in female athletes: A prespective study. Arr: I Sperts Med

2fl05;33{4}:492-501.Medline DGI

36. Easels]: ET. Hewett TE. Reeves NF. Geldberg B. Chelewicki J: The effects ef cnre preprieceptinn en knee injury:

A prespective biemechanical—epidemielegical study. Am

I Sperts Med lflfl?;35l[3}l:363-3?3. Medlitte DID]

3?. Schmitt LG. Paterne MM. Hewett TE: The impact ef quadriceps femeris strength asymmetry en functienal perfermance at return te spnrt fellewing anterier cruciate ligament recenstructien. I Grtbep Sperts Phys Ther 2011:42i9}:?5[l—?59. Medline DD!

Grthepaedic Knewledge Update: Sperrs Medicine 5

uvsvauavuvs :v

ebstacles that arise with activity-based interventiens in patients with lew back pain.

Sectinn 4: Rehabilillntinn

This article is a cress-sectienal examinatieu cf the ef-

fect ef quadriceps asymmetry en RTS using self-reperted

functiun and functienal perfermance iellewing BEL re-

censtructinn. These with weaker quadriceps had reduced functien, whereas these with better strength perfermed similarly te uninjured individuals. 33. Kyritsis F, Witvreuw E: Return te spurt after anterier cru-

ciate ligament recunstructien: A literature review. I Nee Pirysietirer 2014;4{1b1—fi. DD]

This literature review examines RTE criteria fellewing ACL recenstructien. 3.9. Munre AG, Herringten LC: Betweenvsessien reliability

nf feur hnp tests and the agility T-test. ] Strength Cend Res 2fl11:25{5]:l4?fl—l47?. Medline

i: .E 4.!

I'll

r: E

I'fl

.: fill a: Iii

DUI

This article is an evaluatien cf the reliability and learning

effects nf hnp tests and agility tests used after ACL recnn«

structien. Participants achieved greater than er equal te fifl‘ii: symmetry en hep tests, leading re a recemmendatinn that this thresheld be used in RTE decisien making. 4D. lEulvener AG, Schache AG, TIni'iceneine B, et al: Are knee biemechanics different in these with and witheut patellefemetal esteearthritis after anterier cruciate ligament recenstructieni Arthritis Care Res (Hebeizen) 2fl14:6fi{1flj:1556—15?fl. Medline DUI This article is a cruss-secrienal investigatiun ei knee rutatienal angles during running and walking after REL recenstructiun in subjects with and witheut patelleiemeral nsteearthritis. Less internal knee rntatien was fuund in subjects with patelleiemeral esteeartbritis and valgus alignment. 41. Paterne MV, Schmitt LC, Ferd KR, et al: Binmechauical measures during landing and pestural stability predict secend anterier cruciate ligament injury after anterier cruciate ligament recunstructien and return te spert. Am 1 Sparta Med 2B1fl;BB{1B}:IBEB-19?B. Medline DDI This pres ctive cehert study nf Id'iree—dimensinnal bieme— chanical acters assuciated with ACL graft failure reperted

that altered neurumuscular centrel nf the hip and knee

predicted secenda ry injury after primary ACL recenstructinn. Level nf evidence: II.

42. Ferretti A, Fapandrea P, Centeduca F, Mariam PF: Knee ligament injuries in velleyball players. Ant 1 Sparta Med 1992;2fli2}:2fi3-2fl7.Medline DUI 43. CechraneJL, Lleyd DG, Euttfield PL, Seward H, McGivern J: Characteristics ef anterier cruciate ligament injuries in Australian feetball. I Sci Med Spert lflfl?;1fl{2]:96-ili}4. Mcdline DUI

Gardinier E5, Di Stasi 5, Hana] Bi, Buchanan T5, Sny— der-Mackler L: Knee centact fnrce asymmetries in patients whe failed return—te—spurt readiness criteria 6 mentbs af— ter anterier cruciate ligament recenstructien. Ann I Spur-ts

Med2fl14;42{12}:291?-2925.Medline net

This descriptive 1a beratery study at centact ferce symmetries in patients whe underwent RTE readiness testing 5 mentbs after AEL recenstructien reported that patients in

Drthupaedic Knewledge Update: Sperts Medicine 5

whum testing failed demunstrated significant and meaningful centact ferce asymmetries. 45. Myer GD, Ferd KR, Khnury J, Succep P, Hewett TE: Develu ment and validatien ef a clinic—based predictien reel tn i entify female athletes at high risk fer anterier cruciate ligament injury. Arn j Sperts Med 2010;33i1fl]:2ii25-2033.

Medliue DDI

This article is a cressasectienal cehert study ef the clinical predicters ef increased knee abductiun mement during landing tasks. Increased valgus, knee flexinn RUM, bndy mass, tibia length, and uadric s-tu—hamsttings ratie cnrrelated with increasefl knee Eductien mement in a female pepulatien. Level ef evidence: II. 4d. Myer GD, Schmitt LC, Brent JL, et a1: Utilisatien ef medified NFL cnmbine testing In identify functienal deficits in athletes felluwing AEL recunstructiun. J Drtnep Sparta Phys Tirer 2B11;41{E}:3??—337. Medline DDI This case—centrelled study nf mndified Natinnal Feetball League I[Iem bine drills attempted te determine whether bilateral tasks adequately identified unilateral deficits when

biased teward the invelved side. The mudified tests failed

tn identify deficits feund with hep testing.

4?. Struminger AH, Lewek MD, I{Ente- S, Hibberd E, Blackburn JT: Eemparisen ef gluteal and hamstring activatien during five cnmmnnly used plyemetric exercises. Ciirt Binrnecir (Bristei, Arlen} 2013;23[?J:?33-?39. Mcdliue DUI This descriptive laberatery study used electremyegraphy tn investigate gluteal and hamstring muscle activity during cemmen plyemetric exercises. 5a ittal lane plyemetric exercises prnduced greater levels e muscliis activatien than these in the fruntal plane. 43. Barrett D5: Preprieceptiun and functien after anterier cruciate recenstructinn. ] Bene feint Surg Br 1991;?3i5 j:333 33?. Medliue 45'. Pappas E, Nightingale E], Simic M, Ferd KR, Hewett TE, Myer GD: De exercises used in injury preventinn pregrammes mediiy cutting task biemechanicsi' A systematic review with meta-analysis. Br I Sperts Med 2015:49{IDI:E?3—63i}.Medline DOI This article is a systematic review ef the effect ef injury preventinn pregrams en hinmechanical changes during cutting tasks. injury preventinn pregrams have the patential tn impreve binmechauics during cutting tasks, particularly when they target technique currectinn in pustpubertal female athletes.

Video References

26.1: Geldberg P: Videu. Perinbaiiun Training fur Nearernnscniar Centrei and Dynanric Stabiiity. Gainesville, FL, 2015.

26.2: Geldberg P: 1|iiidee. Anticipatery Strategies te Enhance Nenrnrnnscuflar Centrei and Preprieceptien. lGainesville, FL, 2fl15. 26.3: I|.'.3‘reldberg P. Videe. Reactive Strategies te Entrance Hen-

renniecniar Centrei andl Proprieceptien. Gainesville, FL, 2015.

D 2fllfi American Academy ei Drthepaedic Surge-ens

Chapter 27

Patellofemoral Pain Syndrome: Current Concepts in Rehabilitation Mark V. Patcrno. PT. PhD. MBA. 5C5. ATC

Ielfery A. Taylor—Haas. PT. DPT. DES. CECE

therapists.‘ Despite this high prevalence, the etiology of Patellofemoral pain is the most prevalent condition

involving the knee that is referred to physical therapy, and it results from a diverse range of pathomechanics

and pathoanatomic lesions. Despite the conditions prev-

alence, only limited evidence concerning the etiology,

risk factors, and optimal management of this condition

exists in the literature. An evidence-based approach

for the evaluation and nonsurgical management of patcllofemoral pain is suggested. The interventions are

and risk factors for developing PFPS remain unclea r,2 and a variety of theories about its etiology and rehabilitation exist. The most common etiologic theories describe al-

terations andlor impairments in anatomic morphology3 and dynamic neuromuscular function" Rehabilitative and etiologic investigations have focused on three areas

of dynamic neuromuscular function and their associated effect on PF PS: the proximal area at the trunk and pelvis,

the distal area at the foot and ankle, and the local area at

classified by proximal factors related to the hip and

the quadriceps and the patellofemoral joint {PFj} itself.

factors focused on the distal shank and foot. Successful

patient with PFPS, it is critical to complete an accurate and thorough history and physical evaluation to deter-

trunk, local factors specific to the knee joint, and distal management is rooted in the detection of underlying impairments and functional limitations found during a thorough evaluation and in the appropriate applica-

tion of interventions designed to target individually

identified deficits.

Keywords: rehabilitation: patellofemoral pain

syndrome: proximal factors: local factors: distal factors Introduction

Patellofemoral pain syndrome {PFPS} is the most preva-

lent disorder involving the knee‘ and is the second most Dr. Paterno or an immediate family member serves as a

board member. ownec officer. or committee member

of Pediatric and Adolescent Research in Sports Medicine and serves as a consultant for flJL'l Global. Neither Dr. Taylor-Haas nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

fl lflld American Academy of Drrhopaedic Surgeons

Before implementing a course of rehabilitation for a

mine the underlying mechanism. The identification of

specific impairments and dysfunctions associated with the patient’s reports of pain should drive the treatment planning and specific interventions. The authors of a

lflflfl study linked intrinsic risk factors to the development of IJ'FPS.5 They outlined local factors—including a

reduction in quadriceps flexibility, altered neuromuscular coordination between the vastus medialis oblique {VIVID} and the vastus lateralis, decreased quadriceps strength, and patellar hypermobility—to the development of PFPS.

More recently, other authors examining multimodal fac-

tors have identified the interaction of local and proximal

variables such as hip rotation weakness as being related to the presence of PFli'Ei.‘E Another study relates more

distal factors such as foot mechanics to PFPSF This lack

of consensus underscores the theory that no single mech~ anism for the development of PFPS exists. Therefore, a thorough evaluation of the potential underlying factors

that may contribute to the development of PFPS must be undertaken by the physical therapist before developing an evidence—based intervention program. Specific interventions exist to address the proximal, local, and distal

factors that may contribute to PFPS. An ideal rehabilita-

tion program should incorporate components of each of

these areas, as deemed necessary by the initial evaluation.

Drthopaedic Knowledge Update: Sports Medicine 5

uvsvauqvuaa :1:-

common musculoskeletal symptom presenting to physical

Section 4: Rehabilitation

Proximal Interventions

Df all the etiologic and rehabilitative theories, none has

received more recent attention than that focusing on the

proximal factors that may contribute to the development of PFPS. A 21303 study theorized that biomechanical de—

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indicates that females with PFPS have weaker hip internal

rotators and hip flexors compared with controls, whereas no evidence indicates differences in hip adductor strength

between cohorts.” In two separate cross—sectional stud— ies, male and female runners with PFPS demonstrated increased hip adduction and hip internal rotation range

viations of the femur into excessive adduction andl'or internal rotation might result in a relative lateralization of the patella with respect to the trochlear groove.4 These abnormal mechanics were believed to result in increased

of motion, compared with controls, and these deficits correlated with endurance deficits to the hip abductor and

study provided preliminary theoretical support when reporting that, compared with an uninjured cohort, adult

tudinal work is needed to validate a casual relationship between these variables.

infrapatellar compression, pain, and dysfunction.4 A 2010

i: .E 4.!

PFPS have weaker hip external rotators, hip abductors, and hip extensors than controls.” Moderate evidence

females with PFPS demonstrate greater femoral inter

nal rotation during the closed chain single-leg squatfi' Accordingly, enhancing strength andfor neuromuscular activation to the muscles of the pelvic girdle may have

a clinically relevant role.‘ Dver the past decade, many studies have advocated assessing the role of hip muscle strength, hip neuromuscular activation, and dynamic

lower extremity biomechanics on PFPS."5'~” Emerging research highlights the contribution of dynamic ttunk mechanics to altered PF] stress."

Recent prospective research has been conducted on the risk factors that contribute to PFPS. In a military population performing a jump landing task, prospective risk fac— tors for the development of PFPS included decreased knee flexion angle, decreased vertical ground-reaction force,

and increased hip internal rotation angle? In adolescent girls, a large knee abduction moment incurred during a drop vertical jump task was linked prospectively with

the later development of PFPS.” In adult female runners, greater hip adduction, but not hip internal rotation, has

been linked prospectively with the development of PFP'EL"3

This finding agrees, in part, with several cross-sectional

studies that have identified excessive hip adduction and! or hip internal rotation in women with I’FPS compared

with age- and sex-matched controls.“'1'5 These altered

mechanics are not reported consistently in male run-

hip extensor musculature, respectively?” Future longiRehabilitation efforts that focus on hip abductor and

hip external rotator strength have resulted in positive outcomes, including short-term reductions in pain and

improvements in function, in patients with PFPS.‘”1” A recent randomized contmlled trial demonstrated that, compared with quadriceps strengthening alone, posterolateral hip strengthening resulted in superior outcomes in

terms of pain reduction and functional improvement?l Although it is theorized that improvements in hip muscle strength may reduce stress on the PF] through kinematic alterations to the hip joint and the knee joint in the frontal and transverse planes,‘1 several authors have found no

changes in hip and knee kinematics after implementing a variety of hip-strengthening protocols.m*13 Thus, further investigations are required to understand the association

between hip muscle strengthening, hip and knee kinemat-

ics, pain, and functional outcomes. Recent investigations have focused on the association between PFPS, alterations in hip neuromuscular activa-

tion, and lower extremity kinematics. Compared with control subjects, adults with PFPS demonstrate a delayed

and shorter duration of gluteus medius muscle activation during stair negotiation? Furthermore, preliminary evidence indicates that gluteus medius activity is delayed

and of shorter duration during running, whereas gluteus

maximus activity is increased during stair descent in those

ners,” indicating the differing role that sex may play in the development and treatment of PFPS in adults. Recent

with PFPS.” In women with PFPS, increased hip adduc— tion and hip internal rotation excursion were correlated

men with I’FPS squat and run with less hip adduction and increased knee adduction or varus.” Further prospective studies in males are needed to delineate the relative risk of proximal biomechanical abnormalities on the devel— opment of PFPS.

mus, respectively.“ Because of the cross-sectional nature

evidence suggests that, compared with women with PFPS,

Reductions in hip strength have been cited consistently

with later onset in the gluteus medius and gluteus maxiof the studies, however, cause and effect cannot be established, and further prospective studies are warranted.

Dynamic trunk mechanics may influence stress on the PF]. a 1014 study demonstrated that, in a cohort of healthy adult male runners, increased sagittal-plane trunk

in adolescent girls and women with PFPS, compared with age- and sex-matched controls'i" In a systematic review

flexion was associated with reduced peak PF] stress.11 In a cohort of adolescent girls with PFPS, a reduction

summarised strong evidence suggesting that females with

was one of several variables—along with altered hip and

of five cross-sectional studies, the authors of a 2-1] I]? study

firthnpaedic Knowledge Update: Sports Medicine 5

in sagittal—plane trunk flexion during a single—leg squat

fl lfllfi American Academy of Orthopaedic Surgeons

|Chapter 17: Patellnfemnral Pain Syndrnme: Current Ennnepts in Rehabilitatinn

Figure 1

Ph ntngraphs demn ristrate early-stage interventinns tn address impaired hip strength. A, A hip abductinn straight leg raise is shnvvn. B, Lateral side step ping with band resistance facilitates gluteus medius muscle activity. C. Quadru ped hip extensinn is shnwri with the knee straight.

knee kinematics—differentiating injured frnm uninjured

patients.” Frnm a kinetics standpnint, increasing trunk

flexinn reduces the external flexnr mnment acting npnn the PF] and therefore may reduce the internal knee extensnr mnment. The net effect is a reductinn in cnmpressive fnrces acting upnn the PF]. Altered dynamic trunk me-

chanics in the frnntal plane alsn may influence mntinn and thus stress tn the PF]. Cnmpared with cnntrnls, men

and wnmen with PFPS demnnstrate increased ipsilateral

trunk lean and cnntralateral pelvic drnp.“ An increased

ipsilateral trunk lean may result in an increased external knee abductinn mnment acting upnn the PF], which, in turn, may result in altered frnntal-plane knee pnsitinning and thus stress tn the PF].”12l'-~m Therefnre, rehabilitative

side-lying leg lifts {Figure l, A} and side-lying hip external rntatinn with band resistance.31 These fnundatinnal exercises target the isnlated hip muscle weakness nften

seen in patients with PFPS. Other early-stage interven-

tinn nptinns tn activate the gluteal musculature while minimizing activatinn nf the tensnr fascia latae include sidestepping with bands {Figure 1. El. single-leg bridging,

and quadruped hip extensinn with the knee straight and

bend"1 {Figure 1, Cl. Interventinns in the intermediate stage nf therapy

encnmpass npen kinematic chain and clnsed kinematic chain interventinns designed tn increase gluteal and trunk muscle recruitment and tn address altered neurnmuscular mnvement patterns. l[lpen kinetic chain interventinns with

effnrts centered nn altering the abnnrmal frnntal-plane

mnderate gluteal recruitment {40% tn 60% nf MVIC}

with PFP‘S may have a clinically relevant rnle.

elevatinn in quadruped and single-leg bridges}3 {fer the

and sagittal-plane trunk mechanics in patients presenting

include alternating arm and leg {fnr the gluteus maximus]|

A rchabilitatinn plan nf care designed tn target prnximal impairments nften will fncus nn hip strength and

gluwus medius, Figure 2, A}. Clnsed kinetic chain interventinns with similar gluteal recruitment levels include

tinns and return-tn-fuuctinn interventinns. Early inter-

retrn step up.“ Interventinus targeted tn imprnve trunk

muscle activatinn and can be staged intn early interven-

a variety nf lunges and step-ups nntn a bnx, including a

ventinns fncus nn imprnving gluteal muscle recruitment while limiting pain reprnductinn, whereas return-tn-ftmc-

muscle recruitment and stability include a mix nf exercises nn stable surfaces such as anterinn’frnnt planks

muscular reeducatinn that targets the specific mnvement dysfunctinns and participatinn limitatinns unique tn the

that intrnduce instability such as these cnndncted using a therapeutic ball.

Early interventinns tn address impaired hip strength may be staged intn exercises that gradually prngress the

imally recruit and strengthen the prnximal musculature and tn nnrmalice faulty mnvement patterns tn prepare

lnw tn high. Exercises in the lnw categnry, which recruit less than nr equal tn 40% nf the muscle’s maximal vnlun-

maximally recruit the gluteal musculature {greater than

nnn—weight-bearing npen kinetic chain activities such as

{Figure 3, E}.

tinn interventinns fncus primarily nu clnsed- chain neurnpatient.

neurnmuscular activatinn nf the gluteal musculature frnm

tary isnmetric cnntractinn {MVIC}, frequently begin with

ID ants American Academy nf flrthnpaedic Snrgenna

(Figure 2. B} and side planks [Figure 2, Cl and exercises

Returnutnuactivity interventinns are designed tn max-

fnr the return tn activity. Strengthening exercises that

60% cf MVIC} include resisted lateral sidestepping, sin-

gle—limb deadlifts {Figure 3. A], and single—limb siquatsi'l

Drtbnpaedic Knnwledge Update: Spnrts Medicine 5

uailEiiiisELi-as :1:-

A

Secticm 4: Rehabilitation

i: .E 4.!

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p Figure 2

fine

-

E

Phntugraphs shuw interventions frnm the intermediate stage at rehabilitaticin, including single-leg bridging {A}, a

prene plank ta). a side plank {C}. single-leg step down fecusing qn quadriceps fe meris recruitment in}, and singleleg step down facusing an gluteus maximus recruitment {E}.

[n additinn tn strengthening, nptimiaing the technique and muscle activaticm are critical. Medifieatiqns to tech-

aal Interventians

nique can result in a mare targeted apprpach tn certain in—

aal interventipus, specific tn the knee jeint, lnng have

mere an quadriceps recruitment {Figure l, B} if executed

This philesnph},r was driven by the theary that PFPS was

terventicms. For example, a single-leg step dawn can incus

with a mare erect pasture. Cnnversely, if executed with an increase in hip and trunk flexicm, additicmal gluteal

muscle recruitment is required ta successfully accnmplish the task {Figure 2, E}. Mndificatiuns tn the technique can

been advecated in the rehabilitatian pf patients with PFPS.

rented in deficits in lncal facturs, such as patellar tracking, limited muscle flexibility, er altered balance pf quadri-

ceps muscle functinn."‘+1'5 These lacal cantributing factnrs

influence the desired nutenme nf an interventinn. Finally,

cuuld he the result cf pathnanatnmic c-r structural factprs, such as patellar apprehensinn, tibial tuhercle deviaticms,

align the lawer extremity during dynamic movement. Friar research has identified hip adductien mement as a

cartilage injury, and ahnnrmal trachlea mnrphnlngyfi‘i-fl In additian, hie-mechanical and neuramuscular factars

athletes.11 Interventinns that target neurnmuscular recruitment during dynamic tasks may facilitate aptimal

respnnse time and the rural crass-sectional area of the quadriceps have been linked tn eutcemes in this papa-

patterns in this pnpnlatinn.

scheme fucused rm lacal facts-rs that guided treatment

prc-ximal muscle recruitment is necessary tn nptimally potential risk factcrr far the develc-pment pf PFP in yuung muscle activity and, ultimately, mere nprnial movement

firthnpaedic awledge Update: Sparta Medichte 5

patellar alta, the presence pf patellc-femnral articular related tn the quadriceps femnris muscle such as VMU laticin.“ A 2005 study described a clinical classificatipn

fl lfllfi American Academy at Urthnpaedic Surge-ans

uvsvauqsuas :v

|L'Ihapter 17: Patellofemoral Pain Syndrome: Current Conoepts in Rehabilitation

A Figure 3

Photographs depict interventions from the retu rn-to-activity stage of rehabilitation. including single-leg deadlifting {A} and single-leg squatting {B}.

based on malalignment and muscular dysfunction, inclusive of strength deficits, neuromuscular dysfunction, and flexibility deficits.” These muscular deficits provide a template for addressing local modifiable impairments

hamstring, and gastrocnemius-soleus complex flexibility

A primary modifiable local impairment often associ— ated with PFPS is altered quadriceps femoris function.

reported in the literature as a way to reduce PFPS and increase self-reported function in a period of less than 1

ability to provide dynamic stability to the PF]. Coupled with potential pathoanatomie factors, this reduction in

2003 showed that limited evidence in lower quality studies supported using patellar bracing as an effective means

in patients with PFPS.

