# 36 Sports medicine and sports injuries

# ACKNOWLEDGEMENT

ACKNOWLEDGEMENT

The authors are grateful for and wish to acknowledge the contribution of  Dylan Rakowski MD in the preparation of this chapter. ACKNOWLEDGEMENT

The authors are grateful for and wish to acknowledge the contribution of  Dylan Rakowski MD in the preparation of this chapter. ACKNOWLEDGEMENT

The authors are grateful for and wish to acknowledge the contribution of  Dylan Rakowski MD in the preparation of this chapter.

# American football

American football

This contact sport produces a variety of  unique injuries, the main ones of  which are closed head injuries, fractures, hip dislocations, twisting injuries to the knees and ankles leading to ligament tears, and turf  toe. American football

This contact sport produces a variety of  unique injuries, the main ones of  which are closed head injuries, fractures, hip dislocations, twisting injuries to the knees and ankles leading to ligament tears, and turf  toe. American football

This contact sport produces a variety of  unique injuries, the main ones of  which are closed head injuries, fractures, hip dislocations, twisting injuries to the knees and ankles leading to ligament tears, and turf  toe.

# Ankle

Ankle

Low ankle sprains Background Ankle sprains are a common injury that can prevent athletes from competing. These injuries are prevalent in sports that involve cutting actions or uneven surfaces while running, such as basketball, rugby , soccer, football and trail running. The ankle primarily resists inversion through the lateral collateral ligament complex, which is composed of  the anterior talofib ular ligament (ATFL), posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL). The ATFL is the most frequently injured ligament in the complex; it attaches at the most distal aspect of  the fibula and spans anteromedially to the lateral aspect of  the talus to prev ent inversion during it attaches proximal and posterior to the ATFL origin on the fibula and traverses posteromedially to the lateral aspect of the calcaneus. The position and orientation of  the CFL results in resistance against inversion of the ankle while dorsiflexed. The PTFL is the strongest ligament in the complex and is rarely involved in ankle sprains. History and physical examination - Patients with ankle sprains can often recall the injury and will - report the feeling of  the ankle inverting. Post injury , many patients will have swelling and bruising on the lateral aspect of their ankle, which can travel to a dependent position on their foot. Examiners should perform all examination manoeuvres on the contralateral and ipsilateral sides to assist in compari - - sons. The patient may exhibit tenderness to palpation at the lateral collateral ligament complex. The anterior drawer test can be used to evaluate for ATFL injuries. In this test, the ankle is placed into mild plantarflexion while a posterior force is applied to the distal tibia and an anterior translation f orce is applied to the calcaneus. This test is positive when there is excessive anterior translation of  the talus on the tibia compared to the contralateral side. The talar tilt examination evaluates both the CFL and the ATFL. This test is performed with mild plantarflexion of  the foot, followed by stabilisation of  the distal tibia with one hand while the other hand places varus stress on the talus. Excessive tilt during this manoeuvre is indicative of ATFL injury , whereas CFL injury is indicated by excessive tilt when placing the foot in slight dorsiflexion with varus stress on the talus being applied. Imaging Radiographs of  the ankle are indicated if  the patient fulfils any of  the Ottawa ankle rules ( Table 36.1 ). Foot radiographs are obtained if  the patient has tenderness at the base of  the fifth metatarsal or at the navicular bone or if they are unable to bear weight on the foot. Typically , radiographs include weight-bearing AP , mortise and lateral views along with a talar tilt view . These can help rule out other pathologies that may be contributing to ankle pain, such as various types of fractures or osteochondral lesions of  the talus. If  the examiner is concerned about a high ankle sprain, an external rotation radiograph can be obtained. MRI is not a standard modality utilised in the evaluation of  ankle sprains but should be obtained for patients with chronic ankle pain or instability to evaluate for osteochondral lesions of  the talus, tendon injury , anterolateral impingement or tibiofibular syndesmosis injury . /uni25CF /uni25CF /uni25CF - Treatment Ankle sprains are often treated conservatively with rest, ice, compression and elevation. Athletes should limit 

TABLE 36.1
Ottawa ankle rules.
Bone tenderness along the distal 6
/uni00A0
cm of the posterior margin
or at the tip of the lateral malleolus
Bone tenderness along the distal 6
/uni00A0
cm of the posterior margin
or at the tip of the medial malleolus
Inability to bear weight at the time of the accident or at the time
of examination

pain control, reducing swelling and proprioceptive exercises. Strengthening of  the peroneal muscles and stretching can occur once the patient is able to tolerate bearing weight on the ankle. Consider supportive braces to further stabilise the ankle from inversion and eversion. Surgery is indicated in patients with persistent pain and recurrent ankle sprains. This can be achieved through anatomical reconstruction by imbrication of the attenuated ATFL with or without reinforcement using the 9 inferior extensor retinaculum. Several non-anatomical lateral ankle ligament reconstruction techniques have also been described for use in chronic ankle instability . The prognosis following an ankle sprain depends on the severity of  the injury , but many patients are back participating in sports after a few weeks. Differential diagnosis /uni25CF Anterolateral ankle impingement. /uni25CF Peroneal tendon disruption. /uni25CF Fracture of  the lateral talar process. /uni25CF Syndesmotic sprain. /uni25CF Osteochondral lesion of  the talus. /uni25CF Malleolar fracture. /uni25CF Lateral process of  the calcaneus fracture. Summary box 36.5 Low ankle sprains /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Common injury among athletes in sports that involve cutting
actions or running on uneven surfaces
Patients may report the feeling of the ankle inverting and
present with subsequent swelling and bruising on the lateral
aspect of their ankle
Radiographs of the ankle are indicated if the patient ful
/f_i
ls any
of the Ottawa ankle rules
Foot radiographs are obtained if the patient has tenderness
at the base of the
/f_i
fth metatarsal or at the navicular bone or if
they are unable to bear weight on the foot
Ankle sprains are often treated conservatively with rest, ice,
compression and elevation
Surgery is indicated in patients with persistent pain and
recurrent ankle sprains

Ankle

Low ankle sprains Background Ankle sprains are a common injury that can prevent athletes from competing. These injuries are prevalent in sports that involve cutting actions or uneven surfaces while running, such as basketball, rugby , soccer, football and trail running. The ankle primarily resists inversion through the lateral collateral ligament complex, which is composed of  the anterior talofib ular ligament (ATFL), posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL). The ATFL is the most frequently injured ligament in the complex; it attaches at the most distal aspect of  the fibula and spans anteromedially to the lateral aspect of  the talus to prev ent inversion during it attaches proximal and posterior to the ATFL origin on the fibula and traverses posteromedially to the lateral aspect of the calcaneus. The position and orientation of  the CFL results in resistance against inversion of the ankle while dorsiflexed. The PTFL is the strongest ligament in the complex and is rarely involved in ankle sprains. History and physical examination - Patients with ankle sprains can often recall the injury and will - report the feeling of  the ankle inverting. Post injury , many patients will have swelling and bruising on the lateral aspect of their ankle, which can travel to a dependent position on their foot. Examiners should perform all examination manoeuvres on the contralateral and ipsilateral sides to assist in compari - - sons. The patient may exhibit tenderness to palpation at the lateral collateral ligament complex. The anterior drawer test can be used to evaluate for ATFL injuries. In this test, the ankle is placed into mild plantarflexion while a posterior force is applied to the distal tibia and an anterior translation f orce is applied to the calcaneus. This test is positive when there is excessive anterior translation of  the talus on the tibia compared to the contralateral side. The talar tilt examination evaluates both the CFL and the ATFL. This test is performed with mild plantarflexion of  the foot, followed by stabilisation of  the distal tibia with one hand while the other hand places varus stress on the talus. Excessive tilt during this manoeuvre is indicative of ATFL injury , whereas CFL injury is indicated by excessive tilt when placing the foot in slight dorsiflexion with varus stress on the talus being applied. Imaging Radiographs of  the ankle are indicated if  the patient fulfils any of  the Ottawa ankle rules ( Table 36.1 ). Foot radiographs are obtained if  the patient has tenderness at the base of  the fifth metatarsal or at the navicular bone or if they are unable to bear weight on the foot. Typically , radiographs include weight-bearing AP , mortise and lateral views along with a talar tilt view . These can help rule out other pathologies that may be contributing to ankle pain, such as various types of fractures or osteochondral lesions of  the talus. If  the examiner is concerned about a high ankle sprain, an external rotation radiograph can be obtained. MRI is not a standard modality utilised in the evaluation of  ankle sprains but should be obtained for patients with chronic ankle pain or instability to evaluate for osteochondral lesions of  the talus, tendon injury , anterolateral impingement or tibiofibular syndesmosis injury . /uni25CF /uni25CF /uni25CF - Treatment Ankle sprains are often treated conservatively with rest, ice, compression and elevation. Athletes should limit 

TABLE 36.1
Ottawa ankle rules.
Bone tenderness along the distal 6
/uni00A0
cm of the posterior margin
or at the tip of the lateral malleolus
Bone tenderness along the distal 6
/uni00A0
cm of the posterior margin
or at the tip of the medial malleolus
Inability to bear weight at the time of the accident or at the time
of examination

pain control, reducing swelling and proprioceptive exercises. Strengthening of  the peroneal muscles and stretching can occur once the patient is able to tolerate bearing weight on the ankle. Consider supportive braces to further stabilise the ankle from inversion and eversion. Surgery is indicated in patients with persistent pain and recurrent ankle sprains. This can be achieved through anatomical reconstruction by imbrication of the attenuated ATFL with or without reinforcement using the 9 inferior extensor retinaculum. Several non-anatomical lateral ankle ligament reconstruction techniques have also been described for use in chronic ankle instability . The prognosis following an ankle sprain depends on the severity of  the injury , but many patients are back participating in sports after a few weeks. Differential diagnosis /uni25CF Anterolateral ankle impingement. /uni25CF Peroneal tendon disruption. /uni25CF Fracture of  the lateral talar process. /uni25CF Syndesmotic sprain. /uni25CF Osteochondral lesion of  the talus. /uni25CF Malleolar fracture. /uni25CF Lateral process of  the calcaneus fracture. Summary box 36.5 Low ankle sprains /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Common injury among athletes in sports that involve cutting
actions or running on uneven surfaces
Patients may report the feeling of the ankle inverting and
present with subsequent swelling and bruising on the lateral
aspect of their ankle
Radiographs of the ankle are indicated if the patient ful
/f_i
ls any
of the Ottawa ankle rules
Foot radiographs are obtained if the patient has tenderness
at the base of the
/f_i
fth metatarsal or at the navicular bone or if
they are unable to bear weight on the foot
Ankle sprains are often treated conservatively with rest, ice,
compression and elevation
Surgery is indicated in patients with persistent pain and
recurrent ankle sprains

