Transcript for:
Sports Medicine Lecture Notes

been to a Sports Medicine and just like the review text and the Sports Medicine review text will cover it Basin starting with the knee because really the knee is the starting point for arthroscopy and and for a lot of sports medicine and so even though it doesn't flow anatomically from top to bottom the knee is a good starting point and we'll go from there and hopefully today we'll be able to cover all the lower extremity saving in the upper extremity in total shoulder arthroplasty for tomorrow so I appreciate your attention I know this is a tough course I know it's tough to sit through all this and we'll try to make this somewhat enjoyable so first of all sports medicine is not rocket science and I think we all recognize that and sometimes we tell people we have to take them to school and so it's a matter of how you spell that so again we're start with needs and cover lower extremity today tomorrow we'll cover more of the upper extremity as well as some of the head and spine quotes as it appears in sports primarily concussions and then some of the issues about being a team physician which is important as far as drug doping and stuff like that some of the stuff you see in the newspaper more and more and more so let's start off with knee injuries first of all a little bit about anatomy and biomechanics I know that we're gonna cover that some of the anatomy lecture but it's important to recognize that the ACL and PCL cross says they wouldn't names would imply and they form this so called four-bar linkage that's been described by amos and others in addition to those cruise ships we have the collateral ligaments medial and lateral and then what was very confusing to me and my residency and now has become a lot more clear is a so-called posterior medial and posterior lateral corner which we'll discuss in some detail so you know that knee is a Dyer throttle joint it has allows both simultaneous rotation and translation and that's why it's somewhat difficult to figure out and that's why it's susceptible to arthritis if everything's not working correctly it has articular cartilage which we learned from basic science involves type 2 cartilage type 1 cartilage oh any is harder cartilage like bone Bo any oh na 1 the cartilage has mostly water and it has increased water and decrease like ends with arthritis and that's a test question that occurs commonly so it's important to understand what happens with arthritis the ACL itself goes from the tibia to the lateral femoral condyle it's about three to three-and-a-half millimeters wide 11 millimeter excuse me long and 11 millimeters wide and as Freddie foo will tell you because it's in USA Today and everywhere else it has two bundles and so typically we've just worried about one of those bundles but it's becoming more and more popular to talk about the two bundles of the ACL now both the anterior and posterior cruciate ligament are supplied by the middle genicular artery the PCL goes in the media from a condyle to the tibial sulcus it's a little longer and a little wider than the ACL we know this has two bundles and it's always asked on in questions about the anterior lateral bundle and the internal lateral bundle is your pal PIL PCL anterior lateral bundle ACL into a medial bye-bye explosion then so the PCL has the anterior lateral bundle which were years we've concentrated on fixing because it's the most important bundle as far as flexion PCL anterior lateral bundle tied in flexion the PCL role is in flexion and so the PCL the anterior lateral is your pal remember that now remember the lecture on musculoskeletal radiology we saw the minuscule femoral ligaments one goes in front one goes behind alphabetically Humphry in front of Risberg humphrey in front Risberg behind again the middle judah culet artery is the primary blood supply how about the medial collateral ligament well it goes from the media from a condyle and inserts in a long strip all along the medial tibia it has both a superficial and deep component the Houston clinic nomenclature which is confused residents for decades still hangs around and lingers around unfortunately and therefore they call the superficial component is the tibial collateral ligament and the deep component of it the medial capsular ligament the rest of us just call it superficial indeed the lateral collateral ligament is a very stout cord like ligament that's tight and extension it goes from the lateral femoral condyle to the tip of the fibula now it's interesting that this ligament although bound mechanically not strong is very rarely injured in and of itself it's usually only injured and combined ligament injuries the capsule in the lateral side is most distal extent is just posterior to the fibula and that's occurred on that's showed up on some questions so again that question about putting the pins across the knee you want to go at least one point eight to two centimeters below the joint line to avoid getting into the joint otherwise you risk infection well how strong are these ligaments well in general people used to say the PCL was twice as strong as the ACL we've learned later that's really not true it's a little bit strong I'm not twice as strong the MCL is the strongest ligament of all and the LCL even though it's rarely injured by itself is actually the weakest of all the ligaments what about the layers and there's been a lot of press about the different layers and the knee I think it's important if it helps you to organize your thinking about where things are to think about this layer concept and you think about the fact that you have superficial structures such as the Sartorius and the superficial MCL and semimembranosus is more deep and then the deepest structure of all is a capsule or the deep MCL the deep MCL is really just a thickening of the capsule how about the posterior lateral corner this is the most confusing of all well it's really not so confusing we just think about it in two layers really superficially you have the biceps tendon and you have the Ilia to build band and track and then deeper you've got the lateral collateral ligament the popliteus muscular tenderness unit the popliteal fibula ligament which goes from the popliteus to the tip of the fibula and really the post your mantle capsule so that's really what's there in the posterior outer corner patella femoral joint our favorite it really increases the moment arm for the quadriceps it's fully engaged about 40 degrees of flexion and this is the issue is it's that it's even though it's the thickest cartilage in the body it's sometimes susceptible to injury because three to five times the way to the body goes across that joint and that's why when you have an extremely large patient with extremely severe patellofemoral pain you have to encourage them to try to get their weight in ideal body weight so they don't have so much trouble with that joint patella is really divided in the medial and lateral it's rather rather than learning these seven it's probably easy to just think of it in that way and realize and more and more presses occurring in this and this is therefore probably more and more testable is the importance of the medial patellofemoral ligament it acts as a check rein to lateral patellar displacement so I suspect that you're gonna see the media patella femoral ligament on your boards here it goes from the superior aspect of the patella over to the adductor tubercle it is immediately adherent to the vastus medialis obliquus in fact if you dissect this you need to reflect up some of the VMO so you can appreciate this ligament this is a real ligament it does exist the meniscus the minute sky a crescent-shaped the only the peripheral of the meniscus is vascularized through the medial and lateral geniculate arteries the medial meniscus is more C shaped the lateral meniscus more semicircular the medial meniscus has broad attachments to its horns the lateral meniscus has attachments to its horns that are very close to each other and very close to the ACL the mineski served to deepen the tibial surface and act as a secondary stabilizer especially the posterior horn of the medial meniscus which is the primary secondary stabilizer to anterior translation that's an important thing to remember meniscus is composed of two different kinds of fibers the most important fibers by far are the longitudinal fibers these longitudinal fibers are allow hoop stresses to be transmitted across them in Eska and also it's important to capture those longitudinal fibers when you're doing a meniscal repair hence the benefit of doing vertical mattress suture the strongest repair possible in this guy because you're capturing those longitudinal fibers in addition to the longitudinal fibers you have radial fibers that tie those in the meniscus is made out of type one collagen the meniscal excursion is also something important to remember and that is that the lateral meniscus has twice the excursion on dynamic MRI than the medial meniscus and so it's important to remember that again the attachments of the horns lateral real close together near the ACL footprint medial far separated which has implications if you want to do two transplants and so the transplants typically for the lateral have been troughs or bone blocks and on the medial side traditionally more plugs well what about the classic history and physical examination but we'll all familiar with these classic findings as patient presents with these stories and it really helps us to make the diagnosis most of the time if somebody has a pop and swelling and non-contact pivoting injury their need blows up like a balloon then it's very likely an ACL tear in fact 70% of the he mark Roces will be ACL tears 70% if you get hit by a blow to your proximal tibia either by falling on the ground with your foot plantar flexed which is what allows the tibia days impact the ground then you're very likely to have a PCL injury from the force from the tibia forcing back to tear the PCL if however you fall with your dork foot dorsiflexed then the moment arm is going to shift up to the patella and that's why I've fall with the foot dorsiflex will cause patella femoral problems patella Condor osis if you have mechanical symptoms locking catching maybe you have a meniscus tear or loose body and if you have painless stair climbing and sitting in a theatre for a long time then they're not supposed to be in my clinic now how about the examination each injury has a classic examination that you need to focus on and whether you know 15 exams for one injury or whether you know the classic one is really not important for the boards if you know the classic exam at sold you in good stead so ACL injury the classic exam the gold standard is a Lachman exam done in 20 or 30 degrees of flexion from a practical standpoint I'd like to put a pillow under the patient's knee helps them relax keep something that 20 or 30 degrees flexion you can put your hand and feel that their hamstrings are being tensioned and then simply do your Lachman a pivot shift exam is helpful too but it's really only helpful under examiner anesthesia or if you happen to be lucky enough to distract the patient long enough to do it only once now the PCL exam the key exam is a posterior drawer exam done in 70 and 90 degrees of flexion and when you're doing that exam the first thing you're going to do is feel where the medial the plateau is on this side here there