Reduction in quadriceps femoris strength limits the knee‘s

strength may result in pain, instability, or loss of func-

tion. Interventions to target isolated quadriceps femoris weakness can use closed kinetic chain activities such as

those described previously. Although these activities may

successfully strengthen the lower kinetic chain, they may

fail to address isolated weaknesses if compensatory pat-

have been identified in patients with PFPS‘”; however,

the efficacy of targeted interventions to address these impairments has not been reported. Patellar taping to

improve alignment and muscle activation also has been

year.'~‘"*41 Interestingly, a systematic review performed in

to manage PFPS. In summary, local interventions having

the strongest evidence to improve short-t outcomes in patients with PF P5 are focused on therapeutic exercises.“II Distal Interventions

terns of movement develop. As a result, if the presence of isolated quadriceps weakness is appreciated at the

Abnormalities in distal lower extremity biomechanics

may be indicated. This intervention must be approached

affect the proximal lower extremity motion. Because of the tight articulation of the talus within the distal tibi-

evaluation, open kinetic chain quadriceps strengthening

with caution, however, because open kinetic chain knee extension has the potential to increase shear forces on

the PF]. Recent research has identified safe ranges of motion in which to execute this task.” Specifically, the

may be related to PFPS.‘ During dynamic activity, the

foot and ankle provide the initial shock absorption and

al~fi bular joint, pronation at the foot and ankle is coupled

proximally with tibial internal rotation and knee internal

authors recommend a range of extension from 9G“ to 45".

rotation.43 Thus, a theoretical construct exists, in which abnormalities in arch structure and dynamic function

Ifii'ther local interventions have been reported in the

Evidence supporting this theoretical construct is mixed,

Conversely, a closed kinetic chain squat is safest when performed from full extension to 45° of knee flexion.

literature with varying efficacy. Deficits in quadriceps,

IE! lfllfi American Academy of flrthopaedic Surgeons

may lead to abnormal mechanics, stress, and ultimately pain and dysfunction at the PF .‘i-‘i‘ with several authors finding no differences in pronation

Drthopaedie Knowledge Update: Sports Medicine 5

Section 4: Rehabilitation

excursion between subjects with PFPS and uninjured cohorts during walkingfi'” and running.”~”-4‘""'5 |E’Ithers

{PT} and an GTC foot orthosis is better at reducing pain and improving quality of life than an GTE: foot orthosis

A recent investigation using an altered definition of ex-

those receiving PT combined with an GTE foot orthosis

have found increases in pronatiou variables in walkersfi‘” cessive pronatiou found that runners with PFPS used more of their available rear foot range of motion than

did controls.” Additional prospective investigations are

warranted to appreciate the association between altered distal lower extremity mechanics and the risk for PFPS. Many clinicians assess foot posture as a static measure in an attempt to infer dynamic motion. Limited evidence

links reduced medial longitudinal arch height and increased dynamic foot pronation in asymptomatic adults c .E 4.!

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during walking”~51 and runningdlifl1 Limited evidence

also links reduced medial longitudinal arch height and

alonefl'“ Compared with individuals receiving only PT,

have mixed outcomes, with some reports detailing improved subject outcomes‘” and others finding no differ— ence."1 Further ra ndomiaed controlled trials are needed to

better understand the added value, if any, of foot orthoses

in enhancing patient outcomes.

Although rehabilitation frequently has focused on im-

proving dynamic lower extremity alignment by enhancing

hip and quadriceps muscle strength and neuromuscular

activation, emerging evidence suggests that gait retraining may play a role in modifying stress to the PF]. In runners,

increased dynamic foot pronatiou in adults with PFPS.”

two key areas have been studied: step rate manipulation and visual gait retraining.

caution must be used in interpreting the results. Prospective findings are needed to better establish a cause-and-ef—

creased PF] stress.“ An increased step rate has an inverse relationship with stride length“ and PF] forcesfi"f The

Because of the nature of the cross—sectional study design,

fect relationship between static arch height, dynamic foot

pronatiou, and the risk of incurring PFPS. In a prospective

study of novice recreational adult runners, no association

was found between static arch structure and the future development of PFPSF Additional prospective studies in subjects of different ages and activity levels are warranted

to better understand the relationship between static arch structure and the risk of developing PFPS. Because of the coupling between foot pronatiou and

internal rotation of the tibia and knee, clinicians often

prescribe over-the-counter {OTC} or custom foot orthoses

in an attempt to modify distal biomechanics that may afd

fect PF] stress and dynamic function. The biomechanical evidence of the effect of OTC or custom foot orthoses

on walking and running biomechanics is mixed. Several

authors, using a heterogeneous approach to foot orthoses fabrication, have found no effect in healthy runners of a custom foot orthosis on such biomechanical variables as rearfoot eversion pronation,53'55 tibial internal rotationfif-ff or knee kinematics.”r Others have found that custom foot orthoses do significantly reduce pronatiou—re— lated variables at the rearfoot,5f'~53 tibia,53~5*~59 and knee,

however?!Eu Differences in study results may be explained partially by heterogeneity in study design, subject populations, and outcome variable selection.

Biomechanics aside, individuals provided orthotic de-

vices as part of a treatment program for PFPS frequently report reductions in pain'“453 and improvement in the quality of life.‘52 Limited evidence suggests that, com—

pared with a flat insert, CITE foot orthoses reduce knee internal rotation and improve the short-term quality of life in individuals with PFPS.“ Furthermore, limited ev—

idence suggests that a combination of physical therapy

firthupaedic Knowledge Update: Sports Medicine 5

An increased stride length in runners results in in-

proposed mechanisms for reductions in PP] stress may include alterations to hip kinematics,“ knee kinematics,” hip neuromuscular activation,“ and the external ground reaction force vector acting upon the PFJF6 Additional

studies with long-term follow-up in injured patients are

warranted to better understand the role that step rate

manipulation may have on the improvement of functional outcomes in runners with PFPS. Although step rate manipulation seeks to alter stride

length as a means of influencing key kinematic and kinetic variables associated with PFPS, visual gait retraining

primarily focuses on the alteration of frontal plane kinee matic variables at the knee, pelvis, and trunk. Limited

evidence suggests that real-time visual gait retraining using a computer?fl or a mirror?1 alters pelvic kinematicsfr'jf‘r1

hip kinematicsjl'i-T1 loading rate variables,” and external

knee momentsf‘and leads to short-term improvements in painf'flfTI and functiond’f’f”1 The effect of running visual

gait retraining on an untrained task of single-leg squat

mechanics is mixed, with one study reporting a significant

alteration in squat mecha nics“ and another finding no sig—

nificant effectf“ Limitations in these studies include their retrospective nature, homogenous subject populations,

and short-term follow-up periods. Further randomised controlled trials with long-term follow-up are warranted

to better understand the role that visual gait retraining

may have on the reduction of pain and the improvement of function in subjects with PFPS. 5 u m m a ry

Despite the current high prevalence of PFPS, optimal

nonsurgical management has yet to be outlined in the

fl lfllfi American Academy of Orthopaedic Surgeons

|L'lhapter ET: Patellofemoral Pain Syndrome: Current Concepts in Rehabilitation

underlying mechanism. After the syndrome is identified,

the development of a targeted intervention program ad-

dressing appropriate proximal, local, and distal factors is necessary to ensure the best outcome in this population. Key Study Points

1* Successful conservative management of PFPS is

dependent on a thorough history and physical examination. I Following identification of the unique mechanism underlying an individual's PFPS, it is imperative to apply targeted proximal, local, and distal intern ventions as appropriate to meet the patient’s needs. it A targeted plan of care is often unique to the spe-

cific impairments and functional limitations of each patient.

Annotated References 1. Davis IS, Powers CM: Patellofemoral pain syndrome: Proximal, distal, and local factors, an international retreat, April 3llul'viay 2, EDGE}, Fells Point, Baltimore, MD. I Orteop Sports Phys Tire-r 2010;4fli3}:A1-fi.15.

Medline DDI

This article is a summary statement of the EDD? Patellofemoral Pain Retreat. Level of evidence: V. 2.. Wilson T, Carter H, Thomas '3: Pl. mnlticenter, single-masked study of medial, neutral, and lateral patellar taping in individuals with patellofemoral pain syndrome. 1 IIlIIrti'Iop Sports Phys Titer 20G3;33{Sl:43?—443, discussion 444-443. Medline DUI 3. McConnell J: The management ofchondromalacia patellae: A long term solution. dust I Pirysiotber 1936;32i4]:215123. Medline DUI

4. Powers CM: The influence of altered lower-extremity ki-

nematics on patellofemoral joint dysfunction: .5: theoretical perspective. I Drthop Sports Phys Tires- Efl fl3;33{11j:639546. Medline

DUI

S. Witvrouw E, Lysens Il, Bellemans J, Cambier D, Vander-

straeten G: Intrinsic risk factors for the development of

anterior knee pain in an athletic population. A. two-year prospective study. Arts jl Sports Med 2000;2«Ej4jt43fl 439. Medline IS. Lankhorst HE, Eierma-Zeinstra SM, van Middelkoop M:

Factors associated with patellofemoral pain syndrome: Ill.

systematic review. Br 1 Sports Med 1013;4?{4j:193—206.

Medline DUI

IE! lfllfi American Academy of flrthopaedlc Surgeons

This review systematically summarized factors associated

with PFPS. Factors noted were a larger Q-angle, sulcus angle, and patellar tilt angle; less hip abduction strength; a lower knee extension peak torque; and less hip external rotation strength in PFPS patients than in controls. Level of evidence: In.

Thijs ‘1', De Clercq D, Roosen P, 1it'lliitvrouw E: Gait'related intrinsic risk factors for patellofemoral pain in novice recreational runners. Br I Sports Med lflflfiflljfikfilfifi 4'31. Medline DUI Sousa RE, Draper CE, Fredericson M, Powers CM: Femur rotation and patellofemoral joint kinematics: A weight-bearing magnetic resonance imaging analysis. ] Drtirop Sports Phys Titer lllll};4l}{5]:27?-ZSS. Medline DUI

Altered PF] kinematics in females with patellofemoral pain

appear to be related to excessive medial femoral rotation, as opposed to lateral patella rotation. Control of femoral

rotation may be important in restoring normal PF] kinematics. Level of evidence: IV.

Boling ME, Padua DA, Marshall SW, Guskiewica K, Pync S, Beurler A: a prospective investigation of hiomechanical risk factors for patellofemoral pain syndrome: The Joint Undertaking to Monitor and Prevent REL Injury {I UMPACL} cohort. rim _j' Sports Med Zflfl9;3?[llj:EIflS-EIIE. Medline DUI

This study suggested risk factors for the development of PFPS included decreased knee flexion angle, decreased vertical ground—reaction force, and increased hip internal rotation angle during the jump-landing task. In addition, decreased quadriceps and hamstring strength, increased

hip external rotator strength, and increased navicular drop

were risk factors for the development of patellofemoral pain syndrome. Level of evidence: III.

Ill. Earl JE, Hoch AZ: A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Arr: ,7 Sports Med 2011;39i1}:lS4-163.Medline DUI In this study, hip~focused and corewfocused rehabilitation improved symptoms and patient-reported outcomes in female patients with PFP. Level of evidence: IV. 11. Teng HL, Powers CM: Sagittal plane trunk posture influences patellofemoral joint stress during running. } Clrtbop Sports Phys Tirer 2fl14;44{1l}}:?35-?92. Medline DUI This study suggests that increased forward trunk lean may be a strategy to reduce PP] stress. Level of evidence: IV. 12. Myer GD, Ford KR, Di Stasi SL, Foss ED, Micheli L], Hewett TE: High knee abduction moments are common

risk factors for patellofemoral pain {PFP} and anterior

cruciate ligament (ACLI injury in girls: Is PFP itself a predictor for subsequent HCL injury?I Br I Sports Med lfl15;49[2j:llS-122.Medline DUI

This study suggests that in girls age 13.3 years and older than 16.1 years, greater than 15 Nm and greater than 25

Drthopaedic Knowledge Update: Sports Medicine S

usllvslliseuas :1:-

literature. Success in rehabilitation is dependent on a thorough history and physical examination to identify the

Seeders 4: Rehabilitatian

Nm af knee abductian laad during landing, respectively, are assaciated with a greater likelihaad af the develapmllt af PFP. Level af evidence: III. 13. Naehren E, Hamill], Davis I: Praspective evidence far a

hip etialagy in patellafemaral pain. Med Sci Sparta Exerc 2fl13g4illiHIEfl-1134.Medlinc

DUI

This study shawed that adult female runners in wham PFP develaped exhibited significantly greater hip adductian. Ha differences were faund far the hip internal ratatiau angle at rearfa-at evetsian. Level af evidence: III. 14. Hakagawa TH, Mariya ET, i'viaciel CD, Serriia AF: Frantal plane biamechanics in males and females with and withaut patellafemaral pain. Med Sci Sparta Eater-c c .E 4.!

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2fl11;44{9]:1T4?-1?SS.Medline

DUI

In this study, females presented with altered frantal plane biamechanics, which may predispase them ta knee inju— ry. Individuals with FFPS shawed frantal-plane biamechanics that cauld increase the lateral PF] stress. Level af evidence: I‘lv'. 15. Haehren B, Pahl ME, Sanchez Z, lEunningham T, Latterma nn C: Praximal and distal kinematics in female runners with patellafemaral pain. Ciir: Biamecir (Hristai, nears) lflilflfl-‘llflfifi-STI.Medline

DUI

In this study, greater hip adductian, hip internal ratatian,

and shank internal ratatian were seen in female runners

with PFP. Less cantralateral trunk lean in the PFP graup alsa was nated. Level af evidence: W. IE. 1iiii'illsc-n JD, Petrawits 1, Butler E], Kernasek TW: Male and female gluteal muscle activity and lawer extremity kinematics during running. Cfirr :li‘iarrrecilaI fiiristaf, Heart} Eliilflilifilflfljl-IDST. Mcdlinc DUI

19. Prins MR, van der 1ilii'urff P: Females with patellafemaral pain syndrame have weak hip muscles: A systematic review. r'iust] Pbysfatfaer lflfl9;55|[1]:9-15. Medline

DUI

This systematic review suggests that females with PFPS

demanstrate decreased abductian, external ratatiau, and extensinn strength in the affected limb campared ta healthy cantrals. Level af evidence: II.

ll]. Santa RE, Pawers CM: Differences in hip kinematics, muscle strength, and muscle activatian between subjects with and withaut patellafemaral pain. ] Uriirap Sparta Phys Tirer Zflfl9:39i1]:IE-19. Medline DUI This study suggested that females with PFP presented with greater hip internal ratatian and decreased hip abductian

and extensian tarque praductian campared with central

subjects withaut PFPS. Greater gluteus maximus recruitment was present in patients with PFPS during running and step dawn tasks. Level af evidence: I‘v". 11. Sauna RB, Pawers CM: Predictars af hip internal ratatiau

during running: An evaluatian af hip strength and femaral

structure in wc-men with and withaut patellafemaral pain. Arr: I Sparta Med 2009;3Tl3):5?9-531 Medline DUI

Patients with PFP had less hip internal ratatiau, reduced hip muscle strength, and greater femaral inclinatian campared with cantral patients. Isatanic hip extensian endurance predicted hip internal ratatiau matian. Level af evidence: IV. 22. Dierks Tn, Manal KT, Hamill], Davis I: Lawer extremity kinematics in runners with patellafemaral pain during a pralanged run. Med Sci Sparta Exerc 2fl11;43{4}:693 #00. Medline DUI In this study, the PFP graup displayed less averall matian than did cantrals. Three distinct PFP subgranps were

This study she-wed that females run with a greater peak gluteus maximus activatian level and a greater average

nated: a knee valgus graup, a hip abductian graup, and a

played greater hip adductian and knee abductian angles at initial cantact, greater hip adductian at peak vertical graund-reactian farce, and less knee internal ratatian excursian than did males. Level af evidence: IV.

23. Ferber R, Kendall Kl], Farr L: Changes in knee biame— chanics after a hip-abductar strengthening prataccl far runners with patellafemaral pain syndrame. I riff-f Train

activatian level than da males. Female runners alsa dis-

1?. 1Willy KW, Mans] KT, 1|illli'itvrauw EE, Davis IS: Are mechanics different between male and female runners with patellafemaral painiI Med Sci Sparta Exerc 2fl11;44{11}l:2165-21?1.Medline

DUI

hip and knee transverse plane graup. Level af evidence: IV.

2011;46{2}:142-149.Medline nai

This research shawed that hip abductar muscle strength—

ening was effective in increasing muscle strength and reducing pain and impraving knee kinematics in individuals with PFPS. Level af evidence: IV.

In this study, males with PFP ran and squatted in greater

24. Khayambashi K, Fallah A, I'viavahedi a, Bagwell J, Pawers

external adductian mament campared with healthy male cantrals. Males with PFP ran and squatted with less peak hip adductian and greater peak knee adductian than did

ceps strengthening far patellafemaral pain: A. camparative cantral trial. Arch Phys Med Refrebii 2014:95i5}:90{i-90?.

peak knee adductian and demanstrated greater peak knee

females with PFP. Level af evidence: I‘v’.

13. Cichanawski HR, Schmitt J5, Jahnsan R], Niernuth PE: Hip strength in callegiate female athletes with patellafemaral pain. Mari Sci Sparta Exerc lfifl?:39{3h123?1131. Medline DUI

C: Pasteralateral hip muscle strengthening versus quadri—

Medline

DUI

In this study, autcames in the pasteralateral hip exercise graup were superiar ta these in the quadriceps exercise grnnp. The superiar autcames abtained in the pasteralateral hip exercise graup were maintained far 6 mantbs after interventian. Level af evidence: III. 25. Bartan C], Lack S, I'vialliaras P, Marrissey D: Glutcal muscle activity and patellafemaral pain syndrame: A

Urthapaedic Knawledge Update: Sparta Medicine S

D lfllfi American Academy af Cirrhapaedic Surge-ans

|[Chapter 17: Patellefememl Pain Syndreme: Current Eeueepts in Rehabilitation

This study presented current evidence indicating that gluv teus medius activity is delayed and af shatter duratian during stair negatiatian in patients with PFPS. In additian,

limited evidence indicates that gluteus medius activity is

delayed and ef shatter duratien during running and gluteus maximus activity is increased during stair descent. Level ef evidence: I. 26. Willsan JD, Kernarek TW, Arndt RL, Reanichek DA,

Scett Straker J: lGluteal muscle activatieu during run-

ning in females with and witheut patellefemeral pain syndrame. Clin Hiamecfr (Bristal, Apart) lflllflfilflflifiT411}. Medline DUI

In this study, females with PFP demenstrated delayed and sherter gluteus medius activatieu than females witheut knee pain during running. The magnitude and timing af gluteus maximus activatieu was net different between

greups. Greater hip adductien and internal retatien excur-

The anthers praspectively evaluated measures ef frau-

tal-plane knee leading during landing te determine their

relatianship tn the develepment ef PFP. The new PFP greup demenstrated increased knee ahductien mement

at initial centact en the mast symptematic limb and max-

imum knee ahductien mement en the least symptematic litnb at the asymptematic limb relative te the matched central limbs. Level af evidence: III. 31. Distefana L], Blackburn jT, Marshall SW, Padua DA:

Gluteal muscle activatieu during cemmen therapeutic

exercises. I Grahep Sparta Pbya Titer 2Dfl9;39{?}:532v54fl. Medline DGI This study describes the relative gluteal muscle activatieu during several cemmen therapeutic exercises. Side-lying hip ahductien resulted in the greatest gluteus medius activity while single limb squatting and single-limb deadlifting led ta the greatest gluteus maximus activity. Level ef evidence: IV.

2?. Scattene Silva R, Serraa FV: Sex differences in trunk,

31. Selkewita DM, Beneck G], Pawers CM: Which exercises target the gluteal muscles while minimizing activatieu ef the tenser fascia lata? Electreniyegraphic assessment using fine-wire electredes. j firth-up Sparta Phys Ther 2013;43l2}:54—E4.Medline DUI

terque in adelescents. Elie Bic-mach {Bria-tel. Arrest}

This study shewed that the clamshell, side step, unilateral

sien were cerrelated with later sunset in the gluteus medius and gluteus maximus, respectively. Level ef evidence: IV.

pelvis, hip and knee kinematics and eccentric hip lfll‘ltlfllftltlflfid-IDERMedline

DUI

In this study, adelescent females presented with greater hip adductian, hip external ratatian, and knee abductian and smaller trunk flexian during the single-leg squat than did males. Additienally, adelescent females shewed smaller isakinetic eccentric hip tarque narmaliaed by bady mass in all planes than did males. Level af evidence: IV. 28. Nakagawa TH, Mariya ET, Maciel CI}, Serriia FV: Trunk, pelvis, hip, and knee kinematics, hip strength, and glue teal muscle activatieu during a single-leg squat in males and females with and witheut patellefemeral pain syndrame. ] Urtfrap Sparta Phys Thar 2fl12;42{6}:491-501. Medline DDI

In this study, individuals with PFPS had greater ipsilateral

trunk lean, centralateral pelvic drep, hip adductien, and knee abductian when performing a single-leg squat than did cantrals. Individuals with PFPS alsa had 13% less hip ahductien and 17% less hip external retatien strength. Cempared with female cantrels, females with PFPS had mare hip internal ratatian and less muscle activatieu af

the gluteus medius during the single—leg squat. Level ef

evidence: IV.

29. Fewers CM, Ward 5R, Fredericsen M, IGuillet M, Shelleck FG: Patellefemeral kinematics during weight-hearing and nan-weight-bearing knee extensian in persans with lateral

subluxatien ef the patella: A preliminary study. I Drthep

Sparta Pbya Thar 2003;33{11}:E??-635. Medline

DUI

31}. Myer GD, Ferd FIR, Earher Fess KL}, et al: The inci-

dence and patential pathemechanics ef patellefemeral pain in female athletes. Cfirt Hfamecf: (Br-fatal, Ayers)

lfllfl;15{?}:?flfl-?fl?.Medline net

IE! lfllfi American Academy ef flrthepaedic Snrgeens

bridge, and bath quadruped hip extensien exercises weuld appear ta be the mast apprepriate ta preferentially activate the gluteal muscles while minimizing tenser fascia latae activatieu. Level ef evidence: IV.

