Management of Musculoskeletal Injury

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Chapter 679 Management of Musculoskeletal Injury

Gregory L. Landry

679.1 Mechanism of Injury

Acute Injuries

Sprains, strains, and contusions account for the majority of musculoskeletal injuries. A sprain is an injury to a ligament or joint capsule. A strain is an injury to a muscle or tendon. A contusion is a crush injury to any soft tissue. The history of the injury can be unclear, but it is especially helpful in assessing knee and shoulder injuries. More severe injuries, indicating structural derangement, can have acute signs and symptoms such as immediate swelling, deformity, numbness or weakness, inability to continue playing, inability to walk without a limp, a loud painful pop, mechanical locking of the joint, or the sensation of instability. Most sprains are graded 1-3, with grade 1 meaning that some fibers have been torn with no evidence of laxity of the ligament when tested on physical examination. A grade 2 means more fibers are torn resulting in some laxity of the ligament but a good end point, meaning not all fibers are torn. A grade 3 sprain means all the fibers are torn, and testing of the ligaments results in a “mushy” endpoint on physical examination. Strains are also graded 1-3, with a grade 1 causing mild pain with testing the muscle and very little weakness. Grade 2 injuries cause more pain and moderate weakness with testing the muscle. Grade 3 muscle strains are complete rupture of the muscle or tendon and result in marked weakness and sometimes a palpable defect in the muscle or tendon.

Overuse Injuries

Overuse injuries are caused by repetitive microtrauma that exceeds the body’s rate of repair. This occurs in muscles, tendons, bone, bursae, cartilage, and nerves. Overuse injuries occur in all sports but more commonly in sports emphasizing repetitive motion (swimming, running, tennis, gymnastics). Factors can be categorized into extrinsic (training errors, poor equipment or workout surface) and intrinsic (athlete’s anatomy or medical conditions). Training error is the most commonly identified factor. At the beginning of the workout program, athletes might violate the 10% rule: Do not increase the duration or intensity of workouts more than 10% per week. Intrinsic factors include abnormal biomechanics (leg-length discrepancy, pes planus, pes cavus, tarsal coalition, valgus heel, external tibial torsion, femoral anteversion), muscle imbalance, inflexibility, and medical conditions (deconditioning, nutritional deficits, amenorrhea, obesity). The athlete should be asked about the specifics of training. Runners should be asked about their shoes, orthotics, running surface, weekly mileage or time spent running per week, speed or hill workouts, and previous injuries and rehabilitation. When causative factors are identified, they can be eliminated or modified so that after rehabilitation the athlete does not return to the same regimen and suffer reinjury.

For athletes engaged in excessive training that causes an overuse injury, curtailing all exercise is not usually necessary. Treatment is a reduction of training load (relative rest) combined with a rehabilitation program designed to return athletes to their sport as soon as possible while minimizing exposure to reinjury. Early identification of an overuse injury requires less alteration of the workout regimen.

The goals of treatment are to control pain and spasm to rehabilitate flexibility, strength, endurance, and proprioceptive deficits (Table 679-1). In many overuse injuries, the role of inflammation in the process is minimal. For most injuries to tendons, the term tendinitis is obsolete because there is little or no inflammation on histopathology of tendons. Instead, there is evidence of microscopic trauma to the tissue. Most of these entities are now more appropriately called tendinosis and, when the tendon tissue is scarred and very abnormal, tendinopathy. There is little role for anti-inflammatory medication in the treatment except as an analgesic.

Table 679-1 STAGING OF OVERUSE INJURIES

GRADE	GRADING SYMPTOMS	TREATMENT
I	Pain only after activity Does not interfere with performance or intensity Generalized tenderness Disappears before next session

Modification of activity, consider cross-training, home rehabilitation program II

Minimal pain with activity

Does not interfere with performance

More localized tenderness

Modification of activity, cross-training, home rehabilitation program III

Pain interferes with activity and performance

Definite area of tenderness

Usually disappears between sessions

Significant modification of activity, strongly encourage cross-training, home rehabilitation program, and outpatient physical therapy IV

Pain with activities of daily living

Pain does not disappear between sessions

Marked interference with performance and training intensity

Discontinue activity temporarily, cross-training only, oral analgesic, home rehabilitation program, and intensive outpatient physical therapy V

Pain interferes with activities of daily living

Signs of tissue injury (e.g., edema)

Chronic or recurrent symptoms

Prolonged discontinuation of activity, cross-training only, oral analgesic, home rehabilitation program, and intensive outpatient physical therapy

Initial Evaluation of the Injured Extremity

Initially, the examiner should determine the quality of the peripheral pulses and capillary refill rate as well as the gross motor and sensory function to assess for neurovascular injury. The first priorities are to maintain vascular and skeletal stability.

Criteria for immediate attention and rapid orthopedic consultation include vascular compromise, nerve compromise, and open fracture. The exposed wound should be covered with sterile saline-soaked gauze, and the injured limb should be padded and splinted. Pressure should be applied to any site of bleeding. Additional criteria include deep laceration over a joint, unreducible dislocation, grade III (complete) tear of a muscle-tendon unit, and displaced, significantly angulated fractures (depends on the bone involved, the degree of displacement and angulation, and neurovascular status of the extremity).

Transition From Immediate Management to Return to Play

Rehabilitation of a musculoskeletal injury should begin on the day of the injury.

Phase 1

Limit further injury, control swelling and pain, and minimize strength and flexibility losses. This requires the use of an appropriate device such as crutches or a sling, ice, compression, elevation, and analgesia. Crutches, air stirrups for ankle sprains, slings for arm injuries, and elastic wraps (4-8 in) for compression are a reasonable inventory of office supplies. Ice in a plastic bag is placed directly on the skin for 20 min continuously, 3 to 4 times per day until the swelling resolves. Compression limits further bleeding and swelling but should not be so tight that it limits perfusion. Elevation of the extremity promotes venous return and limits swelling. A nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen is indicated for analgesia.

Pain-free isometric strengthening and range of motion should be initiated as soon as possible. Pain inhibits full muscle contraction; deconditioning results if the pain and resultant nonuse persist for days to weeks, thus delaying recovery. Education about the nature of the injury and the specifics of rehabilitation exercises, including handouts with written instructions and drawings demonstrating the exercises, are helpful.

Phase 2

Improve strength and range of motion (i.e., flexibility) while allowing the injured structures to heal. Protective devices are removed when the patient’s strength and flexibility improve and activities of daily living are pain free. Flexibility can then be improved by a program of specific stretches, held for 15-30 sec for 3 to 5 repetitions, once or twice daily. A physical therapist or athletic trainer is invaluable in guiding the athlete through this process. Protective devices might need to be used for months during sports participation. Swimming, water jogging, and stationary cycling are good aerobic exercises that can allow the injured extremity to get relative rest or be used pain free while maintaining cardiovascular fitness.

Phase 3

Achieve near normal strength and flexibility of the injured structures and further improve or maintain cardiovascular fitness. Strength and endurance are improved under controlled conditions using elastic bands and eventually free weights or exercise equipment. Proprioceptive training allows the athlete to redevelop a kinesthetic sense, which is critical to joint function and stability.

