Scott A. Lynch

Groin Injuries in Sport Treatment Strategies

Groin pain in athletes is a common problem that can result in significant amounts ofmissed playing time.Many of the problems are related to the musculoskeletal system, but care must be taken not to overlook other more serious and potentially life threatening medical cases of pelvis and groin pain.Stress fractures of the bones of the pelvis occur, particularly after a sudden increase in the intensity of training. Most of these stress fractures will heal with rest, but femoral neck stress fractures can potentially lead to more serious problems, and require closer evaluation and sometimes surgical treatment.Avulsion fractures of the apophyses occur through the relatively weaker growth plate in adolescents. Most of these will heal with a graduated physical therapy programme and do not need surgery.Osteitis pubis is characterised by sclerosis and bony changes about the pubic symphysis. This is a self-limiting disease that can take several months to resolve. Corticosteroid injection can sometimes hasten the rehabilitation process.Sports hernias can cause prolonged groin pain, and provide a difficult diagnostic dilemma. In athletes with prolonged groin pain, with increased pain during valsalva manoeuvres and tenderness along the posterior inguinal wall and external canal, an insidious sports hernia should be considered. In cases of true sports hernia, treatment is by surgical reinforcement of the inguinal wall.Nerve compression can occur to the nerves supplying the groin. In cases that do not respond to desensitisation measures, neurolysis can relieve the pain.Adductor strains are common problems in kicking sports such as soccer. The majority of these are incomplete muscle tendon tears that occur just adjacent to, themusculotendinous junction.Most of these will respond to a graduated stretching and strengthening programme, but these can sometimes take a long time to completely heal. Patience is the key to obtain complete healing, because a return to sports too early can lead to chronic pain, which becomes increasingly difficult to treat.Management of groin injuries can be challenging, and diagnosis can be difficult because of the degree of overlap of symptoms between the different problems. By careful history and clinical examination, with judicious use of special tests and good team work, a correct diagnosis can be obtained.

Treatment of Acute Lateral Ankle Ligament Rupture in the Athlete Conservative Versus Surgical Treatment

Acute lateral ankle ligament sprains are common in young athletes (15 to 35 years of age). Diagnostic and treatment protocols vary. Therapies range from cast immobilisation or acute surgical repair to functional rehabilitation.The lateral ligament complex includes 3 capsular ligaments: the anterior tibiofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL) ligaments. Injuries typically occur during plantar flexion and inversion; the ATFL is most commonly torn. The CFL and the PTFL can also be injured and, after severe inversion, subtalar joint ligaments are also affected.Commonly, an athlete with a lateral ankle ligament sprain reports having ‘rolled over’ the outside of their ankle. The entire ankle and foot must be examined to ensure there are no other injuries. Clinical stability tests for ligamentous disruption include the anterior drawer test of ATFL function and inversion tilt test of both ATFL and CFL function. Radiographs may rule out treatable fractures in severe injuries or when pain or tenderness are not associated with lateral ligaments. Stress radiographs do not affect treatment.Ankle sprains are classified from grades I to III (mild, moderate or severe). Grade I and II injuries recover quickly with nonoperative management. A nonoperative ‘functional treatment’ programme includes immediate use of RICE (rest, ice, compression, elevation), a short period of immobilisation and protection with a tape or bandage, and early range of motion, weight-bearing and neuromuscular training exercises. Proprioceptive training on a tilt board after 3 to 4 weeks helps improve balance and neuromuscular control of the ankle.Treatment for grade III injuries is more controversial. A comprehensive literature evaluation and meta-analysis showed that early functional treatment provided the fastest recovery of ankle mobility and earliest return to work and physical activity without affecting late mechanical stability. Functional treatment was complication-free, whereas surgery had serious, though infrequent, complications. Functional treatment produced no more sequelae than casting with or without surgical repair. Secondary surgical repair, even years after an injury, has results comparable to those of primary repair, so even competitive athletes can receive initial conservative treatment.Sequelae of lateral ligament injuries are common. After conservative or surgical treatment, 10 to 30% of patients have chronic symptoms, including persistent synovitis or tendinitis, ankle stiffness, swelling, pain, muscle weakness and ‘giving-way’. Well-designed physical therapy programmes usually reduce instability. For individuals with chronic instability refractory to conservative measures, surgery may be needed. Subtalar instability should be carefully evaluated when considering surgery.

