Chapter 07 MSK and Sports Flashcards Preview

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Flashcards in Chapter 07 MSK and Sports Deck (50):
1

AC Sprains/Tears – AC injuries may be seen with falls on the ___________ shoulder. A type I (___________ classification) injury is a nondisplaced ___________ of the AC ligament, manifested by local tenderness w/o anatomic deformity. A type II injury (see Fig. 7-1) involves an AC ___________ and ___________ ligament sprain, but the ___________ interspace is intact. Treatment for type I or II injuries includes an arm sling, ice, analgesics, and progressive ROM exercises. An ___________ type II injury may require arm sling use for 2 to 4 weeks. Sports activities can be resumed when full painless ROM is achieved and deltoid strength is near-baseline. Type III to VI lesions involve rupture of the ___________ and ___________ ligaments with varying displacements of the clavicle. These require orthopedic consultation for potential ___________, although many separations may be followed conservatively with several weeks of sling-and-swathe immobilization, followed by long-term therapy.

AC Sprains/Tears – AC injuries may be seen with falls on the adducted shoulder. A type I (Rockwood classification) injury is a nondisplaced sprain of the AC ligament, manifested by local tenderness w/o anatomic deformity. A type II injury (see Fig. 7-1) involves an AC tear and CC ligament sprain, but the CC interspace is intact. Treatment for type I or II injuries includes an arm sling, ice, analgesics, and progressive ROM exercises. An unstable type II injury may require arm sling use for 2 to 4 weeks. Sports activities can be resumed when full painless ROM is achieved and deltoid strength is near-baseline. Type III to VI lesions involve rupture of the AC and CC ligaments with varying displacements of the clavicle. These require orthopedic consultation for potential ORIF, although many separations may be followed conservatively with several weeks of sling-and-swathe immobilization, followed by long-term therapy.

2

ACJ OA – OA is a very common cause of ACJ pain, especially in the ___________. The presence of ACJ tenderness and pain with cross body abduction suggests ACJ OA. Radiologic studies such as ___________-___________ and ___________ evaluation can help confirm the diagnosis. Treatment includes topical or oral analgesics, PT, injections, and surgery if refractory to conservative care. Traditional injection techniques have proven to be inaccurate; therefore, fluoroscopic or US-guided injections are preferred.

ACJ OA – OA is a very common cause of ACJ pain, especially in the elderly. The presence of ACJ tenderness and pain with cross body abduction suggests ACJ OA. Radiologic studies such as x-rays and US evaluation can help confirm the diagnosis. Treatment includes topical or oral analgesics, PT, injections, and surgery if refractory to conservative care. Traditional injection techniques have proven to be inaccurate; therefore, fluoroscopic or US-guided injections are preferred.

3

ACJ OA (Rotator Cuff Tendinitis/Shoulder Impingement Syndrome) – Predisposing and causative factors include acromion ___________ and repetitive ___________ activities (i.e., throwing, racquet sports, and swimming). Pain and aches are often worse at night and can be aggravated by overhead activities. Shoulder flexion and abduction may be limited.

ACJ OA (Rotator Cuff Tendinitis/Shoulder Impingement Syndrome) – Predisposing and causative factors include acromion shape and repetitive overhead activities (i.e., throwing, racquet sports, and swimming). Pain and aches are often worse at night and can be aggravated by overhead activities. Shoulder flexion and abduction may be limited.

4

A painful arc (Fig. 7-2) may be present at about ___________° to ___________° on passive arm abduction. Neer's test (Fig. 7-3) and Hawkins test evaluate for shoulder impingement. In Neer's test, the examiner fixes the scapula with one hand and elevates the subject's arm with the other hand. Pain indicates a positive test. Hawkins test is performed by ___________ the subject's arm to 90° with the elbow flexed, then ___________ rotating the shoulder. Hawkins test can also be performed in the scapular plane. In the ___________ arm test, the arm is passively elevated to 90° in abduction and the patient is asked to hold the arm in position and then slowly lower the arm to the side. The inability to slowly lower the arm or having severe pain when attempting to do so may be indicative of a severe or complete tear of the rotator cuff pathology.

A painful arc (Fig. 7-2) may be present at about 70° to 110° on passive arm abduction. Neer's test (Fig. 7-3) and Hawkins test evaluate for shoulder impingement. In Neer's test, the examiner fixes the scapula with one hand and elevates the subject's arm with the other hand. Pain indicates a positive test. Hawkins test is performed by abducting the subject's arm to 90° with the elbow flexed, then internally rotating the shoulder. Hawkins test can also be performed in the scapular plane. In the drop arm test, the arm is passively elevated to 90° in abduction and the patient is asked to hold the arm in position and then slowly lower the arm to the side. The inability to slowly lower the arm or having severe pain when attempting to do so may be indicative of a severe or complete tear of the rotator cuff pathology.

5

The painful shoulder should initially be rested until pain and swelling subside. Ice and NSAIDs may be helpful. ___________ activities should be avoided. PT can institute gentle ___________ to preserve ___________ and ___________ strengthening. A steroid injection into the ___________ space may relieve pain and improve motion if the above measures fail. A repeat injection should be avoided in patients with ___________ months of pain relief following the first injection. Unless your clinical diagnosis is unchanged, repeat subacromial injection with US guidance to ensure accurate medication placement may be considered for additional diagnostic and therapeutic purposes.2,3 Exercises should progress until strength and ROM are restored. Surgery is an option if several months of conservative treatment/steroid injections fail to resolve the symptoms (or for complete tears). An ___________, the most common procedure, involves acromial shaving to increase the space around the inflamed tendon. The tendon may also be debrided. Several months may be required to regain full strength after surgery.

The painful shoulder should initially be rested until pain and swelling subside. Ice and NSAIDs may be helpful. Overhead activities should be avoided. PT can institute gentle stretching to preserve ROM and isometric strengthening. A steroid injection into the subacromial space may relieve pain and improve motion if the above measures fail. A repeat injection should be avoided in patients with 2 months of pain relief following the first injection. Unless your clinical diagnosis is unchanged, repeat subacromial injection with US guidance to ensure accurate medication placement may be considered for additional diagnostic and therapeutic purposes.2,3 Exercises should progress until strength and ROM are restored. Surgery is an option if several months of conservative treatment/steroid injections fail to resolve the symptoms (or for complete tears). An acromioplasty, the most common procedure, involves acromial shaving to increase the space around the inflamed tendon. The tendon may also be debrided. Several months may be required to regain full strength after surgery.

6

Anterior Shoulder Dislocation – ___________ dislocations are more common than ___________ dislocations. Complications include ___________ nerve injury, recurrent ___________, and ___________ ___________ tears (especially in older patients). A Bankart lesion (Fig. 7-4) is an avulsion of the ___________ ___________ labrum and capsule from the glenoid rim and is felt to be a primary etiologic factor in recurrent dislocations. A Hill-Sachs lesion is a compression fracture of the ___________ head when the ___________ aspect of the humeral head compresses against the anterior glenoid rim. Age at initial dislocation is prognostic for recurrence: teens/young adults have significantly higher redislocation rates (said to approach 90%) than older patients (said to be ≈10% to 15% for patients >40 years of age).
Various techniques exist for acute reduction, including the modified ___________ technique, where the patient lies prone with a wrist weight (i.e., 5 to 10 lbs) on the affected arm as it hangs over the side of the table. Reduction is achieved over 15 to 20 minutes as the shoulder muscles relax.

Anterior Shoulder Dislocation – Anterior dislocations are more common than posterior dislocations. Complications include axillary nerve injury, recurrent dislocations, and rotator cuff tears (especially in older patients). A Bankart lesion (Fig. 7-4) is an avulsion of the anteroinferior glenoid labrum and capsule from the glenoid rim and is felt to be a primary etiologic factor in recurrent dislocations. A Hill-Sachs lesion is a compression fracture of the humeral head when the posterolateral aspect of the humeral head compresses against the anterior glenoid rim. Age at initial dislocation is prognostic for recurrence: teens/young adults have significantly higher redislocation rates (said to approach 90%) than older patients (said to be ≈10% to 15% for patients >40 years of age).
Various techniques exist for acute reduction, including the modified Stimson technique, where the patient lies prone with a wrist weight (i.e., 5 to 10 lbs) on the affected arm as it hangs over the side of the table. Reduction is achieved over 15 to 20 minutes as the shoulder muscles relax.