Phase 4

Return to exercise or competition without restriction. When the athlete has reached nearly normal flexibility, strength, proprioception, and endurance, he or she can start sports-specific exercises. The athlete will make the transition from the rehabilitation program to functional rehabilitation appropriate for the sport. Substituting sports participation for rehabilitation is inappropriate; rather, there should be progressive stepwise functional return to a full activity or play program. For instance, a basketball player recovering from an ankle injury might begin a walk-run-sprint-cut program before returning to competition. At any point in this progression, if pain is experienced, the athlete needs to stop, apply ice, avoid running for 1-2 days, continue to do ankle exercises, and then resume running at a lower intensity and progress accordingly.

Relative Rest and Return-to-Play Guidelines

Relative rest means that the athlete can do whatever he or she wants as long as the injured structures do not hurt during or within 24 hr of the activity. Exercising beyond the pain threshold delays recovery.

Differential Diagnoses of Musculoskeletal Pain

Traumatic, rheumatologic, infectious, hematologic, psychologic, and oncologic processes can cause the presenting complaint of musculoskeletal pain. Symptoms such as fatigue, weight loss, rash, multiple joint complaints, fever, chronic or recent illness, and persistence of pain suggest diagnoses other than sports-related trauma. Incongruity between the patient’s history and physical examination findings should lead to further evaluation. A negative review of systems with an injury history consistent with the physical findings suggests a sports-related etiology.

Bibliography

Khan KM, Cook JL, Kannua P, et al. Time to abandon the “tendonitis” myth. Br Med J. 2002;324:626-627.

Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87:187-202.

Van Tulder M, Malmivaara A, Koes B. Repetitive strain injury. Lancet. 2007;369:1815-1822.

679.1 Growth Plate Injuries

Gregory L. Landry

About 20% of pediatric sports injuries seen in the emergency department are fractures, and 25% of those fractures involve an epiphyseal growth plate or physis (Chapter 675). Growth in long bones occurs in 3 areas and is susceptible to injury. Immature bone can be acutely injured at the physis (Salter-Harris fractures), the articular surface (osteochondritis dissecans), or the apophysis (avulsion fractures). Boys suffer about twice as many physeal fractures as girls; the peak incidence of fracture is during peak height velocity (girls, 12 ± 2.5 yr; boys, 14 ± 2 yr). The physis is a pressure growth plate and is responsible for longitudinal growth in bone. The apophysis is a bony outgrowth at the attachment of a tendon and is a traction physis. The epiphysis is the end of a long bone, distal or proximal to the long bone, and contains articular cartilage at the joint.

The most common physeal injuries are to the distal radius, followed by phalangeal and distal tibial fractures. About 94% of forearm fractures in skateboarding, roller skating, and scooter riding involve the distal radius. Physeal injuries at the knee (distal femur, proximal tibia) are rare. Growth disturbance following a growth plate injury is a function of location and the part of the physis fractured. These factors influence the probability a physeal bar will form, resulting in growth arrest. The areas making the largest contribution to longitudinal growth in the upper extremities are the proximal humerus and distal radius and ulna; in the lower extremities, they are the distal femur and the proximal tibia and fibula. Injuries to these areas are more likely to cause growth disturbance compared with physeal injuries at the other end of these long bones. The type of the physis fracture relative to risk of growth disturbance is described by the Salter-Harris classification system (see Table 675-1). A grade I injury is least likely to result in growth disturbance, and grade V is the most likely fracture to result in growth disturbance.

Osteochondritis dissecans (OCD) affects the subchondral bone and overlying articular surface (Chapter 669.3). With avascular necrosis of subchondral bone, the articular surface can flatten, soften, or break off in fragments. The etiology is unknown but may be related to repetitive stress injury in some patients. In children and adolescents, 51% of lesions occur on the lateral aspect of the medial femoral condyle, 17% occur on the lateral condyle, and 7% occur on the patella. Bilateral involvement is reported in 13-30% of cases. Other joints where OCD lesions are also seen are the ankle (talus), elbow (usually involving the capitellum), and radial head. OCD classically affects athletes in their 2nd decade. The most common presentation is poorly localized vague knee pain. There is rarely a history of recent acute trauma. Some OCD lesions are asymptomatic (diagnosed on “routine” radiographs), whereas others are manifested as joint effusion, pain, decreased range of motion, and mechanical symptoms (locking, popping, catching). Activity usually worsens the pain.

Physical examination might show no specific findings. Sometimes tenderness over the involved condyle can be elicited by deep palpation with the knee flexed. Diagnosis is usually made with plain radiographs (Fig. 679-1). A tunnel view radiograph should be obtained to better view the posterior two thirds of the femoral condyle. Patients with OCD should be referred to an orthopedic surgeon for further evaluation.

Figure 679-1 Osteochondritis dissecans in the elbow.

(From Anderson SJ: Sports injuries, Curr Prob Pediatr Adolesc Health 35:105–176, 2005.)

Avulsion fractures occur when a forceful muscle contraction dislodges the apophysis from the bone. They occur most commonly around the hip (Fig. 679-2) and are treated nonsurgically. Acute fractures to other apophyses (knee and elbow) require urgent orthopedic consultation. Chronically increased traction at the muscle-apophysis attachment can lead to repetitive microtrauma and pain at the apophysis. The most common areas affected are the knee (Osgood-Schlatter and Sindig-Larsen-Johannson disease), the ankle (Sever disease) (Fig. 679-3), and the medial epicondyle (Little League elbow). Traction apophysitis of the knee and ankle can potentially be treated in a primary care setting. The main goal of treatment is to minimize the intensity and incidence of pain and disability. Exercises that increase the strength, flexibility, and endurance of the muscles attached at the apophysis, using the relative rest principle, are appropriate. Symptoms can last for 12-24 mo if untreated. As growth slows, symptoms abate.

Figure 679-2 Anterior inferior iliac spine avulsion.

(From Anderson SJ: Lower extremity injuries in youth sports, Pediatr Clin North Am 49:627–641, 2003.)

Figure 679-3 Calcaneal apophysitis (Sever disease).

(From Anderson SJ: Sports injuries, Curr Prob Pediatr Adolesc Health 35:105–176, 2005.)

Bibliography

Caine D, DiFiori J, Maffulli N. Physeal injuries in children’s and youth sports: reasons for concern? Br J Sports Med. 2006;40:749-760.

Wall E, Von Stein D. Juvenile osteochondritis dissecans. Orthop Clin North Am. 2003;34:341-353.

Zalavras C, Nikolopoulou G, Essin D, et al. Pediatric fractures during skateboarding, roller skating, and scooter riding. Am J Sports Med. 2005;33:568-573.

679.2 Shoulder Injuries

Gregory L. Landry

Shoulder pain associated with radiating symptoms down the arm should suggest the possibility of a neck injury. Neck pain and tenderness or limitation of cervical range of motion requires that the cervical spine be immobilized and that the athlete be transferred for further evaluation. If there is no neck pain or tenderness or limitation of motion of the cervical spine, then the shoulder is the site of the primary injury.

Clavicle Fractures

One of the most common shoulder injuries is a clavicle fracture. Injury is usually sustained by a fall on the lateral shoulder, on an outstretched hand, or by direct blow. About 80% of fractures occur in the middle third of the clavicle. They are treated with an arm sling. Nondisplaced medial and lateral 3rd fractures are usually treated conservatively. If displaced, medial and lateral 3rd fractures require orthopedic consultation, due to a higher incidence of acromioclavicular osteoarthritis (lateral) and physeal involvement (medial).

