Carol C. Teitz

Understanding and Preventing Noncontact Anterior Cruciate Ligament Injuries A Review of the Hunt Valley II Meeting, January 2005

The incidence of noncontact anterior cruciate ligament injuries in young to middle-aged athletes remains high. Despite early diagnosis and appropriate operative and nonoperative treatments, posttraumatic degenerative arthritis may develop. In a meeting in Atlanta, Georgia (January 2005), sponsored by the American Orthopaedic Society for Sports Medicine, a group of physicians, physical therapists, athletic trainers, biomechanists, epidemiologists, and other scientists interested in this area of research met to review current knowledge on risk factors associated with noncontact anterior cruciate ligament injuries, anterior cruciate ligament injury biomechanics, and existing anterior cruciate ligament prevention programs. This article reports on the presentations, discussions, and recommendations of this group.

Tendon problems in athletic individuals

Tendons attach muscle to bone and transmit the forces generated by muscles across joints to bone in order to achieve movement or stability of the body in space. Even when the muscle-tendon unit is not shortening, it can be performing a useful function when activated under conditions of constant length (isometric) or lengthening (eccentric) contractions. The compliance of tendons varies. Tendons of the digital flexors and extensors are very stiff, and their length changes very little when muscle forces are applied through them. In contrast, the tendons of some muscles, particularly those involved in locomotion and ballistic performance, are more elastic. The Achilles tendon, for example, is stretched in late stance phase as the triceps surae contracts and the ankle dorsiflexes. Near the beginning of plantar flexion, the muscle activation ceases and energy stored in the stretched tendon helps to initiate plantar flexion. Tendons that transmit large loads under eccentric and elastic conditions are more subject to injury.

Evaluation of the use of braces to prevent injury to the knee in collegiate football players.

Data were collected in 1984 from seventy-one schools that were members of Division I of the National College Athletic Association and in 1985 from sixty-one of these schools to assess whether the use of so-called preventive braces for the knee was associated with a decrease in either the severity or the incidence (or both) of injuries to the knee in collegiate football players. Over-all, players who wore braces on the knees had significantly more injuries to the knee than players who did not. The severity of the injuries was no different in the two groups. Based on these findings, we cannot recommend the use of these braces in an attempt to prevent injury to collegiate football players.

Problems associated with tibial fractures with intact fibulae

Of twenty-three patients more than twenty years old who were treated for a tibial shaft fracture without a concomitant fibular fracture, six (26 per cent) had delayed union or non-union and six (26 per cent) had varus malunion of the fractured tibia. Pain and roentgenographic changes developed in the ipsilateral ankle within two years of injury in two of these six patients with malunion. Of forty-five patients less than twenty years old with similar fractures, one had delayed union and twelve (27 per cent) had varus malunion. Pain in the ipsilateral ankle was observed in two of these twelve patients with malunion. In addition, a bent fibula was observed in thirteen patients who incurred their fractures when they were less than twenty but in no patients who were more than twenty years old at the time of fracture. Clinical observations were corroborated by biomechanical studies on an experimental model. These studies suggested that when the fibula remains intact, a tibiofibular length discrepancy develops and causes altered strain patterns in the tibia and fibula. These may lead to delayed union, non-union, or malunion of the tibia with the sequelae of joint disturbances. The lower incidence of complications in patients less than twenty years old may be due to the greater compliance of their fibulae and soft tissues.

Articular cartilage lesions of the knee

The pathogenesis and clinical significance of articular cartilage lesions of the knee persist as topics of considerable interest among orthopedic surgeons. This study was designed to assess the association of articular cartilage degeneration with concomitant intraarticular abnormalities and to correlate the prevalence and severity of articular cartilage damage with preoperative historical and physical exam findings in patients presenting with knee pain. Twenty-six history and physical exam data points were prospectively collected from 192 patients (200 knees), consecutively undergoing arthroscopic knee surgery. During surgery, all articular cartilage lesions were recorded with respect to size, location, and character and were graded according to Oglivie-Harris et al. All concomitant knee joint abnormalities were simultaneously recorded. Of 200 knees examined arthroscopically, 12 knees revealed no demonstrable etiology for the presenting symptoms, 65 knees revealed assorted intraarticular pathology but no articular cartilage degeneration, and the remaining 123 knees revealed a total of 211 articular cartilage lesions (103 femoral, 72 patellar, 36 tibial); 7 femoral, 6 patellar and 0 tibial lesions were completely isolated (no concomitant knee joint pathology). The concomitance of femoral defects with tibial lesions was highly significant (p = 0.01). Femoral and tibial articular cartilage lesions were strikingly correlated with the presence of an unstable torn meniscus (p less than 0.001). Medial compartment articular cartilage lesions were significantly more common (p = 0.001), more closely associated with meniscal derangement, and appreciably more severe than lateral compartment lesions. In 75% of anterior cruciate ligament-deficient knees with concomitant articular cartilage degeneration, the duration from injury to surgery was greater than 9 months, and in each of these cases, a history of reinjury to the knee was elicited. From these data one can conclude that: (a) in some patients with painful knees, isolated articular cartilage lesions may be the only abnormality noted at arthroscopy; (b) unstable meniscal tears are significantly associated with destruction of articular cartilage; (c) the medial compartment is particularly susceptible to articular cartilage degeneration; and (d) in our series, anterior cruciate ligament tears were increasingly associated with articular cartilage destruction as the elapsed time from injury to arthroscopy increased.