7

Anterior Shoulder Dislocation
A newer technique termed ___________ has been published and appears to be superior to the Hippocratic and Kocher methods, but was not compared with the Stimson technique. This method is performed with the patient supine and longitudinal traction is applied as the shoulder is slowly abducted. ___________ status should be checked before and after attempted relocation.
There is no strong evidence to show that immobilization or the duration of immobilization has an effect on the outcome. One option includes ___________ in ER, which may reduce the rate of recurrence, though this should be initiated 24 to 48 hours following injury. Early rehabilitation may include icing and sling immobilization for 1 to 3 weeks to allow healing of the capsule. Maintenance of elbow, wrist, and hand ROM is important. Isometric exercises and gentle pendular exercises with the arm in the sling are encouraged, but passive abduction for hygiene is limited to ___________° and ___________ rotation is avoided. The duration of sling use may be shortened in older patients due to the higher risk of frozen shoulder. Once the capsule has healed, shoulder ROM and strengthening are progressed. There is some debate regarding the optimal type and timing of surgery after shoulder dislocation and in shoulder instability.

Anterior Shoulder Dislocation
A newer technique termed FARES has been published and appears to be superior to the Hippocratic and Kocher methods, but was not compared with the Stimson technique. This method is performed with the patient supine and longitudinal traction is applied as the shoulder is slowly abducted. Neurovascular status should be checked before and after attempted relocation.
There is no strong evidence to show that immobilization or the duration of immobilization has an effect on the outcome. One option includes bracing in ER, which may reduce the rate of recurrence, though this should be initiated 24 to 48 hours following injury. Early rehabilitation may include icing and sling immobilization for 1 to 3 weeks to allow healing of the capsule. Maintenance of elbow, wrist, and hand ROM is important. Isometric exercises and gentle pendular exercises with the arm in the sling are encouraged, but passive abduction for hygiene is limited to 45° and ER (external rotation) is avoided. The duration of sling use may be shortened in older patients due to the higher risk of frozen shoulder. Once the capsule has healed, shoulder ROM and strengthening are progressed. There is some debate regarding the optimal type and timing of surgery after shoulder dislocation and in shoulder instability.

8

Adhesive Capsulitis – A syndrome characterized by a progressive painful loss of ___________ and ___________ glenohumeral ROM that occurs more commonly in females between the ages of 40 and 60 years. ___________ and ___________ rotation are most affected; ___________ rotation is least affected. This condition may be the end result of other conditions that result in prolonged immobility (i.e., ___________ and rotator cuff tendinitis) and has also been associated with other medical conditions (i.e., ___________, ___________ dysfunction, and ___________ diseases). Treatment can consist of an aggressive ROM program, with NSAIDs and heat modalities to improve tolerance. Other techniques include intra-articular steroid injections, brisement (___________ of the capsule), manipulation under ___________, and ___________ nerve blocks. Of these additional options, intra-articular steroid injection has been well studied and appears to improve short-term outcomes. Recovery may take several months to beyond a year.

Adhesive Capsulitis – A syndrome characterized by a progressive painful loss of passive and active glenohumeral ROM that occurs more commonly in females between the ages of 40 and 60 years. Abduction and External Rotation are most affected; internal rotation (IR) is least affected. This condition may be the end result of other conditions that result in prolonged immobility (i.e., bursitis and rotator cuff tendinitis) and has also been associated with other medical conditions (i.e., DM, thyroid dysfunction, and autoimmune diseases). Treatment can consist of an aggressive ROM program, with NSAIDs and heat modalities to improve tolerance. Other techniques include intra-articular steroid injections, brisement (hydrodilation of the capsule), manipulation under anesthesia, and suprascapular nerve blocks. Of these additional options, intra-articular steroid injection has been well studied and appears to improve short-term outcomes. Recovery may take several months to beyond a year.

9

Bicipital Tendinitis – This ___________ injury can be associated with ___________ activities or sports and often coexists with the shoulder impingement syndrome, rotator cuff tears, or labral pathology (i.e., ___________ lesions). Examination often reveals a tender ___________ groove. While palpating this structure, assess for instability/subluxation of the bicipital tendon by ___________ and ___________ rotating the shoulder. If unstable, the tendon may sublux medially over the lesser tuberosity and a clunk or snap may be appreciated. ___________ test (Fig. 7-5) is performed by elevating the subject's arm to 90° with the elbow extended and palm upward, then having the patient attempt forward flexion of the arm against resistance. Pain in the bicipital ___________ is indicative of a positive test. Treatment includes NSAIDs, activity modification, and progressive exercise program, which may include the use of modalities such as heat and postactivity ___________. Local corticosteroid injection may be used in refractory cases and US guidance may help increase your accuracy of performing injections into the tendon sheath.

Bicipital Tendinitis – This overuse injury can be associated with overhead activities or sports and often coexists with the shoulder impingement syndrome, rotator cuff tears, or labral pathology (i.e., SLAP lesions). Examination often reveals a tender bicipital groove. While palpating this structure, assess for instability/subluxation of the bicipital tendon by internally and externally rotating the shoulder. If unstable, the tendon may sublux medially over the lesser tuberosity and a clunk or snap may be appreciated. Speed's test (Fig. 7-5) is performed by elevating the subject's arm to 90° with the elbow extended and palm upward, then having the patient attempt forward flexion of the arm against resistance. Pain in the bicipital groove is indicative of a positive test. Treatment includes NSAIDs, activity modification, and progressive exercise program, which may include the use of modalities such as heat and postactivity icing. Local corticosteroid injection may be used in refractory cases and US guidance may help increase your accuracy of performing injections into the tendon sheath.

10

Scapular Winging
Medial scapular winging (Fig. 7-6) is caused by weakness of the ___________ ___________ (___________ ___________ oracic nerve). It is elicited by having the patient push against a wall and using resisted forward ___________ or resisted scapular ___________.

Scapular Winging
Medial scapular winging (Fig. 7-6) is caused by weakness of the serratus anterior (long thoracic nerve). It is elicited by having the patient push against a wall and using resisted forward flexion or resisted scapular protraction.

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Scapular Winging
Lateral winging is caused by weakness of the ___________ muscle (CN ___________) and is elicited by shoulder ___________.

Scapular Winging
Lateral winging is caused by weakness of the trapezius muscle (CN XI) and is elicited by shoulder abduction.

12

Golfer's Elbow (medial epicondylitis) – An overuse syndrome of the tendinous origin of the ___________-pronator mass and ___________ ___________ ligament of the elbow. The initial treatment is ___________ and ___________. Stretching the elbow during the painful period is important. Once pain and inflammation subside, strengthening exercises are started (important groups include the wrist flexors/extensors, wrist radial deviators, forearm pronator/supinators, and elbow flexor/extensors). Injection of local steroids into the area of max tenderness can also be considered, with care taken not to injure the ulnar nerve. A tennis elbow counterforce strap may be helpful.

Golfer's Elbow (medial epicondylitis) – An overuse syndrome of the tendinous origin of the flexor-pronator mass and medial collateral ligament of the elbow. The initial treatment is RICE and NSAIDs. Stretching the elbow during the painful period is important. Once pain and inflammation subside, strengthening exercises are started (important groups include the wrist flexors/extensors, wrist radial deviators, forearm pronator/supinators, and elbow flexor/extensors). Injection of local steroids into the area of max tenderness can also be considered, with care taken not to injure the ulnar nerve. A tennis elbow counterforce strap may be helpful.

13

Tennis Elbow (lateral epicondylitis) – An ___________ tendinopathy, especially of the ___________. The initial treatment is relative rest, NSAIDs, and heat or cold modalities. Wrist extensor stretching and strengthening should be initiated when tolerated. Conservative measures are usually effective, but recurrences are common. A tennis elbow ___________ worn circumferentially around the forearm just distal to the elbow may be helpful and a wrist ___________ may be considered to rest the common wrist extensor tendons. Modifications to the racquet include a ___________ racquet grip and head and ___________ string tension. A corticosteroid injection into the area of max tenderness may be indicated if conservative treatment fails. Treatment with PRP or autologous whole blood has been shown to be more effective than corticosteroids in those patients who have failed conservative treatment. No more than ___________ injections should be given at intervals of 5 days to 1 week. Surgical fasciotomy or fixation of the conjoined tendon may be considered if the above measures fail.

