Clinics in Sports Medicine

Published by WB Saunders
Print ISSN: 0278-5919
Publications
The specter of catastrophic cervical neurotrauma resulting from athletic participation, although infrequent, has been consistently associated with football, water sports, gymnastics, rugby, and ice hockey. Injury involving intracranial hemorrhage can result in death or permanent neurologic impairment, whereas certain fractures and dislocations of the cervical spine are associated with quadriplegia. Athletic injuries to both the central nervous system and spinal cord demand our attention as an active area of clinical and basic injury. A review of the available literature reveals changing injury patterns as well as current concepts regarding the mechanism responsible for most athletic injuries to these structures. Accurate descriptions of the mechanism(s) responsible for a particular injury transcend simple academic interest. In order that preventive measures be implemented, the manner in which injury occurs must be accurately defined. The purpose of this article is to describe how the application of this principle resulted in the significant reduction of cervical spine injuries associated with quadriplegia that have occurred in tackle football since 1976.
 
A review of the available records indicates that there have been a substantial number of fatalities in boxers due to intracranial injuries sustained in the ring in comparison to the numbers engaged at both amateur and professional levels. The number of such fatalities has decreased steadily in recent years owing to different measures taken by boxing authorities to decrease the physical hazards in the ring and to improve monitoring of boxers during bouts by referees and physicians. The considerable concern about the long-term effects of repeated brain injury as the result of boxing in producing chronic encephalopathy is adequately justified by the many studies of live boxers and pathologic examinations of brains of former boxers made and recorded over the years since 1952. These indicate clearly a significant relationship between the numbers of bouts fought and the presence of severity of chronic encephalopathy. Because it is unlikely that currently adopted protective measures will substantially reduce these hazards, even though they have apparently reduced direct fatalities, a reasonable approach to prevention would be to reduce the number and severity of blows to the head. This might be done by making any blow to the head in boxing a foul and a reason for disqualification. Another approach would be the elimination of boxing.
 
In response to the Amateur Sports Act, which gave the United States Olympic Committee (USOC) the responsibility of being a unifying force in amateur athletics, several changes were made in the Constitution of the USOC. One change was a commitment to the implementation of sports medicine concepts. This commitment is carried out by the Sports Medicine Division of the USOC, whose structure, goals, and philosophy are detailed.
 
Physicians and other health care professionals can play an integral role in encouraging individuals to exercise. This article presents a general philosophical approach to the exercise prescription as well as the Year 2000 Physical Activity and Fitness Objectives for the Nation, which call for greater physician involvement in this area.
 
To perform at the highest level of international competition, athletes need to maximize rest during long travel, and expeditiously overcome the detrimental effects of "jet lag" (JL). The negative effects of JL may be alleviated by adopting a multimodality approach, including the judicious use of melatonin and other pharmacologic agents to aid re-entrainment and improve sleep characteristics. Strict compliance with anti-doping policy is pivotal before and during competition. There have been several recent updates regarding the use of selected medications, which mandate constant vigilance by sports medicine personnel to both evaluate drug efficacy and judiciously prescribe approved medications. It is critical that medical staff maintain familiarity and awareness on a continual basis to effectively educate athletes and support staff.
 
Rotator cuff repairs have evolved from open to arthroscopic techniques. The fundamentals of recognizing rotator cuff tear patterns, tissue mobilization, footprint restoration, and stable repair construct remain largely unchanged. Recent clinical studies have raised concern regarding high retear rate for rotator cuff repairs, despite good clinical outcomes, with single-row repair techniques. As a result, double-row and transosseous-equivalent techniques have been developed. Biomechanical data favor these newer techniques whereas clinical data have not definitively concluded which technique is superior. The most up-to-date arthroscopic rotator cuff repair techniques are presented for partial-thickness and full-thickness rotator cuff tears.
 