is a medial tibia plateau step off anteriorly on this side it's flush that's because that patient has at least a grade two PCL injury because he's starting with the tibia plateau and the media from a condyle flush that's a grade 2 injury if you can push the tibia further back then it may be a grade 3 injury but the key exam is a posterior drawer and the key for that is assessing the starting point so don't get fooled by not knowing where the starting point is thinking the patient has an ACL because he's really starting off post here Lisa blocks and he'd be pulling forward you're pulling them forward to the normal position the other tests that sometimes gets too much press I think's on oh I tease and other exams is the quadriceps active tests all that means is you're sitting there laying supplying your knees flex 70 to 90 degrees and you ask the patient while you're sitting on their foot to kick it out what that does it pulls the tibia forward and recreate your normal step pop point in other words it recreates the tibia pulling forward to its normal position from a subluxed position and that's a quadriceps active test medial and lateral collateral ligament injuries are assessed based upon Boggess for varus instability this test is done in both 30 and 0 degrees of extension if you have opening only in 30 degrees of a extension and not in zero degrees of extension you likely have an isolated media collateral ligament if you have opening in both 30 and 0 degrees then you have at least one and maybe two of the crew ships involved as well now the other test that's really important I think is going to show up on boards for sure is external rotation asymmetry that is the test the dial test that's essential for you to make the diagnosis of posterior lateral corner injuries we're starting to get posting a lot of corner injuries more and more because we're finally recognizing during my fellowship I never spit a single one now I do at least one a month and so the key here is to assess external rotation asymmetry and you simply do that by either lying the patient prone and rotating their foot looking for their 5-foot angle or having somebody help you stabilize the knee while in supine and external rotating the foot you do this test at both 30 and 90 degrees of knee flexion if it dials only at 30 degrees and not 90 degrees then you very likely have an isolated postural outer corner entry or possibly a posted on a corner injury with an ACL tear more likely than not if you dial at 30 degrees and 90 degrees you have more than 15 degrees of asymmetry both a 30 and 90 then you very likely have a combined poster a lot of corner injury and PCL injury and you confirm that then with your posterior drawer so it's very common for post a lot of corner injuries to be shown up with one of the other cruciate ligaments of both but rarely do you see a nice that I post a lot of corner injury but if you do then it'll dial at 30 degrees and you'll have a normal Lachman and a normal posterior drawer now the meniscus exam the key is joint line tenderness and then some type of provocative maneuver whether that's MacMurray or a please compression or duct block or what-have-you patella exam for instability apprehensions the key here we see external rotation asymmetry the dial test here we see a pivot shift actually it's a reverse pivot shift we'll go over that in one of the test questions and here we see the quadriceps active test again starting a subluxed position the tibia is pulled forward and it goes to reduced subluxed to reader reduced with quadriceps activation how about imaging we've had them very nice lecture by Tim Sanders about this I want to go over a cute few key issues that is the lateral capsular sign segond injury highly associated with an ACL rarely do you see this but when you do you can be certain it's an ACL tear old calcification to the MCL Pellegrini's chiotti high-riding patella can be associated patellar instability low-riding patella or patella baha associated with a stiff knee or arthur fibrosis Fairbanks changes squaring ridging narrowing associated with arthritis Fairbanks did not describe sclerosis but that's another funding as well osteo can gratis desiccants very commonly most commonly occurs lateral aspect medial femoral condyle lateral aspect meter firma car now mind or cup-shaped outside can sometimes be associate with a disc lloyd meniscus but the most common fine with the discoid meniscus is the MRI sequence is three sagittal in a row if any exam shows you three Sadler than these in a row you better make sure it's not a discoid meniscus because more likely it's not there's no reason for them to throw you show you three in a row otherwise well how about stress radiograph radiography - two questions occur in this number one have somebody kid with open physis you're not sure if he's got an MCL or US growth plate injury so you know stress exam there's valgus stress exams see if they open up in their faces the other time you do stress imaging becoming more and more common and in fact it's going to become the gold standard for evaluating post your cruciate ligament injuries is an assessment of posterior translation with PCL injuries now it's interesting because we've done some work in the lab and you cannot have more than 12 millimeters of posterior displacement compared to the other side unless you have a combined PCL and poster of outer corner injury so an isolated PCL injury will give you 10 to 12 millimeters of poster displacement but a combined PCL and posterior lateral corner injury will give you significantly more than 12 up to 20 or 25 millimeters of poster displacement so if you have severe post your displacement when you're looking at your posterior door be very suspicious for combined PCL and poster a lot of corner injury likewise if you have Sabae severe Lockman that you can almost reduce the meniscus over the condyles be very suspicious for combined ACL and poster a lot of corner injury now the MRI of course is very helpful helping us for minuscule and ligament diagnosis and also this bone bruise or impaction injury which occurs as dr. Sanders says as a pivot maneuver well really what it is it's a momentary dislocation of the knee and it actually impacts the lateral aspect of the lateral femoral condyle in the back of the tibia that's why you get a bone bruise because this thing this is what the mechanism is and so you get a bone bruise there over by the sulcus terminalis right here or deepening of the sulcus and you get a bruise in the back of the tibia as you would expect note that this bruise is in the middle portion of the lateral femoral condyle anterior middle posterior and is quite lateral and the back of the tibia you really can't have an ACL intact knee in an adult with that injury how about arthroscopy well we all very familiar with our Cosby it's a good portion of our business and the anterior lateral portal is our primary viewing portal if you have a poster horn Media meniscus tear then the recommendation is for you to look at that not only from the anterior lateral portal but also drive the scope back into the back of the knee look to the medial side create a portal in the posterior aspect by putting a spinal needle in first localizing it and doing Nick and spread so you don't cut the saphenous nerve or vein and put in portal in there looking through there for a new scope as well so if you have an MRI says post your own meeting stare you look at the regular scope and you go I can't see any tear then you probably ought to put your scope back in the back of the posterior medial portal and make sure you don't really have this here if you're looking at patellar tracking before or after you do some kind of a solar stabilization procedure you may want to get a superior a far proximal portal from Pikeville standpoint the way that's done knees an extension you drive your scope up to the Internet a lot of portal put a spinal needle er that either medial or lateral way up there and figure out how far up you can get then make a small incision up there and put your scope cannula in there and that allows you to visualize from the top bird's eye view down as you see the patella tracking so that's a very helpful portal I would encourage you to experiment with meniscal tears are the most common injury it is the most common procedure done by orthopedic surgeons taking part two of their boards - 988 one is the top number one a procedure listed and so you'll be doing a lot of scopes and meniscus surgery trying to preserve as much as you can if you do that and still try to repair them with you ever can otherwise you're going to give your total joint fake joint colleagues more business than they need meniscal tears have a high risk in ACL deficient knees and that's why in younger people we recommend doing ACL reconstructions if you take all comers medial meniscus tears are more common than lateral meniscus tears however in acute ACL injuries lateral meniscus tears are more commonly as associated with those scenarios then medial meniscus tears again all comers medium more common acute ACLs lateral more common and the most common location and the older population is a degenerative poster horn medial meniscus tear you've got to be careful with that nomenclature these days because of that New England Journal article and perhaps you're better off calling it a complex post your horn Mito meniscus chair we do a partial minus-- ectomy if you can't repair the meniscus so your first goal is looking there say can i repair this meniscus if you can then do it if you can't then you have to a par so I'm gonna set to me and that's in a situation we have a complex tear or if it's just simply irreparable deformed it or or degenerated when you do a minute's ectomy trying to remove the least amount of meniscus possible because the arthritis risk is directly proportional to the amount of meniscus you leave thermal is probably mentioned only to cannot to to blast it because thermal injury has had multiple problems in sports medicine do not use heat probes if you use heat probes on the meniscus it it may look nice and trim up that other meniscus the problem is it can cause cell death jacent meniscus and a Dacian adjacent articular cartilage and therefore if you're still using thermal and thermal thermal devices routinely i would suggest that you change your practice habits before you take part two of your boards the other issue is that the MRI is not always telling you the truth and not everybody has a Tim Sanders to interpret their MRIs for them so be careful because your radiologists if he's just a regular radiologist not a musculoskeletal radiologist make all intercepts it's degeneration a tear he may call the transverse meniscal ligament a tear he may call some of these other funnies anterior horn media meniscus answer who anonymous does tears when in fact they're not and so be very suspicious of tears and the anterior horn and be very suspicious also if you can't see that tear communicating with the surface on the MRI then you're not going to see it in the scope how about repair when we try to repair whenever we can the best candidate peripheral red red tears that are 1 to 4 centimeters in length with a combined ACL reconstruction for some reason when you fix the ACL at the same time you have an enhanced meniscus repair it may be because you're releasing pleura potent factors during your drilling or it may be because that's the way the tear