Ankle

Low ankle sprains Background Ankle sprains are a common injury that can prevent athletes from competing. These injuries are prevalent in sports that involve cutting actions or uneven surfaces while running, such as basketball, rugby , soccer, football and trail running. The ankle primarily resists inversion through the lateral collateral ligament complex, which is composed of  the anterior talofib ular ligament (ATFL), posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL). The ATFL is the most frequently injured ligament in the complex; it attaches at the most distal aspect of  the fibula and spans anteromedially to the lateral aspect of  the talus to prev ent inversion during it attaches proximal and posterior to the ATFL origin on the fibula and traverses posteromedially to the lateral aspect of the calcaneus. The position and orientation of  the CFL results in resistance against inversion of the ankle while dorsiflexed. The PTFL is the strongest ligament in the complex and is rarely involved in ankle sprains. History and physical examination - Patients with ankle sprains can often recall the injury and will - report the feeling of  the ankle inverting. Post injury , many patients will have swelling and bruising on the lateral aspect of their ankle, which can travel to a dependent position on their foot. Examiners should perform all examination manoeuvres on the contralateral and ipsilateral sides to assist in compari - - sons. The patient may exhibit tenderness to palpation at the lateral collateral ligament complex. The anterior drawer test can be used to evaluate for ATFL injuries. In this test, the ankle is placed into mild plantarflexion while a posterior force is applied to the distal tibia and an anterior translation f orce is applied to the calcaneus. This test is positive when there is excessive anterior translation of  the talus on the tibia compared to the contralateral side. The talar tilt examination evaluates both the CFL and the ATFL. This test is performed with mild plantarflexion of  the foot, followed by stabilisation of  the distal tibia with one hand while the other hand places varus stress on the talus. Excessive tilt during this manoeuvre is indicative of ATFL injury , whereas CFL injury is indicated by excessive tilt when placing the foot in slight dorsiflexion with varus stress on the talus being applied. Imaging Radiographs of  the ankle are indicated if  the patient fulfils any of  the Ottawa ankle rules ( Table 36.1 ). Foot radiographs are obtained if  the patient has tenderness at the base of  the fifth metatarsal or at the navicular bone or if they are unable to bear weight on the foot. Typically , radiographs include weight-bearing AP , mortise and lateral views along with a talar tilt view . These can help rule out other pathologies that may be contributing to ankle pain, such as various types of fractures or osteochondral lesions of  the talus. If  the examiner is concerned about a high ankle sprain, an external rotation radiograph can be obtained. MRI is not a standard modality utilised in the evaluation of  ankle sprains but should be obtained for patients with chronic ankle pain or instability to evaluate for osteochondral lesions of  the talus, tendon injury , anterolateral impingement or tibiofibular syndesmosis injury . /uni25CF /uni25CF /uni25CF - Treatment Ankle sprains are often treated conservatively with rest, ice, compression and elevation. Athletes should limit 

TABLE 36.1
Ottawa ankle rules.
Bone tenderness along the distal 6
/uni00A0
cm of the posterior margin
or at the tip of the lateral malleolus
Bone tenderness along the distal 6
/uni00A0
cm of the posterior margin
or at the tip of the medial malleolus
Inability to bear weight at the time of the accident or at the time
of examination

pain control, reducing swelling and proprioceptive exercises. Strengthening of  the peroneal muscles and stretching can occur once the patient is able to tolerate bearing weight on the ankle. Consider supportive braces to further stabilise the ankle from inversion and eversion. Surgery is indicated in patients with persistent pain and recurrent ankle sprains. This can be achieved through anatomical reconstruction by imbrication of the attenuated ATFL with or without reinforcement using the 9 inferior extensor retinaculum. Several non-anatomical lateral ankle ligament reconstruction techniques have also been described for use in chronic ankle instability . The prognosis following an ankle sprain depends on the severity of  the injury , but many patients are back participating in sports after a few weeks. Differential diagnosis /uni25CF Anterolateral ankle impingement. /uni25CF Peroneal tendon disruption. /uni25CF Fracture of  the lateral talar process. /uni25CF Syndesmotic sprain. /uni25CF Osteochondral lesion of  the talus. /uni25CF Malleolar fracture. /uni25CF Lateral process of  the calcaneus fracture. Summary box 36.5 Low ankle sprains /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Common injury among athletes in sports that involve cutting
actions or running on uneven surfaces
Patients may report the feeling of the ankle inverting and
present with subsequent swelling and bruising on the lateral
aspect of their ankle
Radiographs of the ankle are indicated if the patient ful
/f_i
ls any
of the Ottawa ankle rules
Foot radiographs are obtained if the patient has tenderness
at the base of the
/f_i
fth metatarsal or at the navicular bone or if
they are unable to bear weight on the foot
Ankle sprains are often treated conservatively with rest, ice,
compression and elevation
Surgery is indicated in patients with persistent pain and
recurrent ankle sprains

# Ballet dancing

Ballet dancing

Ballet dancers have problems with posterior impingement of  the ankle and tendinopathy of  the flexor hallucis longus tendon when working en pointe (tiptoe). Stress fractures are also found in female dancers as a result of  repetitive training and can be more frequent in the female athlete triad (osteoporosis, disordered eating and amenorrhoea) ( Figure 36.9 ). 

Third metatarsal
bony oedema
Figure 36.9
Magnetic resonance imaging short T1 inversion recovery
axial sequence showing a stress injury to a metatarsal.

Ballet dancing

Ballet dancers have problems with posterior impingement of  the ankle and tendinopathy of  the flexor hallucis longus tendon when working en pointe (tiptoe). Stress fractures are also found in female dancers as a result of  repetitive training and can be more frequent in the female athlete triad (osteoporosis, disordered eating and amenorrhoea) ( Figure 36.9 ). 

Third metatarsal
bony oedema
Figure 36.9
Magnetic resonance imaging short T1 inversion recovery
axial sequence showing a stress injury to a metatarsal.

Ballet dancing

Ballet dancers have problems with posterior impingement of  the ankle and tendinopathy of  the flexor hallucis longus tendon when working en pointe (tiptoe). Stress fractures are also found in female dancers as a result of  repetitive training and can be more frequent in the female athlete triad (osteoporosis, disordered eating and amenorrhoea) ( Figure 36.9 ). 

Third metatarsal
bony oedema
Figure 36.9
Magnetic resonance imaging short T1 inversion recovery
axial sequence showing a stress injury to a metatarsal.

# COMMONL Y ENCOUNTERED REGIONAL INJURIES Shoulder

COMMONL Y ENCOUNTERED REGIONAL INJURIES Shoulder

Shoulder instability and rotator cuff tear Background Shoulder injuries a ff ect athletes of  all ages; however, the distribution of  shoulder injuries varies between young and Rudolph Grashey , 1876–1950, Professor of  Roentgenology , University of  Cologne, Cologne, Germany . Alfred-Armand-Louis-Marie Velpeau , 1795–1867, French anatomist and surgeon. Harold Arthur Hill , 1901–1973, radiologist, San Francisco, CA, USA. Maurice David Sachs , 1909–1987, radiologist, San Francisco, CA, USA. older participants. In athletes younger than 30 years old, espe - cially those participating in contact sports, anterior shoulder dislocations can occur in instances of  traumatic or forced shoulder abduction and external rotation. Unfortunately , such dislocations, even if  r educed, lead to some degree of  stretch - ing of the anterior capsule and tearing of the anteroinferior labrum, which places the patient at risk for further instability events. In older patients who experience falls and sustain the same anterior shoulder dislocations, additional pathologies, including rotator cu ff tears , can occur. History and physical examination Patients who sustain a shoulder dislocation often describe a violent injury event such as a fall or tackle with the arm in some degree of  abduction. Patients will often describe a sensation of  their shoulder feeling out of  place, especially if - the shoulder does not spontaneously reduce. An important component of  the history involves the details of  the disloca - tion(s): self-reduction versus emergency department reduction, length of  time dislocated prior to reduction, prior dislocations, extremity numbness, general ligamentous laxity and activity profile – all of  these details have implications for management. Examination in the acute period should focus on e valuating anterior apprehension or subjective patient discomfort and fear of  re-dislocation in the positions of  abduction and exter - nal rotation of  the shoulder, as well as rotator cu ff strength and neurovascular integrity , especially of  the axillary nerve (see 1,2 Further reading ). Imaging Radiographs, including at least true anteroposterior (AP) or Grashey , scapular Y , axillary or V elpeau views, should be obtained in all circumstances and evaluated to confirm glenohumeral reduction while ruling out associated fractures, such as Hill–Sachs deformities or glenoid rim fractures. 

To assess the patient and offer treatment and
•
rehabilitation plans

Specific views, including the West Point axillary and the Stryker notch views, can be helpful for evaluating glenoid rim or Bankart fractures or Hill–Sachs lesions, respectively . In cases of  recurrent instability where glenoid bone loss is suspected, computed tomography (CT) with or without three-dimensional reconstruction can be helpful in further determining the extent of bone loss. In most instances of anterior instability , magnetic resonance imaging (MRI) is recommended ( Figure 36.1 evaluate for concomitant soft-tissue injuries, including rotator cu ff tears, humeral avulsions of  the glenohumeral ligament (HAGL), glenolabral articular disruptions (GLAD) or anterior labrum periosteal sleeve avulsion (ALPSA). Treatment After reduction of  an acute anterior glenohumeral dislocation, patients are typically placed in a sling for the first few days. important to begin early gentle range of motion of the shoul der through pendulum exercises but also to continue to move the elbow , wrist and digits actively to maintain range of  motion in those distal joints. The initial period is then progressed to increased passive and then active and active-assisted range of motion of the shoulder. Once range of motion has returned to near normal, rotator cu ff and scapular strengthening is progressed. Surgery is considered for even first-time dislo cators based upon stratification of  several factors, including younger age, activity profile and pathology present on imag ing. Furthermore, depending upon the pathology present, the surgical options exist on a continuum fr om arthroscopic capsulolabral repair to open capsulolabral repair and capsular 3,4 shift to glenoid bony augmentation procedur es. Regardless of  the treatment method chosen, athletes are cleared to return William Schamel Stryker , 1916–2015, orthopedic surgeon and Captain in the United States Navy . Arthur Sydney Blundell Bankart , 1879–1951, orthopaedic surgeon, The Middlesex Hospital, London, UK. to normal levels. Older athletes who acutely tear their rotator cu ff in the set - ting of  shoulder dislocations can be considered for acute rota - 5 tor cu ff repair. The treatment of  rotator cu ff tears has evolved over several years and current techniques of  arthroscopic repair with a knotless, linked, double-row construct ( Figure 36.2 ) have demonstrated excellent patient-reported outcomes with low re-tear rates. Differential diagnosis /uni25CF Proximal humerus fracture. /uni25CF Greater tuberosity fracture. /uni25CF Acromioclavicular joint separation. Summary box 36.1 Shoulder instability /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF ) to 2 It is - - - 

Anterior
labral tear
Figure 36.1
Axial
/f_l
uid-sensitive magnetic resonance image of the
shoulder demonstrating an anterior labral tear.
Dislocations occur in instances of traumatic or forced shoulder
abduction and external rotation
Details of the reduction, time dislocated, history of prior
dislocations, general ligamentous laxity and activity pro
/f_i
le
have implications for management
Radiographs to con
/f_i
rm glenohumeral reduction include true
AP or Grashey, scapular Y , axillary or Velpeau views
A sling should be used for a few days following an acute
anterior glenohumeral dislocation
Surgery is considered based upon strati
/f_i
cation of several
factors, including younger age, activity pro
/f_i
le and pathology
present on imaging
Rotator cuff tendon
Suture anchor with
repair sutures
Figure 36.2
Shoulder arthroscopic image of a rotator cuff repair
viewed from the subacromial space through a lateral portal with a 30°
arthroscope.