Acromioclavicular Separation

An acromioclavicular (AC) separation most commonly occurs when an athlete sustains a direct blow to the acromion with the humerus in an adducted position, forcing the acromion inferiorly and medially. Patients have discrete tenderness at the AC joint and can have an apparent step off between the distal clavicle and the acromion (Fig. 679-4).

Figure 679-4 Palpitation of acromioclavicular joint.

(From Anderson SJ: Sports injuries, Curr Prob Pediatr Adolesc Health 35:105–176, 2005.)

Type I AC injuries involve the AC ligament, have no visible deformity, and have normal radiographs. Cross-chest maneuver of the arm causes sharp pain at the AC joint. Type II injuries, which involve the acromioclavicular ligament and the coracoclavicular ligament, have a slightly more prominent distal clavicle on examination, but radiographs are usually normal (might show slight widening of the AC joint). Type I and II injuries are treated nonoperatively. A sling and analgesic are useful for pain control. Range-of-motion exercises are initiated after pain is controlled. As the pain-free range improves, strengthening of the rotator cuff, deltoid, and trapezius muscles can start. Usual return to play is 1-2 wk for type I and 2-4 wk for type II. When the AC joint is nontender, the shoulder has full range of motion and the patient has sufficient strength to be functionally protected from a collision or fall and perform the maneuvers required for the sport, return to play is allowed.

Type III injury has worsened ligamentous tearing with deltotrapezial fascial detachment from the distal clavicle. Type III injuries should be treated surgically only in rare cases and mostly for cosmetic reasons. The majority can be treated in a similar fashion as grade I and II injuries. Types IV, V, and VI AC injuries have progressive worsening of ligamentous and fascial disruption with worsened clavicular displacement. Fortunately, these injuries are rare but require surgical repair.

Anterior Dislocation

The most common mechanism of injury is making contact with another player with the shoulder abducted to 90 degrees and forcefully rotated externally. A common example of the latter is a football player tackling another player only with the arm. Patients complain of severe pain and that their shoulder “popped out of place” or “shifted.” Patients with an unreduced anterior dislocation have a hollow region inferior to the acromion and a bulge in the anterior portion of the shoulder caused by anterior displacement of the humeral head. Abnormal sensation of the lateral deltoid region (axillary nerve) and the extensor surface of the proximal forearm (musculocutaneous nerve) should be noted.

An attempt to reduce the anterior dislocation is indicated, assuming no crepitance is present. Once the dislocation is reduced and radiographs show a normal position, immobilization for a few days for comfort is indicated. The period of immobilization is controversial, but most sports medicine practitioners believe that early range-of-motion and strengthening exercises are important. As the rotator cuff muscles strengthen, progressive strengthening occurs at greater degrees of abduction and external rotation. Patients can return to play when strength, flexibility, and proprioception are equal to that of the uninvolved side so that they can protect the shoulder and perform the sports-specific activities without pain. In most cases, surgery is not recommended unless the shoulder has been dislocated at least 3 times. Earlier repair may be considered for athletes in high-risk collision sports, because the recurrence rate is very high in those sports.

Rotator Cuff Injury

The rotator cuff is formed by the supraspinatus, infraspinatus, teres minor, and subscapularis. The supraspinatus is most commonly injured. Rotator cuff tendinosis is manifested as shoulder pain at the top of the arc of motion. Pain is usually poorly localized and may be referred to the deltoid area. The onset may be insidious. Pain is worse with activity but is often present at rest, including nighttime pain. Strength testing of the cuff muscles produces pain and can demonstrate some weakness compared to the uninjured shoulder. Supraspinatus tendinosis produces pain with active abduction in the “empty can” position in which the patient abducts the arm to 90 degrees, forward flexes it to 30 degrees anterior to the parasagittal plane, and internally rotates the humerus.

Treatment includes ice, modification of technique, rest, stretching, strengthening of the rotator cuff and scapular stabilizer muscles, physiotherapy, and analgesic. Prevention includes avoiding overwork, proper technique, and strengthening and stretching exercises. Sometimes this is called rotator cuff impingement syndrome in adults because of impingement of the cuff by the bony structures superior to the cuff. Rotator cuff pain in young athletes is almost always secondary to glenohumeral instability. Stretching alone can make the pain worse, and the most important aspect of rehabilitation is strengthening of the cuff muscles.

Glenoid labrum tears can appear like rotator cuff tendinosis. One of the most common lesions, the SLAP lesion (superior labrum anterior and posterior), is difficult to diagnose clinically. Pain that occurs with clicking or catching in the shoulder is suspicious for a labrum tear. Radiographs are usually normal. MR arthrography is the best study to identify lesions.

Proximal humeral stress fracture (epiphysiolysis) is a rare cause of proximal shoulder pain and is suspected when shoulder pain does not respond to routine measures. Gradual onset of deep shoulder pain occurs in a young (open epiphyseal plates) athlete involved in repetitive overhead motion, such as in baseball or tennis, but with no history of trauma. Tenderness is noted over the proximal humerus; the diagnosis is confirmed by detecting a widened epiphyseal plate on plain radiographs, increased uptake on nuclear scan, or edema of the physis on MRI. Treatment is total rest from throwing for 6-8 wk.

Bibliography

Bradley JP, Elkousy H. Decision-making: operative versus nonoperative treatment of acromioclavicular joint injuries. Clin Sports Med. 2003;2:277-290.

Luime JJ, Verhagen AP, Miedema HS, et al. Does this patient have an instability of the shoulder or a labrum lesion? JAMA. 2004;292:1989-1998.

Sciascia A, Kibler WB. The pediatric overhead athlete: what is the real problem? Clin J Sport Med. 2006;16:471-477.

Wasserlauf BL, Paletta GAJr. Shoulder disorders in the skeletally immature throwing athlete. Orthop Clin North Am. 2003;34:427-437.

679.3 Elbow Injuries

Gregory L. Landry

Acute Injuries

The most common elbow dislocation is a posterior dislocation. The mechanism of injury is falling backward onto the outstretched arm with the elbow extended. Dislocation potentially compromises the brachial artery. Intact radial and ulnar pulses are the best indicators of vascular integrity of the distal upper extremity. An obvious deformity is noted, with the olecranon process displaced prominently behind the distal humerus. Reduction is performed by gently applying longitudinal traction to the forearm with gentle upward pressure on the distal humerus. If reduction is not possible, the arm should be padded and placed in a sling and the patient transferred to an emergency facility. Elbow injuries can compromise the radial, median, and ulnar nerves.

Supracondylar humeral fractures can result from the same mechanism of injury as elbow dislocations and can be complicated by coexisting injury to the brachial artery and, to a lesser extent, the median, radial, and ulnar nerves. An acute compartment syndrome can develop after these fractures (Fig. 679-5).

Figure 679-5 Deflection of the coronoid fat pad with a joint effusion (fat pad sign) showing evidence of a fracture.

(From Gomez JE: Upper extremity injuries in youth sports, Pediatr Clin North Am 49:593–626, 2002.)

A blow to the elbow can cause bleeding in the olecranon bursa, resulting in olecranon bursitis. These rarely require aspiration and can be managed with ice, analgesia, and compression dressings. An appropriate pad provides comfort and helps prevent reinjury.