The overhead athlete has unique physical traits and adaptive changes as a result of the repetitive nature of throwing. An effective rehabilitation program depends on an accurate evaluation to determine the causative factors for an athlete's pathology. A treatment program is individualized with specific strengthening and flexibility exercises to achieve dynamic stability that is required for overhead function. In this article the characteristics of the throwing shoulder and specific injuries are described. The rehabilitation program is described in a multiphased approach that allows for the restoration of strength, mobility, endurance, and power to return to sporting activity. Copyright © 2015 Elsevier Inc. All rights reserved.
 
In the past 5 years, a great deal of time and effort has been expended in an effort to better define clinical, anatomic, and laboratory parameters of CECS. It is now a well-recognized entity and one that can be readily resolved with fasciotomy. But the reasons for predisposition and the pathophysiologic mechanisms remain obscure. It appears, however, that basing the decisions for fasciotomy on clinical characteristics alone leads to overdiagnosis and excessive surgery. In this series, almost 50% of the referred subjects failed to demonstrate adequate laboratory criterion for the diagnosis of CECS. Fasciotomy in these patients may have effected a cure, but the reasons may be unrelated to increased intracompartmental pressure. Furthermore, in the laboratory diagnosis of CECS, the rate of return to resting compartment pressure following exercise seems more accurate than reliance on resting pressure alone. 31P-NMR has proved valuable in the dynamic assessment of muscle ischemia as reflected by relative PCr concentrations. Finally, although a mechanism explaining the source of pain has not been established by this study, it appears that ischemia is not a significant factor.
 
Athletes who sustain a direct blow to the abdomen that results in injury to spleen, liver, or kidney may have immediate severe pain and may become "shocky" quickly. Trainers, EMTs, paramedics, and team physicians should be aware of this possibility. In addition, athletes who have sustained direct blow and have had slower bleeding may collapse later either on the field, on the side-lines, or at home. They will be pale, sweaty, may complain of thirst, and the pulse will be rapid and thready. If a blow has been sustained that results in abdominal pain, the athlete should not be given liquids to drink. If he has collapsed or has diffuse abdominal pain he should be kept in a recumbent position, and the legs should be elevated in order to assist blood in returning to the heart (Trendelenberg position). If hypotensive shock is present, the PASG antishock garment should be applied. In cases in which there is serious concern about an intra-abdominal injury or the patient has collapsed in shock, transport to a hospital, preferably to a trauma center, should be effected as rapidly as possible. There should not be excessive delays in starting intravenous fluids or administering time-consuming procedures in the field. Truly serious intra-abdominal injuries as a result of nonvehicular sports-related incidents are not common. It is precisely for this reason that they are dangerous. Teammates, parents, trainers, coaches, EMTs, and paramedics are not accustomed to seeing them with any frequency. Because of this, the early signs of injury are often unrecognized, even in cases that progress to shock or collapse.(ABSTRACT TRUNCATED AT 250 WORDS)
 
Sports medicine physicians should be aware of the many injuries that are associated with blunt abdominal trauma. From benign diaphragmatic spasms and rectus abdominis hematomas to the more concerning liver, splenic, renal, and pancreatic injuries, the sideline physician needs to be able to triage athletic-related injuries. Furthermore, many athletes will ask their physician about return-to-play recommendations and continuing care following blunt abdominal trauma. The sports medicine physician should have a working knowledge of the pathophysiology of various abdominal injuries to best advise and treat his or her team members.
 
Although abdominal and groin injuries are not unique to the game of tennis, the very mechanics of the ground stroke and overhead volley predispose participants in this sport to the chronic pain and frustration of these injuries. Careful consideration must be given not only to the muscular anatomy of the region but also to the visceral and neurologic anatomy. A patient, controlled program of rehabilitation, emphasizing flexibility and subsequent strengthening, must be stressed if recurrence is to be avoided.
 