Repair of distal biceps tendon rupture with suture anchors.

Abstract We retrospectively evaluated six cases of distal biceps tendon rupture that were treated by a two-incision operative repair using suture anchor attachment to the radial tuberosity for clinical outcome and strength testing. All patients had repair performed by the same surgeon. The average age of the patients, all male, was 43 years (range, 32–57 years). Average time from injury to operative repair was 22 days (range, 9–54 days). Follow-up time averaged 24 months after definitive treatment (range, 11–46 months). At follow-up no patient had limitation of activity and all patients were able to return to their previous employment, although three noted some minor antecubital fossa discomfort. No patient developed a synostosis. Cybex (Medway, Mass.) isokinetic testing revealed elbow flexion strength return for peak torque, total work, and average power, of 107%, 103%, and 110% of the uninjured arm, respectively. Elbow flexion endurance was 2% less in the injured arm. Forearm supination strength measured by peak torque, total work, and average power, was 97%, 85%, and 88% of the uninjured arm, respectively. Forearm supination endurance was 10% less in the injured arm. Our results using suture anchor repair are similar to those previously reported in the literature from bone tunnel repair. Based on our data, we believe that a two-incision repair with suture anchor attachment is a safe and effective method for treatment of distal biceps tendon ruptures.

The Effects of Bariatric Surgery Weight Loss on Knee Pain in Patients with Osteoarthritis of the Knee

Studies have shown that osteoarthritis (OA) is highly associated with obesity, and individuals clinically defined as obese (BMI > 30.0 kg/m2) are four times more likely to have knee OA over the general population. The purpose of this research was to examine if isolated weight loss improved knee symptoms in patients with osteoarthritis. Adult patients (n = 24; age 18–70; BMI > 35 kg/m2) with clinical and radiographic evidence of knee OA participated in a one-year trial in which WOMAC and KOOS surveys were administered at a presurgery baseline and six and twelve months postsurgery. Statistical analysis was performed using Students t and Wilcoxon Signed Rank tests. Weight loss six and twelve months following bariatric surgery was statistically significant (P < 0.05) compared to presurgery measurements. All variables from both KOOS and WOMAC assessments were significantly improved (P < 0.05) when compared to baseline. Isolated weight loss occurring via bariatric surgery resulted in statistically significant improvement in patients knee arthritis symptoms at both six and twelve months. Further research will need to be done to determine if symptom relief continues over time, and if the benefits are also applicable to individuals with symptomatic knee arthritis that are overweight but not obese.

Diagnosis and Treatment of Osteoarthritis

Osteoarthritis presents in primary and secondary forms. The primary, or idiopathic, form occurs in previously intact joints without any inciting agent, whereas the secondary form is caused by underlying predisposing factors (eg, trauma). The diagnosis of osteoarthritis is primarily based on thorough history and physical examination findings, with or without radiographic evidence. Although some patients may be asymptomatic initially, the most common symptom is pain. Treatment options are generally classified as pharmacologic, nonpharmacologic, surgical, and complementary and/or alternative, typically used in combination to achieve optimal results. The goals of treatment are alleviation of symptoms and improvement in functional status.