Ulnar collateral ligament tear Background The anterior band of  the ulnar collateral ligament (UCL) is the primary stabiliser to valgus stress at the elbow . Anatomi cally this ligament courses from the medial epicondyle of  the humerus to the sublime tubercle of  the ulna. Although it can be injured acutely through mechanisms of  elbow dislocations, pathology is most frequently encountered in repetitive thro ing athletes, such as baseball pitchers and javelin throwers. In the late cocking and early acceleration phases of  throwing the ligament is under its maximum stress and at this stage is at the highest risk of  ruptur e and chronic attenuation. History and physical examination Throwers who sustain ruptures of  their UCL commonly pres ent with two sets of  complaints. Rarely , the thrower will recall an acute episode when they heard a pop in the throwing cycle followed by medial elbow pain and pain worse with throwing. The v ast majority of  throwers complain of  medial elbow pain and tightness coupled with decreased velocity that comes on more insidiously . Examination focuses on provocative manoeuvres that are specific for the UCL, including valgus stress and the moving valgus stress tests or milking manoeuvre ( Figure 36.3 ), in which the examiner provides a valgus stress 6 through elbow range of  motion. Pain at the medial elbow during these manoeuvres is specific for UCL pathology . The examiner should also focus on both ulnar nerve sensory and motor symptoms in the hand in addition to ulnar nerve sublux ation as these pathologies can a ff ect the proposed treatment algorithm. Imaging Radiographs of  the elbow include a series of  AP , lateral, inter nal and external oblique views. These can help rule out other commonly encountered phenomena seen in overhead throwing athletes, including medial epicondyle fractures, posteromedial impingement and capitellar osteochondral defects. When UCL pathology is suspected, dynamic ultrasound is a helpful imaging modality to help characterise the loca tion of  the UCL pathology . Moreover, it permits easy examination of  the contralateral elbow , which can help to quantify incongruities in medial elbow joint space gapping, an indirect gauge of tear severity . MRI is commonly obtained to precisely define the location of  the UCL tear as well as to better evaluate the articular cartilage and the flexor pronator mass, which can also commonly be a ff ected. Treatment Conservative management of  UCL injuries is considered first line treatment and typically entails a period of  several months of  cessation of  throwing followed by structured rehabilitation that includes strengthening of  secondary stabilising muscles 6 about the elbow and a g radual return of  throwing. The use of biological injections, including platelet-rich plasma, has been To m my  Jo h n  s u rge r y , named after Thomas Edward John Jr, the first major league baseball pitcher who received an ulnar collateral ligament reconstruction in 1974. - w - - proposed for partial-thickness ligament tears in some centres, but more clinical evidence is required. Although ligament repair with an internal brace has recently been demonstrated to have e ffi cacy in certain types of  tears, the gold standard for surgical treatment is UCL reconstruction or Tommy John surgery . The surgery involves an autograft tendon harvest, commonly utilising the ipsilateral palmaris longus tendon, and reconstruction of  the ligament through bone tunnels in - 6 both the humerus and ulna. This surgery can be coupled with in situ decompression or transposition of  the ulnar nerve, if indicated. Ulnar reconstruction surgery is indicated for the highest level of  throwers who wish to continue playing their respective sport, with return to sport taking anywhere from - 12 /uni00A0 to 18 months. Differential diagnosis /uni25CF Flexor pronator mass sprain. /uni25CF Ulnohumeral arthritis. /uni25CF Ulnar nerve compression or subluxation. /uni25CF Loose body . Summary box 36.2 UCL tears /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF 

Examiner
stabilises
patient’s
elbow
Examiner pulls
patient’s thumb
with downward
force
Figure 36.3
Demonstration of the milking manoeuvre. This is consid
-
ered a positive test when this provocative manoeuvre elicits pain in
the medial elbow, indicating ulnar collateral ligament injury.
Injury seen among repetitive throwing athletes
Onset can be acute (‘pop’) or insidious with medial elbow
pain, tightness and decreased throwing velocity
Dynamic ultrasound or MRI can be used to characterise the
location of the UCL pathology
First-line treatment is conservative management with
cessation of throwing followed by structured rehabilitation
Surgical options include UCL reconstruction (gold standard) or
ligament repair with an internal brace

Hip
Femoroacetabular impingement and dysplasia Background Intra-articular hip derangements most commonly manifest as anterolateral groin pain in a characteristic distribution, referred to as a ‘C-sign’ ( Figure 36.4 ). In a young patient, two common sources of  groin pain with intra-articular origin are femoroacetabular impingement (FAI) and dysplasia. These conditions are considered in some detail in Chapter 39 are described here as they can present as a sports-related injury . History and physical examination Y oung patients with a history of  groin pain or repetitive ‘groin or hip flexor sprains’ should be evaluated for dysplasia or FAI. Physical examination focuses on hip range of  motion, strength, palpation and provocative manoeuvres. Some important manoeuvres include the FADIR examination, which stands for hip Flexion, ADduction and Internal Rotation, which is specific for impingement pathologies, but the FABER (Flex ion, ABduction and External Rotation) manoeuvre as well as resisted hip flexion (Stinchfield testing) can also identify true 7 intra-articular pathologies. Imaging Initial imaging includes radiographs of  the pelvis and the a ff ected hip. Anteroposterior pelvis and false profile views can help determine lateral or anterior coverage of  the acetabulum, respectively , while 45° Dunn lateral radiographs of  the hip are the optimal projection for detecting the presence of  a cam lesion ( Figure 36.5 ). Three-dimensional imaging, including CT and MRI, is helpful for better defining the bony morphology and soft-tissue (i.e. labral) integrity , respectively . Frank E Stinchfield , 1910–1992, American orthopaedic surgeon and founder of  The Hip Society . Denis M Dunn , 1916–2001, British orthopaedic surgeon. Treatment Once the correct diagnosis is determined both pathologies can initially be treated conservatively using anti-inflammatory drugs, physical therapy and at times intra-articular injection, for example corticosteroid. Should these modalities fail, both FAI and dysplasia have their own specific surgical interven - tions: arthroscopy ( Figure 36.6 ) and osteotomy , respectively (see Chapter 39 ). Importantly , the aforementioned interven - tions are only a consideration prior to the development of  joint space narrowing and osteoarthritis in an e ff ort to preserve the but 7 hip joint. Differential diagnosis /uni25CF Adductor strain. /uni25CF Hip osteoarthritis. /uni25CF Athletic pubalgia. /uni25CF Lumbar radiculopathy  . Summary box 36.3 - Femoroacetabular impingement and dysplasia /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Figure 36.4
Example of the C-sign for intra-articular hip pathology
when asking a patient to demonstrate where they feel their pain.
Preserved
Large cam lesion
joint space
Figure 36.5
Anteroposterior right hip radiograph demonstrating a
large cam lesion in the setting of the preserved hip joint space.
Intra-articular hip derangements can manifest with
anterolateral groin pain in a characteristic distribution (‘C-sign’)
Consider pathologies in young patients with a history of groin
pain or repetitive ‘groin or hip
/f_l
exor sprains’
Initial imaging includes radiographs of the pelvis and the
affected hip
Three-dimensional imaging includes CT (bony morphology)
and MRI (soft-tissue integrity)
Conservative treatment involves using anti-in
/f_l
ammatory
drugs, physical therapy and/or intra-articular injection
Surgical interventions are arthroscopy (FAI) and osteotomy
(dysplasia) prior to the development of joint space narrowing
and osteoarthritis

Knee anterior cruciate ligament rupture with meniscus tear Background Acute knee injuries are extremely common in most sports that require jumping, twisting and contact. Sports with physical impact or tackling, such as rugby or American football, can result in contact knee injuries that often lead to varus or valgus stresses to the knee, resulting in collateral ligament injuries (i.e. lateral collateral ligament or medial collateral ligament) in addition to concomitant cruciate ligament, meniscus or articular cartilage injuries. More frequently , however, acute non-contact injuries of the knee lead to injury to the anterior cruciate ligament (ACL). The most common mechanism of these injuries is a deceleration when the knee falls into valgus and the tibia externally rotates, leading to a subluxation of  the knee. These injuries are often associated with either medial or lateral meniscus injuries. History and physical examination Patients with an acute ACL injury will often report hearing or feeling a pop in their knee followed by a notable e ff usion and/ or haemarthrosis. Once the e ff usion resolves, they may report a paucity of  knee pain, often leading the patient to believe that the injury has healed itself. However, patients usually present to a physician after attempting subsequent cutting and pivoting activities, which can lead to recurrent instability . Given that the ACL’s primary function is to restrict anterior translation of  the tibia on the femur, the most commonly utilised tests to evaluate the competency of  the ACL are the anterior drawer and Lachman tests (see Chapter 35 ). Imaging The initial evaluation of  an acute knee injury with e ff usion and/or haemarthrosis necessitates radiographic evaluation. John W Lachman , 1919–2007, Professor and Chairman of  the Orthopedic Department at Temple University in Philadelphia, PA, USA. Paul Ferdinand Segond , 1851–1912, French surgeon who was a founder of  obstetrics and also an expert of  the knee, Paris, France. AP , lateral and merchant views are the minimum recom - mended. These radiographs can be useful for identifying any concomitant injuries, including fractures. A Segond fracture located on the anterolateral tibia is pathognomonic for an ACL injury . If  an ACL injury is suspected by physical e xamination, an MRI is performed to better evaluate the intra-articular structures and to aid in surgical planning. A systematic eval - uation of  the MRI is necessary to ensure that no additional pathology is missed ( Figure 36.7 ). ‘Kissing lesions’ of bony oedema seen on fluid-sensitive sequences on the posterolateral tibia and la teral femoral condyle are also pathognomonic for ACL rupture and represent the pivot shift knee subluxation seen in the setting of  ACL rupture. Treatment ACL injuries can be managed conservatively through activ - ity modification and bracing. Should these modalities fail, surgery is an excellent option for restoration of  knee stability and to decrease the potential for further meniscal or articular cartilage degeneration. ACL repair has recently become a resurging option for proximal-type tears when the ACL can be restored back to its anatomic footprint on the femur. The bridge-enhanced ACL repair (BEAR) technique using a colla - gen sca ff old is currently under clinical trial and may emerge as an option in the future. The gold standard for ACL, however, is reconstruction. In younger pa tients, large multicentre cohort studies have indicated that autograft reconstruction o ff ers the best durability and lowest chance for re-rupture. Options for autograft reconstruction include bone–patellar tendon–bone, hamstring and quadriceps–tendon autografts. For older and 