Tennis Elbow (lateral epicondylitis) – An extensor tendinopathy, especially of the ECRB. The initial treatment is relative rest, NSAIDs, and heat or cold modalities. Wrist extensor stretching and strengthening should be initiated when tolerated. Conservative measures are usually effective, but recurrences are common. A tennis elbow strap worn circumferentially around the forearm just distal to the elbow may be helpful and a wrist splint may be considered to rest the common wrist extensor tendons. Modifications to the racquet include a larger racquet grip and head and lesser string tension. A corticosteroid injection into the area of max tenderness may be indicated if conservative treatment fails. Treatment with PRP or autologous whole blood has been shown to be more effective than corticosteroids in those patients who have failed conservative treatment. No more than three injections should be given at intervals of 5 days to 1 week. Surgical fasciotomy or fixation of the conjoined tendon may be considered if the above measures fail.

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De Quervain's Disease – A ___________ of the ___________ dorsal compartment of the hand, including the ___________ and ___________ tendons. ___________ test is positive when pain is elicited in the radial wrist while the wrist is forced into ulnar deviation with the thumb enclosed in a fist. Treatment includes activity modification and NSAIDs followed by a stretching and strengthening program (Fig. 7-7). A thumb ___________ splint with the wrist in neutral position and the first MCP immobilized (IP joint is free) is helpful in resting the tendons. Local corticosteroid injections (maximum of three) into the compartment reduce acute pain and inflammation. US-guided injections have been described and may improve accuracy while decreasing the risk of intratendinous injections. Surgical decompression may be curative in severe, refractory cases.

De Quervain's Disease – A tenosynovitis of the first dorsal compartment of the hand, including the APL and EPB tendons. Finkelstein's test is positive when pain is elicited in the radial wrist while the wrist is forced into ulnar deviation with the thumb enclosed in a fist. Treatment includes activity modification and NSAIDs followed by a stretching and strengthening program (Fig. 7-7). A thumb spica splint with the wrist in neutral position and the first MCP immobilized (IP joint is free) is helpful in resting the tendons. Local corticosteroid injections (maximum of three) into the compartment reduce acute pain and inflammation. US-guided injections have been described and may improve accuracy while decreasing the risk of intratendinous injections. Surgical decompression may be curative in severe, refractory cases.

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___________ Fracture (most common carpal bone fracture) – Often due to a fall on an outstretched hand. ___________ tenderness may be noted. If initial plain films (approximately three to four views) are negative, the wrist should be ___________ (short arm cast or splint with thumb spica) and films repeated in ≈2 weeks (some fractures may not be visible until bone has resorbed around the fracture line). If repeat films are negative and clinical suspicion persists, CT or MRI can be considered.
Because the main blood supply (Fig. 7-8) enters from the ___________ pole, there is a high incidence of ___________ and ___________ in waist and proximal pole fractures. For nondisplaced fractures, a long arm thumb spica cast should be used. Isometric muscle contractions can be performed in the cast to counter atrophy. Displaced fractures or nondisplaced fractures with persistent nonunion should be referred for surgical evaluation.

Scaphoid Fracture (most common carpal bone fracture) – Often due to a fall on an outstretched hand. Snuffbox tenderness may be noted. If initial plain films (approximately three to four views) are negative, the wrist should be immobilized (short arm cast or splint with thumb spica) and films repeated in ≈2 weeks (some fractures may not be visible until bone has resorbed around the fracture line). If repeat films are negative and clinical suspicion persists, CT or MRI can be considered.
Because the main blood supply (Fig. 7-8) enters from the distal pole, there is a high incidence of nonunion and AVN in waist and proximal pole fractures. For nondisplaced fractures, a long arm thumb spica cast should be used. Isometric muscle contractions can be performed in the cast to counter atrophy. Displaced fractures or nondisplaced fractures with persistent nonunion should be referred for surgical evaluation.

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Trigger Finger (digital stenosing ___________) – Digital tendon sheath inflammation may result in a tendinous knot that gets stuck in the finger pulley system as the finger extends. Patients with ___________ or ___________ arthritis are particularly at risk for developing trigger finger. NSAIDs and steroid injections help to reduce inflammation and pain. Use of a ___________ static hand splint that immobilizes the MCP but allows full IP flexion rests the flexor tendons and helps break the vicious cycle of inflammation and catching. In some cases, surgery may be necessary to release tendons in fingers that are locked in flexion.

Trigger Finger (digital stenosing tenosynovitis) – Digital tendon sheath inflammation may result in a tendinous knot that gets stuck in the finger pulley system as the finger extends. Patients with DM or rheumatoid arthritis are particularly at risk for developing trigger finger. NSAIDs and steroid injections help to reduce inflammation and pain. Use of a volar static hand splint that immobilizes the MCP but allows full IP flexion rests the flexor tendons and helps break the vicious cycle of inflammation and catching. In some cases, surgery may be necessary to release tendons in fingers that are locked in flexion.

17

Greater Trochanteric Pain Syndrome – Classically described as trochanteric ___________, but improved visualization of the hip via MRI and arthros-copy has proven that other etiologies of lateral hip pain exist (such as gluteus medius or minimus tendinosis or tears and snapping hip syndrome). Pain is noted with walking, running, climbing stairs, sitting, and especially when side-lying on the involved hip. Physical examination often reveals ___________ tenderness over greater trochanter and pain-limited hip abductor strength, and lateral hip pain with ___________ -FAbERE test is noted. Conservative treatment includes NSAIDs, an iliotibial band stretching program, and hip abductor/ extensor strengthening. If refractory to these measures, a steroid injection into the bursa (Fig. 7-9) can relieve symptoms in many patients. Various etiologies may be responsible for greater trochanteric region pain; therefore, MSK US may become a valuable tool for both diagnostic and therapeutic reasons.

Greater Trochanteric Pain Syndrome – Classically described as trochanteric bursitis, but improved visualization of the hip via MRI and arthros-copy has proven that other etiologies of lateral hip pain exist (such as gluteus medius or minimus tendinosis or tears and snapping hip syndrome). Pain is noted with walking, running, climbing stairs, sitting, and especially when side-lying on the involved hip. Physical examination often reveals point tenderness over greater trochanter and pain-limited hip abductor strength, and lateral hip pain with Patrick-FAbERE test is noted. Conservative treatment includes NSAIDs, an iliotibial band stretching program, and hip abductor/ extensor strengthening. If refractory to these measures, a steroid injection into the bursa (Fig. 7-9) can relieve symptoms in many patients. Various etiologies may be responsible for greater trochanteric region pain; therefore, MSK US may become a valuable tool for both diagnostic and therapeutic reasons.

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Iliotibial Band Syndrome – Potential causes include ___________ or running on ___________ surfaces. ___________ knee pain is noted as the ITB slides over the lateral femoral condyle, especially between 20° and 30° of ___________. Predisposing factors include genu ___________, tibial ___________, ___________ hindfoot, and foot ___________. Tenderness over the lateral knee and ___________ tubercle may be noted on examination. ___________ test may be positive. Rehabilitation should be aimed at stretching the ITB, hip flexors, and gluteus maximus. ___________ may be strengthened to counteract the tight ITB, and hip abductor strengthening may also be performed to improve dynamic hip stability (Fig. 7-10). Helpful modalities include ice, US, and ___________. Foot pronation should be corrected; running only on even surfaces may help. A steroid injection into the area of the lateral femoral condyle may relieve pain. Symptoms can generally take 2 to 6 months to improve.
Figure 7-11 illustrates the Ober test for ITB/TFL contraction. The patient lies on the side with the involved side uppermost. The hip is flexed and then abducted as far as possible while stabilizing the pelvis. Next, the hip is brought into extension and the limb is released. The limb will remain abducted if there is tightness at the ITB or TFL.

Iliotibial Band Syndrome – Potential causes include overtraining or running on uneven surfaces. Lateral knee pain is noted as the ITB slides over the lateral femoral condyle, especially between 20° and 30° of flexion. Predisposing factors include genu varum, tibial varum, varus hindfoot, and foot pronation. Tenderness over the lateral knee and Gerdy's tubercle may be noted on examination. Ober's test may be positive. Rehabilitation should be aimed at stretching the ITB, hip flexors, and gluteus maximus. Adductors may be strengthened to counteract the tight ITB, and hip abductor strengthening may also be performed to improve dynamic hip stability (Fig. 7-10). Helpful modalities include ice, US, and phonophoresis. Foot pronation should be corrected; running only on even surfaces may help. A steroid injection into the area of the lateral femoral condyle may relieve pain. Symptoms can generally take 2 to 6 months to improve.
Figure 7-11 illustrates the Ober test for ITB/TFL contraction. The patient lies on the side with the involved side uppermost. The hip is flexed and then abducted as far as possible while stabilizing the pelvis. Next, the hip is brought into extension and the limb is released. The limb will remain abducted if there is tightness at the ITB or TFL.

