OVERUSE SYNDROMES

Major injuries of the meniscus or ligaments are uncommon in the knees of runners. More frequent are overuse disorders that develop because of the repetitive nature of running (Fig. 15-10). Several areas are commonly affected:

Fig. 15-10 Common areas of tendinitis of the knee. The most common areas of involvement are the quadriceps tendon and its medial (M) and lateral (L) expansions. ITB, Iliotibial band.

ANTERIOR KNEE PAIN SYNDROME (PATELLOFEMORAL PAIN SYNDROME)

This is a condition in which pain develops beneath or, more commonly, around the patella (see Chapter 11). It is sometimes seen in conjunction with varying amounts of fibrillation and degeneration of its articular cartilage (chondromalacia), although the relationship of this to symptoms has not been established. The diagnosis is usually one of exclusion (e.g., meniscus injury, jumper’s knee). Anything that adversely affects the normal “tracking” of the patella in its femoral groove may lead to pain, often on the lateral side. The causes are frequently multifactorial: (1) an increased Q angle with a bowstringing effect; (2) tightness of the lateral retinaculum with relative weakness of the vastus medialis muscle; (3) patellofemoral malalignment, sometimes with subluxation; (4) direct trauma; (5) simple overuse; and (6) malalignment of the extremity (Fig. 15-11).

Fig. 15-11 External tibial torsion. A, With the patella pointing straight forward, the feet are externally rotated. This may cause peripatellar pain with excessive use because of abnormal pressure. Note the high Q angles. B, The knees face inward with the feet pointing straight ahead.

Clinically, patellar or peripatellar pain and discomfort are present and are usually aggravated when stress is applied to the extensor mechanism by stair walking or running up and down hilly terrain. Crepitus may be present, although this finding is of debatable significance. Sitting with the knee flexed for any excessive period of time may cause a stiff feeling to develop that is usually relieved by knee extension. An effusion is rarely present, and palpation of the undersurface of the patella may be painful. A Q angle of more than 20 degrees or other physical findings of malalignment may be present. Roentgenograms are usually not helpful unless subluxation is present.

The wide variety of treatments used to manage this condition attests to the difficulty in curing it. Conservative measures such as rest, anti-inflammatory medication, local heat, stretching exercises, quadriceps exercises in extension, and avoiding the offending activity are useful. Many patients benefit from a referral to a physical therapist. Patellar straps or braces seem to be of only limited benefit. Although arthroscopically shaving the fibrillated articular cartilage has been a common surgical intervention, the results are often inconsistent, probably because the changes in the articular cartilage are not the source of pain. If a distal malalignment problem is present, an orthotic device in the shoe may occasionally be advised to help correct the tracking problem, mainly on empiric grounds. As a last resort, a surgical procedure to realign the patella sometimes eliminates the symptoms, but it would seem difficult to justify such a major operation simply to allow continued running. Despite the frustrating nature of the condition, however, most patients do well with a home exercise program.

MEDIAL TIBIAL STRESS SYNDROME

A common cause of leg pain is what is sometimes referred to as the shin splint, or medial tibial stress syndrome. This is a specific overuse syndrome involving the origin of the soleus muscle and causing pain along the deep midthird of the medial border of the tibia (Fig. 15-12). The flexor digitorum longus may also be involved. The disorder is most likely caused by a bone stress reaction. Many causative factors have been suggested, although excessive pronation of the foot is often present. The disorder often develops in poorly conditioned athletes or runners who run on hard surfaces. There is usually tenderness to palpation along the posteromedial border of the midtibia. The roentgenogram may show some late periosteal reaction or cortical thickening in this area. Bone scanning or magnetic resonance imaging (MRI) may help in the diagnosis.

Fig. 15-12 The area of tenderness and pain with medial tibial stress syndrome.

The treatment is by modification of the running schedule or complete rest. Stretching exercises, NSAIDs, and ice may help. A change to a softer running surface may be necessary. Orthotics and shoe modifications are also tried. The condition usually does not become chronic.

COMPARTMENTSYNDROMES

Vigorous exercise may lead to swelling and mild ischemia in any of the four natural compartments in the calf (Fig. 15-13). The anterior and deep posterior compartments are the most commonly affected in runners, and the condition is usually chronic or recurrent rather than acute when it develops in runners. The disorder develops either from local arterial spasm or swelling that increases the pressure in the unyielding compartment. This compromises the local blood flow and leads to muscle ischemia and pain. Permanent muscle and nerve damage may result, but this is rare in the common chronic type seen in runners. More frequently, the only symptom is cramping pain during exercise that is often relieved by rest and recurs when activities are resumed after rest. Physical findings are minimal, but tenderness may be present in the affected compartment, as well as slight weakness of the involved muscles. Mild paresthesias are occasionally noted. Confirmation of the diagnosis may require measurement of intracompartmental pressures.