is that kind of tear occurs when you have an ACL tear it's not clear regardless what is clear is that an ACL deficient acute ACL injury the meniscus repair does better so stretch the envelope in that setting the meniscus heals by inflammatory cell infiltration it's enhanced by grasping and there's a variety of techniques keep in mind the strongest is the vertical mattress suture one of the risks with this traditional inside-out suture well in the medial side we know the saphenous nerve and vein are most likely a risk and that's because the needles are often poked or tied over these structures and therefore from a practical standpoint before you tie the sutures on the medial side you get a fine hemostat spread and make sure you're not tying over any round structure if you are pull it on both sides of the same structure on the lateral side the biggest risk is the peroneal nerve so if you're doing a ministerís repair your patient wakes up when the with a foot drop and the recovery room you better hope your anesthesiologist put a block in them because otherwise you're in trouble from that standpoint the way you protect that is retractor placement the retractor is placed in front of the biceps tendon behind the lateral head of the gastroc if you do that you can visualize the needles coming out and you will not puncture the popliteal nerve or peroneal nerve because the peroneal nerve is injured by this inaccurate tractor plate retractor placement so bottom line is on both sides of the knee put the retractor deep to the head of the gastroc and visualize your needles coming out you'd be fine but from a testing standpoint those are the common at-risk structures well how about arrows and darts well there's been a host of problems associated with this so the old-timers are right the boards we'll be more than happy to point that out to you so recognize that these arrows and darts had a lot of problems in the literature dating back for at least five years so I think it's fair testable material at this point they can break they can migrate they can cause chondral injury which is the most severe and they're not as strong the strongest report the strongest just device is the double vertical or single vertical mattress suture because it captures those longitudinal fibers well what about a device is bioabsorbable strong low profile iatrogenic efficacious well it doesn't exist yet and therefore vertical mattress sutures is still the best way to go and so from your board standpoint 2005 do you have a chance to repair meniscus on the boards I recommend you do with vertical mattress sutures meniscus transplantation the goal here is to avoid doing this in grade four con grossest because it's going to just wipe away that meniscus despite what you heard and some of the recent podium presentations for your boards do not put meniscus transplants and great for condo cecile fail the other thing to recognize with meniscus transplant or Carly's procedures is to try to make sure your mechanical alignment is corrected before you go do this optician procedures meniscus transplant if you've done it you know it's technically difficult it's tough to get those plugs in and the long-term results are not really clear because the meniscus even though the periphery will heal in it sometimes doesn't function normally and so we don't know the long-term results of this again immediately we use bone plugs laterally bone bridge and then the peripheral sutures is shown here and they do good they heal nicely but the question is do they function we don't know that long-term how about meniscus cyst we've touched on this in the radiology lecture and keep in mind that almost all meniscus cysts are associated with horizontal clearly stairs of the lateral meniscus so what happens is the fluid percolates in through here one way of alva curves and the cysts occurs right here and so the way that we can decompress those is do a partial lateral meniscectomy access those two leaves go in with a shaver or a basket and spread and allow that fluid to egress you can also stick a spinal needle in from outside to also encourage that to egress so the treatment for miniscule cysts is partial meniscectomy an arthroscopic decompression not in bloc resection well how about the discoid meniscus there's three flavors of discoid meniscus one is incomplete two is complete like this example it covers the entire surface of the lateral tibial plateau three is a risk berg variant that may or may not be a disappointment in us all it means is there's no peripheral attachments no coronary ligaments and therefore that meniscus is too free to move it moves more and it can snap and pop and so if you run across a discoid meniscus that has no tear in it live it alone if you run across a meniscus that has to mobile hypermobile meniscus it has no coronary ligaments then do a meniscus repair and create coronary ligaments if you run across the disappointments kazan has a tear in it then like any other meniscus with a tear you need to do a partial minutes ectomy partial MindView partial minutes that can be not complete now again the discoid meniscus they'll show you on your boards will have three successive sagittal images if you see three successive sagittal images of the knee that's your answer Austin - desiccants the key here again it occurs in the lateral aspect of the medial femoral condyle the other key is if the patient has open phi sees and is minimally symptomatic stop there don't do anything operatively only operating adults or kids who are exceeding the symptomatic and failed conservative management what about articular cartilage injury well we all know there's a variety of methods methods to take care of articular cartilage injury focal defects we're not talking about arthritis we're talking about focal articular cartilage defects these can be treated with a variety of treatment options of some of them more controversial and therefore they won't make it pick between oats and microfracture because the literature says they're roughly equivalent results or for that matter oats and ACI because again the literature say they're roughly equivalent results so be familiar with the different options available but they're not going to get you into picking between the how about osteonecrosis well you have your standard osteonecrosis kind of like you have in the femur and humerus that has a wedge-shaped defect and you can do a core decompression just like you do in the hip and then in the knee there's an unusual kind of osteonecrosis called spontaneous osteonecrosis of the knees song this is a weird thing that can occur sometimes in middle-aged patients often falling in arthroscopy and it has to do with subchondral insufficiency so you go in and you scope a knee and you trim a little meniscus but the patients also got some degeneration they come back post-op and they are punishing you because they're complaining of pain so much that's very likely a song and very likely and your MRI you'll see these kind of subchondral insufficiencies is shown here and the treatment is to put them on crutches and make them wait several months for that to recover don't go back in and scope them again well how about Center back to me well if the synovial processes aren't the scopic Center back to me if done carefully and properly can be just as efficacious as open Sinopec Tamizh it's just that you need to remove all that synovium so in order to do that you'll need extra portals and so don't be afraid to make superior portals and posterior portals in order to could do a complete set of ectomy and then it's just as efficacious for RA pv NS haemophilia etc like god placa occurs on too many part two board examination lists okay Plaka is over diagnosed and it is over done however it the entity does exist when there's a thickened band that rubs on the medial femoral condyle and you can see objective evidence of abrasion of the media from a canal patients have tenderness above where they would have tenderness for a medial meniscus chair then this response to resection but again the diagnosis is overused let's get into some ligament injuries the ACL is a very common ligament injury occurs from a non-contact pivoting injury patients will describe a pop or hear a pop and they'll have an effusion yell Daniels classic article patients showing up to the Kaiser system with knee effusion seem arthrosis 70% of those turn out in a CL the patients will present with a quadriceps avoidance Kate kind of a bent knee a gait avoiding their quadriceps the exam the gold standard is the Lachlan the pivot shift is helpful particularly the examiner anesthesia recognized for any of these pivot shifts or redo or reverse pivot shifts where the knee is going to be lacks so recognize that in a pivot shift the knee is lacks an extension and so as you go from extension to flexion it will be go from a subluxed to reduce position and the opposite occurs with a reverse pivot shift in a reverse pivot shift for a PCL deficient knee the PCL is deficient in flexion so as you go to some flexion extension it goes from a displaced position to a reduced position and so it's just a matter of thinking those out so don't have to be gimmies any more in those questions well ACL you can't just put stitches in and it doesn't work and that's been shown for a variety of years because the ends are covered by a mile fibroblasts that basically have smooth muscle covered in smooth muscle actin and so those caps allow you not tell oh it heal won't heal you can't sew it up so you got to reconstruct it in fact the many all medical students that come to my service say that this patient and an ACL repair and I say that's not possible it doesn't work we did an ACL reconstruction on that patient subtle but important point again we talked about the association of meniscus tears with ACL is very common up to half the time and acute injuries more often lateral than medium well what do you do about treating ACLs well contrary to popular belief every single person doesn't get an ACL reconstruction just most and so we do non-operative treatment for patients who are very low demand little older have less laxity the one thing that Dale's Daniels work and subsequently the thien's work has shown that the patients with more higher demand activities higher tech nurse scores where they're more active in sports and the patients with more laxity on KT 1,000 are more likely to get in trouble with at ACL deficient knee and so in that population in particular you need to do ACL reconstructions if you don't do a CL reconstructions the patient's remain active then they're very likely to get meniscus tears and chondral injuries down the line do they get arthritis well that's a very controversial issue and best probably avoided because in fact the Dale Daniels article and the 50 and article both recently have suggested that those ACL reconstructive patients actually get more arthritis well why is that well maybe because they're more active in anyway the reason this is very controversial is because of that very issue so recognizes the meniscus and the articular cartilage injuries that need to be addressed and not the arthritis when you're talking about the patient's about ACLs which graft we use again huge controversy huge studies all of you show roughly similar results the one thing to take to sted is the fact that the patellar tendon graft autograft will cause a higher incidence of anterior knee pain because that's