33. Ekstrem RA, Denatelli RA, Carp KC: Electremyegraph—

ic analysis ef care trunk, hip, and thigh muscles during 9 rehabilitatian exercises. I Drtfrap Sparta Phys Ther Zflfl?;3?{12}:?54—?62.Medline DID]

34. Ayette NW, Stetts DIM, Keenan I}, |lflreenway EH: Electramyagraphical analysis af selected lewer extremity muscles during 5 unilateral weight-hearing exercises. j Drtfrep Sparta Phys Ther EUDT;3?{1}:4E-55. Medline DDI 35. Werner S: Anterier knee pain: tin update ef physical therapy. Knee Surg Sparta Trunmatal Arthrasc 2014;22{10}:2235-1294.Medline

DUI

This clinical cammentary prevides a general update an phsycial therapy management ef anterier knee pain. Level af evidence: V. 36. Lack 5, Earten C, Vicenaine B, Merrissey D: Dutcenie predicters fer censervative patellefemaral pain management: A systematic review and meta—analysis. Sparta Med 2014;44{IZJ:1?03-1?16.Medline DDT This systematic review and meta-analysis seught ta evaluate the efficacy ef preximal rehabilitatian af PFP, campare variaus rehabilitatian pratacels and identify

hiemechanical mechanisms te aptimiae preximal reha—

hilitatien. The review suggests preximal rehabilitatien af PFPF shauld be included in censervative management. Level ef evidence: II.

Drthepeedic Knewledge Update: Sparta Medicine 5

usuaauaeuvs :1:-

systematic review. Br I Sparta Med lflldfiTI-Hflfllllil. Medline DUI

Sectinn 4: Rehabililutinn

3?. 1iiii’itvrciuw E, Urnssley R, Davis I, McUcnnell J, Pcwers |IBM: The 3rd Internatinnal Patellnfemnral Research Retreat: An internatinnal expert cnnsensus meeting tn im-

prcve the scientific understanding and clinical management

natinn and the incidence nf anterinr knee pain amnng military recruits. 1 Rune joint Surg Br Zflfl6:33i?}:9i}5EDS. Medline DUI

The authors discussed the cnnsensus statement Item the E‘-rd Internaticnal Patellufemnral Research Retreat, which attempts tn summarize current trends and research pricrities in the area pf patellnfemc-ral pain. Level nf evidence: V.

4?. Rndrigues P, TenE-rnck T, Hamill]: Runners with anterinr knee pain use a greater percentage cf their available prenatinn range nf mntinn. f Appf Hints-tech EDI 3429l1i=141‘ 146. Medlinc

cf patellnfemcral pain. lirjr Spcrts Med 2014:4SIS}:4IIS. Medline DUI

33. 1ilii'itvri':rm.v E, Werner S, Mikkelsen C, TIv'an Tiggelen D, 1lullanden Eerghe L, Gernlli G: Clinical classificatinn nf

patellnfemnral pain syndrnme: Guidelines fnr nnn—nper—

ative treatment. Knee Sssrg Sports Traumatcf Arthrnse 2fl05;13{2i:112-13fl.Medline DUI E .E 4.!

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46. Hetsrnni I, Finestcne A, Milgrc-m C, et al: A prcspective binmecha nical study Uf the assnciatinn between fnnt pru-

39. Pcwers UM, Hc RY, IEben ‘1'], Scuaa RE, Farrekhi S: Patellnfemnral jnint stress during weight-bearing and nnnweight-bearing quadriceps exercises. ,f Urtfsnp Spnrts Phys Ther 2014:44I5lfilfl—321 Mcdline DUI This study suggests that, re minimise PF] stress while perfnrming quadriceps exercises, the squat exercise shnuld be perfnrmed frnm 4.5“ tn fl“ crf knee flexinn and the knee-extensinn-with-variable-resistance exercise shnuld be perfnrmed frem Si!“ te- 45” cf knee flexinn. Level cf evidence: IV. 4|]. Piva SR, Uncdnite Eh, Childs JD: Strength amend the hip and flexibility nf snf't tissues in individuals with and

withuut patellcfemeral pain syndrcrmc. ] Urtbcp Spurts Phys Ther 2005:35Illlfl93-Efll. Medline

DUI

41. 1ifiniitvrnuw E, Callaghan M], Stefanik J], et al: Patellnfcm—

nral pain: CUHSEI'ISIJS statement frnm the 3rd Internatinnal Patellnfemnral Pain Research Retreat held in Vancnuver,

Sepmmber 2013. Br ,i' Sports Med 2fl14;43{6}:411—414. Medline DUI

A cnnsensus statement frnm the 2013 Patellcfemnral Pain Retreat is discussed. Level nf evidence: V.

In this study, nc- differences in traditinnal prunaticn variables were ncted berween healthy and injured runners. In cnntrast, injured runners used significantly mnre nf their available range nf mntinn than did healthy runners. Level

cf evidence: IV.

43. Rudrigues P, Chang H, TenErnek T, Hamill J: Medially pasted insnles ccnsistently influence fnnt prenatinn in runners with and withnut anterinr knee pain. Gait Pnstnre 1013:3?(4}:52IS-531.Medline DUI

In this study, insules, an average, reduced peak eversicn, peak eversicn velccity, and eversic-n range crf mntinn. Althnugh insnles reduced eversitm variables, hnwever, they had small influences cm the transverse-plane kinematics cf the tibia er knee. Level nf evidence: IV. 49. Eartnn G], Levinger P, Crnssley KM, Webster RE, Men: HE: Relaticnships between the Fact Pasture Index and fact kinematics during gait in individuals with and withnut patellnfemnral pain syndrnme. j at Ankle Res 1D11;4:ID. Medline DUI In individuals with and withnut PFPS, a fair tc mc-derate asscciaticn was fnund between the feet pasture index and same parameters nf dynamic fnnt functitm. Incnnsistent findings between the PFPS grnup and the centre] grnup indicate that pathclc-gy may playr a rule in the relatinnship between static fnnt pnsture and dynamic functinn. Level nf evidence: IV.

SD. Bartnn C], Levinger P, Crnssley RM, Webster RE, Men:

HR: The relatinnship between rearfnnt, tibial and hip

42. Warden SJ, Hinman RS, 1i'iiatsnn MA jr, hvin RU, Bialncerknwski .f'LE, Crnssley KM: Patellar taping and bracing

kinematics in individuals with patellcfemnral pain syndrums. Clix Siamese {Bristnh .tilflflfl} 2012:2?{?}:702-?fl5. Medline DUI

and meta-analysis. Arthritis Rheum lflflflgSSIII:?S-SS. Medline DUI

In this study, greater peak rearfnnt eversinn was assnciatcd with greater peak tibial internal rntatinn in the FFPS grnup. Greater rearfnc-t eversinn range cf mntinn was assnciated with greater hip adductinn range nf mntinn in the PFI’S and centre] grnups and greater peak hip adduc— ticn in the centre] grnup. Level cf evidence: IV.

fer the treatment cf chrc-nic knee pain: A systematic review

43. McClay I, Manal R: A cnmparisnn nf three-dimensinnal Inwer extremity kinematics during running between excessive prenatcrs and ncrmals. Elia Bicmeelr fBrfstcf. Avert) ISBS;'13{3]:ISS-EUS. Medline DUI Tiberic D: The effect of excessive subta lar juint prenaticn cn patellcfemc-ral mechanics: A thecretical mcdel. ] Urtfmp Spnrts Phys Titer 193T;9{4}I:16il-165. Medline DUI

51. IvIail TG, Cnrnwall MW: Predictitm cf dynamic fc-nt pasture during running using the lcngitudinal arch angle. ] Arr: Pnsffsttr Med tissue lflfl?;9?{2}:1fl2-IDT. Medline DUI

4S. iers CM, Chen PT, Reischl SF, Perry J: Ccmparisnn nf fnnt prc-natinn and Inwer extremity rntatinn in persnns

SE. Franettnvich MM, Mail TG, Russell T, Skardnnn G,

with and witbcut patellufemcral pain. Fc-ct Ankle Int 2Dfll:23[?l:634-S4fl. Medline

Urthnpaedic Kncwledge Update: Sperts Medicine S

Vicenainc E: The ability tn predict dynamic feet pes—

ture frcm static measurements. ,I Am Pcdietr Med Asses lflfl?;9?{2}:115-120.Medline DUI

U lflld American Academy cf Urrhtipaedic Surge-ens

Chapter 17: Patellefememl Pain Syndreme: Currenr Eeucepts in Rehabilitatien

DJ: Feet erthetics affect lewer extremity kinematics and kinetics during running. Elia: Biemsch (Bristel', Avert) 2fl33;13{3]:154-262. Medline DUI

54. Staceff A, Reinschrnidt C, Nigg EM, et al: Effects ef feet

ertheses en skeletal metien during running. Clirs Bfemech (Brisrel, Avert} lflfl0515{1}:54-64. Medline DUI

55. Williams D5 III, McClay Davis I, Eaitch SP: Effect ef inverted ertheses en lewer-estremity mechanics in runv ners. Med Sci Sperts Exerc lflflfififlllhlflfifl-fllfifl.

Medline

DUI

56. Eslami M, Eegen M, Hinse S, Sadeghi H, Pepev P, Allard

P: Effect ef feet ertheses en magnitude and timing ef rearfeet and tibial metiens, greund reactien ferce and knee mement during running. J Sci Med Spert ZflflflflltfihrJ'TBES 4. Medline DUI

The authers reperted feet ertheses ceuld reduce rearfeet

eversien se that this can be asseciated with a reductien

ef knee adductien mement during the first fifl‘l’s stance phase ef running. These findings imply that medifying rearfeet and tibial metiens during running ceuld net he related te a reductien ef the greund reactien ferce. Level ef evidence: IV. 5?. Beldt AR, 1illfillsen JD, Earries JA, Kernerek TW: Effects ef medially wedged feel: ertheses en knee and hip jeinl: running mechanics in females with and witheut patelles femeral pain syndreme. J Appi Biemech 2fl13:29{1]:63-??.

Medline

In this research, ne significant greup :u: cenditien er calcaneal angle a cenditien effects were ehserved. The additien ef medially wedged feet ertheses te standardized running shees during running had a minirual effect en knee and hip jeirlt mechanics theught te he asseciated with PEPE symptems. These effects did net appear te depend en injury status er standing calcaneal pestu re. Level ef evidence: IV.

53. lacLean (1, Davis IIvI, Hamill J: Influence ef a custem

feet erthetic interventien en lewer extremity dynamics in healthy runners. Cfffl Bfemech (Eris-tel, Arlen}

sassgusassasseasmm: eel

55‘. Naweczenski DA, Ceek TM, Saltaman |CL: The effect ef

feet erthetics en three-dimensieual kinematics ef the leg

and rearfeet during running. } Grthep Sperts Phys Ther 1995;21f6]:31?—32?.Medline

DUI

El]. Stackheuse CL, Davis Ilvl, Hamill]: Drthetic interventien in ferefeet and rearfeet strike running patterns. Cffn: fifemech {Eristeh risen) lflfl4;19{1}:64-?D. Medline D01

similar te physietherapy and de net impreve eutceme when added te physietherapy. Level ef evidence: II.

61. Jehnsten LE, Gress lT: Effects ef feet ertheses en quality ef life fer individuals with patellefemeral pain syndreme. I Drthep Sperts Phys Ther- Efl fl4;34{3}:44D-443. Medline

DUI

63. McPeil TG, Vicenaine B, Cernwall MW: Effect ef feet ertheses centeur en pain perceptien in individuals with patellefemeral pain. I Am Pediatr Med Asses 2fl11;101l1]:T-16.Medline

DUI

In this study, all participants perceived greater suppert with centeured ertheses in the heel and arch regiens. All ef the participants rated cushiening as equivalent, despite differences in material hardness. In the patellefemeral pain greup, six individuals reperted a clinically significant

reductien in knee pain as a result ef wearing feet ertheses. Level ef evidence: III.

64. Batten (3], Munteanu 5E, IvIeua HE, Eressley Kid: The efficacy ef feet ertheses in the treatment ef individuals with patellefemeral pain syndreme: A systematic review. Sperts Med lfl]fl;4fl{5}:3??—395. Medline III-DI

Limited evidence shews that prefabricated feet ertheses

better reduce the range ef transverse-pla ne knee retatien and previde greater shert-term imprevements in individ-

uals with PFPS than de flat inserts. Findings alse indicate

that cembiniug physical therapy with prefabricated feet ertheses may he superier te prefabricated feet ertheses aleue. Level ef evidence: I. I55. Eng J}, Pierrynewski MR: Evaluatien ef seft feet erthetics in the treatment ef patellefemeral pain syndreme. Phys Ther 1993;?3i1l:62—63, discussien 63—?0. Medline 66. 1|Illll'illsen jIlI, Sharpee R, Mearden 5A, Kernezek TW: Effects ef step length en patellefemeral jeiut stress in female runners with and witheut patellefemeral pain. Eli's-s Biemech fBrfstef, Avert} 2&14;25‘{3J:243-14?. Medline DGI In this study, PF] stress per step increased in the leug step—length cenditien and decreased in the shert steplength cenditien. Tetal stress per mile experienced at the PF] declined with a shert step length despite the greater number ef steps necessaryr te cever the distance. Level ef

evidence: IV.

6?“. Heiderscheit EC, Chumanev E5, Michalski MP, 1Wille CM, Ryan ME: Effects ef step rate manipulatien en juiut mechanics during running. Med Sci Sperts Esters

2011;43i2lflfld-3fl2.Medline net

This study shewed that increased step rate results in an

Vicenaine E: Feet ertheses and physietherapy in the treat-

altered peak hip adductien angle as well as a reductien in peak hip adductien and internal retatien mements. Level ef evidence: IV.

This raudemiaed centrelled trial investigating the efficacy

153. Leuhart ILL, Thelen DIG, Wille CM, |IEhumanuv E5, Heiderscheit EC: Increasing running step rate reduces patellefemeral jeint ferces. Med Sci Sperts Eaters 2fl14;45[3l:55T-5i54.Medline DUI

61. Cellins N, IEressley K, Heller E, Darnell R, McPeil T,

ment ef patellefemeral pain synd reme: Eandemised clinical trial. Br I Sperts Med 2Ufl9;43{3}|:159-1?1. Medline DUI ef feet ertheses and physical therapy in patients with PFPS neted that feet ertheses wEre superier te flat inserts but

IE! lfllii American Academy ef flrthepaedic Snrgeens

Drthepaedic Knewledge Update: Sperts Medicine 5

uvuvavavaas :1:-

53. Miindermann A, Nigg EM, Humble RN, Stefanyshyn

Sectiuu 4: Rehahiflllutiun

In this study, increasing the step rate reduced peak PF] furce. Peak muscle furces were altered as a result uf the increased step rate, with hip, knee, and ankle extensur

fumes and hip abductcr furces all reduced in midstance. Level uf evidence: IV.

6.9. Churnanc—v ES, Wills GM, Michalski MP, Heiderscheit BC: Changes in muscle activatiun patterns when running step rate is increased. Gait Pustrrre ID12;SSI{2}:ESI-235.

Medline DD]

An increase in late swing phase muscle activitv uccurs when the step rate is increased, suggesting an anticipatnrv preactivatiun fur the fuut-grunnd cuntact. Muscle activities dnring the luading respunse were nut reduced as the step rate increased. Level uf evidence: IV. :: .E 4.!

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I’ll. Nuehren E, Schulz], Davis I: The effect uf real-timc gait retraining un hip kinematics, pain and functiun in subjects with patellufemural pain svndrume. Hr] Spurts Med 2fl11:45[9]:691-696.Medline DUI

firthnpaedic Knuwledge Update: Spurn: Medicine 5

In this studv, a reductiun in hip adductiun and cuntralateral pelvic drup while running was seen fulluwing gait retraining. Impruvements in pain and functiun alsu were

seen. Subjects were able tu maintain their impruvements

in running mechanics, pain, and functiun at 1-munth fulluw-up. Level uf evidence: IV. T1. Willy KW, Schulz JP, Davis IS: Mirrur gait rerraining fur the treatment uf patellufemural pain in female runners. Eli's: Bic-mesh (Bristul, Anus} 2012;2?{1fl]:1045-1051.

Medline Dfll

This stud}r fuund decreased peaks uf hip adductiun, cuntralateral pelvic drup, and hip abductiun mument during running with gait retraining. Skill transfer tu single-leg squatting and step descent was nuted. Subjects repurted impruvements in pain and functiun and maintained them thruughuut the S munths after retraining. Level uf evidence: IV.

fl lfllfi American Academy uf Cirrhupaedic Surge-ans

Chapter 28

Foot and Ankle Rehabilitation Rany L. Martin, PhD, PT

tatinn prngram. These interventinns typically are perfnrmed tn decrease pain and restnre nnrmal mntinn,

Manual Therapy

muscle functinn, prnprinceptinn, and binmechanics.

Manual therapy can include jnint and snft—tissue mnbi-

niques are typically used tn reinfnrce nnrmal prntective suppnrt structures, imprnve prnprinceptinn, enhance

and have been nutlined in a cnmprehensive mndel.1 A

Manual therapy prncedures can have binmechanical, neurnphysinlngic, and psychnlngic effects. Taping tech-

neurnmuscular activatinn, andlnr alter hinmechanics whereas exercise typically is directed tnward imprnving range nf mntinn, recruitment pattern, strength, and! nr endurance. Eccentric exercise can alsn be used tn ptnmnte tendnn remndeling. It is impnrtant tn review the literature related tn the pntential effectiveness nf

manual therapy prncedures, taping techniques, and exercise in fnnt and ankle rehabilitatinn, and review

specific evidence tn suppnrt the use nf these interventinns

for individuals with heel pain, plantar fasciitis, Achilles

tendinnpathy, and lateral ankle sprain.

Keywords: manual therapy; taping; exercise; evidence-based practice IntrndUttic-n

Manual therapy, taping, and exercise are cnmmnnly in-

cluded in cnmprehensive fnnt and ankle rehabilitatinn

prngrams. These interventinns typically decrease pain and restnre nnrmal mntinn, muscle functinn, prnptinceptinn,

and binmechanics. The pntential effectiveness nf manu-

al therapy prncedutes, taping techniques, and exercise in fnnt and ankle rchabilitatinn has been reviewed, and Neither Dr. Martin nnr any immediate family member has received anything nf value from nr has stuck nr stnclr nptinns held in a cnmmerclal company nr lnstitutinn related directly nr indirectly tn the subject nf this chapter.

fl lflld American Academy nf Drthnpaedic Surgenns

lisatinn techniques. The effects nf these techniques can he hinmechanical, neurnphysinlngic, and psychnlngic literature review suppnrted using manual therapy as an

interventinn tn treat lnwer extremity cnnditinnsfi Frnm a binmechanical perspective, jnint and snft—tissue mn—

biliaatinn techniques thenretically address restrictinns

in capsular, ligamentnus, tendinnus, muscular, andlnr

fa scial structures. Annther pntential binmechanical effect nf jnint mnbiliaatinn is the realignment nf bnny structures. Generally pnsitivc binmechanical effects can be assnciatcd

with imprnved range nf mntinn. Snft—tissue mnbilitatinn can he directed tnward increasing circulatinn, imprnving vennus and lymphatic flnw, and prnmnting cnllagen red

alignment. The neurnphysinlngic effects [if manual therapy can include altering central pain precessing, muscle

recruitment, and reflex activity patterns, which can result

in imprnved fnrce prnductinn and decreased pain percep-

tinn. The psychnlngic effects nf manual therapy may be placebn in nature and assnciatcd with “a feeling nf being helped;n hnwever, these effects shnuld nnt be underestimated and can change an individual‘s pain perceptinn, stress levels, and nverall emntinnal state.I

Taping techniques can reinfnrce nnrmal prntective suppnrt structures, imprnve prnprinceptinn, enhance neurn~

muscular activatinn, andlnr alter binmechanics. Taping techniques that cnrrect lnwer extremity kinematics and muscle activatinn in individuals with abnnrmal prnnatinn

are generally categnriaed as antiprnnatinn. A review nf the literature shnwed that antiprnnatinn taping can increase medial lnngitudinal arch height, reduce calcaneal eversinn, reduce tibial internal rntatinn, and reduce

Drthnpaedic Knnwledge Update: Spnrts Medicine 5

uvnealisvuas :1:-

Manual therapy, taping, and exercise are cnmmnnly included in a cnmprehensive feet and ankle rehabiliu

specific evidence nutlined tn suppnrt the use nf there interventinns fnr individuals with heel pain, plantar fasciitis, Achilles tendinnpathy, and lateral ankle sprain.

Section 4: Rehabilimtion

tibialis posterior muscle activity.3 The treatment-directed test uses antipronation taping techniques to guide orthotic prescription.‘ Research has disproved many the—

ories5 traditionally used in foot assessment and orthotic fabricatiou.‘5'E Because clinical examination may not be

able to predict dynamic foot function, clinical findings

may not be as helpful as previously assumed in orthotic

prescription. However, the individualized approach to

orthotic fabrication based on response to taping through the treatment-directed test has reduced pain and improved function};

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Exercise

Typically, active exercise is directed toward changing the

characteristics of a muscle contraction by improving recruitment pattern, strength, andr'or endurance. Stretching

exercises are typically used to improve range of motion and flexibility. Because muscles do not work in isolation,

active exercises should target not only muscles in the foot

and ankle but also include proximal muscle groups in

functional activities. Exercises often attempt to correct

abnormal pronation by improving the function of muscles that support the medial longitudinal arch, particularly the

posterior tibialis. Because hindfoot prouatiou has been

coupled with hip internal rotation,"’ exercises that target hip musculature can be beneficial. Due study found that

exercise in individuals with heel painfplantat fasciitis,” Achilles tendinopathy,” and lateral ankle sprain.” Plantar Fasciitis

Plantar fasciitis usually presents as a chronic condition

in both nonathletic and athletic populations.” Limited ankle dorsiflexien range of motion, high body mass index

in nonathletic individuals, running, and work—related

weight-bearing activities under conditions with poor shock absorption have been identified as risk factors for the development of plantar fasciitis. Strong evidence indicates that plantar fasciitis can be diagnosed based on

plantarmedial heel pain that is most noticeable with initial

steps following a period of inactivity but also may be worsened following prolonged weight bearing; the onset

of pain associated with a recent increase in weight—bearing

activity; pain with palpation of the proximal insertion of the plantar fascia; a positive vvindlass test result; and negative tarsal tunnel test results.“ The treatment of plantar fasciitis of the heel is summarized in Table 1 and includes strong evidence for manual therapy, taping, and exercise.“

Manual Therapy

A 21314 review“ recommended that manual therapy con-

should include muscle groups of the lumbopelvic region to

sisting of joint and soft—tissue mobilisation procedures be used to treat relevant lower extremity joint mobility and calf flexibility deficits and to decrease pain and improve function in individuals with heel painfplantar fasciitis. Level I research studies supported this recommendation.