Fig. 15-13 A cross section of the lower portion of the leg shows its four compartments; A, anterior; L, lateral; DP, deep posterior, and SP, superficial posterior.

Treatment for the rare acute case is usually by surgical release of the affected compartment. The more common chronic type seen in runners is treated by rest and modification of training techniques and mileage. Conservative treatment is often unsuccessful, and individuals who wish to continue competitive long-distance running may require fasciotomy to decompress the affected compartment.

STRESS FRACTURES

Stress fractures are common injuries of the lower leg and must always be ruled out in the evaluation of pain. They usually develop in response to a sudden increase in the stress applied to a weight-bearing bone. Thus, they are more likely to occur in the novice who is just beginning running or in the individual who suddenly increases mileage. Any weight-bearing bone may be affected. The proximal medial tibial border and the lower portion of the fibula are the most commonly affected areas in the lower part of the leg. The only physical findings are local tenderness and edema. The roentgenograms are usually negative initially and begin to show healing changes in 2 to 4 weeks (Fig. 15-14). The bone scan is often more sensitive to early changes.

Fig. 15-14 Lateral radiograph of the tibia shows a stress fracture (arrow) of the posterior cortex of the tibia in a distance runner. Posterior fractures heal well, but stress fractures of the anterior cortex are at risk for acute fracture and delayed healing.

The treatment is symptomatic by modification of activities. Casts are usually not necessary. Activity is resumed as symptoms subside. It may take 6 to 10 weeks for the tibial fracture to heal before the patient can return to sports. Swimming or other cross-training may be substituted for running during the healing phase to allow the runner to maintain fitness.

THE PUMP BUMP

This is a painful thickening that develops over the lateral attachment of the Achilles tendon (Fig. 15-16). It is usually the result of friction and irritation from a poorly padded heel counter. Conservative measures including proper shoes are usually curative. The back of the shoe may have to be cut out for a period of time. A heel lift may also be helpful. In resistant cases, the small bump may be removed surgically.

Fig. 15-16 The “pump bump” and common areas of inflammation around the heel. A, Achilles tendon; B, retrocalcaneal bursa; C, plantar fascia.

BLISTERS

Blisters are common in runners and are best treated by the following preventive means:

Another common condition that develops in runners is the black toe, or subungual hematoma. This often develops in a shoe that lacks sufficient room to accommodate the forefoot. It may be caused by repetitive shearing, which leads to bleeding beneath the nail. Seromas develop in a similar manner. It is usually asympto-matic, but the occasional painful tense hematoma may be evacuated by penetrating the nail with a heated paper clip or an 18-gauge needle spun between the fingertips.

Repetitive impacting of toes can also cause subungual hemorrhage, edema, and oncholysis (separation of the nail from the nail bed). This is sometimes called “jogger’s toe.” It is most common in distance runners but is seen in other athletic activities, including dancing and tennis. It is most common in the lateral three toes but may develop in any toe. The condition is prevented by using a properly fitted shoe and diligent nail care. Once it develops, treatment is usually not required, except to be certain the shoe fits properly.

DISORDERS OF THE ROTATOR CUFF

The overarm throwing motion may rank second only to running as the most common factor in athletic events. The range of motion of the shoulder is the greatest of all joints and is made possible by the relatively minimal amount of bony contact between the humeral head and the glenoid. Thus, stability is sacrificed for flexibility, and this places a great burden on the capsule and rotator cuff musculature for joint stability. As a result, the soft tissue may develop overuse injuries because of repetitive strains placed on it during exercise. These strains may lead to overuse changes ranging from simple tendinitis (tendinopathy) to rotator cuff rupture. Tissue calcification may even occur. Swelling of the rotator cuff and subacromial bursa then develops, which narrows the space between the head of the humerus and the overlying acromion and coracoacromial ligament. An abnormally shaped (hooked) acromion may contribute to the problem. This may lead to the development of crepitus and impingement when the shoulder is abducted. Abduction further narrows the subacromial space and can result in a painful catching sensation; thus, the term impingement syndrome (see Chapter 5). Clinically, shoulder pain is present during and after use. The pain may radiate down the deltoid muscle because of the common innervation of the deltoid and supraspinatus muscle. Crepitus is common, and there is tenderness to palpation over the rotator cuff, usually the supraspinatus tendon.