Abdominal pain in an athlete may be due to an intra-abdominal injury or abdominal disease unrelated to athletics; both are uncommon. Because such processes may be life-threatening, awareness of their typical patterns is imperative for all involved in sports medicine. Evaluation of an athlete with abdominal pain is thus directed at deciding if the athlete has significant abdominal disease, and then using appropriate diagnostic methods to determine the specific process.
 
Cervical spine injury has a wide spectrum of consequences for the contact athlete, ranging from minimal to catastrophic. Because of the potentially grave sequelae of cervical injury, it is incumbent on team physicians or treating spine surgeons to be knowledgeable of postinjury treatment and return-to-play algorithms. Sideline physicians must have a rehearsed, comprehensive protocol for ensuring rapid treatment should an on-field injury occur with contingency plans to transport an injured player to a medical facility if necessary. Likelihood of return to play is variable with the extent of injury, but high for stingers, relatively low for patients who suffer episodes of transient neuropraxia, and intermediate for players who undergo cervical fusion for disk herniation based on the best available evidence. However, patients must be evaluated carefully on a case-by-case basis because of the heterogeneity of injury severity and associated pathology.
 
Many types of spinal abnormalities can have an impact on an athlete’s ability to participate in sports. One of the challenges in the current era is distinguishing the clinically relevant lesions from the incidental. Almost without exception, a Chiarimal formation, significant syringomyelia or other cyst compressing the spinal cord or nerve roots, tethered spinal cord, or spinal tumor should prompt referral to a neurosurgeon. However, tonsillar ectopia (descent of the cerebellum less than 5 mm beyond the foramen magnum) and small dilatations of the central canal, are very commonly seen and appear to represent normal anatomic variants that place athletes at no increased risk of spinal injury, and should not be considered a contraindication to play. The recommendations made in this article are largely based on consensus and experience, but as we gain more clinical experience to correlate with the increasingly sophisticated imaging findings, we hope that these recommendations can be refined further.
 
Sexual harassment and abuse by authority figures in sports are discussed in relation to how female athletes might improve their personal safety to guard against such practices. The origins of sport research on this theme are traced, and the processes of sexual harassment and abuse are identified. Risk factors for the coach, the athlete, and the sport are presented, and, finally, sources of prevention measures for coaches, athletes, parents, and clubs are provided.
 
The three types of drugs commonly used in sports--therapeutic drugs, performance-enhancing drugs, and recreational drugs--have been discussed and presented in a way that should be helpful to health care providers dealing with athletes. The goal of this article has been not only to present information concerning drugs but also to raise the awareness level so that abuse of all types of drugs will be considered by athletic trainers, physicians, and health care providers when they deal with athletes. The role of the physician in the area of drug abuse is no different than the physician's role in dealing with any health problem, diagnosis, and management. The responsibility of the physician who deals with athletes always has been, is, and always will be the health and safety of the athlete.
 
Unsatisfactory results following partial meniscectomy and problems related to a retained posterior horn of the medial meniscus are problems often attributed to inadequate arthroscopic partial meniscectomy. Although there are multiple techniques to gain better access to the various compartments in a truly tight knee, most of the problems in obtaining maximum visualization and instrumentation to the posterior aspects of the medial or lateral meniscus can usually be solved by adhering to a strict surgical technique that attempts to control the multiple variables encountered during arthroscopic surgery. These include the use of a tourniquet, leg holder, maximum distention of the knee provided by a large inflow cannula with large-bore tubing connected to 3-L bags, and an 18-gauge needle as a predecessor to the larger arthroscopic instruments. Of utmost importance is establishing the correct portal for the arthroscope, and it is time well spent at the beginning of the surgical procedure to verify the proper location of the arthroscope and not simply insert the arthroscope "a thumb-breadth above the joint line." Once these variables have been controlled, one can usually visualize and perform arthroscopic surgery on most meniscal lesions with minimal scuffing to the articular surfaces.
 