In addition to exercise being directed toward correcting abnormal prouatiou and improving functional stability,

derwent exercise and manual therapy had better function and global self-reported outcomes at both 4 weeks and 6

individuals with overuse injuries had strength deficits in

the hip musculature.11 It is also theorized that exercise

facilitate a stable platform for lower extremity movement.

exercise also can be directed at tendon remodeling using

an eccentric exercise program. A program developed for

individuals with tendiuopathies consists of progressive eccentric loading with resistance high enough to cause

moderate but not disabling pain.ll The exact mechanisms

behind the success of eccentric training can involve alter-

ing tendon blood flow, collagen synthesis, and production of growth factors. A 2013 study suggested that eccentric exercise that loads the tendon in a lengthened position

can cause “squeezing out" and resolution of abnormal neovascularity.”l Evidence—Based Practice

Evidence—based clinical practice guidelines for the or-

thopaedic physical therapy management of individuals with common foot and ankle-related musculoskeletal impairments have been published. These guidelines out—

line evidence for the use of manual therapy, taping, and

firthupaedic Knowledge Update: Sports Medicine 5

Authors of a Bill}? study” found that patients who un-

months when compared with patients in the group treated

with exercise and iontophoresis. Manual therapy consisted of soft-tissue mobilization directed toward the calf and plantar fascia and joint mobilisation directed toward

identified range of motion restrictions of the hip, knee, ankle, and foot. Because limited ankle dorsiflexion is often identified in those with plantar fa sciitis, anterior to posterior talar glides {Figure 1} are commonly performed. Authors of a mu study” found that patients who underwent the addition of soft-tissue mobilisation techniques directed at gastrocnemius and soleus myofascial trigger points had better pain reduction at 4 weeks when com-

pared with patients who underwent self~stretching only.

Taping The authors of the IBM review also recommended that

clinicians should use antipronation taping for immediate

{up to 3 weeks} pain reduction and improved function for

individuals with plantar fasciitis.“ Systematic reviews have

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 23: Foot and Anlde Rehabilitation

Table 1

Summary of Evidence in the Treatment of Plantar Fasciitis Strong Evidence Treatment

Intervention

Manual therapy

Lower extremity joint mobilization

Taping

Antipronation technique

Exercise

Plantar fascia stretching Gastrocnemius and soleus stretching

Foot orthoses

faver-the-counterrprefahricated or a custom foot orthoses that supports the medial arch andror provides cushion to the heel region

Night splints Weak Evidence

Treatment

Intervention

Physical agents

lontophoresis with dexamethasone or acetic acid Low-level laser

Phonophoresis with ketoprofen gel [Data from Martin EL, Davenport TEr Fleischl 5F, et al: Heel pain-plantar fasciitis: Revision Ell-14- J flrthop Sports Phys Ther mlmMIHIfiI-AEB. http:fl|'t:|x.doi.orgflfl.2519!jospt.2fl14.l]303.l

Figure 1

Photograph shows implementation of anterior

to posterior talar glides {arrow} to increase

ankle dorsiflexion range of motion.

found antipronation taping to be effective in reducing pain at 1—week follow-up in subjects with plantar fasciitis.”'1” An example of antipronation tape is demonstrated in Fig-

ure 2. A level I study not included in these reviews found

Figure 1

Photograph shows an antipronation taping technique.

Exercise

therapeutic elastic tape applied to the gastrocnemius and plantar fascia improved pain scores and reduced plantar

Clinicians should use plantar fascia-specific and gastroenemiusl'soleus stretching to provide short-term (1 week

trotherapy treatments at 1-week follow-up.“ Additionally, a level II study found that antipronation taping reduced pain and improved function over a 3—week period in in— dividuals with plantar fasciitis.:1

ciitis.“ Two systematic reviews concluded that stretching exercises for the ankle and foot can provide short-term {2

fascia thickness when compared with ultrasound and elec—

IE! Eillfi American Academy of flrchopaedic Surgeons

to 4 months) pain relief for individuals with plantar fasweeks to 4 months} improvementsfinrfl with plantar fas-

cia—specific stretching being more beneficial than Achilles

Drthopaedic Knowledge Update: Sports Medicine 5

ussvuuqeuas :1:-

Plantar fascia, gastrocnemius, and soleus soft-tissue mobilization

Section 4: Rehabilitation

-— Summary of Evidence in the Treatment of Individuals 1With Achilles Tendinopathy Strong Evidence Treatment

Intervention

Exercises

Eccentric leading of the Achilles tendon

Physical agents

Low-level laser Iontophoresis with dexamethasone Weak Evidence

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Treatment

Intervention

Exercise

Fla ntar flexor stretching

Foot orthoses

Custom semirigid inserts

Manual therapy

Achilles tendon soft-tissue mobilization Expert opinion

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Treatment

Intervention

Taping

Directed toward decreased strain on the Achilles tendon

{Data from Earcia CH, Marlin itL, Hand: J, Wultich DIE; orthopaedic Section of the American Physical Therapy Association: Achilles pain, st'aess,

and muscle power defldts: Achilles tendinitis. J Urthup Sports Phys Ther 2a1a;4a[s]:a1-A2s. http:iii'dx.dal.orgi1D.2519i]ospt.2fl1u.u3u5.l

stretching.m A study not included in these reviews found improved self-reported outcome scores when comparing plantar fascia-specific stretching with shockwave therapy at 2— and 4-month follow—up.“ Achilles Tendinopathy

Achilles tendinopathy is a common pathology in active individuals. Intrinsic risk factors associated with Achilles tendinopathy include abnormal dorsil'lexion range of motion, abnormal suhtalar joint range of motion, decreased

and improve function. This recommendation was further supported by a recent systematic review in Zfllli‘ that outlined low-level evidence for soft-tissue mobilization in individuals with Achilles tendinopathy. Due soft—tissue mobilization technique consisted of gliding a hypomohile Achilles tendon in conjunction with stretching and mus-

cular contraction.” Although not extensively studied, joint and soft-tissue mobilization could be justified for increasing ankle dorsiflexion range of motion.

ankle plantar flexion strength, increased foot pronation,

Taping Taping can also be used to decrease tendon strain in pa-

gested that high body mass index may also he a risl: factor for developing Achilles pathology.” A 2.010 review”

tematic reviewfi" there is low-level evidence to support antipronation taping. Given that abnormal pronation is

and abnormal tendon structure.'5 A recent study sug-

found that Achilles tendinopathy can be diagnosed by the following findings: local tenderness of the Achilles tendon 2 to 6 cm proximal to its insertion; a positive

a_rc sign where the area of palpated swelling moves with dorsiflexion and plantar flexion; and a positive Royal London Hospital Test result where Achilles tenderness in slight plantar flexion decreases as the ankle dorsii'lexes.

Evidence supporting interventions in the treatment of

Achilles tendinopathy is summarized in Table 2 and in— clude weal: evidence for manual therapy, expert opinion for taping, and strong evidence for exercise.

Manual Therapy For individuals with Achilles tendiuopathy, soft—tissue

mobilization can he used to reduce pain, increase mobility,

flrdinpaedic Knowledge Update: Sports Medicine 5

tients with Achilles tendinopathy.” According to a sysa risk factor for developing Achilles tendinopathy, the use of antiprnnatinn taping techniques could be justified as

an appropriate intervention. A case study of an individual with Achilles tendinopathy reported that antipronation

taping reduced symptoms and produced a tenfold increase

in pain-free jogging distance.” IEither taping techniques include “off-loading" and “equinus-constraint,“ which decrease strain on the Achilles tendon and limit dorsiflexion range of motion}? Figure 3 demonstrates the ‘off-lnading' taping technique.

Exercise Clinicians should implement an eccentric loading program to decrease pain and improve function in individ— uals with Achilles tendinopathy.” This recommendation

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 23: Fuut and Ankle Rehabilitation

was further suppurted in ether literature reviews.“hm Cine study nut included in these reviews fuund eccen-

individuals between 2 weeks and 96 munths after initial

strengthening in reducing pain and impruving functiun in individuals with Achilles tendinupathy.“ Additiunally,

either chrunic mechanical ur functiunal ankle instability.

tric strengthening was mure effective than cuncentric

injury.“ Individuals with lung-term symptums fulluwing

lateral ankle sprain are cummunly characterised as having

a 5—year fulluw—up study nuted that althuugh lung-term

The treatment uf acute lateral ankle sprain and chrunic ankle instability is summarised in Tables 3 and 4, respec-

may persist.3L1

weight hea ring with suppurt, and exercise fur thuse with

impruvement in symptums can be expected, mild pain

tively. Strung evidence has been fuund fur manual therapy, an acute lateral ankle injury. Muderate and weak evidence were identified for manual therapy and exercise, respec—

The incidence uf ankle sprain was fuund tu be highest in yuung, active individuals, especially these whu par-

ticipate in cuurt spurts such as basketball.” The fulluw—

ing risk facturs have been identified fur an acute lateral ankle sprain: previuus ankle sprain; nut using external

tively, fur thuse with chrunic ankle instability.

Manual Therapy

Clinicians shuuld use manual therapy prucedures such

as lymphatic drainage, active and passive suft-tissue and

suppurt; nut pruperly warming up with static stretching

and dynamic muvement before activity; abnurmal ankle dursifleniun range uf mutiun; and nut participating in

ueseaiiqsuae :1:-

Ankle Sprain

balance and prupriuceptive preventiun prugrams after a

lateral ligament injury. Clinicians shuuld use the clinical

findings uf decreased functiun, ligamentuus laxity, hemurrhage, puint tenderness, tutal ankle mutiun, swelling,

and pain tu classify a patient with acute ankle ligament

sprain. Tests tu assess lateral ligament stability have nut

shuwn desirable diagnustic accuracy when perfurmed in isulatiun. Additiunal research has shuwn medial ankle

juint pain with palpatiun and dursiflesciun at 4 weeks

as the must valuable prugnustic indicaturs uf functiun 4 munths after injury.” Recurrent lateral ankle sprains are

Figure 3

nut uncumrnun, with reinjury uccurring in 3% tu 34% uf

Phutugraphs shuvvs an Achilles “eff-leading“

taping technique used tu limit painful dursifleaiun range uf mutiun.

_—n_-. Summary uf Evidence in the Treatment uf Acute Lateral Ankle Sprain Strung Evidence Treatment

Interventlen

Exercise

Structured rehabilitatiun prugrain including prugressive active range uf mutiun and resistance exercises incurpurating weight bearing 1inlith suppurt

Physical agents

Cyrutherapy Moderate Evidence

Treatment

lnterventien

Manual therapy

Anteriur—tu—pusteriur talar mubilizatiun, lymphatic drainage. active and passive soft-tissue and juint mubilizatiun prucedures Weak Evidence

Treatment

Intervention

Physical agents

Diathermy

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

IE! Eillii American Academy uf Clrthupaedic Surgeuns

Drthupaedic Knuwledge Update: Spurts Medicine 5

®

Section 4: Rehabilitation

-— Summary of Evidence in the Treatment of Chronic Ankle Instability Strong Evidence Treatment

Intervention

Manual therapy

Non-weight-bearing and weight-bearing joint mobilization Weak Evidence

‘I'reatlnent

Intervention

Exercise

Weight'bearing functionalisports-related exercises and single-limb balance

activities using unstable surfaces

{Data from Martln FlL, Davenport TE. Paulseth 5. Wultlrh tilt, Goclges JJ, Eirthopaecllc Sectlon American Physical Therapy Associatlon: Ankle

stability and movement coordination impairments: Ankle ligament sprains- J firthop Sports Phys Ther 2i]lEl;£lEl[9]:A1-A4u- httpfldxdoi.

orgfluj 519ijospt.2l}13.fl3l15.}

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

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pain-free ankle and foot mobility, and normalise gait parameters in individuals with acute lateral ankle sprain.” According to a level II study, a single session of manual

therapy in the emergency department was associated with

decreased edema and pain in individuals presenting with acute ankle sprain.“ Soft—tissue mobilisation, joint mobi— lization, isometric mobilisation, contractl'relax, positional release, and lymphatic drainage procedures directed

toward identified impairments are examples of manual therapy. A separate level II study found individuals with

acute ankle sprains who received pain-free posterior ta-

lar joint mobilisations had better outcomes, achieving full range of motion and symmetric step length within the first two to three treatments.” The use of manual therapy was further supported by a recent systematic review.35 Recent evidence also exists that the addition of myofascial therapy to thrust and nonthrust manipulation

and exercise can further improve outcomes in those with acute lateral ankle sprain.“ In individuals with nonacute lateral ankle inju—

ries, clinicians should include nonweight-bearing and weight-bearing joint mobilisation to improve ankle dorsiflexion range of motion, proprioception, and weight—bear— ing tolerance.” A weight-bearing joint mobilisation that

.___-'-I. r

Figure 4

Photograph shows implementation of a weight-bearing joint mobilization technique-to improve ankle dorsiflexion range of motion.

Taping Clinicians should strongly encourage use of external

support and progressive weight bearing on the affected

extremity in patients with acute lateral ankle sprain. The

in Figure 4. In addition, a systematic review concluded that manual therapy techniques improve ankle range of

type of external support {which can include tape} and gait-assistance device recommended should be based on the severity of the injury, phase of tissue healing, level of protection indicated, extent of pain, and patient prefer— ence. In patients with more severe injuries, immobilization

with signs and symptoms consistent with a subacute:Ir chronic lateral ankle sprain.“ A study not included in

may be indicated.15 The authors of a systematic review” found that using a semirigid ankle support rather than

associated with improved measures of function for at least 1 week in individuals with chronic ankle instability?“El

return to work and sports, as well as decreased reports

can he used to improve ankle dorsiflexion is demonstrated

motion, decrease pain, and improve function for those that review found that posterior talar mobilisations were

ranging from semirigid bracing to casting below the knee

an elastic wrap was associated with substantially shorter

of instability. External support from tape was most frequently associated with complications, such as skin it—

ritation. Although some studies have noted a positive

383

firthopaedic Knowledge Update: Sports Medicine 5

fl lfllfi American Academy of Orthopaedic Surgeons

Chapter 23: Foot and Ankle Rehabilitation

effect of taping and bracing on proprioception, a recent meta-analysis noted the use of an ankle brace or tape had no overall effect on proprioceptive acuity in those

with recurrent ankle sprain or functional ankle instabil-

ity.” Conflicting evidence exists that fibular reposition taping“=‘” and therapeutic elastic tape43*“ can improve

postural control and proprioception.

Exercise Clinicians should implement a rehabilitation program

Hay Study Points

l The potential effectiveness of manual therapy pro-

cedures, taping techniques, and exercise in foot and

ankle rehabilitation is described according to the current literature. I There is specific evidence to support the use of manual therapy, taping, and exercise for individuals with heel painfplantar fasciitis, Achilles tendinopathy, and lateral ankle sprain.

lateral ankle sprain, along with active range of motion and progressive resistance exercises for the ankle and foot. A study that supports this recommendation found

finnneflxflxxilhefiensnces

conventional medical treatment compared with those

1. Bialosky JE, Bishop MI}, Price DD, Robinson ME, George 52: The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Mar: Thar 2009;14{5}:531-533. Medline DO]

weight—bearing sport-specific exercises and single—limb

The authors present a model of potential mechanisms for manual therapy.

functional improvement in individuals with a severe ankle sprain who underwent physical therapy intervention and who underwent conventional medical treatment alone.” For chronic ankle instability, clinicians should include balance activities using unstable surfaces to improve mo-

bility, strength, coordination, and postural control. This

recommendation is supported by a systematic review that concludes functional exercises and activities, especially using unstable surfaces, promote improvement in dynamic

postural control.“

1. Erantingbam JW, Bonnefin D, Perle SM, et al: Manipulative therapy for lower extremity conditions: Update of a literature review. I Manipxlatise Physiol Thar 2fl11;35{2]:11?-166.Medline DUI

This systematic review outlines the evidence for manipulative therapy in the management of various lower extremity conditions, including plantar fasciitis. Lewl of evidence: II.

Summary

Foot and ankle rehabilitation programs can include

manual therapy, taping, and exercise. Manual therapy

procedures can have biomechanical, neurophysiologic, and psychologic effects. Taping techniques are typically used to reinforce normal protective support structures, improve proprioception, enhance neuromuscular activation, andfor alter biomechanies: exercise typically is directed toward improving range of motion, recruitment

pattern, strength, andfor endurance. Eccentric exercise

can also be used to promote tendon remodeling. Strong

evidence supports manual therapy used in individuals with plantar fasciitis and chronic ankle instability, mod-

erate evidence in those with acute lateral ankle sprain, and

weak evidence in those with Achilles tendinopathy. Strong evidence exists for taping in those with plantar fasciitis and expert opinion in those with Achilles tendinopathy.

Strong evidence exists for using exercise in those with plantar fasciitis, Achilles tendinopathy, and acute lateral ankle sprain but weak evidence for those with chronic

ankle instability.

IE! lfllfi American Academy of flrthopaedic Surgeons

3. Franettovich M, Chapman A, Blanch P, Vicenzino B: A physiological and psychological basis for anti-pronation taping from a critical review of the literature. Sports Med 20D3533l3}:61?—631.Medline DUI 4. Viceneino E: Foot orthotics in the treatment of lower limb

conditions: A musculoskeletal physiotherapy perspective. Mar: The? lflfl4;9{4}:135-195. Medline

DUI

5. Root M, Drien WP, Weed JH: Normal Arid Abnormal Farr-scrim: ofthe Foot: Ch'rsicnf Biomechnrrr'cs. Los Angeles, CA, Clincial Eiomechanics, IQTT, vol 1. 6. Cornwall MW, McPoil TG: Motion of the calcaneus,

navicular, and first metatarsal during the stance phase of walking. I Am Fodiarr Med Assoc Zflfllflllllfiifi.

Medline DUI

3’. McPoil T, Eornwall MW: Relationship between neutral subtalar joint position and pattern of rearfoot motion during walking. Foot Ankle Int 1994;15l3}:141-145. Mcdline D0]

3. McPoil TG, Cornwall MW: Relationship between three

static angles of the rearfoot and the pattern of rearfoot motion during walking. I Drtbop Sports Phys Ther 1996;23{E}:3?0-3?5.Medline DUI

Drthopaedic Knowledge Update: Sports lvledichie 5

uvsvauqvuvs:s

that includes therapeutic exercises for patients with acute

Seefien 4: Rehabilillutiun

Meier K, McPeii TG, IClernwall MW, Lyle T: Use ef antiprenatien taping te determine feet ertheses prescriptien: A case series. Res Sperts Med 2fl03:16{4):25?-1T1. Medline DUI It}. Seuza TR, Pinte RZ, Trede HG, Kirkweed RN, Fenseca 5T: Temperal ceupiings between rea rfeet-shank cemplex and hip jaint during walking. Chi: Emma-ch {Bristeh Avert) 2D1fl:25[?}:?45-T43. Medline DUI The study feund evidence te suppert a tempera] ceupling ef rearfeet prenatien with hip internal retatien and rearfeet supinatien with hip external retatien during walking. Level ef evidence: IV.

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11. Kulig K, Pepevich JM Jr, Neceti-Dewit LM, Reischl SF, Kim D: Wemen with pesterier tibial tenden dys-

functien have diminished ankle and hip muscle perfermance. ] firthep Sperts Phys Ther 2D11:41{9}:6E?-694. Medline DUI

The anthers feund wemen with pesterier tibial tenden dysfunctien had decreased ankle and hip muscle perfer—

mance. Level ef evidence: III.

12. Alfredsen H, Pietilii T,]enssen P, Latentzen R: Heavy-lead eccentric calf muscle training fer the treatment ef chronic Achilles tendinesis. Arr: I Sperts Med 1993;16{3}:360-366. Medline

13. McCreesh KM, Riley 5], Cretty JM: Heevascularity in

patellar tendinepathy and the respense te eccentric train-

ing: A case repert using Pewer Deppler ultraseund. Mar: Thar ED13;13{E}:Efl2-6fl5. Medline DUI

The anthers summarise the evidence related tn the diagnesis, examinatien, and interventien fer these with acute and chrenic lateral ankle injuries. 1?. Cleland ]A, AbhettJH, Kidd MU, et al: Manual physical therapy and exercise versus electrephysical agents and exercise in the management ef plantar heel pain: A multi' center randemized clinical trial. I Drthep Sparta Phys Thar 20fl9;39[3}:5?3-535. Medline Dfll This study feund patients whe underwent exercise and manual therapy had better functien and glebal self-re— perted eutcemes at beth 4 weeks and E menths when cempared with patients in the greup treated with exercise and ientepheresis. Level ef evidence: I. 13. Renan-Urdine R, Alhurquerque-Sendin F, de Seuza DP,

Cleland JA, Fernandez-de-Las-Pefias C: Effectiveness ef

myefascial trigger paint manual therapy cembined with a self-stretching pretecel fer the management ef plantar heel pain: A randemiaed centrelled trial. I Urthep Sperts Phys Ther 2e11:41{s}:43—sn. Medline DUI The authers feund patients whe underwent the additien ef seft-tissue mebiiieatien techniques directed at gastrecnemius and seleus myefascial trigger peints had better pain reductien at 4 weeks when cempared with patients whe underwent self-stretching enly. Leml ef evidence: I.