The treatment of rotator cuff tendinitis is usually conservative. Rest and avoiding the offending activity are most important. Push-ups should be avoided. Local steroid injections may relieve pain but should be used cautiously in athletes. Repetitive injections should certainly be avoided (especially in the young), and vigorous use of the shoulder after injections should not be allowed. Rest, stretching and strengthening exercises, and proper throwing or swimming mechanics should be stressed. Referral is indicated in resistant cases.

Little League shoulder is a condition seen in adolescence that was previously thought to be caused by overuse tendinitis. The presenting complaints were similar. This is now considered a traction irritation of the upper humeral epiphysis that causes a stress reaction around the epiphysis. Roentgenography may reveal widening of the epiphyseal plate. The disorder usually heals with rest and leaves no residuals.

Pitching limits should be placed on the young athlete to prevent such injuries. Proper supervision requires the right atmosphere for sports, which is created by coaches and parents.

INJURIES TO THE ACROMIOCLAVICULAR JOINT

The acromioclavicular joint sustains a wide range of injuries. The most minor is the so-called shoulder pointer, which is a contusion of the deltoid, trapezius, and acromioclavicular joint. It usually heals with rest and protection.

More common is acromioclavicular separation or dislocation (see Chapter 5). The lesion is often graded 1 through 5. A grade 1 injury is simply a minor strain of the acromioclavicular ligaments. A grade 2 injury involves rupture of the acromioclavicular ligaments but preservation of the coracoclavicular ligaments. In grade 3, 4, and 5 injuries, there is complete rupture of all supports with upward displacement of the clavicle. (Grade 4 and 5 injuries are rare.)

Grade 1 and 2 incomplete injuries are usually treated symptomatically. The treatment for grade 3 injuries remains unsettled. If the injury involves the dominant shoulder of an athlete who throws, surgical repair is probably indicated. However, except for the cosmetic deformity, most individuals with chronic acromioclavicular separations are asymptomatic. If symptoms develop at a later date, the individual with a chronic acromioclavicular separation will benefit from reconstruction surgery. Grade 4 and 5 injuries in the athlete are severely displaced and usually need repair.

DISLOCATION OF THE GLENOHUMERAL JOINT

Most shoulder dislocations are anterior in direction and result from trauma (see Chapter 5). The usual cause is a fall on the outstretched arm. The diagnosis is suspected when there is an absence of the normal fullness beneath the deltoid. If the dislocation is anterior, the humeral head is palpable anteriorly, the arm is held externally rotated, and internal rotation is painful. Posterior dislocations characteristically have pain on external rotation, the arm is held in internal rotation, and there is flatness of the anterior shoulder contour. Both types often become recurrent. The treatment is reduction, and this should be accomplished as soon as reasonable. Roentgenograms should always be taken before reduction to rule out other bony injury. Epiphyseal fracture of the upper portion of the humerus should especially be ruled out.

After reduction, the shoulder should be rested in a sling for 1 to 2 weeks. General strengthening exercises are begun, although there is little evidence that they prevent recurrence. (After a third anterior dislocation, the risk for another is almost 100%.) Surgery is often necessary with recurrence and is usually successful in preventing dislocation, but the throwing abilities of the athlete may never return to their previous status.

Shoulder instability may also manifest itself by subluxation rather than dislocation. This is sometimes termed anterior capsular insufficiency. In this disorder, the anterior capsule and cartilaginous rim of the glenoid become weak from repetitive stretching mainly from the throwing motion. The shoulder may not completely dislocate but instead slips slightly forward and downward. This causes a feeling of weakness (dead arm syndrome), pain, and apprehension, especially when the arm is externally rotated and abducted. Rehabilitation exercises may help, but surgery is often necessary to correct the disorder.

EPICONDYLITIS

Inflammation or degeneration of the tendinous origin of the forearm muscles at the epicondyles is a common disorder (see Chapter 6). The extensor origin (tennis elbow) on the lateral aspect is more commonly involved than the flexor side (golfer’s elbow). The disorder is not restricted to tennis players, but may be caused by any activity that involves repeated forceful gripping. Tennis players who use both hands for backhand strokes do not develop this condition as often as those who use the one-handed grip. Whether or not epicondylitis is truly inflammatory is under investigation. Chronic disorders of this type may begin as a traumatic or inflammatory event, but the underlying pathology is often more degenerative (tendinosis). Physical examination reveals point tenderness over the affected epicondyle, typically about 1 cm distal to the bony epicondyle. Provocative maneuvers are often positive with the pain aggravated by gripping against resistance.