The transition to the care of the college student-athlete carries with it a number of adjustments. In private practice it is customary to make medical decisions and initiate therapies from the confines of the examination room. The doctor-patient relationship is the principal focus. Although this relationship remains paramount in college athletics, the world of concerned and affected parties dramatically expands. It is in this context that the authors explore the concept of access in the role of a team physician. To use what is becoming an over used cliché, what makes one a valued team physician is being "the right person, in the right place at the right time."
 
Ballet dancers have an increased risk of developing anorexia nervosa, perhaps because of their preoccupation with appearance and body shape related to their career. The author lists the early warning signs of anorexia nervosa and bulimia in dancers. Techniques are described to assist the practitioner in differentiating the normal dieting dancer from the anorectic dancer. The author emphasizes strategic treatment planning with anorectic dancers who initially deny the severity of their illness.
 
In the past, arthroscopic technique for the treatment of a torn acetabular labrum was limited to simple debridement of the torn tissue. However, due to recent advancements in the understanding of the function of the labrum, it has been suggested that labral repair can be beneficial. The purpose of this article is to report a new technique for arthroscopic rim trimming of pincer-type femoroacetabular impingement and labral repair through the lateral arthroscopic portal.
 
Rim impingement lesions vary based on the underlying pathology. In general, rim impingement occurs with anterosuperior overhang, coxa profunda, protrusio acetabuli, and acetabular retroversion. The method for addressing these pathologic lesions depends on location and size of the impingement lesion, the underlying pathology, and the degree of labral damage. The ultimate goals of surgical management include accurate localization of the rim impingement lesion, adequate removal of the bony impingement lesion, and preservation and refixation of the viable labral tissue. If the surgeon feels that these goals cannot be accomplished safely and effectively by arthroscopic methods, alternative procedures should be considered.
 
Pathologic involvement of the acetabular labrum is an increasingly recognized phenomenon. Athletes involved in sports that require repetitive twisting or who suffer trauma to the hip are at risk of injury to the acetabular labrum. Injury mechanisms that include hyperextension, hyperflexion, or extremes of abduction place the labrum at particular risk. Symptoms may be acute in onset or, more commonly, insidious onset with persistence or escalation of symptoms. The orthopaedic surgeon evaluating patients with sports-related hip injuries needs to remain cognizant of intraarticular injuries within the hip and, in particular, injuries to the acetabular labrum. Further investigation is needed to fully define the functional importance of the acetabular labrum. Arthroscopic management has been successful in evaluation and management of acetabular labral tears.
 
Magnetic resonance imaging (MRI) has become a valuable technology for the diagnosis and treatment of femoroacetabular impingement (FAI). This article reviews the basic pathophysiology of FAI, as well as the techniques and indications for MRI and magnetic resonance arthrography. Normal MRI anatomy of the hip and pathologic MRI anatomy associated with FAI are also discussed. Several case examples are presented demonstrating the diagnosis and treatment of FAI.
 
Labral tears are an important cause of hip pain in the athlete. Knowledge of labral function is now better understood. The labrum acts as a suction seal stabilizing the hip joint. After a detailed history and physical examination, imaging workup is done to achieve an accurate diagnosis. Hip arthroscopy can be performed to treat labral tears in a minimally invasive manner. This article describes operative techniques to treat labral tears, including a method for labral reconstruction using the iliotibial band autograft.
 
Evidence is accumulating from several different sources that relates the subtle osseous abnormalities found in FAI and DDH to early development of osteoarthritis [29]. It is incumbent on the radiologist to be vigilant in making these diagnoses and bringing them to the attention of the referring clinician. Early detection on radiographs, followed by MR arthrogram to fully evaluate the pathology, can result in early surgical intervention. Accurate preoperative analysis can assist in developing the optimal surgical plan for the individual patient. New imaging manipulation is being developed that may allow for smaller surgical approaches. Three-dimensional CT is being used in conjunction with range of motion modeling to identify a specific small osseous focus that is the cause of impingement. This may allow for osteoplasty of this small focus by means of a purely arthroscopic approach in some cases. Avoiding the partial surgical hip dislocation whenever possible is important in reducing postoperative morbidity.
 