one of the least controversial of all of these findings and that's probably a testable item so make sure you know that it's not surprising cuz you're taking a piece of the patella out the other thing is clear is in the initial fixation strength not the initial strength of the graft itself but the fixation strength of the hamstrings is weaker than the patellar tendon and that's why if you have a young aggressive person who wants to accelerate the rehab maybe that's not the best choice for them the other thing that's not controversial is that allografts do carrier resists risk of disease transmission including HIV which is one to one or one to one and a half million and a higher risk of hepatitis the other thing that's clear is preconditioning of grafts regardless of graph choice can reduce the stress relaxation in fact up to 50% and that's why we have these various commercially available graph boards if you use alle graphs you have the risk of disease transmission bacterial transmission you can reduce that by processing your alle grafts one way to do it is to radiate it well if you radiate up to three mega rads you might be able to kill HIV unfortunately if you radiate that much then you're gonna kill your graft also and so therefore there's a big controversy about whether to radiate whether or not to radiate etc the bottom line is is that recognize that most radiation available doesn't kill HIV and therefore probably the best is to is to sterile harvest these grafts and to not irradiated high doses also freezing can destroy the cells this doesn't appear to adversely affect grafts and we do know however that alle grafts have a longer incorporation time this has been studied by Jackson and Long Beach and he showed in an animal model that you have a delayed incorporation of the ala grafts so as far as ACLs summary side slide goes later arthritis is related to the meniscus integrity and therefore you should try to preserve the meniscus whenever possible you try to work on motion early in an hour ACL population we emphasize extension early because you lose extension and all is lost so don't let patients go away from your recover your recovery room go away from your surgery center with their knees a pillow under their knee and come back a week or two later and their knee still has a pillow under it because you're gonna have loss of extension and so emphasize extension early especially if you have combined medial side surgery for example the patient has an ACL MCL or the patient has an ACL and patellar dislocation regardless if the medial sided injury you were at higher risk for your knee getting stiff and you need to emphasize motion early the other thing to do is to avoid ice aquatic isokinetic quadriceps strengthening at fifteen to thirty degrees during early rehab and the reason for that is that could smoke puts the most stress in your graph what are some of the complications of ACL well probably the biggest complications is inaccurate surgery and so tunnel placement is a big problem typically patients will show up with anteriorly placed tunnels because the people that did it don't understand the concept of putting the tibial tunnel back and the posterior medial aspects of the footprint and they don't understand the concept of completely clearing out that lateral wall so the avoid the so called residents Ridge and you get your graft as far posterior as possible the other risk is loss of motion early and that happens sometimes when you operate too early other issues are hardware failure which is an early cause of failure recurrent injuries and then people you didn't understand how to combine injury that may have had an ACL post around a corner you only fix the ACL the post a lot of corner is going to cause it to fail loss of motion is a devastating problem you have a patient like this shows up in your office is really not a lot to offer him except for trying to get that extension by working hard on physical therapy and maybe eventually doing our lysis of adhesions very ungratified when patients show up with that kind of extension loss so preoperatively be aware of this emphasize motion control they refuse and get their quadtone allow them to have good gait before you operate on your ACL this will reduce your incidence of arthur fibrosis unless of course you're above 7,000 foot elevation intraoperatively make sure you put your tunnels in the right location postoperatively control the heme arthrosis either with a drain or ice early loss of motion and is an extension is a problem and if that's a problem you have to do serial casting physical therapy if that fails you may have to do manipulation under anesthesia and lysis of adhesions about the 6 to 12 week part be aware also of RSD which is a devastating problem also called complex regional pain syndrome now whenever we can't figure something out completely we just rename and that solves a problem so we now have complex regional pain syndrome you can also have fractures or patella tendon ruptures this can be reduced by using a smaller saw leg cutting the under surface drilling holes of the corner making a less rectangular more triangular graph and bone grafting the defects also you can have tunnel Ostia lysis which means that the tunnel expands for some reason and there may be a variety of reasons for that that's really not too big of a problem unless you're getting into revision in the avid as far as the other complications there can be some real iterative tissue such as demonstrated here at the tibia tunnel sight people think that's maybe because there was too much leftover debris when you're doing your ACL if they have a click and terminal extension and you make this diagnosis of a cyclops lesion you simply remove it and that gets rid of their problem again tunnel position Howell has taught us you need other tunnel behind bloomin stats line if you have the tunnel in front of Loomis test line then you have strain inflection as you can imagine if you put the tunnel to posterior you can have strain an extension the other thing that Howell has taught us is to consider the coronal plane as well by moving the tibial tunnel starting point further medial than we used to and when you do that then you can have less problems with graft and payment in that plane as well from a practical standpoint what we do is put the tibial tunnel midway between the tibial tubercle and the posterior medial edge of the tibia and we show it in a cadaver model that does the trick do not shrink things if there's one message that I'll try to share with you threats to this time is do not shrink things you shrink ACL ACL they'll rupture you shrink ACL graft cell rupture in fact they did a canine study where they shrinked 18 dog ACLs and eight weeks post treatment 100% of those 18 dogs rupture their ACL so if you just want to kind of tighten it up a little bit with your sprinkle on think again how can we prevent ACL injuries this has become a real big focus of study lately and the way that you can do it is to train your athletes to not land in precarious situations so the ski or training in Vermont they taught these ski patrol guys how to avoid Falls or when they follow how to avoid crossing their tips etc and that provided a benefit they couldn't teach the novices because the novices didn't know how to ski so you still have a chance of you work at a ski resort as far as a female athlete this has been a big focus of research and the bottom line is at least one component of risk of the high ACL injuries and female athletes in pivoting sports such as basketball and soccer is jump training so they we've talked the women to try to land in more flexion and less valgus and focus the engine energy and that's reduced the number of ACL injuries in the female athlete and so neuromuscular training and plyometrics has proven to be beneficial in and particularly that population ACL bracing does not have a prophylactic effect with the exception of one study in skiers and so ACL brace is really not not the solution moving on to the PCL PCL again gets injured by a blow to the proximal tibia or you can have a hyperflexion injury which can cause this hyperflexion injury PCL injury again the key exam is the posterior drawer the key to that is recognizing the normal step off treatment of PCL injuries somewhat controversial what is not controversial if you have a big bony avulsion off the tibia that needs to be fixed and the way you do that you put a screw in washer and fix that primarily isolated PCL injuries grade two PCL doesn't go behind the meter from a condyle then in that case those should be treated non-operatively especially for your board examination isolated PCL is treated non-operatively quadriceps rehabilitation may be an initial period and a brace and extension non-operative management of isolated PCL injuries the problem with ice with treatment of non-operative treatment of PCL injuries down the line again another testable issue is they're gonna get arthritis in the medial femoral condyle and the patella femoral joint medial and patella femoral arthrosis common long-term sequelae of a PCL deficient knee has to do with altered contact pressures and then if you have combined injury PCL postural on a corner PCL ACL anything that's a combined injury the PCL most authors would recommend reconstruction much less controversial multiple ways to do PCL reconstructions the traditional technique is arthroscopic where you go trans tibial from front to back the risk there of course the popliteal vessels the tibial inlay technique which I for involves me mobilizing the media the gastroc and approaching it directly in the back of the knee and then either of these techniques can also take advantage of to bundle techniques to bundles implies to bundles in the femur and so the anterior lateral bundle which is the most important bundle again in flexion and then the posterior medial bundle which is less important but it's important more an extension post-operative from PCL immobilize an extension recognize that gravity is your enemy and therefore do your motion with patient prone or on their side and supported and work emphasize point accept rehabilitation we do know that the inlay method has less graph attrition than a traditional method and this has been shown biomechanically in two separate studies about four years ago so they're there in the test taking time period for you to be aware of it and recognize then that the trans tibial technique can cause graft attrition recognize also probably two years plus out now in testable is the to bundle technique has better stability well how about moving on then to medial collateral ligament injuries as I tell my patients this is the one injury that your body can successfully take care of of the four ligament injuries in the knee so they're lucky if they have this injury mechanism injury valgus contact exam open only at thirty degrees if they open also at zero then their body's not gonna take care because they've got a cruciate ligament also treatment for an isolated MCL injury is a hinged brace for six to eight weeks they're not gonna get into this controversy about what degree of flexion you allow initially and later it's just a hinge brace so treatment for isolated MCL hinged brace if you have a combined ACL MCL injury then you need to recognize either delay your ACL surgery to the MCL Hills up or recognize that the patient is at risk for loss of motion if you do an ACL during the time