John H. Wilckens

A Prospective, Randomized Evaluation of Arthroscopic Stabilization Versus Nonoperative Treatment in Patients with Acute, Traumatic, First-Time Shoulder Dislocations

Background Nonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations. Hypothesis Early arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment. Study Design Prospective, randomized clinical trial. Methods Two groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months. Results Three patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability. Conclusions Arthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.

The Relative Incidence of Anterior Cruciate Ligament Injury in Men and Women at the United States Naval Academy

The purpose of this study was to evaluate the relative risk of anterior cruciate ligament injury in female versus male midshipmen at the United States Naval Academy. From 1991 to 1997, we recorded the incidence of anterior cruciate ligament injury during intercollegiate athletics, intramural athletics, and military training. The subjects were male and female varsity athletes, coed intramural athletes, and participants in military training consisting of the obstacle course and instructional wrestling. All patient data were collected at the time of injury. Records filed at the intramural sports office, along with a questionnaire completed by coaches and trainers, were used to estimate midshipmen exposures. Results showed that in intercollegiate soccer, basketball, and rugby, women had a relative injury risk of 3.96 compared with men. In coed soccer, basketball, softball, and volleyball, the womens relative injury risk was 1.40 compared with men. In military training, women had a relative injury risk of 9.74 compared with men. In comparing overall annual anterior cruciate ligament injury rates among midshipmen, we found that women had a relative injury risk of 2.44 compared with men. We concluded that female midshipmen have an increased relative risk of anterior cruciate ligament injury as compared with men in intercollegiate athletics, basic military training, and throughout their service academy career. This increase was not statistically significant at the intramural level of athletics.

The surgical treatment of symptomatic nonunions of the proximal (metaphyseal) fifth metatarsal in athletes

Eight athletes developed symptomatic nonunions of the base of the proximal fifth metatarsal in the metaphyseal region. All of the athletes were initially treated conserv atively without success. We reviewed their case histo ries and outlined a simple, effective, low morbidity surgical management of these lesions. Two nonunions successfully healed with internal fixation with an intra medullary compression screw. Five additional non unions were shelled out through a lateral incision of the peroneus brevis without disturbing its insertion. An eighth nonunion fragment was large and articulated the cuboid; it was fixed successfully with an intramedullary compression screw to preserve lateral foot mechanics. There were no complications. All patients returned to full activities 2 to 4 months after surgery.

Glenohumeral range of motion in major league pitchers: changes over the playing season.

Background: Although overhead throwing athletes may develop unique glenohumeral range of motion characteristics, to our knowledge these characteristics have not been studied longitudinally in major league pitchers. Hypothesis: Major league pitchers (starters and relievers) experience an increase in glenohumeral external rotation and a decrease in internal rotation and total range of motion. Glenohumeral internal rotation deficit worsens over a regular playing season. Study Design: Retrospective cohort study. Methods: In 21 major league baseball pitchers (29 individual playing seasons), glenohumeral range of motion was measured in external and internal rotation for the throwing and nonthrowing shoulders before and at the conclusion of the regular season. The total range of motion (the sum of external rotation and internal rotation) and the glenohumeral internal rotation deficit were calculated (the difference between internal rotation of the nonthrowing shoulder minus that of the throwing shoulder), and data were compared between starting and relief pitchers. Results: The overall mean changes in external rotation (+1.5°), internal rotation (+2.7°), and total range of motion (+3.3°) were not statistically significant. However, starting pitchers showed statistically significant increases in internal rotation (+6.5°, P = 0.01) and total range of motion (+7.9°, P = 0.04), whereas relief pitchers had significant worsening of glenohumeral internal rotation deficit (+5.3°, P = 0.04). Conclusions: The characteristics of glenohumeral range of motion in major league pitchers did not differ significantly from the beginning to the end of a season, but significant changes did occur between starting and relief pitchers. Clinical Relevance: Adaptations to the daily routines of starter and reliever pitchers may be warranted on the basis of these findings.

Anterior cruciate ligament injury alters preinjury lower extremity biomechanics in the injured and uninjured leg: the JUMP-ACL study

Background Information as to how anterior cruciate ligament (ACL) injury and reconstructive surgery (ACLR) alter lower extremity biomechanics may improve rehabilitation and return to play guidelines, reducing the risk for repeat ACL injury. Aim To compare lower extremity biomechanics before ACL injury and after subsequent ACLR for the injured and uninjured leg. Methods Baseline unilateral lower extremity biomechanics were collected on the dominant leg of participants without ACL injury when they entered the Joint Undertaking to Monitor and Prevent ACL (JUMP-ACL) study. Thirty-one participants with subsequent ACL injury, reconstructive surgery and full return to physical activity completed repeat, follow-up biomechanical testing, as did 39 uninjured, matched controls. Not all injured participants suffered injury to the dominant leg, requiring separation of those with ACL injury into two groups: ACLR-injured leg group (n=12) and ACLR-uninjured leg group (n=19). We compared the landing biomechanics of these three groups (ACLR-injured leg, ACLR-uninjured leg, control) before ACL injury (baseline) with biomechanics after ACL injury, surgery and return to physical activity (follow-up). Results ACL injury and ACLR altered lower extremity biomechanics, as both ACLR groups demonstrated increases in frontal plane movement (increased hip adduction and knee valgus). The ACLR-injured leg group also exhibited decreased sagittal plane loading (decreased anterior tibial shear force, knee extension moment and hip flexion moment). No high-risk biomechanical changes were observed in control group participants. Conclusions ACL injury and ACLR caused movement pattern alterations of the injured and uninjured leg that have previously shown to increase the risk for future non-contact ACL injury.