Chronic Injuries

Overuse injuries occur primarily in throwing sports and sports that require repetitive wrist flexion or extension or demand weight bearing on hands (gymnastics). “Little League elbow” is a broad term for several different elbow problems.

Throwing overhand creates valgus stress to the elbow with medial opening of the joint and lateral compressive forces.

Medial elbow pain is a common complaint of young throwers, resulting from repetitive valgus overload of the wrist flexor-pronator muscle groups and their attachment on the medial apophysis. In preadolescents who still have maturing secondary ossification centers, traction apophysitis of the medial epicondyle is likely. Patients have tenderness along the medial epicondyle; this is exacerbated by valgus stress or resisted wrist flexion and pronation. Treatment includes no throwing for 4-6 wk, pain-free strengthening, and stretching of the flexor-pronator group, followed by 1-2 wk of a progressive functional throwing program with accelerated rehabilitation. This problem has to be treated with rest because of the risk of nonunion of the apophysis and chronic pain. If pain occurs acutely, avulsion fracture of the medial epicondyle must be considered. Radiographs should be taken in any thrower with acute elbow pain (Fig. 679-6). If the medial epicondyle is avulsed, orthopedic consultation is indicated.

Figure 679-6 Medial epicondylitis.

(From Anderson SJ: Sports injuries, Curr Prob Pediatr Adolesc Health 35:105–176, 2005.)

In older adolescents and young adults with a fused apophysis, the vulnerable structure is the ulnar collateral ligament (UCL). UCL tears are usually seen in pitchers but can be seen in any throwing athlete. Laxity may be appreciated with valgus stress of the elbow with it flexed to 30 degrees. MRI arthrography or ultrasonography is often necessary to assess the integrity of the UCL. If there is a complete tear, surgical repair is indicated if the athlete wants to continue a pitching career. Ulnar nerve dysfunction can be a complication of valgus overload and can occur with any of the diagnoses previously discussed.

Lateral elbow pain can be caused by compression during the throwing motion at the radiocapitellar joint. Panner disease is osteochondrosis of the capitellum that occurs between ages 7 and 12 yr (Fig. 679-7). OCD of the capitellum occurs at age 13-16 yr (see Fig. 679-1). These two entities might represent a continuum of the same disease. Although patients with both conditions present with insidious onset of lateral elbow pain exacerbated by throwing, patients with OCD have mechanical symptoms (popping, locking) and, more commonly, decreased range of motion. Patients with Panner disease have no mechanical symptoms and often have normal range of motion. The prognosis of Panner disease is excellent, and treatments consist of relative rest (no throwing), brief immobilization, and repeat radiographs in 6-12 wk to assess bone remodeling. OCD requires orthopedic consultation.

Figure 679-7 Panner disease. Note fragmentation of the humeral capitellum and flattening of the articular surface (arrow).

(Courtesy of Ralph J. Curtis, MD. From Gomez JE: Upper extremity injuries in youth sports, Pediatr Clin North Am 49:593–626, 2002.)

Lateral epicondylitis, or tennis elbow, is the most common overuse elbow injury in adults. It is rare in children and adolescents. It is tendinosis of the extensor muscle origin on the lateral epicondyle. Tenderness is elicited over the lateral epicondyle, and pain is felt with passive wrist flexion and resisted wrist extension. Treatment includes relative rest, analgesia, and specific stretching and strengthening exercises. Functional rehabilitation, such as returning to playing tennis, should be gradual and progressive.

Elbow injuries might not be prevented by preseason stretching and strengthening exercises. The most important consideration for preventing elbow injuries in throwers is limitation of the number of pitches and advising players, coaches, and athletes that they should stop immediately when they experience elbow pain. If it persists, they need medical evaluation. It has been recommended that a young pitcher have age-specific limits on pitch counts. A good rule of thumb is the maximal number of pitches per game should be approximately 6 times the pitcher’s age in years. For more information, consult the Little League Baseball website at www.littleleague.org/media/newsarchive/03_2006/06pitch_count_08-25-06.htm.

Other, less common problems that cause elbow pain are ulnar neuropathy, triceps tendinitis and olecranon apophysitis, and loose bodies.

Bibliography

Assendelft W, Green S, Buchbinder R, et al. Tennis elbow. BMJ. 2003;327:329-330.

Petty DH, Andrews JR, Fleisig GS, et al. Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors. Am J Sports Med. 2004;32:1158-1164.

Samuel J, Olsen SJII, Fleisig GS, et al. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med. 2006;34(6):905-912.

679.4 Low Back Injuries

Gregory L. Landry

Spondylolysis, Spondylolisthesis, and Facet Syndrome

Spondylolysis

Spondylolysis, a common cause of back pain in athletes, is a stress fracture of the pars interarticularis (Chapter 671.6). It can occur at any vertebral level but is most likely at L4 or L5. Prevalence in adolescent athletes evaluated for low back pain is 13-47%. Besides acute hyperextension that causes an acute fracture, the mechanism of injury is either a congenital defect or hypoplastic pars, which is exacerbated by lumbar extension loading, or a stress fracture due to repetitive extension loading. Ballet, weight lifting, gymnastics, and football are examples of sports in which repetitive extension loading of the lumbar spine occurs; it occurs in any activity in which there is repetitive extension loading, including swimming.

Patients often present with pain of insidious onset. However, there may be a precipitating injury such as a fall or single episode of hyperextension. The pain is worse with extension, can radiate to the buttocks, and can eventually affect activities of daily living. Rest or supine positioning usually alleviates the pain.

On examination, the pain is reproduced with lumbar extension while standing, especially when standing on 1 leg (single-leg hyperextension test). Limited forward spinal flexion and tight hamstrings may be seen. Neurologic examination should be normal. There is well-localized tenderness to deep palpation just lateral to the spinous process on the affected side and is usually at L4 or L5.

The diagnosis is confirmed by finding a pars defect on an oblique lumbar spine radiograph. The defect is rarely seen on anteroposterior (AP) and lateral views. Bone single-photon emission CT (SPECT) is needed to confirm diagnosis if radiographs are normal. A plain CT scan can help to identify the degree of bony involvement and is sometimes used to assess healing.

Treatment includes pain relief and activity restriction. Rehabilitation consisting of trunk strengthening, hip flexor stretching, and hamstring stretching is important in most cases. Antilordotic bracing is controversial and is probably most effective for the stress fracture type of spondylolysis.

Spondylolisthesis and Facet Syndrome

Spondylolysis, spondylolisthesis, and facet syndrome are injuries posterior to vertebral bodies. Spondylolisthesis occurs when bilateral pars defects exist and forward displacement or slippage of a vertebra occurs on the vertebra inferior to it (Chapter 671.6). Facet syndrome has a similar history and physical examination findings as spondylolysis. It is caused by instability or injury to the facet joint, posterior to the pars interarticularis and at the interface of the inferior and superior articulating processes. Facet syndrome can be established by identifying facet abnormalities on CT or by exclusion, requiring a nondiagnostic radiograph and nuclear scan to rule out spondylolysis.

Treatment of posterior element injuries is conservative, directed at reducing the extension-loading activity, often for 2-3 mo. Walking, swimming, and cycling are appropriate exercises during rehabilitation.