19. van de Water AT, Speksniider CM: Efficacy ef taping fer the treatment ef plantar fascia-sis: A systematic review ef centrelled trials. I An: Pediatr Med Asset EDI Deli] Miller-ll51. Medline DDI

The authers reviewed centrelled trials and feund limited evidence indicating the effectiveness ef taping ta reduce pain in patients with plantar fasciesis.

This case repert describes cemplete reselutien ef abnermal neevascularity, using ultraseund imaging, after 3 weeks ef eccentric exercise in a subject with chrenic patellar tendinepathy. Leml ef evidence: IV.

2f]. Landerf KB, Men: HE: Plantar heel pain and fasciitis.

14. Martin RL, Davenpert TE, Reischl SF, et al: Heel pain-plantar fasciitis: Revisien 1014. j Urtfrep Sperss

31. Tsai CT, Chang TD, Lee JP: Effects ef shert-term treat-

Phys TIE-er lfl14:44{11}:A1-A33. Medline

DUI

The anthers summarize the evidence related re the diagnesis, examinatien, and interventien fer these with heel painfpla ntar fasciitis.

15. Garcia CR, Martin RL, Heuck J, Wukich DE: Drthepaedic Sectien ef the American Physical Therapy Asseciatien:

Achilles pain, stiffness, and muscle pewer deficits: Achilles tendinitis. I Drrhap Sperts Phys Ther lfllfl:4fl{9]:A1-A26. Medline DUI

The anthers summarize the evidence related te the diagnesis, examinatien, and interventien fer these with

Achilles tendinepathy.

16. Martin EL, Davenpert TE, Paulseth S, 1|iiiin’ukich DK, Gedg-

es 1L flrthepaedic Sectien American Physical Therapy

Asseciatien: Ankle stability and mevement ceerdinatien impairments: Ankle ligament sprains. J Urtfrep Spur-ts Phys Ther 2013;43i9}:A1—A4fl. Medline DUI

BM] Cffr: Enid 1003:2flflflfllll. Mediine

ment with kinesietaping fer plantar fasciitis. I Muscufeskeiet Petr: 2U1fl:13:T1-3fl. DUI

This study feund therapeutic elastic tape applied te the gastrecnemius and plantar fascia impreved pain sceres and reduced plantar fascia thickness when cempared

with ultraseu nd and electretherapy treatments at 1-week

fellew'up in patients with plantar fasciitis. Level ef evidence: I. 22. Abd E1 Salam MS, Abd Elhafr TN: Mw-dye taping versus medial arch suppert in managing pain and pain-related

disability in patients with plantar fasciitis. Feet Article

Spec 2fl11:4{2]l:EE-91. Medline

These anthers femd that antiprenatien taping reduced pain and impreved functien ever a 3-week peried in pa-

tients with plantar fasciitis. Level ef evidence: II.

23. Sweeting D, Parish E, Heeper L, Chester R: The effective-

ness ef manual stretching in the treatment ef plantar heel pain: A systematic review. I Feet Article Res 2011:4:19. Medline

@

firthapaedic Knewledge Update: Sperts Medicine 5

DUI

DUI

fl lfllfi American Academy ef Cirrhepaedic Surge-ens

Chapter 23: Feet and Ankle Rehabilitatien

benefits ef stretching appear te eccur within the first 2 weeks te 4 menths after the initiatien ef treatment. [cvel ef evidence: I.

24. Rempe JD, ICacchie A, Weil L Jr, et al: Plantar fascia-

specific stretching versus radial sheck—wave therapy as

initial treatment ef plantar fasciepathy. ] Benefefnt Surg

Am 2fl10;92{15]:2514-3522. Medline DUI

The authers cencluded that manual stretching is mere ef-

fective than sbeck-wave therapy in the treatment ef plantar fasciepathy. Level ef evidence: I.

2.5. Scett RT, Hyer CF, Granata A: The cerrelatien ef Achilles tendinepathy and bedy mass index. Feet Ankle Spec 2013;6[4k233-235.Medline DUI Statistical analysis was perfermed te demrmine the cerrelatien between bedy mass index and Achilles tenden

pathelegy. Patients with Achilles tenden pathelegy had

a greater bedy mass index than these witheut. Lewl ef evidence: II. 25. Rewe V, Hemmings 5, Barren C, Malliaras P, Maffulli N, Merrissey D: Censervative management ef midpettien

Achilles tendinepathy: A mixed metheds study, integrat-

ing systematic review and clinical reasening. Sperts Med 2012;42{11]:941-961Medline DUI This systematic review feund case-study evidence te sup-

pert the use ef seft—tissue mebilixatien fer these with Achilles tendinepathy. Level ef evidence: IV.

The authers feund eccentric strengthening te be mere

effective than cencentric strengthening in reducing pain

and impreving functien in patients with Achilles tendinepathy. Level ef evidence: I. 32.. van der Plas A, de Jenge 5, de Ves RJ, et al: A 5-year fel-

lew—up study ef Alfredsen’s heel-drep exercise pregramrne in chrenic midpertien Achilles tendinepathy. Br J Sperts Med 2fl12;4fi{3]:214-213. Medline DUI

This study feund a significant increase in VISA-A sceres at 5 years fellewing an interventien that included an eccentric

exercise. The authers neted that although imprevement ef symptems can be expected with eccentric exercises, mild pain may remain leng term. Level ef evidence: I.

33. U’Cenner 5R, Eleakley CM, Tully MA, ivIcDeneugh 5M: Predicting functienal recevery after acute ankle sprain. PLeS Une 2013;3(3}:e?2114. Mcdline DUI The authers feund clinical assessment variables at 4 weeks

were the strengest predicters ef recevery, explaining 50% cf the variance in anltle functien at 4 menths.

34. Eisenhart AW, Gaeta T], 1i’ens DP: Usteepathic manipulative treatment in the emergency department fer pa-

tients with acute ankle iniuries. J Ann Usteepatf: Asses IUD3;1G3[9}:41T~421. Medline

35. Green T, Refshauge K, Cresbie J, Adams It: A randemired centrelled trial ef a passive accessery jeint mebilisatien en acute ankle inversien sprains. Phys Tia-er lflfl1;31(4}:9 34-994. Mcdlinc

1?. Christensen RE: Effectiveness ef specific seft tissue mebilixatiens fer the management ef Achilles tendinesis: Single case study—experimental design. Men Tiler

36. Leuden JK, Reiman MP, Sylvain J: The efficacy ef man-

23. Smith M, Breeker S, Vicenzine E, McPeil T: Use ef

This systematic review feund manual jeint mebiliaatien

scriptien: Ease repert. Aster} Pbysietber lflfidfiflfliflli-

tien in these with acute ankle sprains and impreved ankle range ef metien, decreased pain, and impreved functien in these with subacutei'chrenic lateral ankle sprains. Level ef evidence: I.

researches—sienna: eel

anti-prenatien taping te assess suitability ef erthetic pre— 113. Medline

DUI

29. Martin RL, Paulseth S, Garcia CR: Taping techniques fer achilles tendinepathy. Urtfiepaedfc Physicaf Therapy Practice. lflfl9;2fl:lflfi-1DT.

This clinical cemmentary describes twe taping techniques

that can be used te decrease pain fer patients with Achilles tendinepathy. Level ef evidence: V.

3f}. Sussmilch-Leitch 5P, Cellins N], Bialecerkewski AE, Warden SJ, |Cressley KM: Physical therapies fer Achilles tendinepathy: Systematic review and meta-analysis. J Feet Ankle Res lfllltiilidfi. Medline

DUI

The findings ef this systematic review snpperted the use ef eccentric exercise as an initial interventien fer patients with Achilles tendinepathy. Level ef evidence: I. 31. Yu J, Park D, Lee G: Effect ef eccentric strengthening en pain, muscle strength, endurance, and functienal fitness facters in male patients with achilles tendinepathy. Am J Phys Med Refrabfl 2013;92flkfifi-Tfi. Medline DUI

IE! lfllfi American Academy ef Urthepaedic Snrgeens

ual jeint mebilisatienfmanipulatien in treatment ef lat-

eral ankle sprains: A systematic review. Br I Sperrs Med 2fl14;43(5}:355-3?fl.Medline DUI

diminished pain and increased dersiflexien range ef me-

3?. Truyels-Demi nes 5, fialem—l'vlerene J, Abian-Vicen J, Clela nd JA, Ferndnder-de-Las—Pefias {3: Efficacy ef thrust and nenthrust manipulatien and exercise with er witheut the additien ef myefascial therapy fer the management

ef acute inversien ankle sprain: A randemixed clinical

trial. J Urrhep Sperts Phys The-r 2fl13:43{5}:3flD-3fl9. Medline DUI

These authers feund the additien ef myefascial therapy

te thrust and nenthrust manipulatien and exercise can

further impreve eutcemes in these with acute lateral ankle sprain. Level ef evidence: I. 3E. Hech IvIC, Andreatta RD, Mullineaux DR, et al: Tweweek jeint mebilisatien interventien impreves self-

reperted functien, range ef metien, and dynamic balance

in these with chrenic ankle instability. J Urrbep Res 2fl12:3fl{11}:1?f-'B-1304.Medline DUI

Urthepeedic Knewledge Update: Sperrs Medicine 5

UGIJEi-HHELIEH :1:-

This systematic review cencluded the main pain-relieving

Sectiun 4: Rehabilitatiuu

This study feund pesterier talar mebilizatiens were asseciated with impruved measures ef functien fur at least 1 week in individuals with chrenic ankle instability. Level uf evidence: II. 39. Kerkheffs GM, Rewe EH, Assendelft W], Kelly ED, Struijs PA, van Dijk (IN: Intntebilisatien fer acute ankle sprain. A systematic review. Arch flatbep Trauma San-g 2fl01;111{3}:462-4?1.Medline DUI

cemparing fibular taping te sham taping in patients with chrenic ankle instability. Level ef evidence: III. 43. Simen J, Garcia W, Decherry EL: The effect ef kinesiu tape en furce sense in peuple with fu nctiunal ankle instability. Gift: I Spur-t Med 2fl14;24{4]:239-294. Medline DUI

This study neted that in patients with functienal ankle

instability, prupriuceptive deficits were net impreved immediately after applicatieu uf kinesiu tape, bewever, but did impruve after wearing the tape fur T2 huurs. Level

4|]. Raymund J, Nichelsen LL, Hiller CE, Refshauge KM:

ef evidence: III.

The effect ef ankle taping er bracing en prepriuceptiun

in functienal ankle instability: A systematic review and meta-analysis. j Sci Med Spurs 2fl12:15{5 1:336-392. Medline DUI

:: .E 4.!

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The authurs wanted te determine if wearing an ankle

brace er taping the ankle, cempared with ac brace er

tape, impreves prupriuceptive acuity in individuals with a histury uf ankle sprain er functienal ankle instability. The peeled evidence fuund that using an ankle brace ur ankle tape had ne effect en preprieceptive acuity in participants with recurrent ankle sprain er whu have functienal ankle instability. 4]. fiemeeh M, Nurasteb AA, Daneshmandi H, Asadi 11: Im-

mediate effects uf Mulligan’s fibular repesitiening taping en pestural centrel in athletes with and witheut chrenic ankle instability. Plays The:- Spert 1fl15:16{2}:135-139. Medline DUI

This study feu ad that fibular repusitiuning taping signifi-

cantly impreved pestural centrel in athletes with chrenic

ankle instability. Lavel ef evidence: III.

41. 1ilii'heeler T], Basnett CR, Hanish M], et a1: Fibular tap— ing dees net influence ankle dersifleitien range ef Inetien er balance measures in individuals with chrenic

ankle instability. } Sci. Med Spent lfl]3;16{fi}:433-491. Medline BID]

The anthers did net find a significant change in ankle dursiflestien range ef mutiun er dynamic balance when

firthepaedic Knewledge Update: fiperts Medicine 5

44.

Shields CA, Needle All, Rese WC, fiwanik CE, Kaminski TW: Effect ef elastic taping en pestural centrel deficits in subiects with healthy ankles, cepers, and individuals with functienal ankle instability. Puut Ankle Int

1013:34ilfl}:142?-1435.Medline net

The results uf this study did net suppurt the use ef kinesiu tape fer impreving pestural centrel deficits in these with ankle instability. Level uf evidence: III. 45. van Rijn RM, van Heest 1a, van der Wees P, Kees 3W, Bierma-Zeinstra SM: fieme benefit frem physiutherapy

interventien in the subgreup ef patients with severe an—

kle sprain as determined by the ankle functien scere: A tandumised trial. dust] Pbysfutfser 2i] fl9;55(1]:IUT-113. Medline

DUI

The anthers feund fu nctiunal imprevement in individuals with a severe ankle sprain whu underwent physical therapy interventien and ceuveutienal medical treatment cumpared with these whu underwent ceuventieual medical treatment alene. Level ef evidence: I.

46. Webster Kilt, Gribble PA: Functiunal rehabilitatien interventiens fer chrenic ankle instability: Pi systematic review. I Spent Rehahif lfllfl:19{1}:98-114. Medline This systematic review cuncluded that functienal exercises and activities prumete imprevement in dynamic pestural centrel fer these with chrenic ankle instability. Level ef

evidence: II.

fl lflld American Academy ef Cirrhepaedic Surge-ens

Chapter 29

Core Stabilization Rafael F. Escamilla, PhD, PT, CSCS, FACSM

culature, which is commonly referred to as the core,

enhance core stability, and biomechanical differences between abdominal hollowing and bracing exercises, trunk

are described in the literature. The orthopaedic sur—

other health care or fimess specialists who develop specific

Muscle recruitment patterns of lumbopelvic-hip mus-

and loading of the lumbar spine during core exercises common used during core strengthening programs

geon should be knowledgeable about why the core is important, what muscles comprise the core and which

ones contribute the most to core stability, the benefits and risks of core stabilization exercises, biomechanical

differences berween abdominal bellowing {drawing-in maneuver} and abdominal bracing techniques, traditiona] and nontraditional exercises used for core stability,

flex ion and extension exercises, and crunch and bent-knee sit-up exercises are important concepts to therapists and

core exercises for rehabilitation or training. Why is the Core Important?

In functional and athletic events, the core provides proximal stability for distal mobility.' Trunk musculature

biomechanica] differences between abdominal exercises

helps sta bilise the core by compressing and stiffening the spine, which is important because the osteoligamentous

crunch and the bent—knee sit-up, and abdominal and

9t} N {approximately 20 lb}.I Core muscles act as guy wires around the human spine to prevent spinal buckling.

that cause active hip or trunk flexion or control hip or trunk extension, biomochanical differences between the oblique recruitment between the crunch and reverse

crunch.

Keywords: stability: abdominal hollowing; abdominal bracing; electromyography; EMG; low back pain Introduction

It is important for the orthopaedic surgeon to understand

muscle recruitment patterns of lumbopelvic-hip muscula—

ture {commonly referred to as the core} and loading of the lumbar spine during core exercises commonly used during

core strengthening programs. In addition, the importance of the core, which core muscles are most important for

core stability, the benefits and risks of traditional and

nontraditional core stabilisation exercises, lumbar spinal Neither Dr. Escamiiia nor any immediate famiiy member has received anything of value from or has stock or stock options heid in a commerciai company orinstitution reiateo' directiy or indirectiy to the subject of this chapter.

fl lflld American Academy of Drthopaedic Surgeons

lumbar spine buckles under compressive loads of only

In addition, intra-abdominal pressure increases as core

muscles contractfi1 which further increases spinal stiffness and enhances core stability.‘ll Core Muscles and Stability

Considerable debate exists regarding which core muscles

are the most important in optimizing core stability {spinal

stabilization]. Some studies suggest that the transversus abdominis and multifidi muscles are key to enhancing spi-

nal stability,-"~5 but others have questioned the importance

of these muscles as major spine stabilizerssid Therefore,

the effectiveness of the tra nsversus abdominis and multifidi on lumbar stability is not clear. Isolated contractions from the transversus abdominis have not been demonstrated during functional higher demand activities that require all abdominal muscles to become active.“ In healthy individuals without lumbar pathology, the

transversus abdominis contracts before upper extremity motion irrespective of the direction of the motion.” However, a 2012 study reported that transversus abdominis

activation is direction-specific and that symmetric, bilateral preactivation of the transversus abdominis does

not normally occur in healthy individuals without lum-

bar pathology during rapid, unilateral arm movements}

Drthopaedic Knowledge Update: Sports Medicine 5

uvsvuusvuva :1:-

loading and injury risk during exercises commonly used to

Section 4: Rehabilitation

This is important because bilaterally, preactivation of the transversus abdominis theoretically provides lumbar spine

lifting, can result in injury to the lumbar spine."-“ The literature is scarce regarding the effectiveness of

contrast, tta nsversus abdominis activation is substantially

more research is needed.” Although lumbar stabilisation exercise programs have been effective in treating individ-

stability in anticipation of perturbations of posture? In

delayed in patients with low back pain with all movements, indicating a motor control deficit that can result in

inefficient muscular stabilization of the spine. However,

select low-intensity exercises such as abdominal hollowing

{drawing in} have been shown to preferentially activate the transversus abdominis in patients with chronic low back pain during exercise."J Moreover, evidence exists

that the deep abdominal muscles {transversus abdominis and internal oblique muscles} can be preferentially trained i: .E 4.!

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in individuals with chronic low back pain using targeted

exercises such as abdominal hollowing." To optimize core stabilization, numerous muscles, in-

lumbar stabilization exercises on lumbar pathology, and uals with chronic low back pain,m these programs have

not conclusively demonstrated that lumbar stabilisation programs are more effective in treating individuals with chronic low back pain compared with a generalized, less-specific exercise program.”r Biomechanical Differences Between Abdominal

Hollowinq and Bracing

Abdominal hollowing is often performed supine with the hips flexed 45° and the lcnees flexed 9i)“ {hook lying

cluding smaller, deeper core muscles {such as the trans— versospinales, transversus abdominis, internal oblique,

position]; individuals are instructed to take a deep breath

muscles (such as the erector spinae, external oblique, and rectus abdominis}, must be activated in sequence, with appropriate timing and tension} A 2002 study reported

to globally activate all abdominal and low baclc muscles

contribution of each core muscle to lumbar spine stability

dominis and internal oblique muscles} and lumbar [mul-

and quadratus lumboruml and larger superficial core

that no single core muscle can be identified as the most important for lumbar spine stability, that the relative

and exhale while pulling their navels up and in toward the

Spine}1 In abdominal bracing, individuals are instructed

by teasing all core musculature, without drawing in or

pushing out the abdominal cavityfi“

Abdominal hollowing is effective in the preferential recruitment of the deeper abdominal {transversus ab-

depends on trunk loading direction {spinal instability was greatest during trunk flexion} and magnitude, and that

tifidi} musclesf‘bbifI A lflflfi study“ demonstrated that the transversus abdominis and internal oblique contract

spine stability.“1 Therefore, lumbar sta biliaation exercises may be most effective when they involve the entire spinal

to tighten during abdominal hollowing, enhancing lum~ bar spine stability and decreasing the risk of injury to

no single muscle contributed more than 30% to overall

musculature and its motor control under various loading

conditions of the spine.”

Benefits and Risks of Core Stabilization Exercises

Core strengthening of the lumbopelvic region can de-

bilaterally to form a musculofascial corset that appears

the lumbar spine. Transversus abdominis and internal

oblique activity is thought to enhance lumbar stability by increasing intra-abdominal pressure3 and placing tension

on the thoracolumbar fascia, but the multifidi provides

additional spinal stability by directly controlling lumbar

intersegmental movement.f~“ Moreover, contraction of

hancing spinal stability” and has been shown to decrease

the transversus abdominis has been shown to substan— tially decrease sacroiliac joint laxity to a greater extent

performance;“‘ however, no strong relationship exists between core stability and performance and the results

ingri-5 These data provide some evidence that abdominal hollowing can enhance spinal stability and be beneficial

spinal stability, whereas excessive spinal loading can increase the risk of injury to the lumbar spine.” Therefore,

Using biomechanical models, abdominal hollowing has been compared with abdominal bracing with respect

crease the risk of injury to the thoracolumbar spine by en—

the risk of injury to lower extremities and to enhance

are inconclusive”:If Appropriate spinal loading enhances

in abdominal hollowing compared with abdominal bracfor individuals with select lumbar pathologies.

adequate spinal loading is required to maximise core

to spinal stability and muscle activityFrfL” A 2i] 0? study

during the deadlift exercise has resulted in estimated lum— bar compression forces between 13,1300 to 36,l}fli} NEW

reporting that abdominal bracing improved lumbar spine

stability; excessive loading can cause injury to the lum— bar spine. For example, lifting extremely heavy weights

reported that abdominal hollowing was not as effective as abdominal bracing for increasing lumbar spine stability,

These extremely high lumbar compression forces, which

stability by 32% with only a 15% increase in lumbar spine compression [higher benefit of lumbar stability with

the high muscle forces that are generated during heavy

versus abdominis alone had little effect on lumbar spine

result from both the heavy external load being lifted and

firthupaedic Knowledge Update: Sports Medicine 5

decreased risk of lumbar injury}.H Moreover, the trans—

fl lflld American Academy of Orthopaedic Surgeons

Chapter 15': Core Stabilization

and intra-abdominal pressure are combined with the ef-

fects of the transversus abdominis, core stability improved

as more core muscles were activated, which occurs during

abdominal bracing. The authors of a 20D? study investigated the effec—

tiveness of abdominal bollowing and bracing techniques in controlling spinal mobility and stability against rapid perturbations and reported that abdominal bracing per— formed better.” During rapid perturbations, abdominal

The highest recruitment of the transversus abdominis and internal oblique muscles occurred during the side plank.