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Pes Anserine Bursitis (bursa under ___________, ___________, ___________; mnemonic: “Say Grace before Tea”) – Pain and tenderness at the insertion of the medial hamstrings at the medial proximal tibia may be noted. The treatment should emphasize stretching of the medial hamstrings and improving knee biomechanics. Athletes may wear protective knee padding. Steroid injections may be very effective, but US guidance should be considered since unguided injections rarely infiltrate the pes anserine bursa.

Pes Anserine Bursitis (bursa under Sartorius, Gracilis, semiTendinosis; mnemonic: “Say Grace before Tea”) – Pain and tenderness at the insertion of the medial hamstrings at the medial proximal tibia may be noted. The treatment should emphasize stretching of the medial hamstrings and improving knee biomechanics. Athletes may wear protective knee padding. Steroid injections may be very effective, but US guidance should be considered since unguided injections rarely infiltrate the pes anserine bursa.

20

Anterior Cruciate Ligament – The ACL proceeds superiorly and posteriorly from its anterior medial tibial attachment to attach to the ___________ aspect of the lateral femoral condyle (Fig. 7-12). It prevents excessive anterior translation of the tibia and abnormal ___________ ___________ of the tibia on the femur and knee hyperex-tension. A primary function in the athlete is maintaining joint stability during deceleration.
The most common mechanism of injury is ___________ ___________ of the femur on fixed tibia with a ___________ load. Injuries may be due to excessive pivoting or cutting, as well as hyperextension, hyperflexion, or lateral trauma to the knee. A “pop” is often heard or felt at the time of injury. Immediate swelling due to hemarthrosis and a sense of instability usually follow.

Anterior Cruciate Ligament – The ACL proceeds superiorly and posteriorly from its anterior medial tibial attachment to attach to the medial aspect of the lateral femoral condyle (Fig. 7-12). It prevents excessive anterior translation of the tibia and abnormal external rotation of the tibia on the femur and knee hyperex-tension. A primary function in the athlete is maintaining joint stability during deceleration.
The most common mechanism of injury is external rotation of the femur on fixed tibia with a valgus load. Injuries may be due to excessive pivoting or cutting, as well as hyperextension, hyperflexion, or lateral trauma to the knee. A “pop” is often heard or felt at the time of injury. Immediate swelling due to hemarthrosis and a sense of instability usually follow.

21

Anterior Cruciate Ligament
The Lachman test (Fig. 7-13) is performed at 20° to 30° of knee ___________ and particularly assesses the posterolateral fibers. Some laxity may be normal, so comparison with the contralateral leg is recommended. ___________ is higher than the anterior drawer test (99% vs. 54%).1 The pivot shift (___________) test is performed in the lateral decubitus position with the affected knee extended and the tibia internally rotated. Valgus stress is applied to the knee as it is flexed. A “clunk” felt at 30° of knee flexion is indicative of ACL injury. An MRI confirms the diagnosis and may identify other concomitant injuries.

Anterior Cruciate Ligament
The Lachman test (Fig. 7-13) is performed at 20° to 30° of knee flexion and particularly assesses the posterolateral fibers. Some laxity may be normal, so comparison with the contralateral leg is recommended. Sensitivity is higher than the anterior drawer test (99% vs. 54%).1 The pivot shift (MacIntosh) test is performed in the lateral decubitus position with the affected knee extended and the tibia internally rotated. Valgus stress is applied to the knee as it is flexed. A “clunk” felt at 30° of knee flexion is indicative of ACL injury. An MRI confirms the diagnosis and may identify other concomitant injuries.

22

Nonoperative rehabilitation of ACL injury should concentrate on ___________ training and strengthening of the ___________ (i.e., TheraBand; see Fig. 7-14) to prevent anterior subluxation of the tibia. Terminal range squats to strengthen the quads should be encouraged to prevent ___________ pain, a frequent occurrence after ACL tears. Bracing should limit terminal extension and rotation. Activity modification (e.g., avoiding cutting and pivoting sports) is extremely important if nonoperative management is given a trial to avoid injury to other intra-articular structures, such as the menisci.
The need for operative treatment depends on the amount of damage and degree of laxity and is patient specific as well. A younger, more active patient is more likely to require surgical repair versus the older, sedentary patient. Post-op rehab can last up to 6 to 9 months, although the trend is to shorten this time.

Nonoperative rehabilitation of ACL injury should concentrate on proprioceptive training and strengthening of the hamstrings (i.e., TheraBand; see Fig. 7-14) to prevent anterior subluxation of the tibia. Terminal range squats to strengthen the quads should be encouraged to prevent patellofemoral pain, a frequent occurrence after ACL tears. Bracing should limit terminal extension and rotation. Activity modification (e.g., avoiding ___________ and ___________ sports) is extremely important if nonoperative management is given a trial to avoid injury to other intra-articular structures, such as the menisci.
The need for operative treatment depends on the amount of damage and degree of laxity and is patient specific as well. A younger, more active patient is more likely to require surgical repair versus the older, sedentary patient. Post-op rehab can last up to 6 to 9 months, although the trend is to shorten this time.

23

Anterior Cruciate Ligament
Patients are typically ___________ with an ___________ brace immediately after surgery. As with nonoperative rehab, the emphasis is on strengthening the hamstrings and proprioceptive training. During the first 6 weeks, it is important to regain ___________ (can be assisted by ___________) and enhance ___________ mobility. Intensity and resistance should progressively increase between weeks 6 and 10. By week 10, there should be essentially no limitation in strengthening.
Prevention of these injuries is of utmost importance as well and has been a recent focus of sports medicine research. Young female athletes, especially those that play soccer and basketball, are at a much higher risk of ACL injury than their male peers. ACL injury prevention programs that incorporate proprioceptive and neuromuscular control training may reduce the risk of ACL injuries and, therefore, should be considered in high-risk athletes.

Anterior Cruciate Ligament
Patients are typically WBAT with an extension brace immediately after surgery. As with nonoperative rehab, the emphasis is on strengthening the hamstrings and proprioceptive training. During the first 6 weeks, it is important to regain ROM (can be assisted by CPM) and enhance patellar mobility. Intensity and resistance should progressively increase between weeks 6 and 10. By week 10, there should be essentially no limitation in strengthening.
Prevention of these injuries is of utmost importance as well and has been a recent focus of sports medicine research. Young female athletes, especially those that play soccer and basketball, are at a much higher risk of ACL injury than their male peers. ACL injury prevention programs that incorporate proprioceptive and neuromuscular control training may reduce the risk of ACL injuries and, therefore, should be considered in high-risk athletes.

24

Posterior Cruciate Ligament – The PCL (Fig. 7-15) arises from the posterior intercondylar tibia and extends anteriorly, superiorly, and medially to attach to the medial femoral condyle. It prevents abnormal ___________ ___________ and posterior ___________ of the tibia on the femur, which aids knee flexion.
Injury of the PCL classically occurs secondary to an MVA when the tibia strikes the ___________, forcing the tibia posteriorly. Injury also occurs with high ___________ stress or when falling on a ___________ knee. Swelling is uncommon. Integrity of the PCL can be tested by the posterior drawer test and the sag test, where the examiner tries to observe a posterior displacement of the tibial tuberosity (or tibial joint line in relation to the femur) while the patient is supine and the knees are flexed to 90° to allow the quadriceps to relax. After a ___________ sign is assessed for, the posterior drawer test can be used to further test the integrity of the PCL. In addition, a ___________ stress can be applied to an ___________ knee to assess for concomitant injuries to the PCL and posterolateral corner of the relaxed knee.
Treatment of a mild PCL sprain usually involves ___________ strengthening without need for bracing. Severe PCL injuries will often need to be repaired arthroscopically.

Posterior Cruciate Ligament – The PCL (Fig. 7-15) arises from the posterior intercondylar tibia and extends anteriorly, superiorly, and medially to attach to the medial femoral condyle. It prevents abnormal internal rotation and posterior translation of the tibia on the femur, which aids knee flexion.
Injury of the PCL classically occurs secondary to an MVA when the tibia strikes the dashboard, forcing the tibia posteriorly. Injury also occurs with high valgus stress or when falling on a flexed knee. Swelling is uncommon. Integrity of the PCL can be tested by the posterior drawer test and the sag test, where the examiner tries to observe a posterior displacement of the tibial tuberosity (or tibial joint line in relation to the femur) while the patient is supine and the knees are flexed to 90° to allow the quadriceps to relax. After a sag sign is assessed for, the posterior drawer test can be used to further test the integrity of the PCL. In addition, a varus stress can be applied to an extended knee to assess for concomitant injuries to the PCL and posterolateral corner of the relaxed knee.
Treatment of a mild PCL sprain usually involves quadriceps strengthening without need for bracing. Severe PCL injuries will often need to be repaired arthroscopically.