Lumbar Disk Herniation, Strain, and Contusion

Lumbar disk herniation manifests as back pain that is worse with forward flexion, lateral bending, and prolonged sitting, especially in an automobile. It is less likely to produce sciatica in children and adolescents compared to adults (Chapter 671.8). Physical examination findings may be minimal but usually include pain with forward flexion and lateral bending. It is unusual to have a positive straight leg test or any neurologic deficit in young athlete with an injured disk. There may be tenderness of the vertebral spinous process at the level of the disk. MRI usually confirms the clinical diagnosis. Assuming the herniation is not large and the pain is not intractable, the treatment of choice is analgesia and physical therapy. Bed rest or surgery is rarely necessary.

Acute lumbar strain or contusion occurs after a precipitating event. Physical examination reveals diffuse tenderness lateral to the spine.

Treatment includes analgesia, massage, and physical therapy, as tolerated. The natural history of acute back strain in adults is that 50% are better in 1 wk, 80% in 1 mo, and 90% in 2 mo, regardless of therapy. The course of back pain in young athletes is probably similar.

Sacroiliitis

Sacroiliitis manifests as lumbar pain that is usually chronic but occasionally is associated with a history of trauma. Patients have a positive result with the Patrick test, which includes resting the foot of the affected side on the opposite knee (hip flexed 90 degrees), stabilizing the opposite iliac crest, and externally rotating the hip on the affected side (pushing the knee down and lateral). A radiograph of the sacroiliac joints is indicated, and if results are positive, exploration for a rheumatologic disease (ankylosing spondylitis, juvenile rheumatoid arthritis, ulcerative colitis) is warranted.

Treatment is with relative rest, NSAIDs, and physical therapy. Ankylosing spondylitis is more likely if the onset of lower back pain is before age 40 yr, if there is morning stiffness that is associated with improvement with activity, and if the pain has a gradual onset and has lasted >3 mo.

Other Causes

Other causes of lower back pain include infection (osteomyelitis, diskitis) and neoplasia. These should be considered in patients with fever, weight loss, other constitutional signs, or lack of response to initial therapy. Osteomyelitis of the lower back or pelvis is often, but not always, associated with fever.

Bibliography

Jones GT, Macfarlane GJ. Epidemiology of low back pain in children and adolescents. Arch Dis Child. 2005;90:312-316.

Micheli LJ, Robert Wood R. Back pain in young athletes: significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med. 1995;149(1):15-18.

Standaert CJ. Low back pain in the adolescent athlete. Phys Med Rehabil Clin North Am. 2008;19(2):287-304. ix

679.5 Hip and Pelvis Injuries

Gregory L. Landry

Hip and pelvis injuries represent a small percentage of sports injuries, but they are potentially severe and require prompt diagnosis. Hip pathology can manifest as knee pain and normal findings on knee examination.

In children, transient synovitis is the most common cause. It usually manifests with acute onset of a limp, with the child refusing to use the affected leg and having painful range of motion on examination. There may be a history of minor trauma. This is a self-limiting condition that usually resolves in 48-72 hr.

Legg-Calvé-Perthes disease (avascular necrosis of the femoral head) also manifests in childhood with insidious onset of limp and hip pain (Chapter 670.3).

Until the skeleton matures (Table 679-2), younger athletes are susceptible to apophyseal injuries (e.g., the anterior superior iliac spine). Apophysitis develops from overuse or from direct trauma. Avulsion fractures occur in adolescents playing sports requiring sudden, explosive bursts of speed (Fig. 679-8). Large muscles contract and create force greater than the strength of the attachment of the muscle to the apophysis. The most common sites of avulsion fractures (and the attaching muscles) are the anterior superior iliac spine (sartorius), anterior inferior iliac spine (rectus femoris), lesser femoral trochanter (iliopsoas), and ischial tuberosity (hamstrings). Symptoms include localized pain and swelling, with decreased strength and range of motion. Radiographs are required. Initial treatment includes ice, analgesics, rest, and pain-free range-of-motion exercises. Crutches are usually needed for ambulation. Surgery is usually not indicated because most of these fractures—even large or displaced ones—heal well. Contact to the bone around the hip and pelvis causes exquisitely tender subperiosteal hematomas called hip pointers. Symptomatic care includes rest, ice, analgesia, and protection from reinjury.

Table 679-2 AGE OF APPEARANCE AND FUSION OF APOPHYSES IN HIP AND PELVIS

Figure 679-8 Apophyseal avulsion, pelvis.

(From Anderson SJ: Sports injuries, Curr Prob Pediatr Adolesc Health 35:105–176, 2005.)

Slipped capital femoral epiphysis usually occurs in the 11-15 yr age range during the time of rapid linear bone growth (Chapter 670.4).

A femoral neck stress fracture can manifest as vague progressive hip pain in an endurance athlete. Girls with the female athlete triad are especially at risk. This diagnosis should always be kept in mind in the running athlete with vague anterior thigh pain. On examination, there may be pain with passive stretch of the hip flexors and pain with hip rotation. If radiographs do not demonstrate a periosteal reaction consistent with a stress fracture, a bone scan or MRI may be required. Orthopedic consultation is necessary in femoral neck stress fractures because of their predisposition to nonunion and displacement with minor trauma or continued weight bearing. These fractures carry increased risk of avascular necrosis of the femoral head.

Osteitis pubis is an inflammation at the pubic symphysis that may be caused by excessive side-to-side rocking of the pelvis. It can be seen in an athlete in any running sport and is more common in sports requiring more use of the adductor muscles such as ice hockey, soccer, and inline skating. Athletes typically present with vague groin pain that may be unilateral or bilateral. On physical examination, there is tenderness over the symphysis and sometimes over the proximal adductors. Adduction strength testing causes discomfort. Radiographic evidence (irregularity, sclerosis, widening of the pubic symphysis with osteolysis) might not be present until symptoms are present for 6-8 wk; a bone scan and MRI are more sensitive to early changes. Relative rest for 6-12 wk may be required. Some patients require corticosteroid injection as adjunctive therapy.

Acetabular labrum tears can occur in the hip, similar to glenoid labrum tears in the shoulder. Athletes might have a history of trauma and complain of sharp anterior hip pain associated with a clicking or catching sensation. Clinical diagnosis is difficult; magnetic resonance arthrography is useful for diagnosis.

Snapping hip syndrome is caused by the iliopsoas tendon’s riding over the anterior hip capsule or the iliotibial band over the greater trochanter. It is commonly seen in ballet dancers and runners; it can occur as an acute or overuse injury (more common). Athletes present with either a painful or painless click or snap in the hip, usually located lateral or anterior and deep in the joint. Examination often reproduces the symptoms. Radiographs are not usually needed in the work-up. Treatment involves an analgesia, relative rest, biomechanical assessment, and core flexibility and strengthening. The athlete may return to activity as tolerated.

Bibliography

Bahr R, Khan K. Management of lateral hip pain. BMJ. 2009;338:961-962.

Metzmaker JN, Pappas AM. Avulsion fractures of the pelvis. Am J Sports Med. 1985;13:349-358.

Waite BL, Krabak BJ. Examination and treatment of pediatric injuries of the hip and pelvis. Phys Med Rehabil Clin North Am. 2008;19:305-318. ix

679.6 Knee Injuries

Gregory L. Landry

The knee is the most common musculoskeletal site for complaints among adolescents; some youth may be more prone to such injuries (Table 679-3). Acute knee injuries that cause immediate disability are likely to be due to fracture, patellar dislocation, anterior cruciate ligament (ACL) injury, or meniscal tear. The mechanism of injury is usually a weight-bearing event. After injury, if a player cannot bear weight within a few minutes, a fracture or significant internal derangement is more likely. If a player is able to bear weight and return to play after the injury, a serious injury is less likely to have occurred. If the knee swells within several hours of the injury, the swelling is likely due to a hemarthrosis and a more severe injury.