The senior author has performed more than 600 "therapeutic" arthroscopies under local anesthesia since 1978. The authors believe that the cases presented illustrate the increased diagnostic accuracy offered by performing arthroscopy of the knee under local anesthetic in certain types of cases. We are by no means advocating that all arthroscopies of the knee be performed under local anesthesia. Certainly, the majority of knee arthroscopies need not be performed under local anesthesia, because the diagnosis is usually evident. Perhaps when the diagnosis is not clear, a combination of local with regional or with general would be best, with performance of the diagnostic portion of the arthroscopy under local anesthesia. When an instantaneous improvement is possible, such as change in joint motion, or when some change in joint dynamics may be visualized, local should then be continued through the therapeutic conclusion of the procedure. Arthroscopy under local anesthesia has also been performed by the authors on the shoulder, elbow, and ankle, where the diagnostic benefits have been realized. Certain reconstructive operations, such as patellar realignments, are worthy of performance under local anesthesia in selected cases. In conclusion, the authors believe that arthroscopy of the knee and other joints under local anesthesia may add measurably to the diagnostic capability of the arthroscopist, and not infrequently to a therapeutic advantage.
 
This article describes potentially pathogenic behavior in youth sports. It delineates the four stages of achievement by proxy distortion (ABPD) behavior and attempts to raise awareness of that behavior and to facilitate communication among sports medicine and psychiatry professionals of the potential for exploitation and abuse of children and adolescents by parents, mentors, coaches, and the systems that nurture and develop these children. Information is presented to distinguish motivations behind normal parenting from those that lead to risky sacrifice, objectification of the child, and potential abuse. Distinct abuse stages of ABPD are described. The authors identify "red flags" that indicate distorted views and potentially harmful behavior toward children.
 
Certain similarities can clearly be appreciated between Achilles and patellar tendon ruptures. Both are strong tendons that transmit force bridging at least one joint of the lower limb. When healthy, both require massive forces to be disrupted, and both can be weakened through certain systemic disease processes, steroids, and fluoroquinones. Both allow for a variety of innovative management possibilities that ultimately lend themselves to individual surgical preference. We feel that, although surgical management plays an important role in restoring continuity in knee extension and in plantar flexion, functional outcome inevitably relies on patient motivation and a well-established physiotherapy regime. Sports physicians should be able to identify both conditions early in their presentation, but still hold a high index of suspicion for these problems in athletes who have an acute exacerbation of ongoing tendinopathy.
 
In conclusion, the sports medicine specialist is able to use a spectrum of diagnostic, surgical, and rehabilitation techniques to identify etiologic factors and to choose optimal treatment regimens for patients with Achilles tendinitis or traumatic rupture. Correction of pathomechanic factors, anatomic restoration, and aggressive postoperative rehabilitation allows an early return to sport without significant loss of strength or mobility.
 
Overuse injuries of the Achilles tendon are common in patients engaging in recreational athletics. Achilles tendon overuse injuries exist as a spectrum of diseases ranging from inflammation of the paratendinous tissue (paratenonitis), to structural degeneration of the tendon (tendinosis), and finally tendon rupture. Factors known to predispose patients to Achilles tendinitis include inadequate stretching, training errors, mechanical malalignment of the lower extremities, rigid training surfaces, and occasionally systemic disease. Treatment of the patient with paratenonitis and tendinosis is initially conservative, emphasizing passive stretching, concentric and eccentric strengthening, correction of training errors, and restoration of normal limb alignment. Patients resistant to this protocol often exhibit a more advanced degree of tendon change. A high percentage of these patients can benefit from surgical debridement of the involved tendon, and they can anticipate successful return to recreational athletics. Steroid injections should not be routinely used in patients with Achilles tendinitis. Rupture of the Achilles tendon following intratendinous injection has been reported.
 