25

Meniscal Injury – The menisci (Fig. 7-16) are ___________ structures of the intra-articular knee that increase the contact area between the ___________ and ___________ and can act as “___________ absorbers” for the knee.

Meniscal Injury – The menisci (Fig. 7-16) are fibrocartilaginous structures of the intra-articular knee that increase the contact area between the femur and tibia and can act as “shock absorbers” for the knee.

26

Meniscal Injury
Mechanisms of injury include excessive ___________ stresses, typically the result of twisting a ___________ knee. The medial meniscus is more often injured than the lateral.

Meniscal Injury
Mechanisms of injury include excessive rotational stresses, typically the result of twisting a flexed knee. The medial meniscus is more often injured than the lateral.

27

Meniscal Injury
Knee ___________, ___________, and/or ___________ are characteristic complaints. On examination, an effusion, joint line tenderness, and loss of full knee flexion or extension may be noted. ___________ test is performed with the patient supine and hip and knee maximally ___________.

Meniscal Injury
Knee locking, popping, and/or clicking are characteristic complaints. On examination, an effusion, joint line tenderness, and loss of full knee flexion or extension may be noted. McMurray's test is performed with the patient supine and hip and knee maximally flexed.

28

Meniscal Injury
A ___________-tibial ___________ ___________ force is applied while the knee is ___________; a pop or snap suggests a medial meniscus tear. ___________-tibial ___________ ___________ forces are used to evaluate the lateral meniscus. McMurray's test may be poorly tolerated due to pain, and some consider it to be relatively unreliable. ___________ grind test may be positive, but it is avoided by some clinicians for fear of aggravating the injury. The Thessaly test has recently been described and validated. It is performed in single leg stance with 20° of knee flexion with assistance from the examiner, who holds the hands while the subject rotates the knee internally and externally. MRI may help confirm the clinical diagnosis and identify other injuries. Arthroscopy is the gold standard for diagnosis of a tear.

Meniscal Injury
A valgus-tibial external rotation force is applied while the knee is extended; a pop or snap suggests a medial meniscus tear. Varus-tibial internal rotation forces are used to evaluate the lateral meniscus. McMurray's test may be poorly tolerated due to pain, and some consider it to be relatively unreliable. Apley's grind test may be positive, but it is avoided by some clinicians for fear of aggravating the injury. The Thessaly test has recently been described and validated. It is performed in single leg stance with 20° of knee flexion with assistance from the examiner, who holds the hands while the subject rotates the knee internally and externally. MRI may help confirm the clinical diagnosis and identify other injuries. Arthroscopy is the gold standard for diagnosis of a tear.

29

Meniscal Injury
Treatment is dependent on the severity of injury. For the nonsurgically treated patient, early management consists of ___________, ___________, and ___________ & ___________ stretching, and a ___________ ___________ exercise program for quadriceps/hamstring/hip strengthening. A joint aspiration is sometimes useful to reduce effusion and relieve pain. Aquatic exercises and the use of canes can unload the affected meniscus. The intensity can be gradually increased with avoidance of activities involving compressive rotational loading. It may be reasonable to gradually resume sports activities once strength in the affected limb approaches 70% to 80% of that of the unaffected limb. Orthopedic referral for possible arthroscopic surgery is indicated if the patient is experiencing mechanical symptoms including locking, buckling, or recurrent swelling with pain.

Meniscal Injury
Treatment is dependent on the severity of injury. For the nonsurgically treated patient, early management consists of RICE, NSAIDs, hamstring and ITB stretching, and a progressive resistive exercise program for quadriceps/hamstring/hip strengthening. A joint aspiration is sometimes useful to reduce effusion and relieve pain. Aquatic exercises and the use of canes can unload the affected meniscus. The intensity can be gradually increased with avoidance of activities involving compressive rotational loading. It may be reasonable to gradually resume sports activities once strength in the affected limb approaches 70% to 80% of that of the unaffected limb. Orthopedic referral for possible arthroscopic surgery is indicated if the patient is experiencing mechanical symptoms including locking, buckling, or recurrent swelling with pain.

30

Meniscal Injury
Surgical treatment has been evolving. Total meniscectomy is no longer considered acceptable; efforts are now aimed at preserving as much cartilage as possible in order to prevent degenerative changes. The ___________ thirds of the menisci are vascular and may be repaired; the ___________ two-thirds are avascular and may need to be debrided. Following partial meniscectomy, full WB may occur once the patient is pain free. Following meniscal repair, full WB may be delayed for up to ___________ weeks. ROM exercise, stretching, and progressive strengthening of the lower limbs are the mainstays of post-op therapy. Deep squatting is ___________.

Meniscal Injury
Surgical treatment has been evolving. Total meniscectomy is no longer considered acceptable; efforts are now aimed at preserving as much cartilage as possible in order to prevent degenerative changes. The outer thirds of the menisci are vascular and may be repaired; the inner two-thirds are avascular and may need to be debrided. Following partial meniscectomy, full WB may occur once the patient is pain free. Following meniscal repair, full WB may be delayed for up to 6 weeks. ROM exercise, stretching, and progressive strengthening of the lower limbs are the mainstays of post-op therapy. Deep squatting is discouraged.

31

Patellofemoral Pain Syndrome – The etiology is postulated to be a combination of overuse, muscular imbalance (i.e., hip ___________ and ___________ rotator weakness), and/or biomechanical problems (i.e., pes ___________ or pes ___________, ↑ ___________ angle [Fig. 7-17]). Anterior knee pain may occur with activity and worsen with prolonged ___________ or ___________ stairs.

Patellofemoral Pain Syndrome – The etiology is postulated to be a combination of overuse, muscular imbalance (i.e., hip abductor and external rotator weakness),18 and/or biomechanical problems (i.e., pes planus or pes cavus, ↑ Q angle [Fig. 7-17]). Anterior knee pain may occur with activity and worsen with prolonged sitting or descending stairs.

32

Patellofemoral Pain Syndrome
Acute management involves relative ___________, ___________, and ___________. Prolonged sitting should be avoided. The mainstay of rehabilitation is to address the biomechanical deficits through a combination of quadriceps strengthening exercises with stretching of the quadriceps, hamstrings, ITB, and gastroc–soleus complex.

Patellofemoral Pain Syndrome
Acute management involves relative rest, ice, and NSAIDs. Prolonged sitting should be avoided. The mainstay of rehabilitation is to address the biomechanical deficits through a combination of quadriceps strengthening exercises with stretching of the quadriceps, hamstrings, ITB, and gastroc–soleus complex.

33

Patellofemoral Pain Syndrome
Classically, ___________ ___________ terminal knee ___________ (0° to 30°) exercises were utilized, with the belief that they selectively strengthened the ___________ ___________ ___________. Currently, the idea of ___________ ___________ ___________ selectivity is controversial. In general, short arc (0° to 45°) closed kinetic chain leg press exercises are recommended to strengthen all four heads of the quads, which are thought to be weakened in aggregate. Full arc and open kinetic chain exercises should be avoided to reduce symptom aggravation.

Patellofemoral Pain Syndrome
Classically, short arc terminal knee extension (0° to 30°) exercises were utilized, with the belief that they selectively strengthened the VMO (vastus medialis obliquus). Currently, the idea of VMO selectivity is controversial. In general, short arc (0° to 45°) closed kinetic chain leg press exercises are recommended to strengthen all four heads of the quads, which are thought to be weakened in aggregate. Full arc and open kinetic chain exercises should be avoided to reduce symptom aggravation.

34

Patellofemoral Pain Syndrome
___________ the patella so that it tracks properly (___________ technique) may improve pain symptoms during exercise. Orthotics to correct pes ___________ or foot ___________ and soft braces with patellar cutouts may provide modest symptomatic relief in appropriate cases. Occasionally, electrical stimulation and biofeedback are useful. Prolonged PT with modalities such as US is generally not helpful or cost-effective. Surgery is rarely necessary and is reserved for recalcitrant instability or symptomatic malalignment.

Patellofemoral Pain Syndrome
Taping the patella so that it tracks properly (McConnell technique) may improve pain symptoms during exercise. Orthotics to correct pes planus or foot pronation and soft braces with patellar cutouts may provide modest symptomatic relief in appropriate cases. Occasionally, electrical stimulation and biofeedback are useful. Prolonged PT with modalities such as US is generally not helpful or cost-effective. Surgery is rarely necessary and is reserved for recalcitrant instability or symptomatic malalignment.