Femoral osteoplasty
Labral repair
Burr
Figure 36.6
Hip arthroscopic image viewed through the mid-anterior
portal with a 70° arthroscope.
Complete
ACL rupture
Figure 36.7
Sagittal proton density magnetic resonance image of the
knee demonstrating a complete proximal anterior cruciate ligament
(ACL) rupture.

tendon reconstruction provides an additional graft option. Meniscal tears are frequently encountered in the setting 8 of  ACL rupture. Common tear patterns encountered include radial tears, root tears and bucket-handle tears where the torn portion of  the meniscus can flip like a bucket handle into the centre of  the joint. Previously , meniscus tears were treated with partial excision to remove any mechanical disruptions and associated pain, but in recent years the joint preservation func tions of  the menisci as well as their contribution to stability of the knee have been better appreciated, leading to e ff orts to pre serve as much meniscal tissue as possible, especially in younger patients. Various methods of  meniscus repair ar e currently utilised to restore the meniscus anatomy , including all-inside devices, inside-out, outside-in and root re pair techniques, the details of  which are beyond the scope of  this chapter. Biolog ical strategies, to augment the repair, are being evaluated in some centres. Differential diagnosis /uni25CF Patellar dislocation. /uni25CF Posterior cruciate ligament rupture. /uni25CF Medial collateral ligament knee rupture. /uni25CF Posterolateral corner knee ligament injury . /uni25CF Patellar tendon rupture. Summary box 36.4 ACL ruptures /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Mechanism is commonly a non-contact pivoting injury or a
direct impact to the lateral knee
Patients often hear or feel a pop in their knee followed by a
notable effusion and may experience instability when returning
to cutting and pivoting activities
Radiographic evaluation includes AP , lateral and merchant
views
MRI is performed to better evaluate the intra-articular
structures, aid in surgical planning and ensure that no
additional pathology is missed
ACL injuries can be managed conservatively through activity
modi
/f_i
cation and bracing
Surgical options include ACL reconstruction (gold standard)
and repair in certain select scenarios

COMMONL Y ENCOUNTERED REGIONAL INJURIES Shoulder

Shoulder instability and rotator cuff tear Background Shoulder injuries a ff ect athletes of  all ages; however, the distribution of  shoulder injuries varies between young and Rudolph Grashey , 1876–1950, Professor of  Roentgenology , University of  Cologne, Cologne, Germany . Alfred-Armand-Louis-Marie Velpeau , 1795–1867, French anatomist and surgeon. Harold Arthur Hill , 1901–1973, radiologist, San Francisco, CA, USA. Maurice David Sachs , 1909–1987, radiologist, San Francisco, CA, USA. older participants. In athletes younger than 30 years old, espe - cially those participating in contact sports, anterior shoulder dislocations can occur in instances of  traumatic or forced shoulder abduction and external rotation. Unfortunately , such dislocations, even if  r educed, lead to some degree of  stretch - ing of the anterior capsule and tearing of the anteroinferior labrum, which places the patient at risk for further instability events. In older patients who experience falls and sustain the same anterior shoulder dislocations, additional pathologies, including rotator cu ff tears , can occur. History and physical examination Patients who sustain a shoulder dislocation often describe a violent injury event such as a fall or tackle with the arm in some degree of  abduction. Patients will often describe a sensation of  their shoulder feeling out of  place, especially if - the shoulder does not spontaneously reduce. An important component of  the history involves the details of  the disloca - tion(s): self-reduction versus emergency department reduction, length of  time dislocated prior to reduction, prior dislocations, extremity numbness, general ligamentous laxity and activity profile – all of  these details have implications for management. Examination in the acute period should focus on e valuating anterior apprehension or subjective patient discomfort and fear of  re-dislocation in the positions of  abduction and exter - nal rotation of  the shoulder, as well as rotator cu ff strength and neurovascular integrity , especially of  the axillary nerve (see 1,2 Further reading ). Imaging Radiographs, including at least true anteroposterior (AP) or Grashey , scapular Y , axillary or V elpeau views, should be obtained in all circumstances and evaluated to confirm glenohumeral reduction while ruling out associated fractures, such as Hill–Sachs deformities or glenoid rim fractures. 

To assess the patient and offer treatment and
•
rehabilitation plans

Specific views, including the West Point axillary and the Stryker notch views, can be helpful for evaluating glenoid rim or Bankart fractures or Hill–Sachs lesions, respectively . In cases of  recurrent instability where glenoid bone loss is suspected, computed tomography (CT) with or without three-dimensional reconstruction can be helpful in further determining the extent of bone loss. In most instances of anterior instability , magnetic resonance imaging (MRI) is recommended ( Figure 36.1 evaluate for concomitant soft-tissue injuries, including rotator cu ff tears, humeral avulsions of  the glenohumeral ligament (HAGL), glenolabral articular disruptions (GLAD) or anterior labrum periosteal sleeve avulsion (ALPSA). Treatment After reduction of  an acute anterior glenohumeral dislocation, patients are typically placed in a sling for the first few days. important to begin early gentle range of motion of the shoul der through pendulum exercises but also to continue to move the elbow , wrist and digits actively to maintain range of  motion in those distal joints. The initial period is then progressed to increased passive and then active and active-assisted range of motion of the shoulder. Once range of motion has returned to near normal, rotator cu ff and scapular strengthening is progressed. Surgery is considered for even first-time dislo cators based upon stratification of  several factors, including younger age, activity profile and pathology present on imag ing. Furthermore, depending upon the pathology present, the surgical options exist on a continuum fr om arthroscopic capsulolabral repair to open capsulolabral repair and capsular 3,4 shift to glenoid bony augmentation procedur es. Regardless of  the treatment method chosen, athletes are cleared to return William Schamel Stryker , 1916–2015, orthopedic surgeon and Captain in the United States Navy . Arthur Sydney Blundell Bankart , 1879–1951, orthopaedic surgeon, The Middlesex Hospital, London, UK. to normal levels. Older athletes who acutely tear their rotator cu ff in the set - ting of  shoulder dislocations can be considered for acute rota - 5 tor cu ff repair. The treatment of  rotator cu ff tears has evolved over several years and current techniques of  arthroscopic repair with a knotless, linked, double-row construct ( Figure 36.2 ) have demonstrated excellent patient-reported outcomes with low re-tear rates. Differential diagnosis /uni25CF Proximal humerus fracture. /uni25CF Greater tuberosity fracture. /uni25CF Acromioclavicular joint separation. Summary box 36.1 Shoulder instability /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF ) to 2 It is - - - 

Anterior
labral tear
Figure 36.1
Axial
/f_l
uid-sensitive magnetic resonance image of the
shoulder demonstrating an anterior labral tear.
Dislocations occur in instances of traumatic or forced shoulder
abduction and external rotation
Details of the reduction, time dislocated, history of prior
dislocations, general ligamentous laxity and activity pro
/f_i
le
have implications for management
Radiographs to con
/f_i
rm glenohumeral reduction include true
AP or Grashey, scapular Y , axillary or Velpeau views
A sling should be used for a few days following an acute
anterior glenohumeral dislocation
Surgery is considered based upon strati
/f_i
cation of several
factors, including younger age, activity pro
/f_i
le and pathology
present on imaging
Rotator cuff tendon
Suture anchor with
repair sutures
Figure 36.2
Shoulder arthroscopic image of a rotator cuff repair
viewed from the subacromial space through a lateral portal with a 30°
arthroscope.

Ulnar collateral ligament tear Background The anterior band of  the ulnar collateral ligament (UCL) is the primary stabiliser to valgus stress at the elbow . Anatomi cally this ligament courses from the medial epicondyle of  the humerus to the sublime tubercle of  the ulna. Although it can be injured acutely through mechanisms of  elbow dislocations, pathology is most frequently encountered in repetitive thro ing athletes, such as baseball pitchers and javelin throwers. In the late cocking and early acceleration phases of  throwing the ligament is under its maximum stress and at this stage is at the highest risk of  ruptur e and chronic attenuation. History and physical examination Throwers who sustain ruptures of  their UCL commonly pres ent with two sets of  complaints. Rarely , the thrower will recall an acute episode when they heard a pop in the throwing cycle followed by medial elbow pain and pain worse with throwing. The v ast majority of  throwers complain of  medial elbow pain and tightness coupled with decreased velocity that comes on more insidiously . Examination focuses on provocative manoeuvres that are specific for the UCL, including valgus stress and the moving valgus stress tests or milking manoeuvre ( Figure 36.3 ), in which the examiner provides a valgus stress 6 through elbow range of  motion. Pain at the medial elbow during these manoeuvres is specific for UCL pathology . The examiner should also focus on both ulnar nerve sensory and motor symptoms in the hand in addition to ulnar nerve sublux ation as these pathologies can a ff ect the proposed treatment algorithm. Imaging Radiographs of  the elbow include a series of  AP , lateral, inter nal and external oblique views. These can help rule out other commonly encountered phenomena seen in overhead throwing athletes, including medial epicondyle fractures, posteromedial impingement and capitellar osteochondral defects. When UCL pathology is suspected, dynamic ultrasound is a helpful imaging modality to help characterise the loca tion of  the UCL pathology . Moreover, it permits easy examination of  the contralateral elbow , which can help to quantify incongruities in medial elbow joint space gapping, an indirect gauge of tear severity . MRI is commonly obtained to precisely define the location of  the UCL tear as well as to better evaluate the articular cartilage and the flexor pronator mass, which can also commonly be a ff ected. Treatment Conservative management of  UCL injuries is considered first line treatment and typically entails a period of  several months of  cessation of  throwing followed by structured rehabilitation that includes strengthening of  secondary stabilising muscles 6 about the elbow and a g radual return of  throwing. The use of biological injections, including platelet-rich plasma, has been To m my  Jo h n  s u rge r y , named after Thomas Edward John Jr, the first major league baseball pitcher who received an ulnar collateral ligament reconstruction in 1974. - w - - proposed for partial-thickness ligament tears in some centres, but more clinical evidence is required. Although ligament repair with an internal brace has recently been demonstrated to have e ffi cacy in certain types of  tears, the gold standard for surgical treatment is UCL reconstruction or Tommy John surgery . The surgery involves an autograft tendon harvest, commonly utilising the ipsilateral palmaris longus tendon, and reconstruction of  the ligament through bone tunnels in - 6 both the humerus and ulna. This surgery can be coupled with in situ decompression or transposition of  the ulnar nerve, if indicated. Ulnar reconstruction surgery is indicated for the highest level of  throwers who wish to continue playing their respective sport, with return to sport taking anywhere from - 12 /uni00A0 to 18 months. Differential diagnosis /uni25CF Flexor pronator mass sprain. /uni25CF Ulnohumeral arthritis. /uni25CF Ulnar nerve compression or subluxation. /uni25CF Loose body . Summary box 36.2 UCL tears /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF 