High activity from several important core muscles {the quadratus lumborum, internal oblique, external oblique} was reported during the side plank {resulting in enhanced spinal stability} with moderate spinal compressive load-

ing?” A EGGS study reported high recruitment of the

transversus abdominis and internal oblique muscles and

low compressive spinal loading during the crunch performed after abdominal bollowing,1| which is similar to

bracing actively stabilised the spine and reduced lumbar

the results of a 199? study.” Performing the quadruped

can be inferred that abdominal bracing is more effec—

with minimal recruitment of the internal oblique muscle,

spine displacement, whereas abdominal bollowing was not effective in spinal stabilization. Using these data, it

tive during functional activities such as lifting, iumping, pushing, and pressing activities in sports or activities of daily living. However, core muscle co-contraction during

opposite arm—and—leg lift after abdominal bollowing preferentially recruited the transversus abdominis muscle which provides evidence for its use in the early phases of motor control exercise programs that emphasize the

firing of the transversus abdominis without concomitant

abdominal bracing substantially increases lumbar compression loads compared with abdominal bollowing,

high recruitment from other abdominal muscles.“ Performing abdominal bollowing before abdominal exercises

and pathology. External oblique and rectus abdominis

spinal stability. The effects of prone hip extension exercises on hip and back muscle activity and anterior pelvic tilt performed with and without abdominal bollowing were investigat-

which can be problematic in those with lumbar pain activity was substantiallyr greater in abdominal brac-

ing than abdominal bollowing. Moreover, abdominal bollowing demonstrated a higher spinal compression loading—to—spine stability {cost-benefit] ratio, which im-

plies that bollowing resulted in higher spinal compression loads {increased injury risk] with less spinal stability.

During abdominal bollowing, individuals were not able

is beneficial to improving core muscle recruitment and

ed.1T Hip extension performed with abdominal bollowing

resulted in significantly less erector spinae activity l1?%

i 11% versus 49 i 14% maximum voluntary isometric contraction [MVICD and significantly greater activity

to activate the deep abdominal muscles in isolation, but always included substantial activity from both the exter-

in the gluteus maximus {52% = 15% versus 24% s: 3% MVIC} and medial hamstring (53% i 10% versus 4'?%

The effect of abdominal stabilisation contractions during abdominal bollowing and bracing on posteroan-

significantly greater without abdominal bollowing {lfl‘ :l: 1“) than with bollowing [3" 2 1"}. Performing abdominal bollowing with hip extension can be an effective strategy when the goal is to minimize anterior pelvic tilt, lumbar

nal and internal oblique muscles.”1

terior spinal stiffness was investigated in a 20GB study;

it was reported that stiffness was substantially greater in abdominal bracing:115 More work is needed to assess the long—term effects of abdominal bollowing and bracing on

posteroanterior spinal stiffness in individuals with lumbar pain and pathologies.

Abdominal hollowing or bracing techniques have been performed immediately before core-strengthening exer-

cisesFL‘i-‘fl Compared with the curl-up {crunch} without

abdominal bollowing or bracing, the curl-up with abdominal bollowing or bracing resulted in the deep abdominal muscles {the transversus abdominis and internal oblique}

being recruited earlier than the superficial abdominal

muscles {the rectus abdominis and external oblique}.13 Using ultrasonography, deep abdominal recruitment

e 14% MVIC} muscles. Moreover, anterior pelvic tilt was

motion, and erector spinae activity, and to maximise hip

extensor activity.

Traditional and Nontraditional Exercises for |IEore

stability

Traditional and nontraditional exercises [Figures '1 through E] are used to enhance core stability. Although these exercises are primarily used to strengthen the abdominal musculature, they also recruit additional core

muscles such as the latissimus dorsi and lumbar paraspiual muscles.

The abdominal musculature helps stabilise the trunk

patterns were examined during numerous abdominal exercises (crunch, sit-hack, leg lowering, side plank} and

and unload the lumbar spine,” and is commonly activated by concentric muscle action during trunk flexion such

lift} performed immediately after abdominal bollowing.“

{Figure 2, B}. During the crunch, the hips remain at a

low back exercises [quadruped opposite arm—and—leg

IE! lfllfi American Academy of flrrhopaedic Surgeons

as during the bent—knee sit-up {Figure 2, A} or crunch

Drtbopaedie Knowledge Update: Sports .lvlediebie 5

usssauqeuas :1:-

stability. However, when the effects of internal oblique

Section. 4: Rehabilitation

{EMGJ to report core muscle activity during these and similar exercisesfg'31 Cine study examined core muscle

activity among the crunch, bent-knee sit—up, prone plank on toes, and side plank on toes” {Table 1}. Several important differences were found: {1) upper rectus abdominis activity was greater in the crunch than in both the prone

and side planks on toes, and greater in the bent-knee

sit-up than in the side plan]: on toes; {1} lower rectus ab-

dominis activity was less in the side plank on toes than in the remaining three exercises; [3} external oblique activity

was greater in the side plank on toes than in the other

three exercises; {4} latissimus dorsi activity was greater in the prone plank on toes than in the crunch and bent-knee 4: Rehabilitation

sit—up; {5} lurnbar paraspinal activity was greater in the side plank on toes than in the other three exercises; and {6}

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

than in the side plank on toes and crunch, and greater in

the prone plank on toes than in the crunch. During the prone and side planks on toes, similar ac-

tivity in the rectus abdominis and external oblique has

been reported, along with moderate to high activity in the longissimus thoracis, lumbar multifidi, gluteus medius, and gluteus maximus during the side plank on toes. 3'1 In addition, the internal oblique and quadratus lumborum .

.

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I.

-

II

,

.

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have demonstrated moderate to high activity during the

'_. I

.

_l_' _I . .-

.

I

Photographs depict the Terse Track lTerse Traclt

Inc-) {A}. Ab Slide [Skyway lntertrade} {B}. Super

Abdominal Machine {Wayne Connor, Super Ah

Machine} {E}. and Ab Heller (Tristar Precincts. Inc-) {It}. (Reproduced with permission from

Escamilla HF, McTaggart M5, Fricltlas EJ, et al: An electremyegra phic analysis of co mmercial and common abdominal exercises: Implications for rehabilitation and training. .f Drift-op Sports

Phys Ther zones 5121:4551}

constant angle and the pelvis does not rotate; during the bent-knee sit-up, the hips flex and the pelvis rotates anteriorly. Although the bent-knee sit-up has been effective in activating the rectus abdominis and internal and external oblique musculature, the crunch has been recommended instead of the bentvknee situun'J‘ Although

side plank on toes.31 Therefore, the side plank on toes effectively recruits core muscles that are important for core stability. However, the lumbar compression force is

relatively high in the side plank on toes,33 which can be problematic for individuals with lumbar pathologies. The

prone plank on toes and crunch produce similar amounts

of activity in the rectus abdominis, internal oblique, and external oblique muscles, but the prone plank on toes was more effective than the crunch in recruiting the latissimus

dorsi and rectus femoris muscles. Abdominal musculature is activated in a different man-

ner during nontraditional core exercises than with the

traditional crunch and bent-knee sit-up. ICine example is the reverse crunch {performing the traditional crunch in reverse}, which involves flexing the trunk by posteriorly rotating the pelvis {Figure 4}. Nontraditional core exercises can also involve controlling trunk extension {against an external force such as gravity} using isometric or eccentric

muscle contractions, such as when performing the Swiss

ball decline push ~up {Figure 5, D} while keeping a neutral

the abdominal musculature is activated similarly between the crunch and bent-knee sit-up, the relatively high hip

pelvis and spine.

increase lumbar spine stress.15‘*-1“"3'1 flther traditional abdominal exercises include the prone

traditional core exercises. Some devices or machines allow only uniplanar motion such as trunk flexion; others allow

ure 3, B}, and several studies have used electromyography

or trunk extension and rotation.f9'31~~“ Adding rotational

flexor activity that occurs during the bent—knee sit—up can plank on toes [Figure 3, A} and side plank on toes {Fig—

firthepaedic Knowledge Update: Sports Medicbte 5

The Swiss Ball [Figure 5} or commercial devices or machines {Figures 1 and I5} can also be used during non-

multiplanar motions such as trunk flexion and rotation

fl lflld American Academy of Orthopaedic Surgeons

Chapter 15": Core Stabilization

Deer, Ab Shaper, Ab-Flex, Ab-Roller (Tristar Products},

Ab Rocker, Ab 1Fv'ice, and Ab Twister.19'“=34'39 Several ab-

dominal devices do not appear to offer any advantage in recruiting abdominal musculature compared with the

crunch, reverse crunch, and bent—knee sit—up.11“ Howev-

er, one advantage of the Ab Revolutioniaer is that external

weight can be added, thereby varying exercise intensity. The reverse crunch flat and Ab Revolutioniaer reverse

crunch are almost identical, only differing in that the former was performed without using an abdominal device. In addition, the crunch and Ab Roller, which are also

a ' - éfig '. ,r if

Figure 3

Photographs depicts the prone plank {A} and side planlt [B] planlt.

components to trunk flexion can be advantageous in inter—

nal or external oblique recruitment. The crunch combined

almost identical, produced similar amounts of abdominal activity (Table 2}. fine advantage of the Ab Roller is that the head is supported (Figure 1, D], which may be more comfortable; therefore, many individuals may prefer it over the crunch. Exercises performed with abdominal

devices reportedly do not appear to offer any advantage in recruiting abdominal musculature compared with performing similar exercises without devices.“

Some commercial devices exhibited substantially less abdominal muscle activity than the traditional crunch,

reverse crunch, and bent—knee sit—up, and substantially

less abdominal activity compared with other commer-

with the Ab Roller with rotation results in simultaneous

cial abdominal devices studied.31 Moreover, the devices

oblique] results in greater right external oblique activity

dividuals with lumbar spine pathologies.

trunk flexion and rotation. Performing these exercises with left rotation {the oblique crunch and Ab Roller

compared with performing the crunch and ab roller with trunk flexion with no rotation {normal crunch and Ab

tend to generate relatively high rectus femoris or lumbar paraspinal activity, which may be contraindicated in inCore muscle activity was quantified in 27" traditional

has been quantified while performing abdominal exercises

and nontraditional core exercises with and without various commercial abdominal devices and machines.21ml Twelve of the exercises are illustrated in Figures 1, 2, 4, and 6}; ElviG data are shown in Tables 2 and 3. Among these exercises, upper rectus abdominis activity was high-

Lifeline USA}, hanging strap, Super Abdominal Machine, Ab Revolutioniaer, Ab Slide (Skyway Intertrade}, Ab

crunch, and Ab Roller; and lowest for the Ab Revolu~ tioniner, reverse crunch, Ab Twister, Ab Rocker, and Ab

Roller crunch] 3" {Table 2}. EMG data on performing

nontraditional abdominal exercises with or without ab"

dominal devices are limitedfii'i‘di'” Core muscle activity

using commercial machines or devices, such as the Torso Track {Torso Track Inc}, Power Wheel {Jon H. Hindes,

IE! lfllfi American Academy of flrthopaeclic Surgeons

est for the Power Wheel roll-out, hanging knee-up with straps, reverse crunch inclined 3-3”, Ab Slide, Torso Track,

Drtbopoedic Knowledge Update: Sports Medicine 5

uvnvanavuas :1:-

Photographs depict bent-knee sit-up (A) and the crunch {E}. {Reproduced with permission from Escamilla HF, McTaggart M5, Fricltlas EJ, et al: An electro myog raphic analysis of com mercial and co mm on abdominal exercises: Implications for rehabilitation and training. if Drthop Sports Phys Tiber Eflflfi;35[2]:45-5?.}

Section 4: Rehabilitation

-— Prone and Side Plank Exercises Compared With Traditional Abdominal |Brunch and Sit-Up Exercises

c .E 4.!

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Exercise

Upper Hectus Abdominis

Lower Hectus Abdominis

Internal oblique

External Oblique

Latissimus Dorsi

Lumbar Paraspinal

Rectus Femoris

Prone plank on toes

34 :|:15t

4G :10

29 :e 12

4D :I: 21"

113 :e 12

5 :I: 2”

20 :l: 2

Side plank on toes

25 :I: 15"El

21 :I: 33'“

23 :I: 12

62 :I: 3?

12 :I: 1D

25 3:15

14 :I: 4"

lI'lrunch

53 :I: 13

33 :l: 15

33 :I: 13

23 t1?“

8 :I: 3'

5 :I: 2"

E :I: 45"

Bent-knee sit-up

4D :I: 13

35 :I: 14

31 :I: 11

36 :I: 14'”

E :I: 3"

E :I: 2"

23 :I: 12

Average electromyographic {EMGI [:I: 513} activity for each muscle and exercise expressed as a percentage of each muscle's maximum isometric volu ntarv contraction. A slgniflca nt difference [P s: noon in Elvlfi activity among abdominal exercises was reported for all muscles.

Pairwise comparisons {P c 11.111]: IISignifica ntly less EMG activity compared with the prone planlt on toes; IISIgniiicantlar less EMG activity com pared with the side planl: on toes:

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

J"

Figure 4

Photographs depict the hanging knee-ups with straps {A}. reverse crunch ilat (Bi. and reverse crunch incline 3D“ {C}. [He prod uced with permission from Escamilla RF, Eahh E, DeWitt it, at al: Electro mvog raphic analysis

of traditional and nontraditional abdominal exercises: Implications for rehabilitation and training. Phys Ther 2flflE:EE[5]:I555-5?1.}

Doer. Lower rectus ahdominis activity was highest for the Power 1Fl'ii’l‘reel roll-out, hanging knee-up with straps,

highest for the Power Wheel pike, Power Wheel knee-up, hanging knee-up with straps, Ah Slide, and bent-knee sit-

Ah Rocker, and Ah Doer. External oblique activity was

Internal oblique activity,F was highest for the Power Wheel

Ah Slide, and Torso Track, and lowest for the rib Twister,

@

firthopaedic Knowledge Update: Sports lvledich'ie 5

up; and lowest for the crunch, Ah Roller, and Ah Doer.

fl lfllo American Academy of Orthopaedic Surgeons

Chapter 15': Cere Stabilixafien

F.:I: I'll :r w E

E

ta

1". U

:I

Figure 5

Phetegraphs depict the Swiss Ball {SwisshalL Therat’iear} pike {A}, knee—up in}. reII-eut {C}, and decline push-up

{D}. {Repreduced with permissien frem Estamilla RF, Lewis E, Bell U, et al: [ere muscle activatien during Swiss ball

and traditienal ahde minal exercises. J Drthep Sperts Phys Ther 2e1e;aa[s]:2ss-2vs.}

rell-eut, Pewer Wheel pike, Pewer Wheel knee—up, hang— ing knee-up with straps, reverse crunch inclined 30“, Ah

activityF was relativity law in all exercises. Altheugh rec-

Al:- Deer. Altheugh the traditienal crunch and bent-knee

external ehliqee activities were general],r greater in Swiss

Slide, Terse Track, bent—knee sit-up, and crunch; and lewest fer the Ab Heller, Ab Twister, Ab Recker, and sit—up are effective in recruiting abdeminal musculature,

abdeminal recruitment was higher in the Fewer Wheel

reil-eut, Pewer Wheel pike, Pewer Wheel knee-up, hanging knee—up with straps, reverse crunch inclined SCI", fab Slide, and Terse Track.

i'vIang.r exercises perfermetl with cernrnercial abderninal devices er machines can alse be perfermed using a Swiss ball, and many studies have quantified cere muscle actiVit‘j-F during varieus Swiss Ball exercises.”~”-"‘”"9 A 2010

Bali knee-up, and bent-knee sit—up. Lumbar paraspinal

tus abdeminis recruitment is similar ameng the crunch, bent-knee sit-up, and Swiss Ball exercises, internal and ball exercises than in the crunch and bent—knee sit-up.

Manv abdeminal exercises traditienallv perfermed en a flat surface can alse be perferrned en a Swiss Ball,

such as the push—up, bench press, and crunch. Several

studies have reperted an increase in abdeminal muscle

activitsr when the push-up is perfermed en an unstable surface {such as a Swiss Ball} cempared with a stable

surf'ace.““‘-5f"5l Abdeminal muscle activity.r is greater when

stud}:r quantified cere muscle activitv {Table 4} between

a bench press is perfertned en a Swiss hall cempared with a flat stable surfacefildfl Dther studies have demenstrated

crunch and bentuknee sit-supafll {Figure 2}. Rectus abdemu

ing the crunch en a Swiss Ball cempared with a flat sur-

several Swiss Ball exercises {Figure 5 i and the traditienal

inis activity was greatest in the Swiss ball rell~eut, Swiss

an increase in abdeminal muscle activityr when perferm-

face.“'4'5'*"’9 Bridging using an unstable surface (Swiss Ball and EGSU ball} has alse demenstrated greater abdeniinal

Ball pike, and crunch, whereas external and internal eblique activitv was greatest in the Swiss Ball tell—eut,

activity.r cempared with bridging en a flat surface.“

knee—up, and Swiss Ball decline push-up, whereas rectus

lumbar multifidus activityr in individuals with chrenic Iew

Swiss Ball pike, and Swiss Bali knee-up. Latissimus dersi activity.r was greatest in the Swiss Ball pike, Swiss Ball femeris activity was greatest in the Swiss Ball pike, Swiss

IE! lfllfi American Academy ef flrthepaedic Surgeens

Cine studv reperted that cempared with a nenlabile surface. the use ef a labile surface Swiss Ball enhanced back pain.” Hewever, anether studv reperted that the

Drthepaedic Knewledge Update: Sperts Medicine 5

Section 4: Rehabilitation

Abdominal Exercises Performed With Machine Devices Compared With Traditional Abdominal Crunch and Sit-Up Exercises Exercise or Machine

c .E 4.!

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Upper Hectus

Lower Hectus

Internal Dhllque

External Dbllque

Latissimus Dorsl

Lumbar Parasplnal

Hectus Femorls

Abdominis

Abdominis

AbSlide

62:26

22:13

53:15

46:16

111:4

3:2

':'.~:3El

Torso Track

62:25

22:12

56:14

32:13

111:5

2:2

13:5El

Erunch {normal}

51:3

36:3m

41:3

16:11“

5:1d

2:1

3:1id

Crunch (oblique)

50:15

33:14Elli

46:11

32:22

6:5

5:3

3:2“I

Bent-knee sit-up

33 :12“

44: 13"“

49:21

41 :16

6 : 3‘1

4:2

36 :16

Super Abdominal Machine

42 :1?“

51} : 26““

36 :13“

31 : 21

12 : 6

4:2

2D :15

Ab Heller {crunchJ

46 :1?

42 :12“

33 : 3”

13 : 6"

5 : 2‘I

3:2

1 :1d

Ab Heller (oblique!

4‘3: 12

36: 164':

25: 11"“

26:3

6:2‘I

3:2

2:2“

Muscles

Average electromyographic {EMGI 1,: SD} activity for each Muscle and exercise expressed as a percentage of maximum isometric voluntary contraction. A significant difference {P c 6.661} In EME activity among abdominal exercises was reported for all muscles.

Pairwise comparisons {P c 6.611: IIISignifica ntly less EMG activity compared with the Ab Slide {straight and curved}; l’Slpnificantly less EMG activity compared with the Torso Tracit:

ESignificantly less EMG activity compared with the bent-knee sit-up: iSignificantly less EMG activity compared with the Super Abdominal Machine. Data from Escamllla HF, Mc'Taggart MS. Frlcltlas EJ, et alt An electromyographic analysis of commerdal and common abdominal exercises: Implications for rehabilitation and training. J Orthop Sports Phys 11ter2DDE:3612]:45-5‘i. http:iidx.doi.orgi16.251Dijospt.2i166.36.2.45.

Swiss Ball may not provide a potential effect on erector

significant rectus femoris activity {and to a lesser extent

spiuae activity during Pilates isometric exercises with

lumbar paraspinal activity}, which can be problematic

musculature, the 12 exercises evaluated in this chapter

to accentuate lumbar lordosis, lumbar compression, and

[Tables 1 through 4), which tenses the thoracolnmbar fascia when it contracts and helps stabilize the trunk.

out, Swiss Ball roll-out, Ab Slide, and Torso Track may be the most effective methods of recruiting abdominal

similar posture when compared with stable surfaces.“ In addition to being effective in activating abdominal are also effective in activating the latissimus dorsifl‘i’"

Moreover, tension in thoracolnmbar fascia resulting from contractions of the internal oblique (and presumably the transversus abdominis} muscle can further enhance lum— bar stability, and most of these exercises produce high activity in the internal oblique muscle. However, except for the Power Wheel roll-out, Swiss Ball roll—out, Ab Slide, and Torso Track, these exercises also exhibited

firthopaedic Knowledge Update: Sports Medicine 5

for some individuals with low back pathologies because of the tendency of the hip flexors and lumbar extensors intradiscal pressured” Therefore, the Power Wheel ro1l~

and latissimus dorsi musculature while minimizing rectus femoris and lumbar paraspinal activity. During these rollout exercises, the latissimus dorsi contract eccentrically

during the initial roll-out phase to control the rate of shoulder flexion, and concentrically in the return phase as the shoulders extend. Moreover, although it is logical

to assume that the rectus femoris contracts eccentrically

fl 21316 American Academy of Orthopaedic Surgeons

Ehapter 15': Core Stabilisation

—_ Power Wheel and Reverse Crunch Exercises Compared With Traditional Abdominal Crunch and Sit-Up Exercises Upper flectus

Lower Flectus

Abdominis

Abdominis

Power Wheel roll-out

15 :I: 26

31 :I: 29

56 :I: 25

54 :I: .2?"

15 :I: W“

5 :I: 23“”

E :I: 4%“

Power Wheel pilce

41 :|:11""i"gr

53 :I: 16"”

33 :I: 31

36 :I: 32

2? a: 16

3 :I: 3

26 :I: 11*

Power Wheel knee-up

41 :I: 13"“MEI

45 :I: 12““

32 :I: 32

El} :1: 3D

25 :I: 12

3 :I: 4

43 1:13

Hanging

69 e 21

1'5 3: 16

35 a: 40

1'9 a: 25

21:12

1' e 3

15 e 3“

Reverse crunch inclined 30"

1'? :I: 2?

53 :I: 13*"II

36 :l: 3?

5!} :I: 19"mil

14 a: 3M

3 :t 4

22 :I: 12‘

Reverse crunch flat

41 :I: 21.1“"Eli

31} :I: 1333““?

52 :I: 314""HIE

39 :I: 1633‘“

23 :I: 14

6 e 3”“E

11 :I: 5'1““

Crunch

56 :I: 1?"