35

Exercise-Induced Leg Pain – Shin splint, a nonspecific term, refers to exercise-induced ___________ pain, without evidence of fracture on x-ray. It is believed to represent ___________, usually of the posteromedial tibial border (medial tibial stress syndrome). Runners, gymnasts, and dancers are at risk, with causes including an increase in exercise intensity, inadequate footwear, hard surface training, or poor biomechanics. Local pain and tenderness are noted along the distal one-third of the tibia. Pain is often quickly relieved by rest and not aggravated by passive stretch. Bone scan may be positive in severe cases. Treatment includes rest, NSAIDs, US, preactivity icing, and correction of aggravating factors.

Exercise-Induced Leg Pain – Shin splint, a nonspecific term, refers to exercise-induced tibial pain, without evidence of fracture on x-ray. It is believed to represent periostitis, usually of the posteromedial tibial border (medial tibial stress syndrome). Runners, gymnasts, and dancers are at risk, with causes including an increase in exercise intensity, inadequate footwear, hard surface training, or poor biomechanics. Local pain and tenderness are noted along the distal one-third of the tibia. Pain is often quickly relieved by rest and not aggravated by passive stretch. Bone scan may be positive in severe cases. Treatment includes rest, NSAIDs, US, preactivity icing, and correction of aggravating factors.

36

Causes of TSFs are similar to those of tibial stress syndrome. Stress fractures are also common in the ___________ and the metatarsals, especially the ___________ metatarsal. Pain is initially exercise induced only, but progresses to pain with WB or even at rest. There is often exquisite point tenderness along the distal or middle third of the tibia. X-rays may be negative initially, but may show a clear fracture after several weeks (i.e., a positive “dreaded black line” on oblique radiograph, representing an anterior TSF). Bone scans are more sensitive. TSFs can be treated with relative ___________ (i.e., crutches). Medial TSFs can be treated with relative rest for 4 to 6 weeks, NSAIDs, and TENS. Anterior TSFs may require several months of rest from sports activities and ongoing conservative treatment. Recalcitrant cases may eventually require a bone graft.

Causes of TSFs are similar to those of tibial stress syndrome. Stress fractures are also common in the fibula and the metatarsals, especially the second metatarsal. Pain is initially exercise induced only, but progresses to pain with WB or even at rest. There is often exquisite point tenderness along the distal or middle third of the tibia. X-rays may be negative initially, but may show a clear fracture after several weeks (i.e., a positive “dreaded black line” on oblique radiograph, representing an anterior TSF). Bone scans are more sensitive. TSFs can be treated with relative rest (i.e., crutches). Medial TSFs can be treated with relative rest for 4 to 6 weeks, NSAIDs, and TENS. Anterior TSFs may require several months of rest from sports activities and ongoing conservative treatment. Recalcitrant cases may eventually require a bone graft.

37

In chronic compartment syndrome of the leg, pain is felt after a specific period of ___________ and can be associated with paresthesias, numbness, and weakness in the distribution of the nerve within the compartment. EDx studies are usually ___________. Resting and postexercise compartment pressures should be obtained. Resting pressures > ___________ mm Hg, 15-second postexercise pressures > ___________ mm Hg, or 2-minute postexercise pressures > ___________ mm Hg are all suggestive of chronic compartment syndrome. An initial conservative approach should include ___________, proper ___________ selection, and correction of ___________ errors. If symptoms persist 1 to 2 months after a trial of conservative treatment, referral for surgical fasciotomy may be warranted.

In chronic compartment syndrome of the leg, pain is felt after a specific period of exercise and can be associated with paresthesias, numbness, and weakness in the distribution of the nerve within the compartment. EDx studies are usually normal. Resting and postexercise compartment pressures should be obtained. Resting pressures > 30 mm Hg, 15-second postexercise pressures >60 mm Hg, or 2-minute postexercise pressures >20 mm Hg are all suggestive of chronic compartment syndrome. An initial conservative approach should include NSAIDs, proper footwear selection, and correction of training errors. If symptoms persist 1 to 2 months after a trial of conservative treatment, referral for surgical fasciotomy may be warranted.

38

Achilles Tendinitis – Overuse, ___________, heel ___________ deformity, and poor flexibility of the Achilles tendon/gastroc–soleus/hamstrings may be contributing factors. Basketball players may be particularly susceptible because of the frequent jumping. It is also noted in runners who increase their mileage or hill training. Symptoms include pain and swelling in the tendon during and after activities. On examination, there may be swelling, pain on palpation, a palpable nodule, and inability to stand on tiptoes. Chronic tendinosis may result in tendon weakness, potentially leading to rupture.
There is no consensus on the optimal mode of treatment, but most rehabilitation will likely begin with the PRICE principle. Modalities, especially US, may be helpful. ___________ strengthening is important. ___________ exercises should be emphasized; uphill running should be discouraged, especially early in rehab. Heel lifts may provide early relief but may lead to heel cord shortening with prolonged use. A properly fitted shoe, often with a stiff heel counter, is important. Injection into the Achilles tendon is not recommended by many sources due to the risk of tendon rupture. For severe or chronic cases, recovery to near-normal strength may take up to 24 months, even with good circulation. For this reason, novel treatments (i.e., PRP) are currently being studied, but results are inconclusive. Young, active persons with ruptured tendons are usually operated on; casting is an option for older, sedentary persons.

Achilles Tendinitis – Overuse, overpronation, heel varus deformity, and poor flexibility of the Achilles tendon/gastroc–soleus/hamstrings may be contributing factors. Basketball players may be particularly susceptible because of the frequent jumping. It is also noted in runners who increase their mileage or hill training. Symptoms include pain and swelling in the tendon during and after activities. On examination, there may be swelling, pain on palpation, a palpable nodule, and inability to stand on tiptoes. Chronic tendinosis may result in tendon weakness, potentially leading to rupture.
There is no consensus on the optimal mode of treatment, but most rehabilitation will likely begin with the PRICE principle. Modalities, especially US, may be helpful. Plantarflexor strengthening is important. Downhill exercises should be emphasized; uphill running should be discouraged, especially early in rehab. Heel lifts may provide early relief but may lead to heel cord shortening with prolonged use. A properly fitted shoe, often with a stiff heel counter, is important. Injection into the Achilles tendon is not recommended by many sources due to the risk of tendon rupture. For severe or chronic cases, recovery to near-normal strength may take up to 24 months, even with good circulation. For this reason, novel treatments (i.e., PRP) are currently being studied, but results are inconclusive.19,20 Young, active persons with ruptured tendons are usually operated on; casting is an option for older, sedentary persons.

39

Ankle Sprains – Lateral ankle sprains are usually due to ___________ of a ___________ foot. The ___________ is typically the first structure to be involved. With increasing severity of injury, the ___________ may be involved next, followed by the ___________. The anterior drawer test checks ankle ligament stability, primarily the ATFL (displacement ≥ ___________ mm is considered positive). The ___________ tilt test (Fig. 7-18) checks the CFL; it is performed by providing an inversion stress on the talus (a positive test is a marked difference, i.e., >10°, in the inversion of the affected vs. the unaffected side). X-rays to check the tibiofibular syndesmosis may be necessary in the event of severe sprains; these require surgical consultation.
Injuries of the medial (deltoid) ankle ligament due to an ever-sion injury are less common; an associated proximal fibula fracture (___________ fracture) should be ruled out.

Ankle Sprains – Lateral ankle sprains are usually due to inversion of a plantarflexed foot. The ATFL is typically the first structure to be involved. With increasing severity of injury, the CFL may be involved next, followed by the PTFL. The anterior drawer test checks ankle ligament stability, primarily the ATFL (displacement ≥ 5 mm is considered positive). The talar tilt test (Fig. 7-18) checks the CFL; it is performed by providing an inversion stress on the talus (a positive test is a marked difference, i.e., >10°, in the inversion of the affected vs. the unaffected side). X-rays to check the tibiofibular syndesmosis may be necessary in the event of severe sprains; these require surgical consultation.
Injuries of the medial (deltoid) ankle ligament due to an ever-sion injury are less common; an associated proximal fibula fracture (Maisonneuve fracture) should be ruled out.