period there MCLs healing and emphasize motion all the more lateral collateral ligament injuries is exceedingly rare I have done over 200 knee dislocations never seen an isolated lateral collateral ligament injury but I have seen that injury very commonly with multiple ligament injuries but by itself it's very rarely injured now the mechanism of injury theoretically then would be a varus contact injuries should open up only embarrassed but again isolated injuries be very suspicious that there's something else going on particularly a post your lateral corner injury and here's what we see more often than not is this bomb that goes off in the post a lateral corner from a poster lateral corner injury a seemingly benign appearing injury until you open the skin and see the devastation that occurs from injuries to the biceps the iliotibial band the popliteus tendon it's unbelievable so this occurs as a result of rotational injuries as I indicated it's often combined especially with PCL s and if you don't recognize this then you're gonna have failed ACL reconstruction has failed PCO reconstructions and other problems again the key is external location asymmetry or dial test other associate exam includes external location recur bottom where you grab the big toes where they're laying supine and the knee will fall into Baris and hyperextension the posterior lateral drawer where the tibia not only goes post here but rotates poster laterally as well the treatment then for post a lot of corner injuries is to try to repair what you can primarily and then supplement this supplement with a free graft and that seems to work the best new emphasis has been to also try to reconstruct the popliteal fibula ligament or this arm of the reconstruction that connects the fibula to your popliteus graft multiple ligament injuries the most important thing here is to make sure you assess for neurovascular injury number one and number two reduce the knee so they'll often ask you what the treatment is and if the knees been assessed and it still dislocated then reduce it it's pretty simple that's a gimme so the name of the dislocation is based upon the direction of the tibia the more distal bone always describes the location of these dislocations treatment again assessing their vascular status reducing it reassessing about your status if there's any question you need to get vascular surgery involved with either high-tech non-invasive studies or arteriogram which is the gold standard unusual injury therefore often ask on tasks is the tib fib dislocation if you happen to ever see this then you should reduce it and then immobilize the patient and extension and because it's an unusual injury that's all you really need to know bio absorbable and materials certainly were aware of P poly glycolytic acid which is what the shirt tack was made of it absorbs very quickly pds takes a couple of months and that's why a lot of companies are switching some of their knee meniscus repair implants into PDS rather than the plla because it absorbs more quickly pla it takes a long time to absorb have you ever been involved in a revision ACL reconstruction and you still see a screw that was placed eight or ten years ago that's because this stuff may not ever absorb and then there's various hybrids coming along now to try to get the PLA to absorb a little more quickly what about our favorite problems like patellar tendonitis well this occurs at the inferior border of the patella very common in jumping athletes they'll have pain right below at the bottom of their inferior border of the patella right there at the patellar tendon location it will diminish if their knee is flexed or they pinch their quads patellar tendonitis treatment was Joe Pat strap which is a strap that reduces the tension across it modalities etc quadriceps tendonitis the pains in the superior aspect of the patella less common same problems pre patellar bursitis the key question here is the fact that this occurs in wrestlers they want you to aspirate it so the key test questioning on pre patellar bursitis and a wrestler is to aspirate that Bursa iliotibial band syndrome very commonly asked occurs and Hill runners the exam is the over test you paced the patient on the side the symptomatic leg up a V duct extend and and then take it to a position of a deduction and you'll see tightness in that area or clicking or pain in that case you give them injection and that usually takes care of it rarely do you have to do a surgical excision how about our friend the new complex regional pain syndrome the key here the key testable item is disproportionate pain pain on a proportion of what they should have and the other key testable question is the treatment also confirms the diagnosis so an epidural is sympathetic block will not only get rid of the pain and make the diagnosis and then there's other things that can be tried including alpha blocking agents extensive mechanism injuries can occur we've already heard this if you're over 40 you get a quadriceps tendon rupture if you're under 40 you get patellar tendon rupture it is amazing how true those numbers really turn out to be I do a fair number of both of these and it's very true how the patellar tendon occurs the younger patient until her fractures you gotta treat it if it's displaced patellar dislocation again the key here is the NPFL as the primary restraint and it's probably too controversial to talk about acute reconstruction of that for recurrent instability the keys examination apprehension looking at radiographs for congruence and then treatment of almost any patellar instability thing you'll see on the board if you haven't had a lot of rehab than you better order more rehab because the treatment otherwise a little more controversial occasionally I do realignments if you do recognize that a fulkerson is contraindicated in a patient with superior medial arthritis the reason is is because it will concentrate that area more and cause them even more pain so before you consider doing a focus and stick a scope in and look at their patella if they have superior metal and arthrosis Bale lateral patellar compression syndrome another thing that you should not have a lot of on your board list for part two is lateral releases because they are significantly overdone in this country there's nothing worse than a comeback from the kids come back from college from Spring Break whether you have a half-dozen post-op lateral releases you have to take it's horrible because the surgery was never indicated the only indication for a lateral release is if you have objective evidence of lateral tilting and refractory extended rehabilitation that's the only incidence of it you don't do it because well I didn't find anything else wrong in the knee and so I thought I'd do a lot of release that's not a good answer all right patellar chondros is again you can see this on radiographs the treatments rehabilitation occasionally you can do a tubercle elevation which is called a McKay procedure which got a bad name because it cause skin necrosis in the proximal tibia the reason is because McKay indicated you raise it up an inch so obviously it's gonna cause skin problems in fact if you do a McKay nowadays you should only elevated a centimeter and more often than not people are doing Fulkerson's which really effectively does the same thing by sliding it up the slope of the tibia and you can pick some extra bone graft underneath that if you want and do a elevation of the tubercle for refractory patellar con grossest patellofemoral syndrome pain with stair climbing pain was sitting for long periods exam compression of patella treatment rehab rehab rehab rehab try to avoid operating these patients the so-called miserable triad is characterized by Jessie de lis involves femoral introversion genève album and external tibial torsion the reason it's miserable is not only for the patient but for you and clinic how about some of these pediatric disorders well there's two sides of the patella you can get it on the tibial tubercle side you get osgood-schlatters disease self-limited process you simply do conservative management signe larson johansson occurs the inferior part of the patella same concept Rast activity modification nonsteroidals etc about facial injuries the key test question here number two test questions number one a diagnosis with stress radiographs when you're not sure number two is that these injuries although they are served up here relatively benign initially can be devastating and caused significant growth problems with minimally displaced fractures so you got to counsel the patients and the parents the other thing is ligament injuries you can have a medial tibial spine or medial imminence of Vol'jin and that's the classic one two three categorization you see and so the classic answer is you put them an extension if it reduces fine put them in a cast if not then you have to do surgery and more often than not though you do need to surgery because the lateral meniscus or intermittence caligula it gets displaced in there and it keeps you from reducing it and therefore treatment would be to fix that with a variety of techniques you can either use sutures and pull it down through small drill holes or you can put a screw in that stays above the physis an angled screw stays above the physis the key is to not put screws across a physis whenever you can now unfortunately more and more we're seeing really young kids ten years old with mid substance ACL tears and this is a controversial area as well I think you're best on your boards to avoid any tunnels and these really young kids especially in the femoral side a central tibial tunnel is probably okay that's been shown to be okay but a femoral tunnel is eccentric and it may cause growth problems and so therefore the treatment for these is a facial sparing operation of the distal femur and a soft tissue graft with young kids so here's a case where we make a very vertical six millimeter tunnel past the hamstring graft not through a femoral tunnel but over the top to avoid violating that vises be aware of patellar sleeve fractures this is this is fortunate on this exam because you actually saw the piece of bone but if you see a really high patella Alta and you don't know why this may be a reason so a young kid with the patella also probably had a patellar sleeve fracture an older patient would tell it off - probably had a patellar tendon rupture so you're taking your boards you look at an x-ray you go oh I can't see anything wrong with this thing look at the height of the patella that may be the issue other problems the popliteal cyst and the young patients often ask and the bottom line is this is a spontaneous resolution you don't need to go in and drain that cyst or or remove that cyst Baker cyst and the kids will go away by parked a patella again superior lateral aspect of the tala observe these because rarely they're truly symptomatic if there's some question you do a bone scan and see whether it's really injured let's do some neat questions now wrong answers for knee question is when you order in bra without having a reason for it giving steroid injections is usually not encouraged for bored answers nor is using RF frequency for burning things the role of diagnostic arthroscopy is not hot on the boards in other words you should know what you're doing before you get in there you don't do ACL repairs you do ACL reconstructions you don't do ACL