Table 679-3 SUMMARY OF MODIFIABLE AND NONMODIFIABLE INTRINSIC RISK FACTORS RELATED TO INCREASED RISK OF INJURY OF THE ANTERIOR CRUCIATE LIGAMENT

MODIFIABLE RISK FACTORS	NONMODIFIABLE RISK FACTORS	POTENTIAL CONTROL OR TREATMENT TECHNIQUE
ANATOMIC
	BMI	Monitor and control relative body mass
	Femoral notch index (ACL size)	NM training targeted to decrease other risk factors
	Knee recurvatum	NM training targeted to improve dynamic knee flexion
	General joint laxity	NM training targeted to improve joint stiffness
	Family history (genetic predisoposition)	NM training targeted to decrease other risk factors
	Prior injury history	Full physical rehabilitation following injury
DEVELOPMENTAL AND HORMONAL
	Sex, female	NM training prior to onset of risk factors
	Pubertal and post-pubertal maturation status	NM training during pre-puberty
	Preovulatory menstrual status	Oral contraceptives in female patients*
	ACL tensile strength	NM training targeted to decrease other risk factors
	Neuromuscular shunt	NM training targeted to improve neuromuscular control
BIOMECHANICAL
Knee abduction		NM training targeted to improve coronal plane loads
Anterior tibial shear		NM training targeted to improve dynamic knee flexion
Lateral trunk motion		NM training targeted to improve trunk strength and control
Tibial rotation		NM training targeted to control transverse motions and influence sagittal plane deceleration mechanics
Dynamic foot pronation		Foot orthoses
Fatigue resistance		Strength and conditioning training
Ground reaction forces		NM training targeted to improve force absorption strategies
NEUROMUSCULAR
Relative hamstring recruitment		NM training targeted to improve hamstring strength and recruitment
Hip abduction strength		NM training targeted to improve high strength and recruitment
Trunk proprioception		NM training targeted to improve trunk strength and control

ACL, anterior cruciate ligament; BMI, body mass index; NM, neuromuscular.

* Pilot evidence indicates it might be a potential control strategy.

From Alentorn-Geli E, Myer GD, Silvers HJ, et al: Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: mechanisms of injury and underlying risk factors, Knee Surg Sports Traumatol Arthrosc 7:705–709, 2009.

The injury most likely to occur with a hemarthrosis is an ACL injury. The ACL is usually injured from being hit directly, landing off balance from a jump, quickly changing direction while running, or hyperextension. Significant swelling and instability are often present. The majority of athletes with an ACL injury need orthopedic consultation and an ACL reconstruction. Functional bracing without ACL reconstruction increases the risk of meniscal injury and recurrent instability.

Posterior cruciate ligament injury occurs from a direct blow to the region of the proximal tibia, such as might occur with a dashboard injury or a fall to the knees in volleyball. Posterior cruciate ligament injuries are rare and are usually treated nonsurgically.

Medial collateral ligament (MCL) injuries result from a valgus blow to the outside of the knee. Isolated lateral collateral ligament injuries are uncommon and result from significant varus knee stress. Because they are extra-articular, isolated collateral injuries should not produce much of a knee effusion or disability. Regardless of severity, isolated medial and lateral collateral injuries are managed nonsurgically with aggressive rehabilitation.

Meniscal tears occur by the same mechanisms as ACL injuries. They are associated with hemarthrosis, joint line pain, and often pain in full flexion. Orthopedic consultation is indicated when a meniscal tear is suspected.

Patellar dislocation occurs most often as a noncontact injury when the quadriceps muscles forcefully contract to extend the knee while the lower leg is externally rotated. Patellar dislocation is the second most common cause of hemarthrosis. The patella is almost always dislocated laterally, and this motion tears the medial patellar retinaculum, causing bleeding in the joint. Recurrent episodes of patellar instability are associated with less swelling. Patellar instability is usually treated nonsurgically with a patella-stabilizing sleeve and an aggressive rehabilitation program. Recurrent instability can require surgical intervention.

Initial Treatment of Acute Knee Injuries

The physician should inspect for an effusion and obvious deformities; if any deformity is present, the physician should assess neurovascular status and transfer the patient for emergency care. If no gross deformities are present and neurovascular integrity is intact, initial maneuvers include full passive extension and gentle valgus stress to the knee while it is in extension. If there is laxity of the knee with valgus stress in full extension, both the ACL and MCL have been injured. The patient’s ability to contract the quadriceps muscles should be noted. Pain occurring with quadriceps contraction or inability to contract the quadriceps muscle implies an injury to the extensor mechanism. Tenderness over the medial patella, medial retinaculum, and/or above the adductor tubercle is associated with a patellar dislocation. Point tenderness is consistent with fracture or injury to the underlying structure; a medial meniscal tear can manifest as tenderness along the medial joint line, but medial joint line tenderness is not specific for a medial meniscus tear. Pain or limitation in either passive flexion or extension while rotating the tibia implies a meniscal injury, as do other maneuvers (Fig. 679-9). Ligament injury is manifested as pain or laxity with the appropriate maneuver.

Figure 679-9 Examination maneuvers include the Lachman, anterior drawer, lateral pivot shift, Apley compression, and McMurray tests; the right knee is shown. The Lachman test, performed to detect anterior cruciate ligament (ACL) injures, is conducted with the patient supine and the knee flexed 20-30 degrees. The anterior drawer test detects ACL injuries and is performed with the patient supine and the knee in 90 degrees of flexion. The lateral pivot shift test is performed with the patient supine, the hip flexed 45 degrees, and the knee in full extension. Internal rotation is applied to the tibia while the knee is flexed to 40 degrees under a valgus stress (pushing the outside of the knee medially). The Apley compression test, used to assess meniscal integrity, is performed with the patient prone and the examiner’s knee over the patient’s posterior thigh. The tibia is externally rotated while a downward compressive force is applied over the tibia. The McMurray test, used to assess meniscal integrity, is performed with the patient supine and the examiner standing on the side of the affected knee.

If a patient cannot bear weight pain free or has clinical signs of instability, the knee should be immobilized, crutches given, and plain radiographs obtained. If the patella is dislocated, reduction can be achieved with knee extension. Developed as the Ottawa knee rules, radiographs are required for pediatric patients with knee injury who have any of these findings: isolated tenderness of patella, fibular head tenderness, inability to flex 90 degrees, and inability to bear weight both immediately and in the emergency department for 4 steps (regardless of limping). Straight-leg immobilizers offer no structural support and are only used for comfort. If any brace is used, a hinged brace is indicated for stabilization such as an injury when both ACL and MCL might have been injured. The leg should be elevated, and elastic wrap can be applied for compression.