Examiner
stabilises
patient’s
elbow
Examiner pulls
patient’s thumb
with downward
force
Figure 36.3
Demonstration of the milking manoeuvre. This is consid
-
ered a positive test when this provocative manoeuvre elicits pain in
the medial elbow, indicating ulnar collateral ligament injury.
Injury seen among repetitive throwing athletes
Onset can be acute (‘pop’) or insidious with medial elbow
pain, tightness and decreased throwing velocity
Dynamic ultrasound or MRI can be used to characterise the
location of the UCL pathology
First-line treatment is conservative management with
cessation of throwing followed by structured rehabilitation
Surgical options include UCL reconstruction (gold standard) or
ligament repair with an internal brace

Hip
Femoroacetabular impingement and dysplasia Background Intra-articular hip derangements most commonly manifest as anterolateral groin pain in a characteristic distribution, referred to as a ‘C-sign’ ( Figure 36.4 ). In a young patient, two common sources of  groin pain with intra-articular origin are femoroacetabular impingement (FAI) and dysplasia. These conditions are considered in some detail in Chapter 39 are described here as they can present as a sports-related injury . History and physical examination Y oung patients with a history of  groin pain or repetitive ‘groin or hip flexor sprains’ should be evaluated for dysplasia or FAI. Physical examination focuses on hip range of  motion, strength, palpation and provocative manoeuvres. Some important manoeuvres include the FADIR examination, which stands for hip Flexion, ADduction and Internal Rotation, which is specific for impingement pathologies, but the FABER (Flex ion, ABduction and External Rotation) manoeuvre as well as resisted hip flexion (Stinchfield testing) can also identify true 7 intra-articular pathologies. Imaging Initial imaging includes radiographs of  the pelvis and the a ff ected hip. Anteroposterior pelvis and false profile views can help determine lateral or anterior coverage of  the acetabulum, respectively , while 45° Dunn lateral radiographs of  the hip are the optimal projection for detecting the presence of  a cam lesion ( Figure 36.5 ). Three-dimensional imaging, including CT and MRI, is helpful for better defining the bony morphology and soft-tissue (i.e. labral) integrity , respectively . Frank E Stinchfield , 1910–1992, American orthopaedic surgeon and founder of  The Hip Society . Denis M Dunn , 1916–2001, British orthopaedic surgeon. Treatment Once the correct diagnosis is determined both pathologies can initially be treated conservatively using anti-inflammatory drugs, physical therapy and at times intra-articular injection, for example corticosteroid. Should these modalities fail, both FAI and dysplasia have their own specific surgical interven - tions: arthroscopy ( Figure 36.6 ) and osteotomy , respectively (see Chapter 39 ). Importantly , the aforementioned interven - tions are only a consideration prior to the development of  joint space narrowing and osteoarthritis in an e ff ort to preserve the but 7 hip joint. Differential diagnosis /uni25CF Adductor strain. /uni25CF Hip osteoarthritis. /uni25CF Athletic pubalgia. /uni25CF Lumbar radiculopathy  . Summary box 36.3 - Femoroacetabular impingement and dysplasia /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Figure 36.4
Example of the C-sign for intra-articular hip pathology
when asking a patient to demonstrate where they feel their pain.
Preserved
Large cam lesion
joint space
Figure 36.5
Anteroposterior right hip radiograph demonstrating a
large cam lesion in the setting of the preserved hip joint space.
Intra-articular hip derangements can manifest with
anterolateral groin pain in a characteristic distribution (‘C-sign’)
Consider pathologies in young patients with a history of groin
pain or repetitive ‘groin or hip
/f_l
exor sprains’
Initial imaging includes radiographs of the pelvis and the
affected hip
Three-dimensional imaging includes CT (bony morphology)
and MRI (soft-tissue integrity)
Conservative treatment involves using anti-in
/f_l
ammatory
drugs, physical therapy and/or intra-articular injection
Surgical interventions are arthroscopy (FAI) and osteotomy
(dysplasia) prior to the development of joint space narrowing
and osteoarthritis

Knee anterior cruciate ligament rupture with meniscus tear Background Acute knee injuries are extremely common in most sports that require jumping, twisting and contact. Sports with physical impact or tackling, such as rugby or American football, can result in contact knee injuries that often lead to varus or valgus stresses to the knee, resulting in collateral ligament injuries (i.e. lateral collateral ligament or medial collateral ligament) in addition to concomitant cruciate ligament, meniscus or articular cartilage injuries. More frequently , however, acute non-contact injuries of the knee lead to injury to the anterior cruciate ligament (ACL). The most common mechanism of these injuries is a deceleration when the knee falls into valgus and the tibia externally rotates, leading to a subluxation of  the knee. These injuries are often associated with either medial or lateral meniscus injuries. History and physical examination Patients with an acute ACL injury will often report hearing or feeling a pop in their knee followed by a notable e ff usion and/ or haemarthrosis. Once the e ff usion resolves, they may report a paucity of  knee pain, often leading the patient to believe that the injury has healed itself. However, patients usually present to a physician after attempting subsequent cutting and pivoting activities, which can lead to recurrent instability . Given that the ACL’s primary function is to restrict anterior translation of  the tibia on the femur, the most commonly utilised tests to evaluate the competency of  the ACL are the anterior drawer and Lachman tests (see Chapter 35 ). Imaging The initial evaluation of  an acute knee injury with e ff usion and/or haemarthrosis necessitates radiographic evaluation. John W Lachman , 1919–2007, Professor and Chairman of  the Orthopedic Department at Temple University in Philadelphia, PA, USA. Paul Ferdinand Segond , 1851–1912, French surgeon who was a founder of  obstetrics and also an expert of  the knee, Paris, France. AP , lateral and merchant views are the minimum recom - mended. These radiographs can be useful for identifying any concomitant injuries, including fractures. A Segond fracture located on the anterolateral tibia is pathognomonic for an ACL injury . If  an ACL injury is suspected by physical e xamination, an MRI is performed to better evaluate the intra-articular structures and to aid in surgical planning. A systematic eval - uation of  the MRI is necessary to ensure that no additional pathology is missed ( Figure 36.7 ). ‘Kissing lesions’ of bony oedema seen on fluid-sensitive sequences on the posterolateral tibia and la teral femoral condyle are also pathognomonic for ACL rupture and represent the pivot shift knee subluxation seen in the setting of  ACL rupture. Treatment ACL injuries can be managed conservatively through activ - ity modification and bracing. Should these modalities fail, surgery is an excellent option for restoration of  knee stability and to decrease the potential for further meniscal or articular cartilage degeneration. ACL repair has recently become a resurging option for proximal-type tears when the ACL can be restored back to its anatomic footprint on the femur. The bridge-enhanced ACL repair (BEAR) technique using a colla - gen sca ff old is currently under clinical trial and may emerge as an option in the future. The gold standard for ACL, however, is reconstruction. In younger pa tients, large multicentre cohort studies have indicated that autograft reconstruction o ff ers the best durability and lowest chance for re-rupture. Options for autograft reconstruction include bone–patellar tendon–bone, hamstring and quadriceps–tendon autografts. For older and 

Femoral osteoplasty
Labral repair
Burr
Figure 36.6
Hip arthroscopic image viewed through the mid-anterior
portal with a 70° arthroscope.
Complete
ACL rupture
Figure 36.7
Sagittal proton density magnetic resonance image of the
knee demonstrating a complete proximal anterior cruciate ligament
(ACL) rupture.

tendon reconstruction provides an additional graft option. Meniscal tears are frequently encountered in the setting 8 of  ACL rupture. Common tear patterns encountered include radial tears, root tears and bucket-handle tears where the torn portion of  the meniscus can flip like a bucket handle into the centre of  the joint. Previously , meniscus tears were treated with partial excision to remove any mechanical disruptions and associated pain, but in recent years the joint preservation func tions of  the menisci as well as their contribution to stability of the knee have been better appreciated, leading to e ff orts to pre serve as much meniscal tissue as possible, especially in younger patients. Various methods of  meniscus repair ar e currently utilised to restore the meniscus anatomy , including all-inside devices, inside-out, outside-in and root re pair techniques, the details of  which are beyond the scope of  this chapter. Biolog ical strategies, to augment the repair, are being evaluated in some centres. Differential diagnosis /uni25CF Patellar dislocation. /uni25CF Posterior cruciate ligament rupture. /uni25CF Medial collateral ligament knee rupture. /uni25CF Posterolateral corner knee ligament injury . /uni25CF Patellar tendon rupture. Summary box 36.4 ACL ruptures /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Mechanism is commonly a non-contact pivoting injury or a
direct impact to the lateral knee
Patients often hear or feel a pop in their knee followed by a
notable effusion and may experience instability when returning
to cutting and pivoting activities
Radiographic evaluation includes AP , lateral and merchant
views
MRI is performed to better evaluate the intra-articular
structures, aid in surgical planning and ensure that no
additional pathology is missed
ACL injuries can be managed conservatively through activity
modi
/f_i
cation and bracing
Surgical options include ACL reconstruction (gold standard)
and repair in certain select scenarios

COMMONL Y ENCOUNTERED REGIONAL INJURIES Shoulder

Shoulder instability and rotator cuff tear Background Shoulder injuries a ff ect athletes of  all ages; however, the distribution of  shoulder injuries varies between young and Rudolph Grashey , 1876–1950, Professor of  Roentgenology , University of  Cologne, Cologne, Germany . Alfred-Armand-Louis-Marie Velpeau , 1795–1867, French anatomist and surgeon. Harold Arthur Hill , 1901–1973, radiologist, San Francisco, CA, USA. Maurice David Sachs , 1909–1987, radiologist, San Francisco, CA, USA. older participants. In athletes younger than 30 years old, espe - cially those participating in contact sports, anterior shoulder dislocations can occur in instances of  traumatic or forced shoulder abduction and external rotation. Unfortunately , such dislocations, even if  r educed, lead to some degree of  stretch - ing of the anterior capsule and tearing of the anteroinferior labrum, which places the patient at risk for further instability events. In older patients who experience falls and sustain the same anterior shoulder dislocations, additional pathologies, including rotator cu ff tears , can occur. History and physical examination Patients who sustain a shoulder dislocation often describe a violent injury event such as a fall or tackle with the arm in some degree of  abduction. Patients will often describe a sensation of  their shoulder feeling out of  place, especially if - the shoulder does not spontaneously reduce. An important component of  the history involves the details of  the disloca - tion(s): self-reduction versus emergency department reduction, length of  time dislocated prior to reduction, prior dislocations, extremity numbness, general ligamentous laxity and activity profile – all of  these details have implications for management. Examination in the acute period should focus on e valuating anterior apprehension or subjective patient discomfort and fear of  re-dislocation in the positions of  abduction and exter - nal rotation of  the shoulder, as well as rotator cu ff strength and neurovascular integrity , especially of  the axillary nerve (see 1,2 Further reading ). Imaging Radiographs, including at least true anteroposterior (AP) or Grashey , scapular Y , axillary or V elpeau views, should be obtained in all circumstances and evaluated to confirm glenohumeral reduction while ruling out associated fractures, such as Hill–Sachs deformities or glenoid rim fractures. 