reconstructions acutely because you get are through fibrosis keep in mind this is a very conservative people right in this test you don't initially do operation for great - PCL injuries isolated PCL injuries treated non-operatively and you don't operate on patellofemoral unless you've pried extended rehabilitation so what we do is go through these questions we're gonna cover the odd question so I'll leave the evens for you later so odd questions number one which of the following describes the components the posterior cruciate ligament posterior should remember we talked about it being your pal anterior lateral is is tight in flexion so which of the following statement best describes tension in the components the PCL with the need taken from extension to flexion okay well our pal we know our pal is loose in extension and tight in flexion okay so ace you know let's go through what do you think a co anterior lateral band PCC Lancer lamp al lacks lacks an extension tight inflection post your medial tight and becomes lacks they have a reciprocal action again PCL pal anterior lateral tighten flexion skipping to going to three college football player twists his knee making a tackle no media laxity or joint line tenderness doesn't have a meniscus tear or MCL anterior posterior drawer tests and pivot tests are negative okay doesn't have a PCL however the lachman's positive what's he diagnosis ACL skipping for go to five 13-year old quarterback feels a pop radiographs and Lachlan are normal as tenderness over the distal femoral physis thirteen-years-old physis how we're gonna figure this out stress radiographs skip six go to seven what part of the meniscus has the highest incidence of degenerative or complex tear older patient complex care of the meniscus poster horn Media meniscus skipping it going to nine joint lines cysts lateral meniscus tear horizontally beats more often than not skipping ten node eleven thirteen year old boy MRI has an OCD open physis OCD open physis a little bit of a fusion not too symptomatic what are we gonna do about that open physis don't treat it activity modifications take a look at in a couple months only if they failed extended non-operative management or significantly symptomatic with open faces if this had closed vices it might have been different answer but open faces it still has a chance to heal thirteen gait pattern ACL deficient knee quadriceps avoidance fifteen soccer player knee injury grade three ACL MCL also lateral meniscus he has the new idea Donahue's triad ACL MCL lateral meniscus o'donneii you described ACL MCL medial meniscus but now we know it's more commonly this triad so if you delay ACL surgery what are you going to reduce medial side injury high-risk getting stiff so we reduced the arthur fibrosis 1723 o football player hyperflexion injury hyperflexion injury that's the key to this whole question hyperflexion injuries a PCL until proven otherwise nineteen described the relationship the tibia and the femur with a positive reverse pivot shift well the reverse pivot shift starts in flexion therefore we know that the PCL with the knee inflection should be sub-blocks wrong wrong wrong hey let's look at this some blocks posterior lis with flexion reduces an extension that sounds good to me okay see how these it is those are the same questions you blew off because you couldn't figure them out before 21 32 year old man's swelling on the knee felling the knee with a foot in plantar flexion let's see foot in plantar flexion where did the force go did he go to the patella or did it to go to the proximal tibia Lockman test apparent increase in anterior translation well that's a pseudo Lockland because if the starting points the issue passive external rotation at 30 and 90 is equal to the contralateral side negative dial test doesn't have a poster a lot of corner injury quadriceps active test is positive they love that test for some reason that means that PCL is injured okay so yada-yada-yada the guys got a PCL treat injured he's got an isolated PCL injury how do we treat that on the boards physical therapy water steps rehab 23 cadaver studies show that alteration to joint kinematics following PCL injury leads to arthritis fujifilm studies all show arthrosis or increased contact pressures in the medial patellofemoral component medial patellofemoral compartments 25 which the following physical exam best indicates an isolated poster a lot of corner injury okay remember isolated not a PCL okay isolated on 30 degrees right not 90 here we go 30 degrees 27 25 year-old man struck by motor vehicle sustains an injury to the lower right lower extremity posterior knee dislocation they did their neuro exam and it's attacked now what do we do well the guys sitting there with a dislocated knee what are we gonna do well let's reduce it and then we'll do the rest of what we need to paint pretty simple 26 year old marathon runner Hill training Hill training always means iliotibial band syndrome Hill training elected be dancin Oh Hollis overs test that's the only reason you do the Oberst St let you'll be bouncing him so you got two reasons we're talking about any type of band syndrome Hill training overs test you'll achieve a ban 31rst what is the most common indicator disproportionate pain what's the treatment sympathetic block once the diagnosis confirmed by sympathetic block thirty three what is the most appropriate indication for lateral rednecky release the answer is not that got the kids home from school and he's going back to see dr. Miller lateral patellar compression syndrome following physical therapy and associated lateral tilt tried therapy has objective evidence of tilting then and only then is a lot of release indicated thirty five six-year-old girl painless popliteal cysts just watch it okay so now we still have some time because lunch isn't gonna be ready yet so we're gonna jump into the lower extremity I know that we're usually break for lunch at this point but today we're not we break right now you will get no lunch so we're gonna press on alright moving on to the lower extremity the first thing is a very confusing thing called athletic pew bowel job or still trying to figure out what this means and therefore it's not all testable we do know that you can have lower abdominal or inguinal pain at the extremes of exertion occurs more often in males particularly hockey players and there may be a problem at the adductor longus and it can occur with a valgus valsalva maneuver Zoar stress and sit-ups treatment is conservative I don't think the board at this point is going to ask you to recommend a hernia operation for an orthopedic surgeon so don't worry about it but that's what's going on sports hernia same sort of thing again we haven't figured this out there may be a facial defect in that area and more and more you're seeing endoscopic repairs and other repairs and these athletes again probably not appropriate for us in this board exam a variety of other things include rectus femoris tightness adductor strains all treated non-operatively osteon is pubis the mystery an x-ray of a pelvis if you look at an x-ray of pelvis and it then you can't see any fractures look at the pubis see if it's Ostia lytic and that'll help you make that diagnosis how about snapping hip I know this was mentioned in the radiology record lecture and I agree there's three kinds one external that's the iliotibial band not the iliotibial tract but really the fash a lotta up here band and tract are more distal but the fascia Lata is up here at the hip and that's what gets tight and the treatment for that is conservative management and occasionally you have to do release now interesting we recently traditionally it's called a z-plasty but but recently burr described doing this this kind of cut where you make this transverse cut in two other cuts and then when you do that the completely releases the tissue and that this is if you ever run into this problem that's failed conservative manage this is a good way to go this works out really nice so I've done this a couple of times now now internal snapping hip is because the iliopsoas it snaps over the imminence there and you can see that in bursts ography and so the recommendation is do a Bursa gram and if that if that shows that indeed is positive then you can do a release now you probably want to send him somewhere else to release unless you're very familiar with this area interesting Tom Berg down in Nashville is doing this through a purse Ilia source births ographers gossipy so he's doing it through the scope not me brother but anyway that's what he's doing now the other third kind of anyway for the board's the treatment is to lengthen it if it fails conservative management probably open now the third option is an intra-articular thing when you'll see with an Arthur MRI maybe a labral tear or loose body and therefore the treatment is hip arthroscopy how about hip subluxation and dislocation well most of the time if you have a hip injury goes posterior Lee as you know what happens with a little unusual in sports is is this hip subluxation issue so it's called Bo Jackson syndrome where you had an injury to the hip and it momentarily sub-blocks and they immediately reduced you know the key here is to have a high index of suspicion because if that happens there's a high risk of osteonecrosis and so what this recent JBJ article probably two years ago now recommended would be to get a oblique x-ray judez views awkward obliques and to see if there is a tiny injury to the poster acetabulum if there is then they recommend considering doing an aspiration of the hip because the blood and the hip can cause a vascular necrosis of the hip and so that would be something to be aware of greater trochanteric bursitis those usually respond to steroid injections hip arthritis is something that comes up in the the key exam question in the sports world for hip arthritis is what do you lose first and the answer is internal rotation hip arthroscopy there's two different ways to do it either take lateral decubitus or supine and it's beneficial for loose bodies labral tears etc the key here is whenever you're considering doing arthroscopy on unusual joints or joints with a lot of nerves around the area is to know what those nerves are because that's what they love to ask on these exam questions and so if we're doing a hip arthroscopy some of these old guys but i think that's crazy and they're gonna ask you then about injuries and so be aware that the anterior lateral portal has a risk of the superior gluteal nerve the posterior lateral will be straight to posterior has a risk for the sciatic nerve and the anterior portal has a risk to the lateral femoral cutaneous nerve and even the femoral nerve itself and so if you're going to see a hip arthroscopy question is probably going to be what kind of actor agentic injury you can cause these nerve injuries and articular cartilage injury about stress fractures when we talk to this in the radiology lecture again a very common problem and MRI is gradually supplanting bone scans in this area it's important to recognize the key treatment for stress fractures is to avoid Tootie's reduce activities and so keep test questions on the femoral neck looking on MRI and seeing which side it's on okay the compression fractures you can be a little more conservative with on the inferior surface of the neck the tension fractures on the superior surface of that be very