Treatment consists of rest, anti-inflammatory medication, local heat, ice, or ultrasound and local steroid injections. A tennis-elbow brace may help relieve the strain, and a gradual, progressive, controlled stretching and strengthening exercise program for the forearm and hand muscles may be helpful (Fig. 15-19). Tennis players can prevent recurrences by using proper techniques. The handle of the tennis racquet should be the proper size, and the ball should be struck in the center of the racquet face. The body rather than the arm should be used for power. In addition, a good ball should always be used, and there should be less tension on the strings for the average player. Oversized racquets seem to help by providing a larger “sweet spot.”

Fig. 15-19 Tennis-elbow brace. The brace should be applied approximately 2.5 cm below the epicondyle and fit snugly enough to partially relieve the strain on the affected muscles. A variety of other devices are available.

LITTLE LEAGUE ELBOW

Little League elbow is a term that has been used for a variety of lesions in immature athletes. All of them are related to the repetitive act of throwing, an act that places unusual medial tension stretching and lateral compression stress on the elbow. Osteochondritis, avulsion fractures, loose bodies, tendinitis, and a variety of other bony and soft tissue disorders have been reported.

The symptoms may be of acute or gradual onset. When the onset is sudden, the symptoms are usually secondary to an avulsion injury of either the lateral or the medial epicondyle (Fig. 15-20). More commonly, the process is chronic, and the symptoms are usually those of persistent discomfort and stiffness that are aggravated by use of the extremity.

Fig. 15-20 Avulsion of the medial epicondyle in association with a throwing injury in an adolescent.

The physical findings depend on the specific lesion. There is usually point tenderness to palpation over the affected area. The range of motion may be restricted, and a chronic joint effusion is not uncommon.

Treatment is usually conservative, with rest and the elimination of the offending activity being all that is necessary in most cases. A light program of stretching and strengthening may be helpful. If osteochondritis dissecans is present, the joint may have to be protected for several months to allow healing to occur and to prevent the formation of a loose body. If a loose body is present, surgical removal is usually indicated.

Prevention is the key. To protect the elbow of the immature player from developing these disorders, most authorities believe that the number of pitches and the innings pitched should be monitored. In addition, at least 3 to 4 days of rest should be allowed between pitching. (Games and practices all count.) If enough irritation and swelling are present that a flexion contracture of 20 to 30 degrees exists, the adolescent should not be allowed to pitch again until normal motion has returned. Young pitchers should never “pitch through” their pain. Permanent growth disturbances and arthritis could be the end result.

MALLET FINGER (BASEBALL FINGER)

Avulsion of the insertion of the extensor tendon at the base of the distal phalanx is a common injury. It occurs secondary to sudden forceful flexion of the distal phalanx, often from a blow to the tip of the extended finger. A fragment of bone may be avulsed along with the tendon. Active extension of the distal phalanx is lost. Tenderness and swelling are noted on the dorsum of the distal interphalangeal joint, and the distal phalanx rests in the position of moderate flexion. Long-standing cases occasionally develop a mild hyperextension deformity of the proximal interphalangeal joint (Fig. 15-22). This contributes to what is called the swan-neck deformity. Roentgenographic examination may reveal an avulsion fracture of the distal phalanx.

Fig. 15-22 A, Mallet finger. A mild hyperextension deformity is present at the proximal interphalangeal joint. B, Roentgenogram of a mallet finger with a large avulsion fracture. C, Volar opening of the DIP joint indicative of instability. After avulsion of the extensor insertion distally, overpull of the central slip mechanism at the middle phalanx may result in recurvatum at the middle joint, producing a swan neck deformity (A).

If no fracture is present or if the fracture is small, the distal interphalangeal (DIP) joint is immobilized in slight hyperextension for 5 weeks (Fig. 15-23). Vigilance is the key. The splint should not be removed by the patient until the treatment is complete. If the fracture fragment is large (more than 25% of the joint surface) and displaced, the joint should be tested for stability (Fig. 15-24). If the joint is stable, the same treatment is recommended; that is, treatment used in hyperextension. If the joint is unstable or the fragment is quite large, surgical repair may be necessary. Some residual lack of extension may persist regardless of treatment, but the functional result is usually excellent. Patients should be warned that the tender dorsal swelling and redness may last for 2 to 3 months.