Back Pain in Intercollegiate Rowers

Background: Back pain is prevalent among intercollegiate rowers. Purpose: We conducted a large-scale study to determine the rate of and the potential etiologic factors for clearly defined back pain that developed during intercollegiate rowing. Study Design: Survey. Methods: Surveys from 1632 former intercollegiate rowing athletes were analyzed. These surveys concerned training methods and back pain before and during intercollegiate rowing. Back pain was defined as pain that lasted at least 1 week. Results: Five hundred twenty-six subjects reported that back pain developed during intercollegiate rowing. Factors significantly associated with the development of back pain included age at the time of the survey; history of rowing before age 16; use of a hatchet oar blade; training with free weights, weight machines, and an ergometer; midline ergometer cable position; and ergometer training sessions longer than 30 minutes. Back pain while in college also was associated with higher mean college weight and height. Conclusions: Intercollegiate rowers in the last 10 years covered by this study were larger, started rowing at an earlier age, trained more intensely, and developed more back pain during college than their predecessors.

A Biomechanical Analysis of the Squeeze Test for Sprains of the Syndesmotic Ligaments of the Ankle

The “squeeze test” is a clinical test for detecting “stable” syndesmosis injuries. The test is positive when proximal compression of the calf produces pain in the area of the distal tibiofibular and interosseous ligaments. The purpose of this study was to examine what fibular movement, if any, occurs at the level of the ankle mortise when compression is applied proximally. A differential variable reluctance transducer was inserted into the origin and insertion of the anterior tibiofibular ligaments of fresh cadaver human lower limbs which had been prepared to simulate the clinical conditions of the squeeze test. Compression was applied both manually and with a specially designed clamp. Squeezing the calf caused separation of the distal fibula and tibia.

Patellar stress fracture

one symptomatic bipartite patella suggesting stress fracture, in three male athletes aged 16, 23, and 28.’ Since that time, patellar stress fractures have been described in two groups of people, patients with cerebral palsy’, 17,18,25 and adolescent athletes.’ 9’z ls zs In the athletic group, patellar stress fractures have been reported in six boys aged 11 to 179 lz 16 and in one girl aged 10.16 These fractures included three longitudinal and four transverse stress fractures. The transverse

Back Pain in Former Intercollegiate Rowers A Long-term Follow-up Study

Background Research has shown that 32% of intercollegiate rowers develop back pain during their college career. Hypothesis Rowers who develop back pain in college are more likely than the general population to have back pain later in life. Study Design Survey. Methods Surveys from 1561 former intercollegiate rowing athletes were analyzed. Subjects who completed the surveys had graduated from college at a mean and median of 13 years previously, with a range of 0 to 20 years between graduation and completion of the survey. The survey was designed to determine the presence of back pain and its severity before, during, and after intercollegiate rowing. Back pain was defined as pain that lasted at least 1 week. Results Age was a significant predictor of back pain after college. Nevertheless, the lifetime prevalence of back pain in former intercollegiate rowers was no different from that of the general population (51.4% versus 60% to 80%). However, rowers who developed back pain in college had more subsequent back pain than rowers who were asymptomatic in college (78.9% versus 37.9%). Rowers who were asymptomatic in college had significantly lower rates of back pain as they aged than did the general population. The mean severity of current back pain was 3.5 ± 1.9 on a scale of 1 to 10. Conclusions Intercollegiate rowers are no more likely than the general population to have back pain later in life.

Axillary artery injury as a complication of proximal humeral fractures. Two case reports and a review of the literature.

Proximal humeral fractures are commonly seen in orthopedic practice. The vast majority of these fractures are nondisplaced. Infrequently, displaced proximal humeral fractures have associated neurovascular injuries. Injury to the brachial plexus is uncommon; axillary artery injury is rare. This is a report of two displaced proximal humeral fractures in elderly, intoxicated patients following low-energy trauma. Both fractures resulted in axillary artery injury requiring vascular reconstruction. Only nine similar cases were found in a review of the literature. Displaced proximal humeral fractures should be carefully evaluated for vascular injury, and arteriography should be used when necessary. If vascular reconstruction is indicated, the fracture must be internally fixed to prevent redisplacement and potential compromise of the vascular repair. Serial postoperative Doppler examinations are necessary to detect thrombus formation. With prompt diagnosis and treatment, prolonged limb ischemia and its sequelae can be prevented.