40

Ankle Sprains
Rehabilitation of ankle sprains involves three phases: Phase I normally lasts 1 to ___________ days, until the patient is able to bear ___________ comfortably. This phase involves the ___________ principle: rest (i.e., crutches), ice 20 minutes 3 to 5×/day, compression with Ace wrap, and elevation of the foot above the heart. Hot showers, EtOH, methyl salicylate counterirritants (i.e., Ben Gay), and other treatments that may increase swelling should be avoided during the initial 24 hours. Phase II usually lasts days to ___________. The goals in this phase are to restore ___________, strengthen the ankle ___________, and stretch/strengthen the Achilles tendon. Phase III is initiated when motion is near ___________ and pain and swelling are almost ___________. Reestablishing motor coordination via proprioceptive exercises and endurance training are emphasized, i.e., balance board, running curves (figure-of-8), and zigzag running.
Return to play guidelines vary. Some recommendations may be as follows: Grade I (no laxity and minimal ligamentous tear): 0 to 5 days. Grade II (mild to moderate laxity and functional loss): 7 to 14 days. Grade III (complete ligamentous disruption and cannot bear weight): 21 to 35 days. Syndesmosis injury: 21 to 56 days. Recent literature has demonstrated that an early and accelerated rehabilitation program results in better short-term outcomes for grades I and II lateral ankle sprains.

Ankle Sprains
Rehabilitation of ankle sprains involves three phases: Phase I normally lasts 1 to 3 days, until the patient is able to bear weight comfortably. This phase involves the RICE principle: rest (i.e., crutches), ice 20 minutes 3 to 5×/day, compression with Ace wrap, and elevation of the foot above the heart. Hot showers, EtOH, methyl salicylate counterirritants (i.e., Ben Gay), and other treatments that may increase swelling should be avoided during the initial 24 hours. Phase II usually lasts days to weeks. The goals in this phase are to restore ROM, strengthen the ankle stabilizers, and stretch/strengthen the Achilles tendon. Phase III is initiated when motion is near normal and pain and swelling are almost absent. Reestablishing motor coordination via proprioceptive exercises and endurance training are emphasized, i.e., balance board, running curves (figure-of-8), and zigzag running.
Return to play guidelines vary. Some recommendations may be as follows: Grade I (no laxity and minimal ligamentous tear): 0 to 5 days. Grade II (mild to moderate laxity and functional loss): 7 to 14 days. Grade III (complete ligamentous disruption and cannot bear weight): 21 to 35 days. Syndesmosis injury: 21 to 56 days. Recent literature has demonstrated that an early and accelerated rehabilitation program results in better short-term outcomes for grades I and II lateral ankle sprains.

41

Plantar Fasciitis – Commonly seen in athletes and in persons whose jobs require much ___________ or ___________. Repetitive ___________ to the plantar fascia can cause inflammation and pain in the acute phase. In chronic conditions, the fascia is less commonly inflamed; instead, it becomes degenerative and painful and is commonly termed plantar fasciopathy. Biomechanical issues (i.e., an overpronated foot with increased tension on the fascia) are often at fault. The classic symptoms are heel pain with the first few steps in the morning or pain that is worse at the beginning of an activity.

Plantar Fasciitis – Commonly seen in athletes and in persons whose jobs require much standing or walking. Repetitive microtrauma to the plantar fascia can cause inflammation and pain in the acute phase. In chronic conditions, the fascia is less commonly inflamed; instead, it becomes degenerative and painful and is commonly termed plantar fasciopathy. Biomechanical issues (i.e., an overpronated foot with increased tension on the fascia) are often at fault. The classic symptoms are heel pain with the first few steps in the morning or pain that is worse at the beginning of an activity.

42

Plantar Fasciitis
The key component of treatment is a home exercise program of routine, daily ___________ of the plantar fascia (Fig. 7-19) and Achilles tendon, which has proven to be superior to other treatment modalities. Patients should be on relative ___________ from walking, running, and jumping and consider switching to activities such as swimming or cycling to allow for the fascia to heal. Proper footwear includes well-cushioned soles, possible use of an extra-deep heel pad/cup insert, and avoiding high heels. Soft medial arch supports are generally preferable to rigid orthotics, which can exacerbate symptoms. NSAIDs and ice may help decrease inflammation. For patients not responding to other measures, splints may be useful to supply a gentle constant stretch across the sole of the foot and gastrocnemius at night while sleeping. Once the pain resolves, patients should return to increased levels of activity only gradually, while continuing their stretching program.

Plantar Fasciitis
The key component of treatment is a home exercise program of routine, daily stretching of the plantar fascia (Fig. 7-19) and Achilles tendon, which has proven to be superior to other treatment modalities. Patients should be on relative rest from walking, running, and jumping and consider switching to activities such as swimming or cycling to allow for the fascia to heal. Proper footwear includes well-cushioned soles, possible use of an extra-deep heel pad/cup insert, and avoiding high heels. Soft medial arch supports are generally preferable to rigid orthotics, which can exacerbate symptoms. NSAIDs and ice may help decrease inflammation. For patients not responding to other measures, splints may be useful to supply a gentle constant stretch across the sole of the foot and gastrocnemius at night while sleeping. Once the pain resolves, patients should return to increased levels of activity only gradually, while continuing their stretching program.

43

Plantar Fasciitis
The majority of cases will improve with conservative measures within 6 to 12 weeks, if faithfully followed. In the rare, persistent case, a local corticosteroid injection may be considered. A potential complication is ___________ of the fatty pad of the heel, which cannot be easily reversed or treated. Surgical intervention, which consists of a release of the involved fascia from its attachment to the calcaneus, can be considered if all other measures fail, but is necessary in only very rare cases.

Plantar Fasciitis
The majority of cases will improve with conservative measures within 6 to 12 weeks, if faithfully followed. In the rare, persistent case, a local corticosteroid injection may be considered. A potential complication is necrosis of the fatty pad of the heel, which cannot be easily reversed or treated. Surgical intervention, which consists of a release of the involved fascia from its attachment to the calcaneus, can be considered if all other measures fail, but is necessary in only very rare cases.

44

SPORTS/EXERCISE PREPARTICIPATION EVALUATION (PPE)
Questions about personal and family history of cardiovascular disease are the most important initial component of the H&P. A thorough history of neurologic or MSK problems should also be emphasized. Physical examination should emphasize cardiac auscultation with provocative maneuvers to screen for ___________ ___________ (see below), which is the most common cause of sudden death in young male athletes. The use of ECG in the PPE screen remains controversial.23 For most young, asymptomatic persons, screening tests such as electrocardiography, treadmill stress testing, and lab tests are not indicated in the absence of symptoms or a significant history of risk factors.1 For older asymptomatic persons w/o cardiopulmonary risk factors or known metabolic disease, the American College of Sports Medicine recommends exercise stress testing in men ≥ ___________ years and women ≥ ___________ years before starting a vigorous exercise program (≥60% of Vo2max). Most older persons can begin a moderate aerobic and resistance training program without stress testing if they begin to slowly and gradually increase their level of activity.

SPORTS/EXERCISE PREPARTICIPATION EVALUATION (PPE)
Questions about personal and family history of cardiovascular disease are the most important initial component of the H&P. A thorough history of neurologic or MSK problems should also be emphasized. Physical examination should emphasize cardiac auscultation with provocative maneuvers to screen for hypertrophic cardiomyopathy (see below), which is the most common cause of sudden death in young male athletes. The use of ECG in the PPE screen remains controversial.23 For most young, asymptomatic persons, screening tests such as electrocardiography, treadmill stress testing, and lab tests are not indicated in the absence of symptoms or a significant history of risk factors.1 For older asymptomatic persons w/o cardiopulmonary risk factors or known metabolic disease, the American College of Sports Medicine recommends exercise stress testing in men ≥ 45 years and women ≥ 55 years before starting a vigorous exercise program (≥60% of Vo2max). Most older persons can begin a moderate aerobic and resistance training program without stress testing if they begin to slowly and gradually increase their level of activity.

45

Conditions That Contraindicate Sports Participation
The following conditions preclude participation: active ___________ or ___________; ___________ cardiomyopathy; uncontrolled severe ___________ (static resistance exercises are particularly contraindicated); suspected ___________ until fully evaluated; long ___________ interval syndrome; history of recent concussion and symptoms of postconcussion syndrome (no contact or collision sports); poorly controlled ___________ disorder (no archery, riflery, swimming, weight lifting, strength training, or sports involving heights); recurrent episodes of burning UEx pain or weakness or episodes of transient quadriplegia until stability of cervical spine can be assured (no contact or collision sports); sickle cell disease (no high exertion, contact, or collision sports); mononucleosis with unresolved splenomegaly; eating disorder where athlete is not compliant with treatment or follow-up or where there is evidence of diminished performance or potential injury because of eating disorder.