To assess the patient and offer treatment and
•
rehabilitation plans

Specific views, including the West Point axillary and the Stryker notch views, can be helpful for evaluating glenoid rim or Bankart fractures or Hill–Sachs lesions, respectively . In cases of  recurrent instability where glenoid bone loss is suspected, computed tomography (CT) with or without three-dimensional reconstruction can be helpful in further determining the extent of bone loss. In most instances of anterior instability , magnetic resonance imaging (MRI) is recommended ( Figure 36.1 evaluate for concomitant soft-tissue injuries, including rotator cu ff tears, humeral avulsions of  the glenohumeral ligament (HAGL), glenolabral articular disruptions (GLAD) or anterior labrum periosteal sleeve avulsion (ALPSA). Treatment After reduction of  an acute anterior glenohumeral dislocation, patients are typically placed in a sling for the first few days. important to begin early gentle range of motion of the shoul der through pendulum exercises but also to continue to move the elbow , wrist and digits actively to maintain range of  motion in those distal joints. The initial period is then progressed to increased passive and then active and active-assisted range of motion of the shoulder. Once range of motion has returned to near normal, rotator cu ff and scapular strengthening is progressed. Surgery is considered for even first-time dislo cators based upon stratification of  several factors, including younger age, activity profile and pathology present on imag ing. Furthermore, depending upon the pathology present, the surgical options exist on a continuum fr om arthroscopic capsulolabral repair to open capsulolabral repair and capsular 3,4 shift to glenoid bony augmentation procedur es. Regardless of  the treatment method chosen, athletes are cleared to return William Schamel Stryker , 1916–2015, orthopedic surgeon and Captain in the United States Navy . Arthur Sydney Blundell Bankart , 1879–1951, orthopaedic surgeon, The Middlesex Hospital, London, UK. to normal levels. Older athletes who acutely tear their rotator cu ff in the set - ting of  shoulder dislocations can be considered for acute rota - 5 tor cu ff repair. The treatment of  rotator cu ff tears has evolved over several years and current techniques of  arthroscopic repair with a knotless, linked, double-row construct ( Figure 36.2 ) have demonstrated excellent patient-reported outcomes with low re-tear rates. Differential diagnosis /uni25CF Proximal humerus fracture. /uni25CF Greater tuberosity fracture. /uni25CF Acromioclavicular joint separation. Summary box 36.1 Shoulder instability /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF ) to 2 It is - - - 

Anterior
labral tear
Figure 36.1
Axial
/f_l
uid-sensitive magnetic resonance image of the
shoulder demonstrating an anterior labral tear.
Dislocations occur in instances of traumatic or forced shoulder
abduction and external rotation
Details of the reduction, time dislocated, history of prior
dislocations, general ligamentous laxity and activity pro
/f_i
le
have implications for management
Radiographs to con
/f_i
rm glenohumeral reduction include true
AP or Grashey, scapular Y , axillary or Velpeau views
A sling should be used for a few days following an acute
anterior glenohumeral dislocation
Surgery is considered based upon strati
/f_i
cation of several
factors, including younger age, activity pro
/f_i
le and pathology
present on imaging
Rotator cuff tendon
Suture anchor with
repair sutures
Figure 36.2
Shoulder arthroscopic image of a rotator cuff repair
viewed from the subacromial space through a lateral portal with a 30°
arthroscope.

Ulnar collateral ligament tear Background The anterior band of  the ulnar collateral ligament (UCL) is the primary stabiliser to valgus stress at the elbow . Anatomi cally this ligament courses from the medial epicondyle of  the humerus to the sublime tubercle of  the ulna. Although it can be injured acutely through mechanisms of  elbow dislocations, pathology is most frequently encountered in repetitive thro ing athletes, such as baseball pitchers and javelin throwers. In the late cocking and early acceleration phases of  throwing the ligament is under its maximum stress and at this stage is at the highest risk of  ruptur e and chronic attenuation. History and physical examination Throwers who sustain ruptures of  their UCL commonly pres ent with two sets of  complaints. Rarely , the thrower will recall an acute episode when they heard a pop in the throwing cycle followed by medial elbow pain and pain worse with throwing. The v ast majority of  throwers complain of  medial elbow pain and tightness coupled with decreased velocity that comes on more insidiously . Examination focuses on provocative manoeuvres that are specific for the UCL, including valgus stress and the moving valgus stress tests or milking manoeuvre ( Figure 36.3 ), in which the examiner provides a valgus stress 6 through elbow range of  motion. Pain at the medial elbow during these manoeuvres is specific for UCL pathology . The examiner should also focus on both ulnar nerve sensory and motor symptoms in the hand in addition to ulnar nerve sublux ation as these pathologies can a ff ect the proposed treatment algorithm. Imaging Radiographs of  the elbow include a series of  AP , lateral, inter nal and external oblique views. These can help rule out other commonly encountered phenomena seen in overhead throwing athletes, including medial epicondyle fractures, posteromedial impingement and capitellar osteochondral defects. When UCL pathology is suspected, dynamic ultrasound is a helpful imaging modality to help characterise the loca tion of  the UCL pathology . Moreover, it permits easy examination of  the contralateral elbow , which can help to quantify incongruities in medial elbow joint space gapping, an indirect gauge of tear severity . MRI is commonly obtained to precisely define the location of  the UCL tear as well as to better evaluate the articular cartilage and the flexor pronator mass, which can also commonly be a ff ected. Treatment Conservative management of  UCL injuries is considered first line treatment and typically entails a period of  several months of  cessation of  throwing followed by structured rehabilitation that includes strengthening of  secondary stabilising muscles 6 about the elbow and a g radual return of  throwing. The use of biological injections, including platelet-rich plasma, has been To m my  Jo h n  s u rge r y , named after Thomas Edward John Jr, the first major league baseball pitcher who received an ulnar collateral ligament reconstruction in 1974. - w - - proposed for partial-thickness ligament tears in some centres, but more clinical evidence is required. Although ligament repair with an internal brace has recently been demonstrated to have e ffi cacy in certain types of  tears, the gold standard for surgical treatment is UCL reconstruction or Tommy John surgery . The surgery involves an autograft tendon harvest, commonly utilising the ipsilateral palmaris longus tendon, and reconstruction of  the ligament through bone tunnels in - 6 both the humerus and ulna. This surgery can be coupled with in situ decompression or transposition of  the ulnar nerve, if indicated. Ulnar reconstruction surgery is indicated for the highest level of  throwers who wish to continue playing their respective sport, with return to sport taking anywhere from - 12 /uni00A0 to 18 months. Differential diagnosis /uni25CF Flexor pronator mass sprain. /uni25CF Ulnohumeral arthritis. /uni25CF Ulnar nerve compression or subluxation. /uni25CF Loose body . Summary box 36.2 UCL tears /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF 

Examiner
stabilises
patient’s
elbow
Examiner pulls
patient’s thumb
with downward
force
Figure 36.3
Demonstration of the milking manoeuvre. This is consid
-
ered a positive test when this provocative manoeuvre elicits pain in
the medial elbow, indicating ulnar collateral ligament injury.
Injury seen among repetitive throwing athletes
Onset can be acute (‘pop’) or insidious with medial elbow
pain, tightness and decreased throwing velocity
Dynamic ultrasound or MRI can be used to characterise the
location of the UCL pathology
First-line treatment is conservative management with
cessation of throwing followed by structured rehabilitation
Surgical options include UCL reconstruction (gold standard) or
ligament repair with an internal brace

Hip
Femoroacetabular impingement and dysplasia Background Intra-articular hip derangements most commonly manifest as anterolateral groin pain in a characteristic distribution, referred to as a ‘C-sign’ ( Figure 36.4 ). In a young patient, two common sources of  groin pain with intra-articular origin are femoroacetabular impingement (FAI) and dysplasia. These conditions are considered in some detail in Chapter 39 are described here as they can present as a sports-related injury . History and physical examination Y oung patients with a history of  groin pain or repetitive ‘groin or hip flexor sprains’ should be evaluated for dysplasia or FAI. Physical examination focuses on hip range of  motion, strength, palpation and provocative manoeuvres. Some important manoeuvres include the FADIR examination, which stands for hip Flexion, ADduction and Internal Rotation, which is specific for impingement pathologies, but the FABER (Flex ion, ABduction and External Rotation) manoeuvre as well as resisted hip flexion (Stinchfield testing) can also identify true 7 intra-articular pathologies. Imaging Initial imaging includes radiographs of  the pelvis and the a ff ected hip. Anteroposterior pelvis and false profile views can help determine lateral or anterior coverage of  the acetabulum, respectively , while 45° Dunn lateral radiographs of  the hip are the optimal projection for detecting the presence of  a cam lesion ( Figure 36.5 ). Three-dimensional imaging, including CT and MRI, is helpful for better defining the bony morphology and soft-tissue (i.e. labral) integrity , respectively . Frank E Stinchfield , 1910–1992, American orthopaedic surgeon and founder of  The Hip Society . Denis M Dunn , 1916–2001, British orthopaedic surgeon. Treatment Once the correct diagnosis is determined both pathologies can initially be treated conservatively using anti-inflammatory drugs, physical therapy and at times intra-articular injection, for example corticosteroid. Should these modalities fail, both FAI and dysplasia have their own specific surgical interven - tions: arthroscopy ( Figure 36.6 ) and osteotomy , respectively (see Chapter 39 ). Importantly , the aforementioned interven - tions are only a consideration prior to the development of  joint space narrowing and osteoarthritis in an e ff ort to preserve the but 7 hip joint. Differential diagnosis /uni25CF Adductor strain. /uni25CF Hip osteoarthritis. /uni25CF Athletic pubalgia. /uni25CF Lumbar radiculopathy  . Summary box 36.3 - Femoroacetabular impingement and dysplasia /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Figure 36.4
Example of the C-sign for intra-articular hip pathology
when asking a patient to demonstrate where they feel their pain.
Preserved
Large cam lesion
joint space
Figure 36.5
Anteroposterior right hip radiograph demonstrating a
large cam lesion in the setting of the preserved hip joint space.
Intra-articular hip derangements can manifest with
anterolateral groin pain in a characteristic distribution (‘C-sign’)
Consider pathologies in young patients with a history of groin
pain or repetitive ‘groin or hip
/f_l
exor sprains’
Initial imaging includes radiographs of the pelvis and the
affected hip
Three-dimensional imaging includes CT (bony morphology)
and MRI (soft-tissue integrity)
Conservative treatment involves using anti-in
/f_l
ammatory
drugs, physical therapy and/or intra-articular injection
Surgical interventions are arthroscopy (FAI) and osteotomy
(dysplasia) prior to the development of joint space narrowing
and osteoarthritis