aggressive about recommending putting screws in there because otherwise it'll displace the femur they recommend a fulcrum test which is basically you stress that across a kind of a three point Bend and that'll if that's painful then obviously you want to look at you limit your activities the tibia this the question here is about the dreaded black line which on a lateral radiograph you see a black line through some sclerotic anterior cortex the treatment for that is recommended is to put a rod down it the navicular is a very commonly asked test question on stress fractures partial navicular if you see a linear line going through that then you should put a screw across it if not then the answer is non-weight-bearing that's one of the bones that you treat non-weight-bearing how about some of these other shin splints well medial tibial stress syndrome is probably the most common of those and the pain decreases with running which is a little unusual and so that helps you differentiate that from exertional compartment syndrome exertional compartment syndrome ask on a lot of examinations because of its several things that are eminently testing about testable about this including the requirements for making the diagnosis and again the biggest requirement for making the diagnosis is increase in pressure by doing exertional testing put them on a treadmill stick them with a striker evaluation and you can see that the after exercise a minute after exercise if the crusher stays above 30 then that's that's diagnostic treatment then activity modifications etc but most these kids aren't very successful in non-operative measures and then you have to have a discussion with them about treating them now unfortunately this is not home run operation and I tell this to the kids all the time because I see a lot of this a lot more than I want to but the bottom line is you tell them it's not a home run operation because there's a lot of overlying conditions that can be mimicked this true stress shin splints stress phenomenon stress fractures etc and so if you have the diagnostic criteria clearly set out then you have a counseling discussion about all these other problems and then sometimes you have to do the surgery anyway and if you're doing the anterior compartment usually it's successful but if they have other compartments involved it's not always successful so again the take-home answer anterior compartment most often affected it has the best results of treatment and the treatment is to release the fashio but if you have other compartments not always is successful and there's other overlying conditions that can make your treatment suboptimal so you don't want 20 of these on your boards how do you do it well from a practical standpoint we like to go about 12 to 15 centimeters above the tip of the lateral malleolus on the lateral side and that allows us to see the superficial peroneal nerve where it exits and protect it because that's a risk superficial perimeter of risk and so sometimes there will actually be a fashionable hernia in that area and that's gratifying because if you release above and below that factual hernia that'll give them good relief keep in mind that that superficial peroneal nerve is right about at the junction of the anterior and lateral compartments and therefore after you isolate that nerve you can release just both above that anterior compartment and below the post the lateral compartment and get both compartment both the answer and enter lateral compartments released if those are affected in your studies in order to release the posterior compartment you have to make a medial incision and that is typically done about the middle of the tibia right below the level of the tibia and you can release the superficial poster compartment just by releasing the fashio there in order to release the deep media compartment you actually have to elevate off the back of the tibia and so that can be a little scary so you gotta be a little careful with that how about this really weird thing called popliteal artery entrapment syndrome patient may present with intermittent claudication diminished pulses and you do in our teria gram and if that's the case then you can release the medial head of the gastroc and and release this constriction I have never seen this except on multiple examinations how about other nerve entrapment syndromes well there's some weird ones out there and weird things get tested a lot one of them is a surfer dude who complains of need numbness on a regular basis what happens is they're paddling their board all the time on their knees and the saphenous nerve gets impinged as a result of that and so that's called surfers neuritis saphenous nerve problems and the treatment then is find some knee pads superficial peroneal nerve again can get in trapped in that same place you're doing those a lot of releases lateral plantar nerve the foot guys probably hit this too but this is always asked because this Baxter nerves and it's a nerve to the abductor digiti Quinte and that is entrapped in the AV dr. halleck is fashio and so you have to do a release to release that fashion medial plantar nerve that can be entrapped as well the key exam for this they'll always tell you somebody's wearing a foot orthotic and it makes it worse okay that's because the foot orthotic is pushing on that nerve making it worse and so the answer is medial plantar nerve get rid of the foot orthotic how about muscle injuries well this are very common of course in day to day life and the thing that sometimes occurs is the question about the fatigue muscle fatigue this reduces the muscles ability to absorb energy and so therefore makes it more susceptible to injury hamstring injuries they occur anywhere up and down the back of the thigh quadriceps contusion severe quadriceps - contusions as shown by two separate studies from West Point are treated with the knee in flexion overnight so you flex the knee have to put an ace wrap from wrap around there and flex the knee overnight with a severe quadriceps contusion the gastroc soleus complex can be injured and I know for a fact that Tim Sanders talked about this tennis leg being occurring as a result of the plant terrorist well most of us feel it's really the media have the gastroc that's injured rather than the plantaris tendon in any rate is treated with conservative management the one time you operate on the hamstrings injury potentially is when it's pulled off for the issue of tuberosity and significantly displaced Garrett and others have described this in waterskiing injuries where the water-ski gets caught and if you have a water skier that's a bolsa and they show you an MRI then early repair is recommended for that how about Myositis ossificans this is a result of direct trauma the key here is to differentiate this from a tumor and the key there is to recognize mature bone is at the periphery remember that beautiful CT scan that dr. Sanders showed you where you had that egg and that periphery had a mature bone at the end of it so the treatment for Myositis ossificans is active range of motion not passive but active range of motion and the other thing is to wait and see how it matures don't go operate on an acute phase you'll just piss it off so wait until it matures if it's a problem then you can excise it we've had some interesting football players with this that have just horrible x-rays but didn't bother them and he left it alone wisely and they did fine variety of tendon injuries in the lower extremity and we'll go through those peroneal tendon injuries the main thing you can have is this popping out of its behind a lot of malleolus if that happens when you do when you do a aversion that you've had the patient Evert against resistance if they pop it out then they may want to have reconstructed this is what Barry Foster had the football player for Pittsburgh and the treatment then is to try to reconstruct it by putting it back behind the fibula and reconstructing then this this cartilaginous Ridge that allows it to stay in you can try to do that acutely if you can otherwise you'll have to bring swing some tissue in there to do that or group deep in the groove to keep it in there okay so that's that's subluxation for dislocations apparent in is now also very commonly happens especially with the peroneus brevis is longitudinal tears in that that may or may not be associate with the same problem if you see that then the treatment thinness to debride it and repair those those Tennant ears posterior tibialis tendinitis got a lot of press in the sports world because we're talkin x' wrote an article about it but it's the treatments the same as in the foot world so there's nothing special the bottom line is you just debris it or reconstruct the FBL excuse me with a FDLR fhl transfer so to breed it and then transfer either party FDL or fhl well there's some other weird tendon injuries the flexor Halleck is longus the reason this is a fun one is because the exam the exam is poured reported to have decreased great toe passive extension and neutral but when you put them to put in plantar flexion you have normal great toe passive extension and because that's such a weird exam it appears on exams and so if you ever see something weird about that some kind of toe foot position thing big toe the answer is big toe tenant never seen it okay achilles tendonitis this is an overuse injury and therefore the treatment in most cases especially for the boards unless you're patrick ewing is rest and therapy as far as ruptures well we know the classic teaching on this and that is that if you treat it closed you have an increased we're up to rate you'll be treated open you have risk of skin slough and so the answer is to be very careful with our skin incisions and avoid the sural nerve and make nice flaps how about the us try going um authsub fibula and us perineum well the key here is the osprey gone this occurs when you're a ballet dancer on your tiptoes which is called endpoint and if it fails conservative management then you can excise it acceptable error is just a little piece of bone off the fibula sub fibular it all it means it's only significance is that it has association with chronic ankle instability because it probably wasn't opposing the ATT FL in the first place and so it's a social with ankle instability ah sparrin IAM the only significance here again this occurs near its fifth metatarsal base insertion is if it's displaced proximally it may have been associated with a parent its longest rupture ankle sprain is very common we see this every day the 80 FL is the most common injury and the key test question in these ankle sprains is what the foot position is if the foot positions plantar flexion it's an 80 FL injury either in the mechanism or in your exam if the foot flexion is in dorsiflexion then it's a CFL injury either in the mechanism or the exam so think about the foot position and that's the only thing they're going to ask you about this now as far as high ankle sprains is important for you if you're a high school or college or pro doctor is to tell the coach how long that guy's going to be out and so you need to recognize this so-called high ankle sprain by having a high index of suspicion and doing external rotation stress test squeeze tests and trying to figure out whether they have proximal fibula tenderness because they're going to be out longer than it with a regular ankle sprain when do you get an x-ray