Plantar fasciitis and Achilles enthesopathy are two of the most common causes of posterior heel pain. In the vast majority of cases, nonsurgical treatment methods are effective. In recalcitrant cases, surgery has been shown to be generally effective. There are a variety of described techniques for both conditions. Endoscopic treatment of plantar fasciitis leads to slightly enhanced recovery times compared with the traditional open release, but in the long term the results seem to be equivalent. Open debridement of the retrocalcaneal bursa, calcaneal osteophyte, and diseased tendon is the underlying principle behind surgical treatment of Achilles enthesopathy. This can be performed through a variety of approaches, and augmentation with suture anchors, tendon transfers, or allograft may be necessary when more than 50% of the tendon is excised.
 
Allograft usage for cruciate ligament reconstruction has gained in popularity. Many techniques are described for posterior cruciate reconstruction with both autograft and allograft tendons. Achilles tendon allograft is a versatile and effective graft that can be used for a transtibial, double femoral bundle posterior cruciate reconstruction.
 
Achilles tendon ruptures can be treated nonsurgically in the nonathletic or low-end recreational athletic patient, particularly those more than 50 years of age, provided the treating physician does not delay in the diagnosis and treatment (preferably less than 48 hrs and possibly less than 1 week). The patient should be advised of the higher incidence of re-rupture of the tendon when treated nonsurgically. Surgical treatment is recommended for patients who are young and athletic. This is particularly true because the major criticism of surgical treatment has been the complication rate, which has decreased to a low level and to a mild degree, usually not significantly affecting the repair over time. Surgical treatment in these individuals seems to be superior not only in regard to re-rupture but also in assuring the correct apposition of the tendon ends and in placing the necessary tension on the tendon to secure appropriate orientation of the collagen fibers. This in turn allows them to regain full strength, power, endurance, and an early return to sports. Surgery is also recommended for late diagnosed ruptures where there is significant lengthening of the tendon. Surgical technique should involve a medial incision to avoid the sural nerve, absorbable suture, and augmentation with fascia or tendon where there is a gap or late rupture. Postoperatively, the immobilization should be 7 to 10 days in a splint. A walking boot with early motion in plantar flexion or a short leg cast with the tendon under slight tension should thereafter be used for 4 to 5 weeks. An early and well-supervised rehabilitation program should be initiated to restore the patient to the preinjury activity level.
 
Persistent pain in the Achilles tendon is often caused by partial ruptures leading to a hypoxic state in the tissues, insufficient healing, and a remaining, immature, and painful scar. The rupture is caused by overuse and conservatively treated with orthotic devices to reduce tendon load and physiotherapy to correct training errors and strength the muscle-tendon unit. Significant partial ruptures seem to respond poorly to conservative measures and do not improve with time. Surgical treatment with excision of degenerated tissue which leads to complete pain relief and full restoration of function with long-standing effects in most cases is why persistent Achilles tendon pain due to partial rupture preferably should be treated surgically.
 
Direct in vivo Achilles tendon force measurements open up new possibilities for understanding the loading of the Achilles tendon during natural locomotion. This article describes how these human experiments can be performed. The results of these experiments imply that Achilles tendon forces are unexpectedly high in certain activities (e.g., hopping) and that the rates of loading rather than the absolute magnitudes of the recorded forces may be more relevant for clinical purposes as well as for the construction of artificial tendon materials.
 
Chronic painful midportion Achilles tendinosis has been known as a difficult condition to treat, and surgical treatment was often needed. In recent scientific studies, however, treatment with painful eccentric calf muscle training has shown very good short-term clinical results and significantly reduced the need for surgical treatment. Also, very recently, a new method consisting of sclerosing of neovessels in the area with painful tendinosis showed promising short-term results. Ongoing and future research will evaluate the potential of these treatment models.
 