Chronic Injuries

Patellofemoral Stress Syndrome

Patellofemoral stress syndrome (PFSS) is the most common cause of anterior knee pain. PFSS is also known as patellofemoral pain syndrome or patellofemoral dysfunction (Chapter 669.5). It is a diagnosis of exclusion used to describe anterior knee pain that has no other identifiable pathology. Pain is usually difficult to localize. Patients indicate a diffuse area over the anterior knee as the source, or they might feel as if the pain is coming from behind the patella. Bilateral pain is common, and pain is often worse going up stairs, after sitting for prolonged periods, or after squatting or running. There should be negative history for significant swelling, which would indicate a more serious injury. History of change in activity is common, such as altered training surface or terrain, increased training regimen, or performance of new tasks.

Examination should include evaluation of stance and gait for lower limb alignment, musculature, and midfoot hyperpronation. Flexibility of the hamstrings, ITB, and gastrocnemius should be assessed, because stress is increased across the patellofemoral joint when these structures are tight. Hip range of motion should be assessed to rule out hip pathology. Medial patellar tenderness or pain with compression of the patellofemoral joint confirms the diagnosis in the absence of an effusion and no other positive findings on the examination. PFSS is a clinical diagnosis usually managed without imaging.

Treatment focuses on assessing and improving flexibility, strength, and gait abnormalities. In the presence of midfoot hyperpronation (ankle valgus), new shoes or use of arch supports can improve patellofemoral mechanics and improve pain. Ice and an analgesic can be used to help control pain. Reduced overall activity or training is important initially in rehabilitation. Upon return to activity, starting at 50% of the usual amount and intensity of work is recommended, with an increase of 10% weekly until full participation is achieved. Maintenance rehabilitation via home exercises is essential to prevent recurrences. Surgery is rarely indicated.

Osgood-Schlatter Disease

Osgood-Schlatter disease is a traction apophysitis occurring at the insertion of the patellar tendon on the tibial tuberosity (Chapter 669.4). Because it is also related to overuse of the extensor mechanism, Osgood-Schlatter disease is treated like PFSS. A protective pad to protect the tibial tubercle from direct trauma can be used. The most common complication is cosmetic; the tibial tubercle on the affected side (or both if bilateral) may be slightly more prominent. Patients only need to take time from sports if they are limping.

Other Chronic Injuries

Sinding-Larsen-Johansson disease is a traction apophysitis occurring at the inferior pole of the patella. It occurs most often in volleyball and basketball athletes. Treatment is similar to that of PFSS and Osgood-Schlatter disease.

Patellar tendinosis (jumper’s knee) is due to repetitive microtrauma of the patellar tendon, usually at the inferior pole of the patella. In about 10% of the cases, the quadriceps tendon above the patella is affected. It is associated with jumping sports but occurs in runners as well. Treatment is similar to that for PFSS. Relative rest is more important in patellar tendinosis because chronic pain is associated with irreversible changes in the tendon.

ITB friction syndrome is the most common cause of chronic lateral knee pain. Generally it is not associated with swelling or instability. It is due to friction of the ITB along the lateral knee, resulting in bursitis. Tenderness is elicited along the ITB as it courses over the lateral femoral condyle or at its insertion at the Gerdy tubercle, along the lateral tibial plateau. Tightness of the ITB is also noted using the Ober test. To perform an Ober test, the athlete lies on one side and the superior hip is extended with the knee flexed. The examiner holds the ankle in midair, and if the knee moves inferiorly, it implies a flexible ITB and a negative Ober test. If the knee and leg stay in midair, the ITB is tight and the Ober test is positive. Treatment principles follow those for PFSS, except emphasis is on improving flexibility of the ITB.

Bibliography

Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. Am J Sports Med. 2005;33:524-530.

Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc. 2009;7:705-709.

Frobell RB, Roos EM, Roos HP, et al. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010;363:331-342.

LaBotz M. Patellofemoral syndrome: diagnostic pointers and individualized treatment. Phys Sportsmed. 2004;32:7.

Macmull S, Skinner JA, Bentley G, et al. Treating articular cartilage injuries of the knee in young people. BMJ. 2010;340:587-592.

Spindler KP, Wright RW. Anterior cruciate ligament tear. N Engl J Med. 2008;359:2135-2142.

Van Linschoten R, van Middelkoop M, Berger MY, et al. Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomized controlled trial. BMJ. 2009;339:1010-1013.

Vaquero J, Vidal C, Cubillo A. Intra-articular traumatic disorders of the knee in children and adolescents. Clin Orthop. 2005;432:97-106.

679.7 Lower Leg Pain: Shin Splints, Stress Fractures, and Chronic Compartment Syndrome

Gregory L. Landry

Stress injury to the bones of the lower leg occurs on a continuum from mild injury (shin splints) to stress fracture. All occur by an overuse mechanism.

Shin splints, also known as medial tibial stress syndrome, manifests with pain along the medial tibia or both tibiae and is the most common overuse injury of the lower leg. The pain initially appears toward the end of exercise, and if exercise continues without rehabilitation, the pain worsens and occurs earlier in the exercise period. There is diffuse tenderness over the lower third to half of the distal medial tibia. Any focal tenderness or tenderness of the proximal tibia is suspicious for a stress fracture. A stress fracture tends to be painful during the entire workout. Shin splints can usually be distinguished from a tibial stress fracture in which the tenderness is more focal (2-5 cm) and more severe. Shin splints and stress fracture represent a continuum of stress injury to the tibia and are thought to be related to traction of the soleus on the tibia.

The diagnosis can be made by history and physical examination. Findings on plain radiographs of the tibia are normal with shin splints and in tibial stress fractures within the first 2 wk of the injury. Afterward, the radiographs can demonstrate periosteal reaction if a stress fracture is present. Sensitivity of plain radiographs may be increased by obtaining 4 views of the tibia: AP, lateral, and both oblique views. A bone scan is the most sensitive test to diagnose stress fractures; it demonstrates discrete tracer uptake at the site(s) of the stress fracture. Increased uptake may be noted in the presence of shin splints, but in a fusiform pattern along the periosteal surface. If results of the bone scan are normal, the diagnosis is likely to be shin splints or chronic compartment syndrome (CCS). MRI has replaced bone scan as the most sensitive tool for diagnosing stress fractures in long bones in many medical centers.

The treatment of shin splints and tibial stress fractures is similar, involving relative rest, correcting training errors and kinetic chain dysfunction, and often the use of better running shoes. Fitness can be maintained with non–weight-bearing activities such as swimming, cycling, and water jogging. With shin splints, after 7-10 days, patients can usually start on the walk-jog program. If pain worsens, 2-3 pain-free days are required before resuming the walk-jog program. Ice should be used daily and an analgesic should be used for pain control. Orthotics or new shoes may be useful in patients who hyperpronate. Stretching the plantar flexors and strengthening the ankle dorsiflexors can be useful. Being pain free for 7-10 days is recommended before exercise is commenced.

CCS occurs in an athlete in a running sport, usually during a period of heavy training. It is due to muscle hypertrophy and increased intracompartmental pressure with exercise. There is typically a pain-free period of about 10 min at the beginning of a workout before onset of constant throbbing pain that is difficult to localize. It lasts for minutes to hours after exercise and is relieved by ice and elevation. In a classic case, there is numbness of the foot associated with high pressure within the corresponding muscle compartment. The most common compartment affected is the anterolateral compartment with compression of the peroneal nerve. The physical examination in the office is often normal, but weakness of the extensor hallucis longus and decreased sensation in the web space between the 1st and 2nd toe may be present.