Knee anterior cruciate ligament rupture with meniscus tear Background Acute knee injuries are extremely common in most sports that require jumping, twisting and contact. Sports with physical impact or tackling, such as rugby or American football, can result in contact knee injuries that often lead to varus or valgus stresses to the knee, resulting in collateral ligament injuries (i.e. lateral collateral ligament or medial collateral ligament) in addition to concomitant cruciate ligament, meniscus or articular cartilage injuries. More frequently , however, acute non-contact injuries of the knee lead to injury to the anterior cruciate ligament (ACL). The most common mechanism of these injuries is a deceleration when the knee falls into valgus and the tibia externally rotates, leading to a subluxation of  the knee. These injuries are often associated with either medial or lateral meniscus injuries. History and physical examination Patients with an acute ACL injury will often report hearing or feeling a pop in their knee followed by a notable e ff usion and/ or haemarthrosis. Once the e ff usion resolves, they may report a paucity of  knee pain, often leading the patient to believe that the injury has healed itself. However, patients usually present to a physician after attempting subsequent cutting and pivoting activities, which can lead to recurrent instability . Given that the ACL’s primary function is to restrict anterior translation of  the tibia on the femur, the most commonly utilised tests to evaluate the competency of  the ACL are the anterior drawer and Lachman tests (see Chapter 35 ). Imaging The initial evaluation of  an acute knee injury with e ff usion and/or haemarthrosis necessitates radiographic evaluation. John W Lachman , 1919–2007, Professor and Chairman of  the Orthopedic Department at Temple University in Philadelphia, PA, USA. Paul Ferdinand Segond , 1851–1912, French surgeon who was a founder of  obstetrics and also an expert of  the knee, Paris, France. AP , lateral and merchant views are the minimum recom - mended. These radiographs can be useful for identifying any concomitant injuries, including fractures. A Segond fracture located on the anterolateral tibia is pathognomonic for an ACL injury . If  an ACL injury is suspected by physical e xamination, an MRI is performed to better evaluate the intra-articular structures and to aid in surgical planning. A systematic eval - uation of  the MRI is necessary to ensure that no additional pathology is missed ( Figure 36.7 ). ‘Kissing lesions’ of bony oedema seen on fluid-sensitive sequences on the posterolateral tibia and la teral femoral condyle are also pathognomonic for ACL rupture and represent the pivot shift knee subluxation seen in the setting of  ACL rupture. Treatment ACL injuries can be managed conservatively through activ - ity modification and bracing. Should these modalities fail, surgery is an excellent option for restoration of  knee stability and to decrease the potential for further meniscal or articular cartilage degeneration. ACL repair has recently become a resurging option for proximal-type tears when the ACL can be restored back to its anatomic footprint on the femur. The bridge-enhanced ACL repair (BEAR) technique using a colla - gen sca ff old is currently under clinical trial and may emerge as an option in the future. The gold standard for ACL, however, is reconstruction. In younger pa tients, large multicentre cohort studies have indicated that autograft reconstruction o ff ers the best durability and lowest chance for re-rupture. Options for autograft reconstruction include bone–patellar tendon–bone, hamstring and quadriceps–tendon autografts. For older and 

Femoral osteoplasty
Labral repair
Burr
Figure 36.6
Hip arthroscopic image viewed through the mid-anterior
portal with a 70° arthroscope.
Complete
ACL rupture
Figure 36.7
Sagittal proton density magnetic resonance image of the
knee demonstrating a complete proximal anterior cruciate ligament
(ACL) rupture.

tendon reconstruction provides an additional graft option. Meniscal tears are frequently encountered in the setting 8 of  ACL rupture. Common tear patterns encountered include radial tears, root tears and bucket-handle tears where the torn portion of  the meniscus can flip like a bucket handle into the centre of  the joint. Previously , meniscus tears were treated with partial excision to remove any mechanical disruptions and associated pain, but in recent years the joint preservation func tions of  the menisci as well as their contribution to stability of the knee have been better appreciated, leading to e ff orts to pre serve as much meniscal tissue as possible, especially in younger patients. Various methods of  meniscus repair ar e currently utilised to restore the meniscus anatomy , including all-inside devices, inside-out, outside-in and root re pair techniques, the details of  which are beyond the scope of  this chapter. Biolog ical strategies, to augment the repair, are being evaluated in some centres. Differential diagnosis /uni25CF Patellar dislocation. /uni25CF Posterior cruciate ligament rupture. /uni25CF Medial collateral ligament knee rupture. /uni25CF Posterolateral corner knee ligament injury . /uni25CF Patellar tendon rupture. Summary box 36.4 ACL ruptures /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF 

Mechanism is commonly a non-contact pivoting injury or a
direct impact to the lateral knee
Patients often hear or feel a pop in their knee followed by a
notable effusion and may experience instability when returning
to cutting and pivoting activities
Radiographic evaluation includes AP , lateral and merchant
views
MRI is performed to better evaluate the intra-articular
structures, aid in surgical planning and ensure that no
additional pathology is missed
ACL injuries can be managed conservatively through activity
modi
/f_i
cation and bracing
Surgical options include ACL reconstruction (gold standard)
and repair in certain select scenarios

# DIAGNOSIS OF SPORTS INJURIES

DIAGNOSIS OF SPORTS INJURIES

Within the history , there are some additional questions that need to be asked when treating a patient with a sports injury: /uni25CF How was the injury sustained? /uni25CF When was the injury sustained? /uni25CF What intervention(s) has the patient tried and what reha bilitation have they had? /uni25CF How many hours of  training is the patient doing and has this changed recently? /uni25CF Has the patient had a previous injury? /uni25CF What are the patient’s competitive goals? The examination should follow the general system described in Chapter 35 . DIAGNOSIS OF SPORTS INJURIES

Within the history , there are some additional questions that need to be asked when treating a patient with a sports injury: /uni25CF How was the injury sustained? /uni25CF When was the injury sustained? /uni25CF What intervention(s) has the patient tried and what reha bilitation have they had? /uni25CF How many hours of  training is the patient doing and has this changed recently? /uni25CF Has the patient had a previous injury? /uni25CF What are the patient’s competitive goals? The examination should follow the general system described in Chapter 35 . DIAGNOSIS OF SPORTS INJURIES

Within the history , there are some additional questions that need to be asked when treating a patient with a sports injury: /uni25CF How was the injury sustained? /uni25CF When was the injury sustained? /uni25CF What intervention(s) has the patient tried and what reha bilitation have they had? /uni25CF How many hours of  training is the patient doing and has this changed recently? /uni25CF Has the patient had a previous injury? /uni25CF What are the patient’s competitive goals? The examination should follow the general system described in Chapter 35 .

# FURTHER READING

FURTHER READING

1 Goldenberg BT , Lacheta L, Rosenberg SI et al . Comprehensive review of  the physical exam for glenohumeral instability . Phys Sportsmed 2020; 48 (2): 142–50. 2 Norte GE, West A, Gnacinski M et al . On-field management of  the acute anterior glenohumeral dislocation. Phys Sportsmed 2011; 39 (3): 151–62. 3 Godin JA, Altintas B, Horan MP et al . Midterm results of  the bony Bankart bridge technique for the treatment of bony Bankart lesions. Am J Sports Med 2019; 47 (1): 158–64. 4 Martetschläger F , Kraus TM, Hardy P , Millett PJ. Arthroscopic man - agement of  anterior shoulder instability with glenoid bone defects. Knee Surg Sports Traumatol Arthrosc 2013; 21 (12): 2867-76. 5 Bhatia S, Greenspoon JA, Horan MP et al . Two-year outcomes after arthroscopic rotator cu ff repair in recreational athletes older than 70 years. Am J Sports Med 2015; 43 (7): 1737–42. 6 Jones KJ, Osbahr DC, Schrumpf  MA et al . Ulnar collateral ligament reconstruction in throwing athletes: a review of  current concepts. AAOS exhibit selection. J Bone Joint Surg Am 2012; 94 (8): e49. 7 Philippon MJ, Maxwell RB, Johnston TL et al . Clinical presentation of  femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2007; 15 (8): 1041–7. 8 Millett PJ, Willis AA, Warren RF . Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment - increase the risk of  meniscal tear? Arthroscopy 2002; 18 (9): 955–9. 9 Chen ET , Borg-Stein J, McInnis KC. Ankle sprains: evaluation, reha - bilitation, and prevention. Curr Sports Med Rep 2019; 18 (6): 217–23. FURTHER READING

1 Goldenberg BT , Lacheta L, Rosenberg SI et al . Comprehensive review of  the physical exam for glenohumeral instability . Phys Sportsmed 2020; 48 (2): 142–50. 2 Norte GE, West A, Gnacinski M et al . On-field management of  the acute anterior glenohumeral dislocation. Phys Sportsmed 2011; 39 (3): 151–62. 3 Godin JA, Altintas B, Horan MP et al . Midterm results of  the bony Bankart bridge technique for the treatment of bony Bankart lesions. Am J Sports Med 2019; 47 (1): 158–64. 4 Martetschläger F , Kraus TM, Hardy P , Millett PJ. Arthroscopic man - agement of  anterior shoulder instability with glenoid bone defects. Knee Surg Sports Traumatol Arthrosc 2013; 21 (12): 2867-76. 5 Bhatia S, Greenspoon JA, Horan MP et al . Two-year outcomes after arthroscopic rotator cu ff repair in recreational athletes older than 70 years. Am J Sports Med 2015; 43 (7): 1737–42. 6 Jones KJ, Osbahr DC, Schrumpf  MA et al . Ulnar collateral ligament reconstruction in throwing athletes: a review of  current concepts. AAOS exhibit selection. J Bone Joint Surg Am 2012; 94 (8): e49. 7 Philippon MJ, Maxwell RB, Johnston TL et al . Clinical presentation of  femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2007; 15 (8): 1041–7. 8 Millett PJ, Willis AA, Warren RF . Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment - increase the risk of  meniscal tear? Arthroscopy 2002; 18 (9): 955–9. 9 Chen ET , Borg-Stein J, McInnis KC. Ankle sprains: evaluation, reha - bilitation, and prevention. Curr Sports Med Rep 2019; 18 (6): 217–23. FURTHER READING