Fig. 15-23 Mallet finger splint maintaining the distal interphalangeal joint in extension.

Fig. 15-24 Testing for subluxation of the distal phalanx. The phalanx is grasped, and volar pressure is applied (A). If instability is present, the distal phalanx will sublux (B).

Cases diagnosed after 4 to 6 weeks may still be helped by splinting for 3 to 4 weeks. If a major fragment has been avulsed, surgical repair is often beneficial. If no fracture is present, the amount of actual functional loss that the injury represents to the patient should be assessed. If the impairment is minimal, which is usually the case, then no treatment is indicated. Otherwise, surgical reconstruction is necessary.

FLEXOR DIGITORUM PROFUNDUS AVULSION (JERSEY FINGER)

The deep flexor may be avulsed from its attachment by sudden DIP hyperextension. The ring finger is most often involved. The injury commonly occurs in football when a tackler grabs the jersey of the opponent who pulls away. The tendon eventually retracts proximally into its sheath (Fig. 15-25). If bone is avulsed, it may be evident, but otherwise, roentgenograms are not revealing. Clinically, the volar aspect of the DIP joint is tender, and the patient is unable to flex the distal phalanx. The end of the tendon with its bony fragment may be palpable.

Fig. 15-25 Flexor digitorum profundus avulsion.

Treatment is usually surgical repair. Early recognition is important because direct repair produces the best clinical results. Late cases may require tendon-grafting procedures.

PROXIMAL INTERPHALANGEAL JOINT INJURIES

This joint is one of the most commonly called “jammed.” Several different areas may be injured. A careful physical examination should always be performed to establish the diagnosis.

Central Slip Injuries

Damage to the central slip attachment to the middle phalanx is easily missed. Rupture can occur from forceful flexion of the proximal interphalangeal (PIP) joint or in conjunction with a volar PIP dislocation. The PIP joint is usually swollen, and if injury to the slip is present, there is point tenderness on the dorsum of the joint. PIP extension may still be present because the lateral bands may not have migrated volarward yet. If the slip is completely avulsed, Elson’s test is usually positive (Fig. 15-26).

Fig. 15-26 Elson’s test. The PIP joint is held firmly flexed over the edge of a table, and the patient is asked to extend the finger. If the central slip is intact, pressure is felt against the middle phalanx, and the distal phalanx will remain flail (A). If the central slip is ruptured (B), the pressure is felt at the distal phalanx, which will extend via the lateral bands.

The diagnosis may be difficult. The injury often occurs in conjunction with the rare volar PIP dislocation. If untreated, the lateral bands may gradually migrate into a volar position, anterior to the axis of the PIP joint (Fig. 15-27). This may take 14 to 21 days. The lateral bands then become flexors of the PIP joint and hyperextend the DIP joint to produce the typical boutonnierre deformity. Late loss of DIP flexion is the most disabling problem.

Fig. 15-27 Central slip rupture with boutonniere deformity. As the attempt to extend the finger is made (1), the subluxed lateral bands, which are now volar to the axis of PIP joint motion, cause PIP flexion (2) rather than extension.

Roentgenograms are usually normal, although on rare occasions a fragment of bone may be avulsed (Fig. 15-28).

Fig. 15-28 Avulsion fracture of the central slip (arrow). Also note the dorsal soft tissue swelling.

These cases should probably be referred whenever this injury is suspected, especially if there has been a straight volar dislocation. The PIP joint must be splinted in extension for 4 to 6 weeks to allow healing. The DIP and metacarpophalangeal joints are allowed movement. Chronic injuries may require reconstructive surgery, but the results are never as good as with acute care.

Volar Plate Injuries

A thickened part of the capsule called the volar plate normally acts to protect the PIP joint and prevent hyperextension. It can be avulsed (with or without a bony fragment) in conjunction with the common dorsal PIP dislocation or by a forced hyperextension to the joint (Fig. 15-29).

Fig. 15-29 Avulsion fracture of the volar plate (arrow).

Clinically, there is usually local volar tenderness, and passive joint extension may be increased and painful. If untreated, hyperextension of the PIP joint may occasionally develop and produce a swan-neck deformity.

If unstable, the injury is treated by splinting both interphalangeal (IP) joints in 20 degrees of flexion for 3 to 4 weeks. Buddy taping for 2 to 3 weeks is sufficient if the joint is stable. Large bony fragments may need surgical repair.