If CCS is suspected, referral to an appropriate surgeon (orthopedic or vascular) to measure the intracompartmental pressure is indicated. Treatment is surgical and requires fasciotomy to relieve the pressure.

Bibliography

Pell RF4th, Khanuja HS, Cooley GR. Leg pain in the running athlete. J Am Acad Orthop Surg. 2004;12:396-404.

679.8 Ankle Injuries

Gregory L. Landry

Ankle injuries are the most common acute athletic injury. About 85% of ankle injuries are sprains, and 85% of those are inversion injuries (foot planted with the lateral fibula moving toward the ground), 5% are eversion injuries (foot planted with the medial malleolus moving toward the ground), and 10% are combined.

Examination and Injury Grading Scale

In obvious cases of fracture or dislocation, evaluating neurovascular status with as little movement as possible is the priority. If no deformity is obvious, the next step is inspection for edema, ecchymosis, and anatomic variants. Key sites to palpate for tenderness are the entire length of the fibula; the medial and lateral malleoli; the base of the 5th metatarsal; the anterior, medial, and lateral joint lines; and the navicular and the Achilles tendon complex. Assessment of active range of motion (patient alone) in dorsiflexion, plantar flexion, inversion, and eversion and of resisted range of motion is indicated.

Provocative testing attempts to evaluate the integrity of the ligaments. In a patient with a markedly swollen, painful ankle, provocative testing is difficult because of muscle spasm and involuntary guarding. It is more useful on the field before much bleeding and edema have occurred. The anterior drawer test assesses for anterior translation of the talus and competence of the anterior talofibular ligament. The inversion stress test examines the competence of the anterior talofibular and calcaneofibular ligaments (Fig. 679-10). In the acute setting, the integrity of the tibiofibular ligaments and syndesmosis is examined by the syndesmosis squeeze test. Pain with squeezing the lower leg implies injury to the interosseous membrane and syndesmosis between the tibia and fibula, making a severe injury more suspicious. Athletes with this injury cannot bear any weight and also have severe pain with external rotation of the foot. Occasionally the peroneal tendon dislocates from the fibular groove simultaneously with an ankle sprain. To assess for peroneal tendon instability, the examiner applies pressure from behind the peroneal tendon with resisting eversion and plantar flexion, and the tendon pops anteriorly. If either a syndesmotic injury or an acute peroneal dislocation is suspected, orthopedic consultation should be sought.

Figure 679-10 Inversion stress tilt test for ankle instability.

(From Hergenroeder AC: Diagnosis and treatment of ankle sprains. A review, Am J Dis Child 144:809–814, 1990.)

Radiographs

AP, lateral, and mortise views of the ankle are obtained when patients have pain in the area of the malleoli, are unable to bear weight, or have bone tenderness over the posterior distal tibia or fibula. The Ottawa ankle rules help define who requires radiographs (Fig. 679-11). A foot series (AP, lateral, and oblique views) should be obtained when patients have pain in the area of the midfoot or bone tenderness over the navicular or 5th metatarsal. It is important to differentiate an avulsion fracture of the proximal 5th metatarsal from the Jones fracture of the proximal 5th metatarsal (a lucency about 2 cm from the proximal end). The former is treated as an ankle sprain; the latter fracture has an increased risk of nonunion and requires orthopedic consultation. The talar dome fracture is manifested as an ankle sprain that does not improve. Radiographs on initial presentation can have subtle abnormalities. Any suspicion on the initial radiographs of a talar dome fracture warrants orthopedic consultation and further imaging. In the early adolescent, always look carefully at the tibial epiphysis. Nondisplaced Salter III fractures can be subtle and need to be recognized early and referred to an orthopedic surgeon promptly.

Figure 679-11 Ottawa ankle rules.

(From Bachmann LM, Kolb E, Koller MT, et al: Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot; systematic review, BMJ 326:417–419, 2003.)

Initial Treatment of Ankle Sprains

Ankle sprains need to treated with RICE: rest, ice, compression, and elevation. This should be followed for the first 48-72 hr after the injury to minimize bleeding and edema. For an ankle injury, this consists of crutches and an elastic wrap, although other compression devices such as an air stirrup splint work quite well. This allows early weight bearing with protection and can be removed for rehabilitation. It is important to start a rehabilitation program as soon as possible.

Rehabilitation

Rehabilitation should begin the day of injury; for patients who have pain with movement, isometric strengthening can be started. Important deficits to correct include loss of dorsiflexion, peroneal muscle weakness, and decreased proprioception. Until these deficits are restored, the ankle is vulnerable to reinjury. When determining when an athlete is ready for running, there must be full range of motion and nearly full strength compared to the uninjured side. While standing on the uninjured side only, the athlete is instructed to hop 8 to 10 times, if possible. When this can be achieved without pain, the athlete can began to run, starting out with jogging and progressing to speed, speed, and finally to sprints. The athlete must stop if there is significant pain or limp. Finally, before returning to sport, the athlete must be able to sprint and change directions off the injured ankle comfortably. Performing some sport-related tasks is also helpful in determining readiness for return to play.

Recurrent ankle injuries are more likely in patients who have not undergone complete rehabilitation. Ankle sprains are less likely in players wearing high-top shoes. Proper taping of the ankle with adhesive tape can provide functional support but loosens with use and is unavailable to most athletes. Lace-up ankle braces are useful for preventing recurrences. They are more supportive than tape and can be tightened repeatedly during the course of a practice or a game. Most sports physicians recommend their use indefinitely to help prevent further sprains.

679.9 Foot Injuries

Gregory L. Landry

Metatarsal stress fractures can occur in any running athlete. The history is insidious pain with activity that is getting worse. Examination reveals point tenderness over the midshaft of the metatarsal, most commonly the 2nd or 3rd metatarsal. Radiographs might not show the periosteal reaction before pain has been present for 2 wk or more. Treatment is relative rest for 6-8 wk. Shoes with good arch supports reduce stress to the metatarsals.

Vague dorsal foot pain in an athlete in a running sport can represent a navicular stress fracture. Unlike other stress fractures, it might not localize well on examination. If there is any tenderness around the navicular, a stress fracture should be suspected. This stress fracture can take many weeks to show up on plain radiographs, so a bone scan or MRI should be obtained to make the diagnosis. Because this fracture is at high risk of nonunion, immobilization and non–weight bearing for 8 wk is the usual treatment. A CT scan should be obtained to document full healing after the period of immobilization.

Sever disease (calcaneal apophysitis) occurs at the insertion of the Achilles tendon on the calcaneus and manifests as activity-related pain (see Fig. 679-3). It is more common in boys (2 : 1), is often bilateral, and usually occurs between ages 8 and 13 yr. Tenderness is elicited at the insertion of the Achilles tendon into the calcaneus, especially with squeezing the heel (positive squeeze test). Sever disease is associated with tight Achilles tendons and midfoot hyperpronation that puts more stress on the plantar flexors of the foot. Treatment includes relative rest, ice, massage, stretching, and strengthening the Achilles tendon. Correcting the midfoot hyperpronation with orthotics, arch supports, or better shoes is important in most athletes with Sever disease. If the foot is neutral or there is mild hyperpronation, -in heel lifts will be helpful to unload the Achilles tendon and its insertion. With optimal management, symptoms improve in 4-8 wk. Generally, if there is no limp during the athletic activity, young athletes with Sever disease should be allowed to play.