5. Sports Medicine MCQs

MR images reveal a posterior horn root tear of the medial meniscus. LaPrade and associates found that outcomes after posterior meniscal root repair significantly improved postoperatively and patient satisfaction was high, regardless of age or meniscal laterality. Patients aged <50 years had outcomes similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair. In patients undergoing pullout fixation for posterior medial meniscus root tear, Chung and associates found that patients with decreased meniscus extrusion at postoperative 1 year have more favorable clinical scores and radiographic findings at midterm follow-up than those with increased extrusion at 1 year. Krych and associates found that nonoperative treatment of medial meniscus posterior horn root tears is associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up. Reconstruction would have no role in the setting of a reparable meniscal root tear.

DISCUSSION: Injuries to the MCL usually result from repetitive high valgus stress on the medial aspect of the elbow joint due to overhead throwing or racquet sports. Excessive stresses during the late cocking and acceleration phase of throwing can injure the anterior band of the MCL. Clinically, the injuries may present as chronic or acute, and a pop may be noted in the latter. Associated ulnar nerve involvement is common. Valgus instability is present in about 25% of patients. Patients typically are athletes who participate in throwing and have localized medial elbow pain and tenderness along the course of a ligament that extends from the medial epicondyle of the distal humerus to the sublime tubercle of the ulna. Surgical reconstruction is the procedure of choice in an athlete desiring a return to a high level of throwing.

Appropriate management of osteitis pubis includes rest, nonsteroidal anti-inflammatory drugs, directed rehabilitation, and gradual return to sports. Lack of fever or chills excludes osteomyelitis as a source of pain. Examination with tenderness over the symphysis pubis and pain with resisted rectus abdominus testing is consistent with osteitis pubis as opposed to a sports hernia, where a patient would be tender in the abdomen, not the pubis. There is no symphyseal instability that would require symphyseal plating.

DISCUSSION: Cadaveric studies have demonstrated the important role of the posterior horn of the medial meniscus in stabilizing the anterior cruciate ligament-deficient knee with significantly greater resultant force in the medial meniscus when subjected to anterior tibial loads. The posterior horn of the medial meniscus is thought to limit anterior tibial translation by acting as a buttress by wedging against the posterior aspect of the medial femoral condyle. The other soft tissues mentioned do not play any significant role in prevention of anterior tibial translation in the anterior cruciate ligament-deficient knee. REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 200. Allen CR, Wong EK, Livesay GA, et al: Importance of the medial meniscus in the anterior cruciate ligament-deficient knee. J Orthop Res 2000;18:109-115. Levy IM, Torzilli PA, Warren RF: The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am 1982;64:883-888.

DISCUSSION: This athlete sustained an isolated PCL injury. The mechanism of injury is typical for a PCL injury. When a PCL injury is identified, one must rule out other ligamentous injuries to the knee. The patient has a stable examination to varus and valgus and a negative dial test, so the lateral collateral, medial collateral, and posterolateral corner (respectively) are intact. It is common to have increased anterior to posterior translation in isolated PCL injuries, even with an intact ACL, as the tibia will rest posterior to the medial femoral condyle. Treatment of isolated PCL injuries is typically nonoperative, with an initial focus on quadriceps strengthening. Hamstring strengthening and rehabilitation is added at a later time, as this places increased stress on the healing PCL. The images reveal an isolated PCL injury with intact menisci and ACL, ruling out ACL reconstruction using autograft tissue and PCL reconstruction using autograft tissue.

Latissimus dorsi tendon transfer is considered a surgical option for treatment in patients with chronic supraspinatus and infraspinatus tendon tears. Preoperative subscapularis function is necessary for good clinical results. Additionally, men with active elevation to shoulder level and active external rotation to 20 degrees have predictably good results. Women with active shoulder elevation limited to below chest level have poor results from this procedure and should not be considered candidates. Postoperatively they lack pain control, active elevation, and active external rotation. Muscular atrophy in the latissimus dorsi does not occur, and glenohumeral arthritic changes frequently develop postoperatively.