INTERPHALANGEAL DISLOCATIONS

These common injuries are almost always dorsal in direction and usually involve the PIP joint (Fig. 15-30). They are usually easily reduced. Although the volar plate may be damaged, dorsal dislocations are generally stable after reduction and may be treated by simply taping the finger to the adjacent finger for 3 to 4 weeks. Collateral ligament stability should always be evaluated. Unstable injuries should be referred. Volar PIP dislocations have the potential for central slip rupture and should probably be referred after reduction.

Fig. 15-30 Proximal IP dislocation. Simple traction usually reduces most IP dislocations. Occasionally, the joint must be hyperextended, and the reduction is accomplished by digital pressure.

PROXIMAL INTERPHALANGEAL FRACTURE-DISLOCATIONS

Many minor IP joint injuries are accompanied by small avulsion fractures. If the joint is stable, the fracture can usually be ignored and the joint injury treated conservatively by splinting for 4 weeks. A more serious injury, sometimes called Wilson’s fracture, is the fracture-dislocation or subluxation of the PIP joint (Fig. 15-31). This injury should be suspected if any volar instability is present when the finger is tested in extension or if the volar fracture fragment is greater than 30% of the joint surface. These injuries should be referred. Special splinting is usually necessary, and surgery may even be indicated.

Fig. 15-31 PIP fracture-dislocation (arrow).

METACARPOPHALANGEAL DISLOCATIONS

These injuries are sometimes difficult to recognize. The index finger and thumb are more commonly involved. The proximal phalanx is usually displaced dorsally (Fig. 15-32). This injury often requires surgical reduction because the metacarpal head may buttonhole through the volar soft tissue. The more vigorous the attempt at reduction, the more the tissue tightens around the metacarpal neck. Closed reduction should be attempted, however, by hyperextending the joint and gradually reducing the phalanx. If the joint is stable, buddy taping for 3 weeks is sufficient. As after any reduction, the joint should “feel” reduced, and motion should be free. If the joint does not feel reduced, soft tissue interposition or an incomplete reduction should be suspected. Open reduction is then required. Referral is indicated if the joint is unstable.

Fig. 15-32 Metacarpophalangeal dislocation of the thumb. The sesamoid may seem to remain in the joint after an unsuccessful attempt at reduction.

BOWLER’S THUMB

This is a traumatic digital neuroma that develops from the irritation of the bowling ball against the digital nerve on the web side of the thumb. Pain and tenderness are present over the affected nerve, and paresthesias may be present along the course of the nerve. A tender mass is usually present, and Tinel’s sign may be positive. Rest and avoiding the offending activity are often curative. Changing the grip on the ball may also help, and protective devices are available to prevent recurrent irritation.

GAMEKEEPER’S THUMB AND SKIER’S THUMB (RUPTURED ULNAR COLLATERAL LIGAMENT)

The radial and UCLs of the metacarpophalangeal joint of the thumb prevent subluxation of the proximal phalanx and provide the stability that is necessary for normal function. Either ligament may be chronically or acutely injured, but injury to the UCL is more common and potentially more serious because of its importance in pinch and grip.

The patient usually has a history of a sprained thumb, often from a fall on the hand. Chronic cases of UCL injury (called gamekeeper’s thumb) may have a history of instability, weakness with pinch, and recurrent effusions of the metacarpophalangeal joint. Local tenderness over the ligament and a joint effusion are usually present on physical examination. The ligamentous laxity is usually manifested clinically by valgus opening of the joint in both extension and flexion. This may be confirmed by abduction stress roentgenograms (Fig. 15-33). Plain radiographs to evaluate for avulsion fracture should be taken before any vigorous testing for stability to prevent displacing the fragment.

Fig. 15-33 The ulnar collateral ligament (UCL) maintains stability of the thumb when pinching. Injury to this ligament may cause significant loss of strength of the thumb (A). Rupture of this ligament may require repair. B, Stress roentgenogram of the thumb with complete ulnar collateral ligament rupture. Injury to the radial collateral ligament (RCL) is less serious and can generally be treated with casting.

Referral for surgical repair is usually indicated in acute cases of complete rupture of the UCL. Partial ruptures and ruptures associated with undisplaced avulsion fractures are treated by immobilization for 5 weeks in a cast that includes the thumb. Chronic cases without traumatic arthritis are treated by ligamentous reconstruction. If the disorder has progressed to the point where degenerative arthritis is present, arthrodesis of the metacarpophalangeal joint may be necessary.