1 Goldenberg BT , Lacheta L, Rosenberg SI et al . Comprehensive review of  the physical exam for glenohumeral instability . Phys Sportsmed 2020; 48 (2): 142–50. 2 Norte GE, West A, Gnacinski M et al . On-field management of  the acute anterior glenohumeral dislocation. Phys Sportsmed 2011; 39 (3): 151–62. 3 Godin JA, Altintas B, Horan MP et al . Midterm results of  the bony Bankart bridge technique for the treatment of bony Bankart lesions. Am J Sports Med 2019; 47 (1): 158–64. 4 Martetschläger F , Kraus TM, Hardy P , Millett PJ. Arthroscopic man - agement of  anterior shoulder instability with glenoid bone defects. Knee Surg Sports Traumatol Arthrosc 2013; 21 (12): 2867-76. 5 Bhatia S, Greenspoon JA, Horan MP et al . Two-year outcomes after arthroscopic rotator cu ff repair in recreational athletes older than 70 years. Am J Sports Med 2015; 43 (7): 1737–42. 6 Jones KJ, Osbahr DC, Schrumpf  MA et al . Ulnar collateral ligament reconstruction in throwing athletes: a review of  current concepts. AAOS exhibit selection. J Bone Joint Surg Am 2012; 94 (8): e49. 7 Philippon MJ, Maxwell RB, Johnston TL et al . Clinical presentation of  femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2007; 15 (8): 1041–7. 8 Millett PJ, Willis AA, Warren RF . Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment - increase the risk of  meniscal tear? Arthroscopy 2002; 18 (9): 955–9. 9 Chen ET , Borg-Stein J, McInnis KC. Ankle sprains: evaluation, reha - bilitation, and prevention. Curr Sports Med Rep 2019; 18 (6): 217–23.

# INJURIES ASSOCIATED WITH INDIVIDUAL SPORTS Golf

INJURIES ASSOCIATED WITH INDIVIDUAL SPORTS Golf

The shoulder and the back are the common sites of  overuse injuries. Golfer’s elbow or medial epicondylitis is due to a common flexor origin tendinosis that also commonly occurs in weightlifters and rodeo athletes. INJURIES ASSOCIATED WITH INDIVIDUAL SPORTS Golf

The shoulder and the back are the common sites of  overuse injuries. Golfer’s elbow or medial epicondylitis is due to a common flexor origin tendinosis that also commonly occurs in weightlifters and rodeo athletes. INJURIES ASSOCIATED WITH INDIVIDUAL SPORTS Golf

The shoulder and the back are the common sites of  overuse injuries. Golfer’s elbow or medial epicondylitis is due to a common flexor origin tendinosis that also commonly occurs in weightlifters and rodeo athletes.

# Introduction

INTRODUCTION

In addition to a clinical assessment, an understanding of  the biomechanics of  injury associated with sporting activity can facilitate diagnosis, treatment and management of  the patient according to their competitive level and recovery goals. This chapter aims to provide a brief  clinically directed overview of selected common injuries, with the examples associated with a wide variety of  sports.

# Javelin

Javelin

Javelin throwers experience various injuries to the kinetic chain given the violent and abrupt throwing approach. Injuries due to abnormal stresses on the elbow are similar to those seen in - baseball. This causes abnormalities of  the hip, shoulder, UCL and phalanges. Shoulder injuries are more common in swimmers, especially in those performing the crawl or the butterfly stroke because of  multidirectional instability , which can provide a competitive advantage for swimming but can become pathological. Javelin

Javelin throwers experience various injuries to the kinetic chain given the violent and abrupt throwing approach. Injuries due to abnormal stresses on the elbow are similar to those seen in - baseball. This causes abnormalities of  the hip, shoulder, UCL and phalanges. Shoulder injuries are more common in swimmers, especially in those performing the crawl or the butterfly stroke because of  multidirectional instability , which can provide a competitive advantage for swimming but can become pathological. Javelin

Javelin throwers experience various injuries to the kinetic chain given the violent and abrupt throwing approach. Injuries due to abnormal stresses on the elbow are similar to those seen in - baseball. This causes abnormalities of  the hip, shoulder, UCL and phalanges. Shoulder injuries are more common in swimmers, especially in those performing the crawl or the butterfly stroke because of  multidirectional instability , which can provide a competitive advantage for swimming but can become pathological.

# Learning objectives

Learning objectives

To review some common sports injuries • To understand the basics of history, physical examination • and imaging for common injuries Learning objectives

To review some common sports injuries • To understand the basics of history, physical examination • and imaging for common injuries Learning objectives

To review some common sports injuries • To understand the basics of history, physical examination • and imaging for common injuries

# Rowing

Rowing

The common injuries that are encountered in rowing but that are rare in other athletics include rib stress fractures and intercostal muscle tears ( Figure 36.8 ), which occur from the repetitive engagement of  the latissimus dorsi muscles. Fore - arm tendon issues such as intersection syndrome (a tendinosis where the first and second extensor tendon compartments of the forearm cross) are also a commonly encountered problem in rowing a thletes. Rowing

The common injuries that are encountered in rowing but that are rare in other athletics include rib stress fractures and intercostal muscle tears ( Figure 36.8 ), which occur from the repetitive engagement of  the latissimus dorsi muscles. Fore - arm tendon issues such as intersection syndrome (a tendinosis where the first and second extensor tendon compartments of the forearm cross) are also a commonly encountered problem in rowing a thletes. Rowing

The common injuries that are encountered in rowing but that are rare in other athletics include rib stress fractures and intercostal muscle tears ( Figure 36.8 ), which occur from the repetitive engagement of  the latissimus dorsi muscles. Fore - arm tendon issues such as intersection syndrome (a tendinosis where the first and second extensor tendon compartments of the forearm cross) are also a commonly encountered problem in rowing a thletes.

# Rugby

Rugby

This is a high-intensity contact sport. Patients present with neck injuries including fractures of  the cervical spine; acromio - clavicular joint and finger injuries including dislocation of  the phalanges; and tendon injuries such as jersey finger, in which there is injury to the flexor digitorum profundus tendon. Rugby

This is a high-intensity contact sport. Patients present with neck injuries including fractures of  the cervical spine; acromio - clavicular joint and finger injuries including dislocation of  the phalanges; and tendon injuries such as jersey finger, in which there is injury to the flexor digitorum profundus tendon. Rugby

This is a high-intensity contact sport. Patients present with neck injuries including fractures of  the cervical spine; acromio - clavicular joint and finger injuries including dislocation of  the phalanges; and tendon injuries such as jersey finger, in which there is injury to the flexor digitorum profundus tendon.

# SUMMARY

SUMMARY

Athletic activities commonly result in a variety of  injuries. For providers who take care of athletes, a basic knowledge of both common injuries and treatment algorithms as well as various sport-specific injury patterns is necessary to provide optimal care. SUMMARY

Athletic activities commonly result in a variety of  injuries. For providers who take care of athletes, a basic knowledge of both common injuries and treatment algorithms as well as various sport-specific injury patterns is necessary to provide optimal care. SUMMARY

Athletic activities commonly result in a variety of  injuries. For providers who take care of athletes, a basic knowledge of both common injuries and treatment algorithms as well as various sport-specific injury patterns is necessary to provide optimal care.

# Snowboarding and skiing

Snowboarding and skiing

Participants in both snowboarding and skiing have the full range of  injuries associated with these high-speed sports. The rigid high boots used by skiers protect the ankle but increase the loads transmitted up the limb, risking fracture of  the tibia and ligament disruption of  the knee (especially the anterior cruci ate). Novice snowboarders tend to get wrist fractures, while all levels of  snowboarder can injure the acromioclavicular joint. Most common problems include electrolyte abnormalities during events and iliotibial band syndrome and stress fractures in the feet and shins chronically . Snowboarding and skiing

Participants in both snowboarding and skiing have the full range of  injuries associated with these high-speed sports. The rigid high boots used by skiers protect the ankle but increase the loads transmitted up the limb, risking fracture of  the tibia and ligament disruption of  the knee (especially the anterior cruci ate). Novice snowboarders tend to get wrist fractures, while all levels of  snowboarder can injure the acromioclavicular joint. Most common problems include electrolyte abnormalities during events and iliotibial band syndrome and stress fractures in the feet and shins chronically . Snowboarding and skiing

Participants in both snowboarding and skiing have the full range of  injuries associated with these high-speed sports. The rigid high boots used by skiers protect the ankle but increase the loads transmitted up the limb, risking fracture of  the tibia and ligament disruption of  the knee (especially the anterior cruci ate). Novice snowboarders tend to get wrist fractures, while all levels of  snowboarder can injure the acromioclavicular joint. Most common problems include electrolyte abnormalities during events and iliotibial band syndrome and stress fractures in the feet and shins chronically .

# Tennis

Tennis

Tennis elbow or lateral epicondylitis is angiofibrous dysplasia of  the common extensor origin. Treatment consists of  brac ing, activity modification, injection (with some centres using platelet-rich plasma) and surgery if  conservative measures fail. Partial ruptures of  the calf  muscles, especially the medial head of  the gastrocnemius, are also found in tennis players (called tennis leg), and in patients who take part in other sports requiring sudden extreme acceleration. 

Intercostal muscle strain
Figure 36.8
Coronal magnetic resonance imaging scan of the chest
showing an intercostal muscle injury in a rower.

Tennis

Tennis elbow or lateral epicondylitis is angiofibrous dysplasia of  the common extensor origin. Treatment consists of  brac ing, activity modification, injection (with some centres using platelet-rich plasma) and surgery if  conservative measures fail. Partial ruptures of  the calf  muscles, especially the medial head of  the gastrocnemius, are also found in tennis players (called tennis leg), and in patients who take part in other sports requiring sudden extreme acceleration. 

Intercostal muscle strain
Figure 36.8
Coronal magnetic resonance imaging scan of the chest
showing an intercostal muscle injury in a rower.

Tennis

Tennis elbow or lateral epicondylitis is angiofibrous dysplasia of  the common extensor origin. Treatment consists of  brac ing, activity modification, injection (with some centres using platelet-rich plasma) and surgery if  conservative measures fail. Partial ruptures of  the calf  muscles, especially the medial head of  the gastrocnemius, are also found in tennis players (called tennis leg), and in patients who take part in other sports requiring sudden extreme acceleration. 

Intercostal muscle strain
Figure 36.8
Coronal magnetic resonance imaging scan of the chest
showing an intercostal muscle injury in a rower.