MRI has led to significant advancement in diagnosis of soft tissue injuries. Previous technology has been limited to morphologic diagnosis and static images. Recent advances allow high-resolution images with shorter acquisition time and compositional analysis of tissues. Static, unloaded, and morphologic examination became dynamic, loaded, and biochemical analyses. This article focuses on the use of advanced MRI techniques in the evaluation of anterior cruciate ligament (ACL) injury and its surgical outcome. Up-to-date applications of quantitative MRI and kinematic analysis of ACL injuries and reconstructed knees are reviewed.
 
While bone-patellar tendon-bone (BPTB) autograft continues to be the "gold standard" and most popular graft choice for primary anterior cruciate ligament (ACL) reconstructions, the use of allograft tissues in ACL reconstruction has steadily increased over the last 2 decades. Advantages of allograft include a lack of donor-site morbidity, unlimited available sizes, shorter operative times, availability of larger grafts, smaller incisions, improved cosmesis, lower incidence of postoperative arthrofibrosis, faster immediate postoperative recovery, and less postoperative pain. Disadvantages include the potential for disease transmission and prolonged graft healing. Presented in this article are 2 techniques used at the authors' institution for primary ACL reconstruction with allograft. With the proper indications, knowledge of graft preparation and handling, and technique, allograft tissues in ACL reconstructions can provide the surgeon with clinical results equal to those of autograft reconstructions.
 
Operative reconstruction of a torn anterior cruciate ligament (ACL) has become the most broadly accepted treatment. An important, but underreported, outcome of ACL reconstruction is graft failure, which poses a challenge for the orthopedic surgeon. An understanding of the tendon-bone healing and the intra-articular ligamentization process is crucial for orthopedic surgeons to make appropriate graft choices and to be able to initiate optimal rehabilitation protocols after surgical ACL reconstruction. This article focuses on the current understanding of the tendon-to-bone healing process for both autografts and allografts and discusses strategies to biologically augment healing.
 
Acute anterior cruciate ligament (ACL) tears are most frequently sustained by young, physically active individuals. ACL injuries are seen at high incidence in adolescents and young adults performing sports and occupational activities that involve pivoting. Young women participating in pivoting sports have a 3 to 5 times higher risk of ACL injury than men. Studies show that ACL injury increases osteoarthritis (OA) risk with symptomatic OA appearing in roughly half of individuals 10-15 years later. Because the majority of patients sustaining acute ACL tears are younger than 30, this leads to early onset OA with associated pain and disability during premium work and life growth years between ages 30 and 50. Effective strategies to prevent ACL injury and to reduce subsequent OA risk in those sustaining acute ACL tears are needed.
 
Anterior cruciate ligament (ACL) rupture occurs in hundreds of thousands of active adolescents and young adults each year. Despite current treatment, posttraumatic osteoarthritis following these injuries is common in these young patients. Thus, there is widespread clinical and scientific interest in improving patient outcomes and preventing osteoarthritis. The current emphasis on the removal of the torn ACL and subsequent replacement with a tendon graft (ACL reconstruction) stems from adherence to a long-held and widely accepted doctrine that the ACL has only a limited healing response and, therefore, cannot heal or regenerate with suture repair. Recent work has shown that, despite an active biologic response in the ACL after injury, the two ends of the torn ligament never reconnect. Additional studies have detailed findings after placement of a substitute provisional scaffold in the wound site of the ACL injury to bridge the gap and initiate healing of the ruptured ligament after primary repair. This technique, called enhanced primary repair, has significant potential advantages over current ACL reconstruction techniques, including the preservation of the complex attachment sites and innervation of these structures, thus retaining much of the biomechanical and proprioceptive function of these tissues. This manuscript summarizes the recent in vitro and in vivo studies in the area of enhancing ACL healing using biologic supplementation. Subsequent work in this area may lead to the development of a novel approach to treat this important injury.
 