Radial collateral injuries of the thumb are much less common. Complete radial collateral ligament injuries are safely treated with a thumb spica cast. The rare case of persistent radial collateral ligament instability may benefit from late reconstruction.

INJURIES TO LIGAMENTS

Along with fractures, these are the most important injuries to diagnose immediately. The first individual on the sideline has the best chance to evaluate the knee before spasm and swelling develop. As previously described (see Chapter 11), the knee should first be palpated for specific areas of tenderness. With the knee flexed 30 degrees, the collateral ligaments are evaluated, and Lachman’s test is performed. If possible, the cruciate ligaments are then tested with the knee flexed 90 degrees. Any acute rapid swelling within 12 hours suggests an anterior cruciate ligament rupture with hemarthrosis, especially if a “pop” is felt at the time of injury. (Swelling after 12 hours is usually caused by reactive synovitis, often the result of a meniscal tear.) If only a minor strain is present, it may be possible for the athlete to return to activity, but any more severe injury should have a compression dressing and ice applied, and the activity should be ceased pending further evaluation.

Plain roentgenograms should always be performed. Stress films may be especially helpful in the adolescent with open growth plates. In this age group, epiphyseal fractures are more common than ligamentous injuries because the growth plate is weaker than the ligaments (Fig. 15-34).

Fig. 15-34 Stress roentgenogram of an epiphyseal fracture of the lower portion of the femur (arrow) that easily simulates ligamentous disruption.

Postpubertal females are at high risk for knee ligament injuries, especially those involving the anterior cruciate ligament. The cause is not completely understood, but it may be because of poor neuromuscular control of knee muscles. Prevention includes conditioning and muscular strengthening.

INJURIES TO THE MENISCUS

These are the most common of all knee injuries. They usually result from a twisting force applied to the knee with the extremity bearing weight. The athlete experiences sudden pain and is often unable to continue playing. Swelling develops gradually in contrast to ligament injury and may not be noticed until the following day. The pain may be localized to one joint line. The knee may actually lock if the meniscus is sufficiently torn and catches across the joint surface.

Suspected meniscus injuries are initially treated conservatively with a Robert Jones dressing, ice, quadriceps exercises, and elevation. Over the next several weeks, the response to rest and time determines whether surgery will be necessary to repair or remove the torn meniscus.

REHABILITATION

A program of progressively increasing exercises to improve strength and endurance is begun on all athletes with injured knees as soon as tolerated (see Chapter 11). Specific exercises to strengthen the quadriceps, hamstrings, and calf muscles are begun. Progressive range-of-motion exercises are added as tolerated, and the athlete is allowed to return to activities only when the effusion and pain have completely subsided and strength, range of motion, and thigh circumference have returned to normal.

ANKLE SPRAINS

The ankle sprain may be the most common of all athletic injuries. The lateral ligaments are the most frequently involved as a result of an inversion force (see Chapter 12). Mild to moderate sprains are best treated by early gentle motion (avoiding inversion) and exercise the day after the injury when pain begins to subside. Ice should be continued. Heat is never used. Peroneal muscle exercises are added and progressed against resistance as tolerated. More strenuous activity is allowed when the athlete is able to perform more vigorous activities such as hopping. Limited workouts may be resumed at this stage, but the ankle should always be taped. Return to full activity should not be allowed until there is full, pain-free motion and equal strength and the athlete is able to change direction quickly and jump without discomfort.

Treatment of severe sprains remains controversial. Although surgery, casting, and simple symptomatic treatment have been recommended, all with good results, functional rehabilitation without surgery is the preferred treatment regardless of severity. Lace-up ankle stabilizers and taping are helpful.

WRAPPING AND TAPING

To prevent ankle injury, many physicians and trainers advise wrapping the uninjured ankle (Fig. 15-35). A reusable dressing may be applied by the athlete over a sock. Even though half of the support of tape loosens in 10 minutes, the athlete who has had previous injury will benefit from taping when activity is resumed. For this individual, wrapping is probably not adequate, and applying adhesive tape is necessary to prevent reinjury. Adhesive taping is more beneficial because it can be applied tighter and extended as high on the leg as necessary for protection.

Fig. 15-35 The “Louisiana” ankle wrap. Approximately 100 inches of webbed bandage are used. The patient sits on the table, holding the ankle at 90 degrees. The wrap may be applied over a stocking. Steps 1 and 2 secure the wrap; steps 3, 4, and 5 are the lateral and medial “heel locks” that prevent eversion and inversion, respectively. After step 6, the procedure is repeated. The wrap is then spiraled up over the ankle, as shown in step 7, and secured with tape. This technique may prevent needless ankle taping.