43 :I: 13"”

43 a: 16W'

2? a: 16'3”“

5 :I: 3'3““

3:1”1'“

3 :I: 3“"""""'

Bent-knee

39 a: 3““

33 a: 11““

49 a: 22W'

So :I: 16Mil

6 a: 3m“

6 a: 3"“

22 :I: 12‘

lcnee-up with straps

sit-up

Internal flbllque

External Dbllque

Latissimus Dorsi

Lumbar Paraspinal

Rectus Femorls

Muscles

Average electromyographic lEMGl {:I: 5D] activity for each muscle and exercise expressed as a percentage of maximum isometric voluntary contraction. A significant difference [P -c 6.13131] in EMG activity among abdominal exercises was reported for all Muscles. Pairwise comparisons lPe H.111}:

'Signiticantly less EME activity compared with the Power Wheel roll-out; ”Significa ntly less EMG aclivity compared with the Power Wheel pilce; ‘Slgnlfica ntly less EMG activity compared with the Power Wheel knee-up;

dSignifica ntly less EMG activity compared with the hanging knee-up with straps; 'Significantly less EMG activity compared with fine reverse crunch inclined 3x11“; *Slgnlticantly less ElylE activity compared with the reverse crunch flat;

"Significa ntly less EMG activity compared with the crunch; “Significa ntly less EMG activity compared with the bent-It nee sit-up. Data from Escamllla RF. Babb E. DeWitt It. at al: Electromyographic analysis of traditional and nontraditional abdominal exerdses: Implications for rehabilitation and training. Phys Ther Iii-66:66l5]:656-61'1.

during the initial rollout phase {to control the rate of hip extension] and concentrically during the return phase {to

dorsi (and upper extremity.r muscles in general] may play a greater role in both controlling and causing the roll-out

these four exercises. This may partially be explained by

hip flexors.

cause hip flexion}, rectus femoris activity was low during

and rollback movements during these exercises than the

Exercises that recruit the rectus femoris and lumbar

the neutral pelvic and spine positions that are maintained while performing these exercises. It has been reported that

paraspinal muscles may be contraindicated for those with

in neutral or posteriorly tilted positions compared with

tract cause anterior pelvis rotation and increase the lor-

abdominal activity»r tends to increase and rectus femoris activity tends to decrease when the pelvis is maintained an anteriorly tilted position.55 Therefore, the latissimns

ID 21116 American Academy of flrthopaedic Surgeons

weak abdominal muscles or lumbar instability. The forces generated when the hip flexors and lumbar extensors condotic curve of the lumbar spine, as well as increase L4-L5

Drthopaedic Knowledge Update: Sports Medicine 5

usseaussuaa :s

Exercise or Machine

Section 4: Rehabilitation

Prone Position Swiss Ball Exercises Compared With Traditional Supine Position Abdominal Crunch and Sit-Up Exercises Exercise or Machine

Upper Hectus Abdominis

Lower Hectus Abdominis

Internal |I‘Jibligue

External Oblique

Latissimus Dorsi

Lumbar Faraspinal

Hectus Femorls

Swiss Ball

53 :I: 3G

53 :I: 23

46 :I: 21

45 :I: 13"

12 :I: 5""

6 :I: 2

8 :I: 5""Ilr

Swiss Ball pike

4? 5:13

55 :I: iii

55 :I: 22

34 a 3?

25 a: 11

B :I: 3

24 e S

SwissBall Knee-up

32:15“

35:14

41 3:15

54:39

22:13

63:3

23:13

Crunch

53 :I: 19

35 :I: 15

33 :I: 13"

23 :I: 1ir'"-E

E :I: 3"-'=-f

5 :I: 2

E :I: 4"“

Bent-knee Sit-up

4D :I: 13"

35 :I: 14

31 :I: 11"

35 114“

E :I: 3"-'=-f

E :I: 2

23 :I: 12

Swiss ball decline pushup

35 :I: 21]"

3? :I: 15

33 :15"

35 :I: 24"'E

13 :I: 12

6 :I: 2

11] :I: 15"“

rollout

i: .E 4.!

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.: Ill o: 1's:

Average electromyographic {EM-Si is: SD} activity for each muscle and exercise expressed as a percentage of each muscle's maximum isometric

voluntary contraction- A significant difference ii" -c [1-0111] in EMt'i activity among abdominal exercises was reported for all muscles. Pairwise comparisons [F -c 11.131]:

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

h5ii_yr-.iiicantl1_.l- less EMG activity compared with the Swiss ball pike: "Significantly less EMG activity compared with the Swiss ball kneemp; "Significantly less EMG activity com pared with the crunch:

IISigniiica ntiy less EMG activity compared with the bent-l: nee sit-up; 'Sign 'rfica nfly less EMG activity compared with the Swiss ball decline push-up. Data from Escamllla HF, Lewis C, Bell D. et al: Core muscle activation during Swiss ball and traditional abdominal exercises. J Orthop Sports Phys

Ther 2illflt4fllS] :255-21'5. httpxidx.doi.orgi1D.2S1Si]ospt.2fl1il.3fl?3.

compression and intradiscal pressure," when coupled with weak abdominal musculature, the risk of low back pathol-

action may be detrimental to some individuals with lumbar instability. The psoas muscle can also generate lumbar

ogies increases during these conditions.” Exercises such

compression and anterior shear force at L5-51,13=-“' which

knee-up, reverse crunch inclined 30“, and reverse crunch

gies. Although muscle force from the lumbar paraspinal

as the bent-knee sit- up, Power Wheel pike, Power Wheel

flat, which have relatively high rectus femoris or lumbar paraspinal activity compared with the crunch, Ab Roller, Ab Slide, Torso Track, and Power Wheel roll-out, may

be contraindicated in individuals with weak abdominal muscles or lumbar instabilityfiiii'd” Moreover, during ab-

dominal exercises, the EMG magnitude and recruitment

pattern of the psoas and iliacus is similar (within 113%] to that of the rectus femoris,"5 which implies that the psoas, iliacus, and rectus femoris may exhibit similar EMG re—

cruitment patterns and magnitudes when performing the

aforementioned abdominal exercises. The psoas muscle, because of its attachments to the lumbar spine, attempts

to hyperextend the spine as it flexes the hip, and this

firthopaedic Knowledge Update: Sports Medicine 5

can be problematic for those with lumbar disk patholo-

muscles can also increase lumbar spine compression, the aforementioned abdominal exercises generated relatively low muscle activity is 10% of MVIC] from the lumbar paraspinal musclesli'ri‘ {Tables 1 and 2}.

Biomechanical Differences Between Abdominal

Exercises That Cause Active Hip or Trunk Flexion and Control Hip or Trunk Extension

Some core exercises may be appropriate for some indi-

vid uals but not others. Some core exercises {for example, the bent—knee sit—up} cause hip and trunk flexion; other

core exercises (for example, the Power Wheel roll-out or

fl 2fllti American Academy of Orthopaedic Surgeons

Chapter 19': Core Stabilization

Swiss Ball roll-out} control hip and trunk extension. Core exercises that actively flex the trunk can be problematic for some individuals with lumbar disk pathologies be—

cause of increased intradiscal pressure and lumbar spine

compression,3+” as well as individuals with osteoporosis because of the risk of vertebral compression fractures.”

In these individuals, it may be more beneficial to maintain

a neutral pelvis and spine {such as when performing the Power 1'Il'if'heel or Swiss Ball roll—out} rather than forceful

flexion of the lumbar spine {such as when performing the bent-knee sit-up]. Lumbar stabilization exercises using a

Swiss Ball have been demonstrated as effective interven— tional therapy to alleviate chronic low back pain and to increase bone mineral density.“

£a: I'D :r m E

Some individuals with facet joint syndrome, spondy-

lolisthesis, and vertebral or intervertebral foramen stenosis may nut tolerate exercises in which the trunk is

5

re

maintained in extension, but may better tolerate trunk

1". U

flexion exercises such as the crunch. In these individuals, trunk flexion exercises can decrease facet joint stress and

:I

pain and increase vertebral or intervertebral foramina openings, decreasing the risk of spinal cord impingement, nerve root impingement, or facet joint syndrome.

Although rollout exercises (such as the Swiss Ball

roll-out] and reverse crunch—type exercises {such as the

hanging knee—up with straps) are effective in activating abdominal musculature, the exercises are performed in a different manner. Du ring rollout exercises, the abdominal

musculature contracts eccentrically or isometrically to resist gravity and extend the trunk and rotate the pelvis. During the return motion, the abdominal musculature

contracts concentrically or isometrically. If the pelvis and spine are stabilized and maintained in a neutral po-

sition throughout the rollout and return movements, the

abdominal musculature primarily contracts isometricalr 1y. A relatively neutral pelvis and spine are maintained

while performing rollout exercises. In contrast, in reverse

crunch—type exercises {such as the hanging knee-up}, the

lII -.

abdominal musculature initially contracts concentrically

as the hips flex, the pelvis rotates posteriorly, and the lumbar spine flexes. As the knees are lowered and the hips extend, the reverse movements occur, and the abdominal

musculature contracts eccentrically to control the rate of return to the starting position. The hanging kneebup with straps, Swiss Ball pike, Pow—

er 1Wheel pike, Swiss Ball knee~np, and Power Wheel knee-up are all performed similarly by flexing the hips,

posteriorly rotating the pelvis, and flattenn the lumbar

spine, which is basically the reverse action of what occurs

during the bent-knee sit-up, which involves trunk flex-

ion followed by hip flexion {bent—knee sit—up only}.19'3'

Cine limitation to the hanging knee-up with straps is a

IEI lfllfi American Academy of flrrhopaedic Surgeons

- '

-

2'

s’ I

Figure E

_

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:__'I*'1_,,

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,

I“

Photographs depict the Power Wheel (.Iol'I

H. Hinds Lifeline USA) pilte {A}, ltnee- up {I},

and roll-out {l2}. {Reproduced with permission from Escamilla HF, Babb E. DeWitt H, et al: Electro myog raphic analysis of traditional and nontraditional abdominal exercises: Implications for rehabilitation and training. Phys Ther IflflE;EE[5]:EEE-E?1.)

relatively high L4-L5 disk compression that occurs; however, compression has been shown to be slightly higher in the bent—knee sit-up}3 Furthermore, EMG from the upper and lower rectus abdominis and internal and external

Drthopaedic Knowledge Update: Sports Medichie 5

Sectinn 4: Rehabilitatinn

nblique muscles are all substantially greater in the hanging knee-up with straps cnmpared with the bent-knee

the crunch.“ In cnntrast, several studies repnrted substantially greater upper and lnwcr rectus abdnminis activities

be preferred nver the bent-knee sit-up fnr higher level

and internal nblique activity was nnt substantially differ-

sit—up.” Therefnre, the hanging knee—up with straps may

individuals whn want tn elicit a greater challenge tn the ahdnminal musculature; hnwever, neither exercise may be

ent between the exercisesfii-JIJE These discrepancies may be the result nf methndnlngic differences amnng studies.

because nf relatively high L4-L5 cnmprcssinn.

having subjects raise the lnwcr half cf the bndy eff the table as far as pnssible; ‘5‘ in tvvn nther studies, the subjects

apprnpriate fnr snme individuals with lumbar pathnlngies

11iii'hen the lumbar spine is fnrcefully flexed, which can necur when using cnmmercial ahdnminal machines such

as the Ab Twister, Ab Rncker, and Ab Dner, the anterinr

c .E 4.!

I'll

: E

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.c cu n: if

in the crunch than in the reverse crunch flat, and external

In nne study, the reverse crunch flat was perfnrmed by

were instructed tn pnsterinrly tilt the pelvis and flex the

hips tn maximal extent.39*3‘ Hnwever, during the reverse

fibers nf the intervertebral disk are cnmpressed and the pnsterinr fibers are in tensinn. In additinn, in extreme

crunch inclined 3D", which invnlved a higher degree nf difficulty cnmpared with bnth the crunch and reverse

times abnve nnrmal frnm a resting supine pnsitinnd| Althnugh the stresses en the disk may nnt be prnblematic

ternal nblique, and external nblicjue muscles was significantly greater than in the crunch and reverse crunch flat,

lumbar flexinn, intradiscal pressure can increase several

fnr the nnrmal healthy disk, they can be detrimental tn

the degenerative disk nr pathnlngic spine.

Binmechanical Differences Between the Crunch

and Bent-Knee- Sit-Up

hint all ahdnminal exercises invnlve the same degree nf

lumbar spine flexinn. Dne study demnnstrated that lum-

bar spine flexinu was nnly 3" during the crunch but ap-

crunch flat, activity in the upper rectus abdnminis, in‘ but nn significant difference was repnrted in lnwer rectus

abdnminis activity between the reverse crunch inclined 3i)” and the crunch-19 {Table 1}. These data shnw that the increasing difficulty nf the reverse crunch inclined

30” results in prnpnrtinnal increases in muscle activity. Summary

Understanding hnw different exercises elicit cnre muscle

prnximately 30" during the bent-knee sit-up.‘m In additinu, the bent-knee sit-up has been shnwn tn generate greater

activity and lnad the lumbar spine is useful tn therapists and nther health care nr fitness specialists whn develnp

with exercises similar tn the crunch, largely because nf increased lumbar flexinn.” This finding implies that the

needs nf their patients nr clients. It is impnrtant tn be knnwledgeable abnut the relevant literature regarding cnre

individuals whn need minimize lumbar spinal flexinn nr cnmpressive fnrces because nf lumbar pathnlngy.”

nal exercises, and lumbar spinal lnading and injury risk during exercises cnmmnnly used tn enhance cnre stability.

lumbar intradiscal pressure3 and cnmpressinn” cnmpared

crunch may be safer than the bent-knee sit—up fnr snrne

specific cnre exercises fer the rehabilitatinn nr training stability, cnre muscle activity during cnmmnn abdnmi-

Althnugh the crunch and bent-knee sit—up are bnth

The cnre exercises discussed in this chapter activated ab‘

thrnugh 4}, snme differences exist. Several studies have shnwn that external nblique activity and, tn a lesser ex—

ways such as actively flexing the trunlr, cnntrnlling trunl-r extensinn, flexing the hips with pnsterinr pelvis rntatinn,

effective in recruiting ahdnminal musculature {Tables 2 tent, internal nblicjue activity, are substantially greater in

the bent-knee sit-up cnmpared with the crunch.”+39'31~”

Hnwever, upper rectus abdnminis activity has been shnwn tn be greater in the crunch than in the bent-knee sit-up.19'31

dnminal muscles and lnaded the lumbar spine in varinus

nr a cnmbinatinn nf flexing the trunk and flexing the hips with spinal and pelvis rntatinn. Several nnntraditinnal ahdnminal exercises generated substantially greater rectus abdnminis, internal nblique, and exten'lal nblique activity

In additinn, rectus femnris and psnas activity have been

cnmpared with traditinna] ahdnminal exercises such as the

femnris and psnas can exacerbate lnw back pain in snme

ahdnminal activity, the crunch may be a safer exercise

repnrted as greater in the bent—knee sit-up than in the crunch.“'31r” Increased muscle activity frnm the rectus individuals with lnw back pathnlngies.

Abdnminal and Dblicjue Recruitment Between the Crunch and Reverse Crunch

Perfnrmiug the reverse crunch flat activates the lnwer

abdnminals and external nblique tn a greater extent than

firthnpaedic Knnwledge Update: Spnrrs Ivledich'ie 5

crunch and bent-knee sit-up. Althnugh bnth the crunch and bent-knee sit-up demnnstrated similar amnunts nf fnr individuals with lnw baclc pathnlngies because nf rel~ atively high rectus femnris activity and lumbar intradiscal

pressure generated during the bent-knee sit—up. Rnll-nut exercises {fnr example, ier Wheel rnll-nut, Swiss Ball

rnll-nut, Ab Slide, and asn Track} were shnwn tn be the

mnst effective exercises in activating rectus abdnminis,

internal nblique, external nblique, and latissimus dnrsi

fl lflld American Academy nf Urrhnpaedic Surge-nus

Chapter 15': Cute Stabilisatieu

pike, Pewer Wheel knee—up, Swiss Ball knee—up, hanging

knee-up with straps, and reverse crunch inclined 3i)" were all shewu te be effective exercises in activating recrus ah-

deminis, internal eblique, external eblique, and latissimus

dersi muscles, but at a cest ef alse producing relatively high rectus femeris er lumbar paraspinal activity [which can be preblematic fer individuals with lumbar pathel— egies}. Many exercises that generated high activity frem multiple cere muscles, such as abdeminal bracing, alse

preduced the greatest cere stability as well as relatively high lumbar cempressive leads {which can increase injury

risk tn the lumbar spine}. Exercises that activated enly a

few muscles, such as abdeminal hellewing, may net be effective in producing the level ef cere stability needed fer many functieual activities, such as lifting, running,

and jumping. Hewever, these types ef exercises may be apprepriate early in a cere stabilizatien pregram, as well as fer individuals whe cannet telerate high lumbar cem-

pressien leading. Many individuals, such as athletes whe

are training, use a wide array ef spurt-specific functienal exercises te develep cere muscles and enhance cere

stability. Hewever, research invelving the effectiveness

ef perferming higher level functieual exercises en cere stability are needed, and this sheuld be the fecus ef future research. Key Study Peints

e An understand ef the impertancc ef the cere, the muscles that cemprise the cere, and which mus-

cles centribute the mest te cere stability is imper— tant te previde effective rehabilitatien er training pregrams. - Eiemechanical differences exist between abdeminal hellewing {drawing-in maneuver] and abdeminal

bracing techniques. * Biemcchanical difffleuces exist between abdeminal exercises that cause active hip er trunk flexien er centrel hip er trunk extensien.

Hachemsen AL: Disc pressure measurements. Spine (Phillis

Fri 19.76} 193 I;EI[I]:93 3?. Medline DUI

Essendrep M, Andersen TB, Schibye B: Increase in spinal

stability ebtaiued at levels ef intrawabdeminal pressure and back muscle activity realistic te werk situatiens. Appi Ergert IDflE;33{5}:4T1-476. Medline

DUI

Hedges PW: Is there a rele fer transversus abdeminis in lumbe-pelvic stability? Men Tiber 199*954llj:?4~35.

Medlinc DUI

1|iiiiillre H], Welf 5, Class LE, strand ivi, 1|iiiiiesend A: Stability increase ef the lumbar spine with different muscle greups. .i'i. biemechanical in vitrn study. Spine (Haifa Pia JESUS) 1995;2{i{2}:192-193. Medline DUI Merris 5L, Lay B, Allisen GT: Cerset hypethesis rebutted—transvcrsus abdeminis dees net ce—centract in unisen prier te rapid arm mevements. Clix Eiemech (Brisrei, Ayes) 2fl12;2?{3]:249-254. Medline DUI The anthers tested the “cerset” medel ef spinal stability,

specifically the hypethesis that feed ferward transversus

abdeminis activity is bilaterally symmetric and independent ef the directien ef perturbatieu re pesrure because ef arm mevements. This study assessed transversus ab-

deminis EMG activity bilaterally. Level ef evidence: I.

Grenier EU, l'vIcGill SM: Quantificatien ef lumbar stability by using 1 different abdeminal activatien strategies. Arch Phys Med Rehebii 2Gfl?;33{l}:54-62. Medline DUI

Hedges PW, Richardsen CA: Inefficient muscular stabilisatien ef the lumbar spine asseciated with lew baclc pain. A meter centrel evaluatien ef transversus abdeminis. Spine (Firiie Pa 19.76,! 1996;2H22kld4fl—165fl.

Medline DUI

Ii}. Teyhen D5, Miltenberger CE, Deiters Hl, et al: The use ef ultraseund imaging ef the abdeminal drawing-in maneuver in subjects with lew back pain. I Urtihep Sperts

Phys Ther seesesrsieas-sss. Medline eet

11. U’Sullivan PB, Twemey L, Alliseu GT: Altered abdeminal

muscle recruitment in patients with chreeic back pain

fellewing a specific exercise interventien. j Urtiiep Sperts Phys Ther 1993;1T1121fl‘l4-124. Medline

DUI

12. IEhelewiclti J, VanVliet J] IV: Relative centributien ef

trunk muscles tn the stability ef the lumbar spine during

isemetric exertieus. Uiie flieaireciir (Bristei, Aves} 2Ufl2;1?{2}:99-105.Medline DUI AuuyetaEedlfleienences 1. fliblcr WE, Press J, Sciascia A: The relc ef cere stability in athletic functien. Sperts Med lflflfi;35{3}:139-193. Medline DUI 2. McGill SM: Lew back stability: Frem fermal descriptien te issues fer perfermance and rehabilitatien. Exerc Spert Sci Ree lflfl1;29{1}:16-31. Medline DUI

IE! lfllfi American Academy ef Urthepaedic Surgeens

13. Axler CT, l'vIcGill 5M: Lew back leads ever a variety ef abdeminal exercise-I: Searching for the safefl abdeminal challenge. Med Sci Sperts Exerc 199T;29{E}:flfl4-E11. Medline

DUI

14. 1|Illliillsen JD, Deugherty CF, Ireland ML, Davis IM: Cure stability and its relatienship te lewer extremity functien and injury. I Am Aced Urtirep Snag lflfljfli’iifi1:31E-325. Medline

Urthepaedic Knewledge Update: Sperts Medichie 5

uasviuiaeuaa :1:-

muscles while minimizing lumbar paraspinal and rectus femeris muscle activity. The Pewer Wheel pike, Swiss Ball

Seatian 4: Rehabilillatiun

15. Ukada T, Huxel KC, Nesser W: Relatienship between care stability, functianal mavement, and perfarmance. I Strength {laneII Rea 1011;15{1]:252-261. Medline DUI The authars determined the relatianship between care stability, functienal mevement, and perfermance. Level

ef evidence: II.

16. Reed Eh, Ferd KR, Myer GD, Hewett TE: The effects af isalated and integrated ‘care stability’ training an athletic perfarma nce measures: A systematic review. Sparta Med 2fl12;42{3}:69?-TDE.Mcdline DUI

The anthers previded a systematic review that fecusea en identificatien ef the asseciatien berween cere stability and spans-related pcrfarmance measures. A secandary

ebjective was ta identify difficulties enceuntered when

c .E 4.!

training cere stability te impreve athletic perfermance. Level af evidence: II.