Infectious mononucleosis (IMN) is a self-limiting viral (Epstein-Barr virus) infection that affects mostly adolescents. One of the clinical findings in IMN is splenomegaly. Unfortunately, the splenomegaly is palpable only 50% of the time. The risk for spontaneous splenic rupture is highest 3 weeks after the onset of symptoms. Thus, most clinicians recommend return to contact sports after 4 weeks from the onset of symptoms. This patient presented 1 week after the onset of symptoms, so he can return to play in 3-4 weeks from the time he was examined. The athlete should be afebrile, well hydrated, and asymptomatic. Airway obstruction is usually not of concern. Disease transmission to teammates is possible in the acute phases.

The anterior cruciate ligament is attached to a portion of the lateral femoral condyle. The posterior cruciate ligament attaches to the medial femoral condyle. The lateral collateral and oblique popliteal ligaments attach proximal to this fragment. The intermeniscal ligament attaches the anterior horns of the menisci.

DISCUSSION: The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is lower with a double-row construct for small and medium-sized tears. This may be attributable to the stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing between the 2 techniques.

DISCUSSION: The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability. Since there is no Bankart lesion, open or arthroscopic labral repairs are not indicated. Nonsurgical management is possible if the patient does not want to undergo surgery; however, the recurrence rate is very high.

Humeral arthroplasty is indicated when there is a defect equivalent to more than 45 percent of the articular surface of the humeral head or dislocation that had been present for more than six months. Posterior dislocations is often missed during initial management. Twenty-five of forty-one dislocations were diagnosed in less than six months.( Hawkins RJ,JBJS 87)

Stress fractures can be seen in female athletes who develop the female athletic triad including amenorrhea, osteoporosis, and eating disorders. Any female athlete with a history of stress fractures should undergo a workup for this disorder. Workup should include obtaining a menstrual history, obtaining a nutritional consultation, and obtaining a bone density. When properly counseled, these athletes may return to high endurance sports activities. Although these athletes may require a change in training intensity or psychiatric consultation, it would not be the next step in management. Psychiatric consultation may not be necessary unless an eating disorder has been diagnosed. Serum calcium levels are normal in these patients. Tension-sided stress fractures of the femoral neck require surgical stabilization with internal fixation as opposed to compression-sided stress fractures that can be treated with rest and nonsurgical management.

As described by Segond in 1987, an avulsion fracture of the lateral tibial plateau is commonly referred to as a Segond fracture. Subsequent to 1987, several authors have also found that the lateral capsular sign represents, but is not limited to, a disruption of the middle third of the lateral capsule and a tear of the anterior cruciate ligament.

The radiographs show severe osteoarthritis of the shoulder. The best surgical option would be an arthroplasty. The major determining factor for which type of arthroplasty to choose is the integrity of the rotator cuff tendons. Although the radiographs do not reveal any obvious signs of rotator cuff failure, the patient had an open Bankart 20 years ago. The integrity of the subscapularis tendon following a previous open shoulder procedure is crucial in deciding which type of arthroplasty to consider. Range of motion and infraspinatus strength do not affect the decision-making process, assuming the rotator cuff is intact. Activity level can be important when deciding whether to proceed with an arthroplasty, but it is not as important as the rotator cuff integrity when choosing which arthroplasty to use.

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

DISCUSSION: Schilders and associates reported their results of treating adductor-related groin pain in competitive athletes. They reported that a single corticosteroid injection into the pubic cleft can be expected to provide at least 1 year of relief of adductor-related groin pain in a competitive athlete with normal findings on MRI. In contrast, when there is evidence of enthesopathy on MRI in this competitive athlete population, these injections are not therapeutic and are associated with a high likelihood of recurrence of symptoms. Hip arthroscopy is generally reserved for intra-articular problems. Percutaneous adductor tenotomy is not indicated for this condition. A bone scan is unlikely to provide any useful information for clinical decision-making. Rheumatology consultation is also not indicated in the absence of any evidence of inflammatory arthropathy. REFERENCES: Schilders E, Bismil Q, Robinson P, et al: Adductor-related groin pain in competitive athletes: Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007;89:2173-2178. Robinson P, Barron DA, Parsons W, et al: Adductor-related groin pain in athletes: Correlation of MR imaging with clinical findings. Skelet Radiol 2004;33:451-457.