Several taping techniques are commonly used. Each physician should become familiar with a single method and learn to apply it easily. The closed basket weave described by Gibney is commonly used (Fig. 15-36). The open basket weave is the same except that the tape does not overlap in front. The open method may be used in acute sprains with excessive swelling because the tape is not circumferential and allows for swelling and ankle motion. An elastic wrap is applied over the open taping method.

Fig. 15-36 The closed basket weave taping technique. A, Two anchor strips are applied, one at the base of the gastrocnemius and one below the midfoot. B, The first stirrup and horizontal strips are applied. C, The finished weave. Close the strapping by alternating strips with stirrups. Overlap half the width of the tape. D, Apply three circular anchoring strips distally, and add a set of medial and lateral heel locks (not shown). E, The open Gibney method. No heel lock system is used. Whatever method is used, avoid taping too low, and avoid wrinkles.

The closed basket weave may be supplemented by a heel lock taping system for added medial or lateral support (Fig. 15-37). With any method, the ankle is first prepared by shaving and spraying with adhesive spray or tincture of benzoin. Either 1- or 1½-inch tape is normally used. Many modifications of these techniques are used (Figs. 15-38 and 15-39). Sensitivity to benzoin is possible; it must be used with caution.

Fig. 15-37 The heel lock system. A, The lateral heel lock that prevents eversion. B, The medial heel lock that prevents inversion. Both may be applied together in a continuous wrap.

Fig. 15-38 The modified Gibney technique. A, The circular strip completely encircles the leg, and the vertical strips may extend as high as necessary. B, Additional vertical and circular strips are added. C, A top circular strip (7) anchors the vertical strips. After the rest of the circular strips have been applied (D), heel locks should be added.

Fig. 15-39 A slightly quicker method than the Gibney technique uses an anchor and two stirrups (A), five to six circular strips (B), two to three arch strips (C), and a heel lock system (D).

ATHLETE’S FOOT

Many varieties of fungus affect the foot. The most common areas of involvement are between the toes and under the arch. Moisture and warmth predispose feet to the development of athlete’s foot. Itching, redness, and burning are present. Allergy to stockings or shoe materials should be ruled out. Treatment is with one of the many commercial or prescription medicated powders available. The foot should be kept dry, and stockings may need to be changed frequently. If symptoms persist, the newer antifungal agents are quite effective (see Chapter 12).

EVALUATION

The player often comes off the field unable to move the arm. Pain begins in the supraclavicular area and radiates down the arm. It may resolve within minutes. These symptoms are usually unilateral. Bilateral symptoms such as burning hands syndrome or symptoms involving the legs should cause concern for a neck injury. There is usually no neck pain with the burner. (Any patient with neck pain or symptoms of spine injury should not be moved without proper immobilization on a spine board.)

It is important to determine whether the injury is outside or inside the cervical spine. On-the-field screening should include an evaluation of (1) the location of pain and tenderness, (2) the amount of pain with isometric contraction of neck muscles, (3) deltoid, biceps, and triceps strength, and (4) range of neck motion. The last should be evaluated very carefully. Range of motion should not be tested if spine injury is suspected. When cervical spine injury has been ruled out, stretching the brachial plexus by pulling down the arm may elicit symptoms if the injury is due to traction. There may also be tenderness in the supraclavicular fossa. Spurling’s test (Chapter 3) may be positive in the patient with a compression injury.

If there are any signs of neck injury, cervical spine films are taken. Computed tomography and MRI may be needed to rule out cord or cervical root involvement. If a cervical root(s) is involved, MRI studies may be helpful to determine if there are related disc changes. If not, a plexus injury is probably the cause, and clinical progress can be used to determine return to sports. Electomyography is not helpful.

If the neck examination is negative and complete recovery (full strength and motion with no pain or tenderness) occurs in 1 to 2 minutes, the athlete may return to play. Stretching the plexus should not reproduce symptoms. In most cases, the symptoms from burners subside quickly; often, they are not reported at all. A protective collar worn inside the shoulder pads may prevent further injury. Strengthening and range of motion exercises are recommended. Reinjury can be avoided by proper technique and good equipment.

PROGNOSIS

Most brachial plexus injuries are minor and recover in a short time without residuals. Athletes with disc degeneration or stenosis, however, are at greater risk of serious neurologic injury and may have to be excluded from further participation in contact sports.