Lesões ligamentares do tornozelo

RESUMOAs lesoes ligamentares agudas do tornozelo sao comuns.A maioria delas ocorre durante a atividade esportiva entre15 e 35 anos. Apesar da preferencia dessas lesoes, os proto-colos de diagnosticos e tratamentos apresentam grande varia-cao.As lesoes do complexo ligamentar lateral sao, de longe, asmais comuns do tornozelo. A lesao ligamentar lateral ocor-re, tipicamente, durante a flexao plantar e inversao, que e aposicao de maximo estresse no ligamento talofibular ante-rior (LTFA). Por essa razao, o LTFA e mais comumente lesa-do durante o traumatismo e inversao. Em lesoes por inversaode maior gravidade os ligamentos calcaneofibular (LCF), otalofibular posterior (LTFP) e o subtalar tambem podem serlesados.A maioria das lesoes ligamentares laterais do tornozeloresolve-se espontaneamente com tratamento conservador. Oprograma denominado “tratamento funcional” inclui a apli-cacao do principio RICE (Rest – repouso, Ice – gelo, Com-pression – compressao e Elevation – elevacao) imediatamenteapos a lesao, um curto periodo de imobilizacao e protecaocom bandagens elasticas ou inelasticas e exercicios de mo-bilizacao precoce seguidos de carga precoce e treinamentoneuromuscular precoce. Treinamento de propriocepcao compranchas de inclinacao e iniciado assim que possivel, usual-mente apos tres a quatro semanas. Seu objetivo e melhorar oequilibrio e controle neuromuscular do tornozelo.As sequelas apos lesoes ligamentares do tornozelo sao mui-to comuns. Cerca de 10% a 30% dos pacientes com lesoesligamentares laterais apresentam sintomas cronicos. Os sin-tomas geralmente incluem sinovite ou tendinite persistente,rigidez do tornozelo, edema e dor, fraqueza muscular e fre-quentes falseios.Um programa de fisioterapia bem estruturado com forta-lecimento dos peronios e treinamento proprioceptivo, alon-gamento e aparelhamento ou imobilizacao funcional podealiviar os problemas em muitos pacientes. Para casos de ins-tabilidade cronica que sao refratarios ao aparelhamento esuporte externo, o tratamento cirurgico pode ser considera-do. Se a instabilidade cronica esta associada a instabilidadesubtalar refrataria as medidas conservadoras e aparelhamen-to como enunciado acima, o tratamento cirurgico deve con-siderar tambem a articulacao subtalar.A lesao e instabilidade ligamentar subtalar sao provavel-mente mais comuns do que o observado. Entretanto, a defi-nicao e diagnostico dessa entidade sao dificeis. Felizmente,parece que a cicatrizacao da maioria das lesoes agudas ocor-re com o mesmo programa de reabilitacao funcional das le-soes ligamentares laterais do tornozelo.Nas instabilidades subtalares cronicas uma tentativa ini-cial de reabilitacao funcional com aparelhamento e treina-mento proprioceptivo do tornozelo deve ser feita. Se esseprograma falhar, reparacao primaria ou reconstrucao podemser beneficas. Os procedimentos de reconstrucao devem con-templar a articulacao subtalar.Instabilidade subtalar ocorre geralmente em associacaocom a instabilidade tibiotarsica; dessa forma, o diagnosticocuidadoso e critico em qualquer pessoa com instabilidadecronica do tornozelo. Se ambos nao sao contemplados, opaciente persistira tendo problemas.As lesoes do ligamento deltoide ocorrem, mais frequente-mente, associadas a fraturas do tornozelo. Elas sao raras comolesao isolada. Se nenhuma fratura e evidenciada nas radio-grafias, particular atencao deve ser dada a sindesmose paraassegurar que nao ha associacao com ruptura desta. Lesoesisoladas verdadeiras do deltoide parecem evoluir bem comtratamento conservador funcional, a exemplo de lesoes liga-mentares laterais do tornozelo. As rupturas do deltoide asso-ciadas a fraturas do tornozelo parecem cicatrizar bem; tra-tam-se as outras lesoes, deixando que o deltoide cicatrizeespontaneamente. E vital que se corrija qualquer lesao dasindesmose e que se obtenha alinhamento osseo correto.As lesoes de sindesmose podem ser incapacitantes se naotratadas adequadamente. Exame fisico cuidadoso e interpre-tacao de radiografias sao necessarios para obter um diagnos-tico correto. Lesoes parciais parecem evoluir bem com a rea-bilitacao funcional. Entretanto, lesoes complexas, se o alar-gamento nao for corrigido, podem conduzir a dor e altera-

Anatomic Tunnel Placement in Anterior Cruciate Ligament Reconstruction.