in the training room well the Ottawa ankle rolls attempts to answer that question if you have an inability to walk and you have tenderness in these locations that is the distal and posterior fibula fifth metatarsal baseline for a Jones fracture navicular highly associated with stress fractures then you get an x-ray and you can also do stress radiographs to try to see if you have ankle instability objective management comparing it to the contralateral ankle you can test for us send us modoch injuries by stress external rotation stress test look at the mortis on that test if you have significant asymmetry and opening you may want to put it to consider putting a screw across there MRI is very helpful also with looking for peroneal tendon pathology and osteochondral injuries as shown here ankle sprains treatment rest ice compression elevation strengthen proprioception training only surgery after extended non-operative management was strengthening and bracing and then the surgery most people recommend is an anatomic reconstruction which is a Brostrom operation which basically involves an invocation of the tissue or advancement of the tissue and sometimes people will recommend arthroscopy for recurrent ankle problems and pain after ankle sprains and there you may see various meniscal type lesions which just means some fibrous proliferation and pinching of the fibrous tissue in the joint so the question is how long will your athlete be out well it depends upon the degree of injury whether they have a sinister injury whether they have associated injuries and how much rehab they've done so let's talk about that they have various grades of ankle sprains it depends on home with your ter smallest one fairs the 80 FL the second-degree tears the 80 FL but intact CFL well how do you figure that out well again it depends upon the foot position where you're doing your tilt testing and then complete AFL and CFL they're out for the longest probably do they have a sinister injury again extra notation provocative testing squeeze a production expert location single leg hop and then that'll keep you out longer the other thing is how high up the fibula they have tenderness higher up the fibula the longer they're out the other issue is whether they have associated injuries osteochondral defects granule tendon injuries fractures etcetera so back to the original question how long are they out well if you have a grade one or two just a week or two a grade three a few weeks a sin despotic injury you need to tell the coach is going to be out several weeks or you may be out several weeks and if you have a severe syndesmotic injury we have to put a screw across it they're very likely out for the season how about surgical management for a for ankle instability well there's over 80 surgical procedures that are described whenever that happens you know that they haven't figured out the best one with the exception of the modified Brostrom which is an anatomic reconstruction so most surgeons will recommend trying this first and most of the time is successful if it's not then you may have to do some other type of reconstruction involving free tendon grafts again a TfL the torn ends are imbricated and sutured you can also advance these up the bone and advance them onto suture anchors if you're so inclined again the arthroscopic impingement lesions can occur to various locations and they're all a sequela of ankle sprains and may benefit from arthroscopy debridement if all else fails prevention of ankle sprains involves various ortho sees strengthening and improtant exercises let's move on to Timmy Oh Taylor impingement syndrome pain when the foot is dorsiflex may see a spur as shown here on lateral radiographs treatment arthroscopic excision lower extremity fractures has been touched upon already proximal femur so-called skier hips nothing more than a proximal femur fracture ankle fracture is going to be concerned about articular cartilage injuries proximal fibula fractures can be associated with ankle injuries and the so called snowboarders ankle which gets into my talk because snowboarding is a sport this is associated with a lateral process the talus fracture as we've discussed a big piece needs to be fixed because it's got articular cartilage on it it'll get our throught I don't fix it especially when it's displace that much how about osteochondral injuries again on the medial side they're deeper and more posterior harder to get to that's why you sometimes have to do an osteotomy of the medial malleolus - there's access to it on the lateral side they're more superficial and shallow treatment arthroscopic and again for purposes of the board the most likely treatment option is to do a debridement or a drilling okay don't worry about other cartilage procedures ankle arthroscopy again I told you arthroscopy guys are gonna want to know about complications so make sure you know these complications is probably the most important thing you can review for our osku P in the case of the ankle you can get in trouble an anterior lateral portal because you can risk the superficial peroneal nerve which in fact is one of the landmarks for your portal so the way you avoid that is you feel the peroneus tercius and try to go just adjacent to it and do the knick and spread method make a small incision take your hemostat and spread so you don't involve that nerve on the medial side well you have the saphenous vein right there now from practical standpoint you should mark out that vein before you put your tourniquet up because you're not going to know where that vein is up after the tourniquets up if you exciting 1/8 the limb so take your pin before you put the tourniquet up mark out where that vein is put your tourniquet up and then make the medium portal between the tibialis anterior and the saphenous vein that you've marked out the other risks for ankle arthroscopy include synovial continuous fistula and that's why that's true for any joint you scope that's relatively thin skin around it such as the elbow as well and so therefore after you do an ankle scope you should put the patient in a protected orthotic or a cast or splint for a week or so after that to reduce the risk of those biskits us so you can visualize all these structures with your ankle arthroscopy but I can't visualize the ATF bail too well plantar fasciitis pain in the plantar fascia treatment we have stretching stretching stretching stretching stretching and probably the guys that write the test questions the board's are not wanting you to put a scope into the plantar fascial so keep that in mind how about fractures again a stress fracture is very common with recruits or ballet dancers the base the fifth metatarsal we've talked about in an athlete's that is competitive athletes then treatment may be intra meds later fixation when the screw in a non-competitive athlete you simply treat this non-operatively like you would at Grandma okay so competitive athletes you put a screw in it non-competitive athletes you simply do it non-weight-bearing and allow that to heal up that allows you earlier we or training in your competitive athletes how about turf toe mechanism forced flexion here and it can injure the plantoids says muy complex and unfortunately this has been the ruin of many a competitive athlete in football is from that little big toe problem but it can be devastating and so the treatment initially is to try to do it non-operatively but more and more of these competitive athletes are having these plantar sesamoid injuries repaired and may allow them to return to play for the boards however recognizes incompetent plantar or says lloyd complex and that most of those are treated conservatively if they develop problems down the line the sequela is hallux rigidus arthritis of that joint let's go on to some questions and then we're going to break for lunch again we're gonna go with the odd concept here wrong answers for a lower extremity include again steroid injections with the exception of the greater trochanteric versa wrong answers our initial operative treatment of ankle sprains and the wrong answer is aggressive management of recreational athletes again i'm trying to make the distinction between recreational and competitive athletes and some of these injuries particularly jones fractures because the treatment varies so with that in mind go to number one 17 year old boy runs cross country has deep bilateral media leg pain that persists two or three hours after running he has no pain to palpation radiographs normal what can we do to figure this out he may have exertional compartment syndrome which is a delayed onset occurs when they're running and takes a while to recover from the only way to make that diagnosis is to get him on his treadmill and stick him number three twenty-five-year-old competitive runner progressive pain in the medial arch of the foot he's exacerbated by the old medial orthotic so we talked about this we talked about what nerves in the medial side of the foot and is exacerbated by an orthotic on the medial side medial plantar nerve that's not rocket science there number five which the following rehab used first 24 hours following a blunt injury to the quadriceps Westpoint studies immobilized in flexion number seven three months 35 year old man pain in the posterior medial ankle when running walking or climbing stairs he has tenderness behind the medial malleolus passing extension the great toe is greater when the foot is plantar flex what's that well that's that weird thing about that flexor of the DOE okay that's all you got to know flex with the toe number nine thirty one-year-old woman instability right ankle for ten years stress radiographs show asymmetric anterior drawer excessive lateral opening and there's our friend the authsub fibular well what does that mean well all that means is that they have a non-union fracture the fibula from the ATF fell pulling it off and recurrent ankle instability number eleven seventeen year old boy steps into a hole forces the ankle and dorsiflexion dorsiflexion CFL plantar flexion eighty FL which which of the following is injured CFL thirteen twenty year old college athlete has an injury the ankle no fractions no fractures or a widening of the mortis swelling in the ankle pain with lateral compression what can you do to figure this out you got to make sure you don't have ass in this modoch injury and may need to have a screw across the syndesmosis and the way you do that is a stress radiograph put some LED gloves on and externally rotate the foot way you stabilize the tibia 15 which Oh which of the following nerves is injured with the ankle arthroscopy we know that one because it borders one of the portals superficial peroneal nerve seventeen eighteen-year-old recreational soccer player pain and a lateral foot for four weeks x-rays show of fracture the base the fifth metatarsal okay stop recreational okay how do we treat recreational athletes leg grandma non-weight-bearing 19 competitive competitive proximal shaft for our fifth metatarsal how do we compete competitive athletes with the screw and allows them to return to training early 21 what's the most common sequelae of a turf toe Alex rigidus great ok so that really completes our review of sports medicine for the lower extremity tomorrow we'll talk about upper extremity this afternoon your schedule is exactly like it's in your syllabus you'll have an extended period of pediatrics and then a you