I'll

:I: E

I'fl

.c fill a: if

1?. Chelewicki J, McGill SIvI, Herman KW: Lumbar spine Iaads during the lifting af extremely heavy weights. .lirfet.‘I Sci Sparta Exerc 1991;23f1fl}:11?9-11SE. Medline DUI 13. |[iranhed H, Jansan R, Hanssan T: The laads an the lum-

bar spine during extreme weight lifting. Spine {Phiie Pa ISIS} 193?:12f11fl4d-149. Medline

DUI

19. Standaert C], Weinstein SM, Rumpeltes J: Evidence-infermed management ef chrenic lew back pain with lumbar stabiliaatian exercises. Spine ] 2DDS;S{1}:114-110. Medline DUI III. 1Wang IQ, Zheng J], Yu 2W, et al: Pr metaaanalysis af care stability exercise versus general exercise fer chrenic lew back pain. PLeS Una 2012:?{12}:e52fl SE. Medline DUI

The authers reviewed the effects ef cere stability exercise ar general exercise for patients with chmnic law back: pain. Level af evidence: II.

11. Teyhen D5, Rieger JL, Westrick RE, Miller AU, Malley JIvI, |Elhilds JD: Changes in deep abdeminal muscle thickness during cemmen trunk-strengthening exercises using ultrasaund imaging. I Urthap Sparta Phys Ther 2UflS:33l10}:596-Efl5.Medline DUI

35. Richardsen Ch, Snijders C], Hides JA, Damen L, Pas MS, Starm J: The relatian between the transversus abdaminis muscles, sacrailiac iaint mechanics, and lawr back pain. Spine {Phillie Pa 19%?) lflfllfl'FHIflQF-dflfi.

Medline

DUI

26. Stanten T, Kawchuk G: The effect ef abdeminal stabilizatien cemractiens en pestereanterier spinal stiffness. Spine {Phila Pa IS'F’EJ lflflfl;33{6]:ES4-TD1. Medline DUI 2?. Uh JS, Cynn HS, Wan JH, Ewan UT, Ti CH: Effects af perfarming an abdaminal drawing-in maneuver during prene hip extensien exercises an hip and back extenset muscle activity and ameunt ef anterier pelvic tilt. I Urthep Sparta Phys Ther IIIDTQHEIJZD-Slil. Medline DUI 23. McGill S, Jul-tar D, Krapf P: Quantitative intramuscular myaelectric activity af quadratus lumbarum during a wide variety ef tasks. C‘h‘n Eiemech (Briatei. Avert} 1995;11l3lflTG-ITZ.Medline DUI 2.9. Escamilla RF, Babb E, DeWitt R, et al: Electmmyegtapbic analysis ef traditienal and neutraditienal abdeminal exercises: Implicatians far rehabilitatian and training. Phys Ther 2i] [16,:SEIS 1:656 -6 TI . Medlinc

311. Escamilla RF, Lewis C, Bell D, et al: Care muscle acti-

vatien during Swiss ball and traditienal abdeminal exercises. ,l Urthep Sparta Phys Ther lflIflHflUhlfii-ETE. Medline

DUI

The authers tested the ability af eight Swiss ball exercises [rail—eut, pike, knee—up, skier, hip extensien right, hip extensien left, decline push-up, and sitting march right] and twa traditienal abdeminal exercises [crunch and bentlcnee sit-up} an activating care musculature {lumbapelvic

hip cemplex]. Level ef evidence: II.

31. Escamilla RF, IvIcTaggart MS, Fricklas E], et al: An electremyegraphic analysis ef cemmercial and cammen abdaminal exercises: Implicatians far rehabilitatian and training. } Urthap Sparta Phys Ther 2005;36f2}:4S-ST. Medline DUI

31. Ekstram Rh, Danatelli Rh, Carp ICC: Electramyagraph-

ef abdeminal stabilisatien maneuvers en the centre] ef

ic analysis ef care trunk, hip, and thigh muscles during 9 rehabilitatian exercises. I Urthap Sparta Phys Ther lDfl?;3?{12}:?54-?62.MedIine DUI

13. Barnett F, Gilleard W: The use af lumbar spinal stabili-

33:. Kavcic hi, Grenier 5, McGill 5M: Quantifying tissue laads and spine stability while perfarming cammanly prescribed law back stabilisatian exercises. Spine (Phife Pa 19%} 20H4;19{lfl}:2319-2329. Medline DUI

Vera-Garcia F], Elvira jL, Brawn SH, McGill SM: Effects spine metien and stability against sudden trunk perturbatians. I Efectrarnyagr aest'af lflfl?;1?{Si:SSE-Sti?. Medline DUI

satian techniques during the perfarmancc af abdeminal

strengthening exercise variatiens. I Sparta Med Phys Pitnesa 20fi5;45[1]:33- 43. Medline

24. Hides], 1illiilsen S, Sta nten W, et al: An MRI investigatien inta the functian af the transversus abdaminis muscle

during “drawing—in” cf the abdeminal wall. Spine (Phife Pa 19715} 2096;31{6}:E1?5-E1?3. Medline

Urthepaedic Knewledge Update: Sparta Medicine 5

DUI

34. Schaffstall JE, Titcemb DA, Kilbeurne BF: Electramyagraphic respense af the abdaminal musculature ta varying abdaminal exercises. ] Strength Canrf Rea 2010;24[12}:3422-3426.Medline DUI The authers examined the EMU respense ef the upper rectus abdaminis, lawer rectus abdaminis, internal ablique, external ablique, and rectus femaris muscles during varieus abdeminal exercises (crunch, supine V—up, prene V—up

fl sets American Academy ef Urthapaedic Serge-ens

Chapter 15': Cute Stabilizatien

and preue V—up en Fewer Wheel}. Level ef evidence: 11.

35. Avedisiau L, Kewalslry DS, Albre RC, Geldner I}, lGill RC:

Abdeminal strengthening using the AbVice machine as measured by surface electremyegraphic activatien levels. ,1 Strength Cend Res lflflS:19[3}:?flS-T11. Medline

46. Scett IR, 1li'aughan AR, Hall]: Swiss ball enhances lumbar multifidus activity in chreuic lew back pain. Phys Ther Spert 2015:16f1]:4U-44. Medline Ill-DI The anthers examined the effects ef sitting surfaces en the

cress-sectienal area ef the lumbar multifidus in patients with ch renic lew back pain and healthy centre] patients. Level ef evidence: II.

SS. Clark KM, Helt LE, Sinyard J: Electremyegraphic cemparisen uf the upper and lewer rectus abdeminis during abdeminal exercises. ] Strength Cend Res 2003:1?i3}:4?5v

4?. Staeten R, Reaburn PR, Humphries E: The effect ef shert-term Swiss ball training en cere stability and running eceuemy. I Strength lfiend Res lflfl4;13(3}:522-523. Medline

3?. Hildenbrand E, Neble L: Abdeminal Muscle Activity While Perferming Trunk-Flexien Exercises Using the Ab Heller, ,AEslide, FitEall, and Cenventienally Perfermed Trunlt Curls. I Athf Trein 2004:39i1}:S?—4S. Medline

43. Sternlicht E, Rugg S, Fujii LL, Tememitsu KP, Selti

433. Medline

33. Sternlicht E, Rug 5: Electremyegraphic analysis ef ab—

deminal muscle activity using pertable abdeminal exercise devices and a traditienal crunch. I Strength Cend Res lflfl3;1?{3}:463-4SS. Medline

35'. Warden S], Wajswelner H, Eennell KL: Cemparisen ef

Abshaper and cenventienally perfermed abdeminal ex-

ercises using surface electremyegraphy. Med Sci Sports Exerc 1999;31i11lflSSS-1S64. Medline DUI 4D. Behm DIG, Leena rd AM, Yeung WE, Bensey WA, Machiinnen SN: Tru tilt muscle electremyegraphic activity with unstable and unilateral exercises. ] Strength lI’Senrf Res lflfljtlflfllflflfi -2.Dl . Medline

41. Cesie—Lima LM, Reynelds KL, 1Winter C, Paeleue 1|I.i',_]enes MT: Effects ef physieball and cenventienal fleer exercises en early phase adaptatiens in back and abdeminal cere stability and balance in wemen. }' Strength lEersd Res

lflflS:1?{4}:?ll-?ES. Medline

41. ISteprewslti D, Afeltewica A, niclta A, et al: Abdeminal muscle EMG~activity during bridge exercises en stable and unstable surfaces. Phys Ther Spert 2fi14;15{3}:162-163. Medline DUI The authurs assessed abdeminal muscle activity during prene, side, and supine bridge en stable and unstable surv faces (BUSH, Swiss ball]. Invel ef evidence: II. 43. Imai A, Kaneeka K, flkube '1’, et al: Trunlt muscle activity during lumbar stabilizatien exercises e11 beth a stable and unstable surface. }' Drthep Sperts Phys Ther' lflli};4i}{6}:369-3T5.Medline DUI The authers examined whether differences in surface stav bility influence trunl-t muscle activity. Lew] ef evidence: [L

44.

Marshall PW, Murphy BA: Cere stability exercises en and eff a Swiss ball. Arch Phys Med Rehehff ZEUS;SS{2]:E4E249. Medline DUI

45. Meri A: Electremyegraphic activity ef selected trunk mus-

cles during stabilizatien exercises using a gym ball. Elec-

trernyegr Chin Nenrephyste! 2004;“{115164. Medline

IE: lfllfi American Academy ef flrthepaedic Surgeens

MM: Electremyegraphic cemparisen ef a stability ball

crunch with a traditienal crunch. 1 Strength lfiend lies Zflfl?;21{2}:Si}S-SUS. Medline 49. 1lilera-IIGarcia F], Grenier SG, McGill SM: Abdeminal muscle respense during curl-ups en b-eth stable and labile surfaces. Phys Ther lflflfl;3fl{6}:SS4-SSS. Medline Si}. Calatayud ], Berreani S, lCelade JC, Martin F, Regers ME: Muscle activity levels in upper—bedy push exercises with different leads and stability cenditiens. Phys Spertsrned 2e14;4a{4}:1es-11a Medline D0] The authurs cempared the muscle activatien levels during push-up variatiens {such as suspended push-ups with.If witheut visual input en different suspensien systems, and push-ups en the fleer withfwitheut additiunal elastic re-

sistance} with the bench press exercise and the standing

cable press exercise beth perfermed at Sflh’n, Tfl‘ir’u, and 35% ef the ene-repetitien maximum. Level ef evidence: II. 51. Lehman G], MacMillan B, MacIntyre I, |[Shivers M, Fluter M: Sheulder muscle EMG activity during push up

variatiens en and eff a Swiss ball. Dyn Med lflflfififl. Medline DUI

SI. Marshall PW, Murphy BA: Increased delteid and ab—

deminal muscle activity during Swiss ball bench press. ] Strength Cend Res lflflS:2fl{4]:?45-?5fl. Medline

53. Nerweed JT, Andersen GS, Gaeta MB, Twist PW: Electremyegrapbic activity ef the trunk stabilizers during stable and unstable bench press. I Strength Bend Res lflfl?:ll{2}:343-34?. Medline

S4. Par {3, Maia M, Sautiage F, Lima V, Miranda H: Muscle activity ef the erecter spinae during Pilates isemetric exercises en and eff Swiss Hall. I Sperts Med Phys Fitness

2e14;54{s}:sn—5se. Medline

The authurs investigated the muscle activity ef the erecter spinae during Pilates isemetric exercises perfermed en and eff a Swiss ball. Level ef evidence: I].

55. 1|ilii'erltman JC, Decherty I}, Parfrey KC, Eehm DG: Influence ef pelvis pesitien en the activatien ef abdeminal and

hip flexer muscles. ] Strength I{Send Res lflflSgfliS }:1 5531569. Medline

DUI

Drtbepeedic Knewledge Update: Sperts Medicine S

uvsvuuavuva :1:-

en ball, prene 1bleep en slide beard, prune 1iinf-up en TEE,

Sectinn 4: Rehabililltltinn

56. McGill S, Julter D. Krepf P: Apprnptiately placed surface EMG electrncles reflect deep muscle activity {psuras, quadratus lumbnrum, abdnminal wall} in the lumbar spine. jflinmeci: 1996:29i11]:15fl3-1501Medline DDI 5?. Juker D, McGill S.I Krnpf P, Steffen T: Quantitative intramuscular myeelectric activity nf lumbar pe-rtic-ns nf pseas and the ahdeminal wall during a wide variety nf taslts. Med Sci Spurts Exet'c 1993;3fl{2}:3fl1-31ll Medline Dfll SS. Sinalti M: Exercise fur patients with nstenpnrnsis: Man-

agement nf vertebral c-nmpressinn fractures and trunk strengthening fur fall preventinn. PM E 2fl12;4{11,l:332383. Medline DUI

4: Fiehabilitatiun

The anthers examined the effects ef exercise fer patients

with nstenpnrnsis and the management nf vertebral cumpressiun fractures and trunk strengthening fer fall preventien. Leml nf evidence: II.

firthnpaedic Knewledge Update: Sperts Medichie 5

59. Tenn 15. Lee JH, Kim 15: The effect nf swiss ball stabiliaatinn exercise an pain and heme mineral density {if patients with chrcvnic lnw back pain. J Phys Ther Sef 1013;25[3]:953—955.Mcdlinc D0]

The anthers examined the effects ef a 16—week lumbar stabilisatinn exercise pregram using a Swiss ball targeting patients with chrc-nic lnw back pain nn alleviating the pain

and increasing brine mineral density. Level of evidence: II.

ED. Halpern 151A, Bleclc EE: Sit-up exercises: An electrnmyngraphic study. [Hie Ortbnp Refer Res 19?9;145:i?1-1?3.

Medline

51. Willett GM, Hyde JE, Uhrlaub ME, Wendel CL, Karst GM: Relative activity of abdominal muscles during cemmnnly prescribed strengdtening exercises. } Strength Grind Res 1001;15{4}:43fl-435. Medline

fl lfllfi American Academy ef Cirrhnpaedic Surge-ens

tio ’

Head and Spine

Chapter 30

Concussion Siobhan Ivl. Statute... MD. CAQSM

John M. . =

Ieremy L. Riehm, DC]

Abstract

Concussion is, undoubtedly, one of the most prevalent topics within the sports medicine arena. New discoveries

are improving understanding of what exactly occurs on

the subcellular and cellular levels, and how they manifest certain clinical Features displayed by the athlete. Despite these advances in knowledge, each concussion presents and plays out in a unique fashion that depends on variables such as sport played, position of the athlete,

occurs both acutely and over time within the brain, and

to answer some important questions: What transpires on the cellular level? Can this cellular activity explain the

subsequent alterations observed in athlete behavior and function? What are the long-term effects of concussion? Concussions can result from simple falls, motor vehicle

accidents, assaults, or any similar motion causing sudden

acceleration or deceleration to the brain. The annual inci-

dence of recreational or sports-related concussion {SEC}

is estimated to be 3.3 million,“ although these values are

and age of the athlete. Several tests are available to help diagnose concussion and track symptoms. Using

considered low because of underreporting. Certain behaviors place an individual at increased risk

back into sports in a safe, stepwise pattern. |Concussion complications such as postconcussive syndrome and

sports and athlete positions produce more concussion

these data, medical providers can help guide the athlete

second—impact syndrome are real entities that could

have lasting effects and devastating results. Education } and early identification of these conditions is crucial.

for sustaining a concussion. In athletic activities, certain

events than others. Contact sports confer the greatest

risk, particularly American football, ice hockey, soccer, boating, and rugby. Athletes with a previous history of

SEC are at increased risk of sustaining another coucussive event. The accumulation of concussion episodes, severity of the concussion, and growing symptom duration cor-

Keywords: concussions: sports-related concussion

relate with prolonged recovery. Female athletes are more likely than male athletes to sustain SEC in similar sports.

Children and adolescent athletes appear to have a higher

Introduction

Concussion is currently one of the most frequently dis—

risk of coucussive events, with prolonged recovery courses or a subsequent catastrophic event.]

cussed topics in sports medicine. Concerted efforts have been made on the national and local levels to improve edu-

cation regarding concussions in an attempt to better diag— nose and manage this condition. Special attention is being directed to improve understanding of what specifically Di: Maclt’night or an immediate family member serves as

a board member. owner. offices or committee member

of the American College of Sports Medicine. None of the following authors or any immediate family member has received anything of value from or has stuck or stoclt options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Di: Statute. Di:

Kent. and Dr. Riehm.

fl lflld American Academy of Drthopaedic Surgeons

The term “concussion“ is derived from the Latin word concutere, meaning “to shake violently ” and often is referred to as commotio cerebri in countries outside the United States. No single, agreed-on definition for concussion exists. Concussion can be categorized as a mild,

diffuse brain injury resulting in clinical symptoms but

not necessarily attributed to a pathologic injury. When a coucussive head injury occurs, the brain sustains a con-

tusion. If the head is stationary and is struck by a moving

object, a coup injury ensues, resulting in a focal injury of the brain under the site of skull impact. A contrecoup

injury—or bruise to the opposite side of the brain—likely

results when the moving head strikes an immobile object.

Drthopaedic Knowledge Update: Sports Medicine 5

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Section 5: Head and Spine

Although often used interchangeably with the term “mild traumatic brain injury“ {mTBI}, concussion refers to a

specific, less severe subset of the traumatic brain injury

[TBIJI spectrum.1 Symptoms are generally limited, with

resolution within a few weelrs.L2

1"ili'hen the head is jolted, the biomechanical forces im—

parted to the brain trigger a complex neuronal patho-

physiologic cascade, resulting in changes to personality,

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emotional and physical status, and rate and precision of

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cognition. Each concussion is unique in its presentation, yet according to the consensus statement released at the

4th International lL'Jonference on li'fjoncussion in .‘.'i1::~ort,2 the following generalities appear to hold true:

1. |Concussion may be caused by a direct blow to the head, face, neck, or other part of the body, with an

impulsive force transmitted to the head.

2.. |Concussion typically results in the rapid onset of a

short-lived impairment of neurologic function that resolves spontaneously. In some cases, symptoms and signs may evolve over several minutes to hours.

3. |liloncussion may result in neuropathologic changes, but these acute clinical symptoms largely reflect a functional disturbance rather than a structural injury; there—

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Diagram shows the acute cellular biologic processes occurring after concussion or mild traumatic brain injury. (Reproduced with permission from Giza EC, Hovda DA: The new

metabolic cascade of concussion. Neurosurgery

2m 435911535.)

channels, resulting in a state of sluggishness {Figure l}.

The brain is left in a state of ionic disarray. Adenosine

triphosphate {ATM-dependent pumps go into action to

attempt to restore homeostasis. This process requires

fore, no abnormality is seen on standard structural

energy obtained via hyperglycolysis, which rapidly leaves

4. Concussion results in a graded set of clinical symptoms that may or may not involve the loss of consciousness.

plus of adenosinc diphosphate {ADP}. Consequently, a demand for an increase in energy reserves occurs at the

neuroimaging studies.

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Resolution of the clinical and cognitive symptoms typ-

the brain in a state of energy depletion and with a sursame time as a paradoxical drop in cerebral perfusion. An

ically follows a sequential course. It is important to note that symptoms may be prolonged in some cases.

energy crisis ensues because of this mismatch of supply

in one or several clinical domains, including physical symptoms or signs, behavioral changes, cognitive impair-

well as the cellular level. The cells receive an overwhelming influx of calcium. To manage this influx, mitochon-

The diagnosis can include a single impairment or more

ment, or sleep disturbances.

Pathophysiology Questions have been raised rcga rding what occurs on the

microscopic level that effects such behavioral and emotional changes. Studies reveal that, following a concussivc force to the brain, neurologic changes result without macroscopic neural damage.J As each individual concussion differs, the threshold needed to sustain a clinical concus-

sion also differs among athletes. At the neural cellular

level, an alteration occurs to the mechanopotation of

the membranes, which triggers an abnormal exchange of substances into and out of the neurons—the neurometabolic cascade. The neurotransmitter glutamate is leaked,

followed by an ionic flux. Potassium exits the cells while an influx of sodium and calcium occurs. This ion fluctuation can result in a cellular depolarization, which in

turn affects the reactivity of voltage or ligand-gated ion

firthopaedic Knowledge Update: Sports Medicine 5

and demand?

This disarray continues on the mitochondrial level as

dria attempt to sequester the excess, but doing so leads to

mitochondrial dysfunction. Mitochondria play a crucial role in oxidative metabolism, responsible for the formation of ATP. If they are malfunctioning, the mitochondria

exacerbate the energy crisis by slowing down the recycling of ATP. In addition to the mitochondrial malfunction,

shifts in subcellular metabolic pathways occur, resulting in the production of damaging free radicals. This process

leaves the brain even more vulnerable to reinjury. After

the initial insult and neurometabolic cascade, glucose metabolism rates slow paradoxically. This slowness can last up to T to 10 days and has been observed to result in

behavioral and learning impairments in animal models} The structure, or cytoskeleton, of the brain also can be affected by these traumatic biomcchanical forces.

The delicate axons, dendrites, and astrocytic processes are thought to undergo a loss of structural integrity,

subsequently leading to an interference of normal neu— rotransmission. [in a more severe level, axonal stretch is

fl lflld American Academy of Orthopaedic Surgeons

|L'ihapter 3i]: l|i'..‘oncl.lssions

postulated to lead to atrophy and shrinkage of neurons without necessarily resulting in cell death. The damaged

cell is likely incapable of normal function, as demon— strated in different animal models.

Concussion Modifiers Factors

Modifier

Symptoms

Number Duration [31!] days)

Classification of Concussion

T31 is a spectrum of pathology ranging from mild to severe, with SEC representing a subset of mild Tli'lI.4 The Glasgow Coma Scale [GCSl helps assess the level of consciousness following head trauma using an objective

scoring scale that is reliable and reproducible. GCS scores for moderate head trauma range from 9 to 11; in severe

Severity Signs

Prolonged LO: (:1 min}. amnesia

Seguelae

Concussive convulsions

Temporal factors

Frequency — repeated concussions Timing - injuries close together in time

trauma, scores drop to a range of 3 to 3. For concussions,

the (SSS is typically normal, and any alterations of conscinusness or amnesia are relatively brief. Grading sysmms for concussions have been proposed in the past but are no

longer used because of their inability tn reliably predict severity or patient outcomes}

The most recent concussion management guidelines use

a more generalized scheme of predicting severity instead of grading scales1 {Table 1}. in this revised system, each

predictor is not necessarily cumulative. The provided list of symptoms is not all-inclusive, but can be used as a man-

over time

Recenty - recent concussion or TBI Threshold

Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion

Age

Child and adolescent {