The anatomic anterior cruciate ligament (ACL) reconstruction concept has developed in part from renewed interest in the insertional anatomy of the ACL, using surgical techniques that can reproduce this anatomy reliably and accurately during surgical reconstruction. Several technical tools are available to help identify and place the tibial and femoral grafts anatomically, including arthroscopic anatomic landmarks, a malleable ruler device, and intraoperative fluoroscopy. The changes in technique for anatomic tunnel placement in ACL reconstruction follow recent biomechanical and kinematic data that demonstrate improved time zero characteristics. A better re-creation of native ACL kinematics and biomechanics is achieved with independent femoral drilling techniques that re-create a central footprint single-bundle ACL reconstruction or double-bundle reconstruction. However, to date, limited short-term and long-term clinical outcome data have been reported that support using either of these techniques rather than a transtibial drilling technique. This lack of clear clinical advantage for femoral independent and/or double-bundle techniques may arise because of the potentially offsetting biologic incorporation challenges of these grafts when placed using these techniques or could result from modifications made in traditional endoscopic transtibial techniques that allow improved femoral and tibial footprint restoration.

Practical Approach to Hip Pain

Hip pain is a common complaint among patients presenting to outpatient clinics. Stratifying patients based on age, acuity, and location of pain (extra-articular vs intra-articular) can help to aid in appropriate imaging and timely referral to an orthopedic surgeon. A thorough history and an organized physical examination combined with radiographs are usually sufficient to diagnose most hip complaints. If the diagnosis remains uncertain, magnetic resonance imaging, usually with intra-articular gadolinium, is the imaging modality of choice in diagnosing both intra-articular and extra-articular pathologies.

Residency Review Committee (RRC) Foot and Ankle Curriculum: We Don't Need To Reinvent The Wheel

The Accreditation Council for Graduate Medical Education (ACGME) and Residency Review Committee (RRC) have mandated that residency programs follow specific guidelines with respect to resident curriculum.3 In the past few years, six core competencies have been introduced and are now a requirement (Table 1). Designing a curriculum where all of the competencies are addressed can be a difficult task. In many cases residency programs interpret the guidelines to the best of their ability without any real guidance or assurance that the requirements will be met; implementation, documentation, and accountability have been largely up to the individual program. Resources do exist to assist in the implementation of these core competencies; for example, the American Orthopaedic Foot and Ankle Society has an example of a residency curriculum listed on their web site. This, however, provides few specifics about coordinating a residency program. We recently had a site visit, and our Foot and Ankle (F&A) curriculum was approved. We are presenting our own curriculum as a template for assembling a curriculum that would meet the standards of the ACGME/RRC (Table 2 Online Supplement). We do not claim this as the best practice, or the only way to accomplish

Effect of Enzogenol® Supplementation on Cognitive, Executive, and Vestibular/Balance Functioning in Chronic Phase of Concussion

ABSTRACT This study examined the feasibility of Enzogenol® as a potential treatment modality for concussed individuals with residual symptoms in the chronic phase. Forty-two student-athletes with history of sport-related concussion were enrolled, comparing Enzogenol® versus placebo. Testing was conducted using virtual reality (VR) and electroencephalography (EEG), with neuropsychological (NP) tasks primarily used to induce cognitive challenges. After six weeks, the Enzogenol® group showed enhanced frontal-midline theta, and decreased parietal theta power, indicating reduced mental fatigue. Subjects enrolled in the Enzogenol® group also self-reported reduced mental fatigue and sleep problems. This suggests that Enzogenol® has the potential to improve brain functioning in the chronic phase of concussion.