Conditions That Contraindicate Sports Participation
The following conditions preclude participation: active myocarditis or pericarditis; hypertrophic cardiomyopathy; uncontrolled severe HTN (static resistance exercises are particularly contraindicated); suspected CAD until fully evaluated; long QT interval syndrome; history of recent concussion and symptoms of postconcussion syndrome (no contact or collision sports); poorly controlled convulsive disorder (no archery, riflery, swimming, weight lifting, strength training, or sports involving heights); recurrent episodes of burning UEx pain or weakness or episodes of transient quadriplegia until stability of cervical spine can be assured (no contact or collision sports); sickle cell disease (no high exertion, contact, or collision sports); mononucleosis with unresolved splenomegaly; eating disorder where athlete is not compliant with treatment or follow-up or where there is evidence of diminished performance or potential injury because of eating disorder.

46

REHABILITATION AFTER HIP FRACTURE
The lifetime risk of hip fractures in industrialized countries is 18% for ♀ and 6% for ♂. ___________ and falls are the primary risk factors. Mortality and morbidity following hip fractures are high: 20% are not alive by 1 year postfracture and 33% by 2 years. Nearly one of three survivors is in institutionalized care within a year after the fracture, and as many as two of three survivors never regain their preoperative activity status. Surgery is usually indicated for most hip fractures, unless medically contraindicated or in nonambulatory patients.
Complications seen during rehabilitation and convalescence after hip fracture include ___________ ___________, ___________, fracture nonunion, ___________, surgical site infection, component loosening, leg length discrepancy, HO, DVT, constipation, and skin breakdown.

REHABILITATION AFTER HIP FRACTURE
The lifetime risk of hip fractures in industrialized countries is 18% for ♀ and 6% for ♂. Osteoporosis and falls are the primary risk factors. Mortality and morbidity following hip fractures are high: 20% are not alive by 1 year postfracture and 33% by 2 years. Nearly one of three survivors is in institutionalized care within a year after the fracture, and as many as two of three survivors never regain their preoperative activity status. Surgery is usually indicated for most hip fractures, unless medically contraindicated or in nonambulatory patients.
Complications seen during rehabilitation and convalescence after hip fracture include atelectasis pneumonia, anemia, fracture nonunion, AVN, surgical site infection, component loosening, leg length discrepancy, HO, DVT, constipation, and skin breakdown.

47

Femoral Neck Fracture – ___________ fixations (Fig. 7-20) are typical for stable, nondisplaced fractures. Ambulation with WBAT and an appropriate assistive device may be started during the first few days post-op. ___________ endoprostheses (Fig. 7-21) may be used for unstable, displaced fractures when satisfactory reduction cannot be achieved and the patient is >65 years of age or has preexisting articular pathology (i.e., OA). Patients are usually mobilized quickly and allowed WBAT within the first few days post-op. Abduction pillows and short-term ROM restrictions (no ___________ past midline and no ___________ ___________) may be ordered to reduce the risk of prosthetic displacement.

Femoral Neck Fracture – Screw fixations (Fig. 7-20) are typical for stable, nondisplaced fractures. Ambulation with WBAT and an appropriate assistive device may be started during the first few days post-op. Bipolar endoprostheses (Fig. 7-21) may be used for unstable, displaced fractures when satisfactory reduction cannot be achieved and the patient is >65 years of age or has preexisting articular pathology (i.e., OA). Patients are usually mobilized quickly and allowed WBAT within the first few days post-op. Abduction pillows and short-term ROM restrictions (no adduction past midline and no internal rotation) may be ordered to reduce the risk of prosthetic displacement.

48

Intertrochanteric Fractures (Fig. 7-22) – Sliding hip ___________ fixation allows for early WBAT for stable fractures (intact posteromedial cortex) and provides dynamic compression of the fracture during WB. ___________ hip screws are another surgical option. A period of limited WB may be necessary following fixation of unstable fractures. Surgical management for subtrochanteric fractures also includes the use of sliding screw fixation and intramedullary nails/rods, although initial WB may be more limited.

Intertrochanteric Fractures (Fig. 7-22) – Sliding hip screw fixation allows for early WBAT for stable fractures (intact posteromedial cortex) and provides dynamic compression of the fracture during WB. Intramedullary hip screws are another surgical option. A period of limited WB may be necessary following fixation of unstable fractures. Surgical management for subtrochanteric fractures also includes the use of sliding screw fixation and intramedullary nails/rods, although initial WB may be more limited.

49

Total Hip Arthroplasty
Biologically fixed or “___________” implants provide a more durable bio-prosthetic interface, but require a longer period of protective WB (i.e., touchdown WB to PWB × ≥2 to 3 months) to allow for osseous integration into the porous prosthetic surface. Cement-fixed implants are cheaper and may offer immediate WBAT. The cement, however, can be prone to deterioration, which may result in component loosening and ultimately require revision.
Patients may be out of bed to chair with assist on post-op day 1. A ___________ hip abduction pillow in bed is highly recommended for the first 6 to 12 weeks. Hip precautions generally continue for up to 12 weeks postop to allow for formation of a pseudocapsule and minimize the chance of dislocation. Patients are allowed flexion up to 90°, passive abduction, and gentle (≤30°) IR while extended. There should be no adduction past midline and no IR while flexed. Active ___________ and hyper ___________ are allowed with a posterior approach (gluteus medius preserved) but avoided after an anterolateral approach (gluteus medius split open). Typical patient instructions are diagrammed in Fig. 7-23.
Other key issues include DVT prophylaxis, monitoring for post-op anemia and infection, and pain control. Patients may often complain about perceived leg length discrepancies during the first several months post-op; PT to address muscle imbalances and tight capsules may be helpful. In general, prognosis following THA is excellent, although being younger, male, obese, and highly active may adversely affect outcomes.

Total Hip Arthroplasty
Biologically fixed or “cementless” implants provide a more durable bio-prosthetic interface, but require a longer period of protective WB (i.e., touchdown WB to PWB × ≥2 to 3 months) to allow for osseous integration into the porous prosthetic surface. Cement-fixed implants are cheaper and may offer immediate WBAT. The cement, however, can be prone to deterioration, which may result in component loosening and ultimately require revision.
Patients may be out of bed to chair with assist on post-op day 1. A triangular hip abduction pillow in bed is highly recommended for the first 6 to 12 weeks. Hip precautions generally continue for up to 12 weeks postop to allow for formation of a pseudocapsule and minimize the chance of dislocation. Patients are allowed flexion up to 90°, passive abduction, and gentle (≤30°) IR while extended. There should be no adduction past midline and no IR while flexed. Active abduction and hyperextension are allowed with a posterior approach (gluteus medius preserved) but avoided after an anterolateral approach (gluteus medius split open). Typical patient instructions are diagrammed in Fig. 7-23.
Other key issues include DVT prophylaxis, monitoring for post-op anemia and infection, and pain control. Patients may often complain about perceived leg length discrepancies during the first several months post-op; PT to address muscle imbalances and tight capsules may be helpful. In general, prognosis following THA is excellent, although being younger, male, obese, and highly active may adversely affect outcomes.1

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Total Knee Arthroplasty
Cemented fixation may allow immediate ___________; cementless fixation may require several months of restricted WB for complete stability. Neither addresses the issue of polyethylene liner wear, which may be the key factor in eventual prosthetic failure. Microscopic wear debris can trigger an inflammatory response with ensuing osteolysis and component loosening.
Regaining knee ___________ (i.e., 0° to 90° before going home) is an important rehabilitation goal for all TKA patients. Pillows under the knee should be avoided. The use of CPM is controversial. Some have argued that it may decrease length of inpatient rehabilitation stay and improve ROM (by 10°) at 1 year post-op, but most studies have not demonstrated long-term benefits in ROM or functional outcome.

Total Knee Arthroplasty
Cemented fixation may allow immediate WBAT; cementless fixation may require several months of restricted WB for complete stability. Neither addresses the issue of polyethylene liner wear, which may be the key factor in eventual prosthetic failure. Microscopic wear debris can trigger an inflammatory response with ensuing osteolysis and component loosening.
Regaining knee ROM (i.e., 0° to 90° before going home) is an important rehabilitation goal for all TKA patients. Pillows under the knee should be avoided. The use of CPM is controversial. Some have argued that it may decrease length of inpatient rehabilitation stay and improve ROM (by 10°) at 1 year post-op, but most studies have not demonstrated long-term benefits in ROM or functional outcome.