Cutaneous Infections in Wrestlers

Context: Cutaneous infections are common in wrestlers. Although many are simply a nuisance in the everyday population, they can be problematic to wrestlers because such infections may result in disqualification from practice or competition. Prompt diagnosis and treatment are therefore important. Evidence Acquisition: Medline and PubMed databases, the Cochrane Database of Systematic Reviews, and UpToDate were searched through 2012 with the following keywords in various combinations: skin infections, cutaneous infections, wrestlers, athletes, methicillin-resistant Staphylococcus aureus, skin and soft tissue infections, tinea corporis, tinea capitis, herpes simplex, varicella zoster, molluscum contagiosum, verruca vulgaris, warts, scabies, and pediculosis. Relevant articles found in the primary search, and selected references from those articles were reviewed for pertinent clinical information. Results: The most commonly reported cutaneous infections in wrestlers are herpes simplex virus infections (herpes gladiatorum), bacterial skin and soft tissue infections, and dermatophyte infections (tinea gladiatorum). The clinical appearance of these infections can be different in wrestlers than in the community at large. Conclusion: For most cutaneous infections, diagnosis and management options in wrestlers are similar to those in the community at large. With atypical presentations, testing methods are recommended to confirm the diagnosis of herpes gladiatorum and tinea gladiatorum. There is evidence to support the use of prophylactic medications to prevent recurrence of herpes simplex virus and reduce the incidence of dermatophyte infections in wrestlers.

Epidemiology of Injuries in Major League Baseball Catchers

Background: In part because of the perception that many injuries occur during collisions with the catcher at home plate, Major League Baseball (MLB) officials recently implemented rule changes to prevent these injuries. There is little research on the rate, type, and severity of injuries in MLB catchers. Purpose: To (1) determine the types and severity of injuries to catchers, (2) determine catchers’ athlete exposure (AE) rate of injuries, and (3) assess the perception that catchers are at risk for career-ending injuries caused by home plate collisions. Study Design: Descriptive epidemiology study. Methods: The MLB Electronic Baseball Information System was queried for injuries in catchers during the 2001-2010 seasons categorized by cause (collision vs noncollision), diagnosis, and severity. All collision injuries were confirmed by reviewing publicly accessible records and news media. The injury exposure rate per 1000 AEs was calculated, and the rate of injury, associated days on the disabled list (DL), and injury severity were determined on the basis of cause and location of injury. Poisson regression was used to compare rates among seasons, and significance was set at P < .05. Results: During the study period, 134 injuries were sustained, resulting in 6801 days lost. The mean time on the DL was 50.8 days (range, 15-236). The average injury rate was 2.75 injuries per 1000 AEs (range, 0.82-5.14). Of those 134 injuries, 20 were collision injuries. Collision injuries resulted in a mean of 39 days (range, 15-93) of DL time, compared with 53 days for noncollision injuries (range, 15-236), which was not a significant difference. No collision injury was career ending. Noncollision injuries more commonly resulted in >100 days on the DL compared with collision injuries (P = .049). Conclusion: Study findings indicated that (1) the most common type of injury to catchers was noncollision injury, (2) the rate of injuries to catchers is lower than previously reported rates for other player positions, and (3) this study did not support the perception that collision injuries are a frequent cause of career-ending injury to catchers.

Modification of the Subscapularis Splitting Technique for Anterior Shoulder Reconstructions

One approach to the anterior shoulder for stabilization of shoulder instability is the subscapularis splitting approach. We have modified this technique and the instrumentation for use on 154 shoulders. The procedure was performed for 118 patients with traumatic anterior instability, 12 for multidirectional instability, and 24 for painful impingement with presumed instability. 27 of these were revision cases. This technique can be used for repairing Bankart lesions and capsular lesions and for bone grafting procedures to the anterior glenoid. There was only one axillary nerve neuropraxia and one partial laceration of the biceps tendon. This technique is safe and effective for treating a variety of instability patterns.

An Unusual Mechanism for Injury of the Anterior Cruciate Ligament in Figure Skating

A 20-year-old competitive figure skater presented with an acute disabling knee injury that occurred in the overhead, non-weight-bearing knee during the performance of a Biellmann spin. Examination and magnetic resonance imaging confirmed the diagnosis of a complete anterior cruciate ligament (ACL) tear. To our knowledge, no previous cases of acute injury of the ACL sustained during the execution of a Biellmann spin have been reported. The ACL injury we report is unique because it occurred without the blade contacting the ice. The mechanism of injury has some features that are similar to those of other noncontact ACL injuries, with the addition of centrifugal force as a potential contributor to the injury.

Lower extremity overuse injuries in the skeletally immature athlete

Sport participation is a leading cause of injury in children and adolescents. Although the focus often is on acute injuries, overuse injuries are extremely common and can cause lasting damage when not recognized early and treated appropriately. Overuse injuries result from the combination of repetitive microtrauma and inadequate healing time. Children are especially susceptible for many reasons, including muscle-tendon imbalance, improper technique, and difficulty identifying early signs of injury. In the last decades, not only have more children been participating in sporting activities, but the intensity of their participation has increased, with many participating year-round on multiple teams, often with professional or scholarship aspirations. As a consequence, overuse injuries have become even more prevalent. Bone, cartilage, tendon, physis, or apophysis may be affected, and the diagnosis can be challenging. In an effort to promote prevention, early recognition, and treatment of overuse injuries in children and adolescents, this article provides an overview of these injuries, describes vulnerabilities of the immature skeleton, and provides guidance and talking points for physicians, parents, and coaches.