Figure 1 is the MRI scan of a 61-year-old man who had left shoulder pain with a massive rotator cuff tear. Active forward elevation was 120°. Arthroscopic examination revealed that the rotator cuff tear was irreparable. The articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment option for pain relief in this patient?A. Biceps tenotomyB. Loose body removalC. Latissimus dorsi transferD. Reverse total shoulder arthroplasty

DISCUSSION: Nonsurgical treatment for a first-time traumatic dislocation may not be effective in a young, athletic patient; moreover, a Bankart lesion may be present in 70% of all traumatic subluxations. A period of immobilization in external rotation may decrease the risk for recurrence, but only if the patient is placed in a brace immediately and complies with the treatment. Return to play may be possible after 2 weeks of immobilization, provided the patient undergoes appropriate range of motion, cuff strengthening, and scapular stabilization exercises. Among athletes in 1 study, 80% were able to finish the season, but 40% experienced episodes of subluxation or recurrent dislocation prior to the end of the season. The rate of recurrence after arthroscopic stabilization should be lower than 10% and may be equivalent to open repair for most patients. Bone loss remains the primary indication for open procedures, as coracoid transfers or other bone-grafting operations may be needed to reconstruct the glenoid if more than 20% of its surface area is missing. Furthermore, collision athletes may fare better with open surgery than arthroscopic options. Bone loss remains the most significant factor for recurrence across many studies. Glenoid bone loss may be present in 20% of primary dislocations and 70% of recurrent dislocations. Age younger than 30 has a high correlation with recurrence. Although men may be almost twice as likely as women to have a recurrent dislocation, age seems to be the most reliable patient-related risk factor for recurrence. Thermal capsulorrhaphy has not proven to be effective and carries a high risk for complication. More recent studies have found equal recurrence rates between open and arthroscopic Bankart repair, with a greater loss of motion in patients who underwent open repair. Longitudinal studies have demonstrated that 40% to 50% are likely to develop arthritis after a shoulder dislocation; however, recurrent dislocation seems to be the most important factor for early development of arthritis, while age younger than 25 may be protective. Postcapsulorrhaphy arthropathy may be more associated with open repairs or those that severely limit external rotation.

DISCUSSION: The anteromedial bundle originates on the anterior and proximal aspect of the lateral femoral condyle and inserts on the anteromedial aspect of the anterior cruciate ligament (ACL) footprint on the proximal tibia. The posterolateral bundle originates posterior and distal to the anteromedial bundle and inserts on the posterolateral aspect of the tibial footprint. The fibers are parallel when the knee is in an extended position. As the knee moves into flexion, the fibers of the anteromedial bundle rotate externally with respect to the posterolateral bundle. The anteromedial bundle is tensioned in both flexion and extension. The posteromedial bundle is tensioned in extension, but relaxes as the knee moves into flexion. The lateral meniscus is more commonly injured with an acute injury to the ACL. The medial meniscus is injured more commonly when the ACL is chronically unstable. The ACL is an intra-articular and intrasynovial structure. It is innervated by posterior articular branches from the tibial nerve. Innervation of the ACL involves several types of mechanoreceptors (Ruffini, Pacini, Golgi tendon, and free-nerve endings) that may contribute to proprioceptive function of the knee and modulation of quadriceps function. Injury to the ACL is predominantly associated with instability to anterior translation of the tibia in extension. The ACL plays a secondary role to limit internal rotation of the tibia, and a loss of ACL stability is confirmed by the reduction of the tibia from a position of anterior translation and internal rotation (pivot shift). The radiographs demonstrate anterior placement of the femoral tunnel. The convex shape of the lateral femoral condyle can make it more difficult to visualize the anatomic femoral origin of the ACL. Failure to identify the anatomic footprint can result in anterior placement of the femoral tunnel. Anterior ACL graft placement can result in its impingement against the posterior cruciate ligament and early limitation of knee flexion. Over time, impingement on the graft may result in stretching of the graft and recurrent knee instability symptoms. RECOMMENDED READINGS: Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):204-13. Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006 Oct;14(10):982-92.

Physical and cognitive rest are recommended as treatment for sports-related concussion. Cognitive rest involves minimizing activities that require concentration and attention such as reading, schoolwork, video games, text messaging, working online, and playing games that require concentration such as chess. Limiting or eliminating video games after concussion is a form of cognitive rest.