Concomitant ACL and meniscal tears pose a higher risk for premature osteoarthritis than either condition alone, especially in the active athlete. Given that the ACL-deficient knee is also at risk of initiating tears and propagating smaller tears, ACL reconstruction is advisable. The meniscal repair in the ACL-unstable knee is at a higher risk for retear. Therefore, ACL reconstruction should be considered seriously for the ACL-deficient patient with a reparable meniscal tear, as well as for the irreparable meniscal tear, as long as the patient is an otherwise appropriate reconstruction candidate. The meniscal tear with a vertical longitudinal pattern that is less than 5 mm from the meniscosynovial junction and longer than 10 mm should be repaired. Tears with rim widths greater than 5 mm may be repaired if there is evidence for vascularity. Those tears that have rim widths greater than 5 mm without evidence for significant vascularity may be repaired, but healing enhancement techniques are recommended, including rasping of synovial fringes and insertion of fibrin clot, and both the patient and the surgeon need to be aware of the significantly lower success rates. If repairs of double flap, double longitudinal, or radial tears are performed, then use of the fascia sheath coverage with fibrin clot, as proposed by Henning et al, can be considered. Partial meniscectomy is acceptable for the complex meniscal tear.
 
The primary objectives of ACL surgery and rehabilitation are to restore knee function to preinjury levels and promote long-term joint health. Often these goals are not achieved, however. The quadriceps is critical to dynamic joint stability, and weakness of this muscle group is related to poor functional outcomes. Because of this, identifying strategies to minimize quadriceps weakness following ACL injury and reconstruction is of great clinical interest. This article reviews the current literature and critically discusses current rehabilitation approaches to restore quadriceps muscle function after ACL reconstruction.
 
Imaging of the anterior cruciate ligament (ACL) requires adequate understanding of the unique structural features of the pediatric skeleton, the injury patterns as they relate to skeletal maturity, and the specific mechanisms of trauma. Magnetic resonance (MR) imaging is the preferred modality for the evaluation of the ACL because it allows characterization of ligamentous abnormalities and associated injuries without exposing the child to ionizing radiation. This article describes the normal appearance, primary, and secondary imaging findings of ACL injuries in children, and related traumatic lesions of the knee.
 
The purpose of this article is to update the orthopedic community on the role of lateral extra-articular tenodesis in the management of anterior cruciate ligament-deficient knees. Information includes historical perspective, current applications and techniques, and a review of published outcomes.
 
Variations in the architecture of the coracoacromial arch can lead to a clinically symptomatic rotator cuff lesion. Differences in the development and morphology of the acromion, and the presence of anterior acromial spurs and inferior acromioclavicular osteophytes decrease the volume of the subacromial space, leading to impingement. Recent anatomic, radiographic, biomechanical, and SPG studies have confirmed these architectural variations and their effects on the contents of the subacromial space. Abnormal contact between the acromion and these soft tissues can lead to pathologic lesions. Surgical procedures should be directed at increasing the space beneath the coracoacromial arch to reduce wear on the rotator cuff.
 
Acromioclavicular injuries are common and most often can be accurately diagnosed using history, physical examination, and routine radiography. Sternoclavicular subluxations and dislocations may also be accurately characterized with only history, physical examination, and routine radiography (i.e., serendipity view). In many cases of sternoclavicular dislocation, however--especially posterior--CT scanning or MR imaging will be necessary. Posterior sternoclavicular dislocation may cause compression of mediastinal structures. When this is suspected, angiography or CT angiography is indicated. Physeal injuries should be suspected at either end of the clavicle in adolescent patients.
 
Arthroscopic resection of the acromioclavicular joint is obviously in its infancy. Nonetheless, the procedure seems to be well founded in theory and laboratory work. The early clinical results seem supportive.
 
Top-cited authors
Russell F Warren
  • Hospital for Special Surgery
Lyle J. Micheli
  • Harvard University
Nicola Maffulli
  • Università degli Studi di Salerno
Louis C Almekinders
  • Duke University
Elizabeth A Arendt
  • University of Minnesota Twin Cities