Sports Medicine

Acromioclavicular joint (AC joint) dislocation or shoulder separation is one of the most common injuries of the upper arm. It involves separation of the AC joint and injury to the ligaments that support the joint. The AC joint forms where the clavicle (collarbone) meets the shoulder blade (acromion).

Causes

It commonly occurs in athletic young patients and results from a fall directly onto the point of the shoulder. A mild shoulder separation is said to have occurred when there is AC ligament sprain that does not displace the collarbone. In more serious injury, the AC ligament tears and the coracoclavicular (CC) ligament sprains or tears slightly causing misalignment in the collarbone. In the most severe shoulder separation injury, both the AC and CC ligaments get torn and the AC joint is completely out of its position.

Symptoms

Symptoms of a separated shoulder may include shoulder pain, bruising or swelling, and limited shoulder movement.

Diagnosis

The diagnosis of shoulder separation is made through a medical history, a physical exam, and an X-ray.

Conservative treatment options

Conservative treatment options include rest, cold packs, medications, and physical therapy.

Surgery

Surgery may be an option if pain persists or if you have a severe separation.

Anatomic reconstruction

Of late, research has been focused on improving surgical techniques used to reconstruct the severely separated AC joint. The novel reconstruction technique that has been designed to reconstruct the AC joint in an anatomic manner is known as anatomic reconstruction. Anatomic reconstruction of the AC joint ensures static and safe fixation and stable joint functions. Nevertheless, a functional reconstruction is attempted through reconstruction of the ligaments. This technique is done either through an open procedure or through an arthroscopically assisted procedure. A small open incision will be made to place the graft.

This surgery involves replacement of the torn CC ligaments by utilizing allograft tissue. The graft tissue is placed at the precise location where the ligaments have torn. The new ligaments gradually heal and help restore the normal anatomy of the shoulder.

Postoperative rehabilitation includes use of shoulder sling for up to 6 weeks followed by physical therapy exercises, which should be done for 3 months. This helps restore movements and improve strength. You may return to sports typically 5-6 months after surgery.

The ankle joint is composed of three bones: the tibia, fibula, and talus which are articulated together. The ends of the fibula and tibia (lower leg bones) form the inner and outer malleolus, which are the bony protrusions of the ankle joint that you can feel and see on either side of the ankle. The joint is protected by a fibrous membrane called a joint capsule, and filled with synovial fluid to enable smooth movement.

Ankle injuries are very common in athletes and in people performing physical work, often resulting in severe pain and impaired mobility. Pain after ankle injuries can either be from a torn ligament and is called ankle sprain or from a broken bone which is called ankle fracture. Ankle fracture is a painful condition where there is a break in one or more bones forming the ankle joint. The ankle joint is stabilized by different ligaments and other soft tissues, which may also be injured during an ankle fracture.

Causes

Ankle fractures occur from excessive rolling and twisting of the ankle, usually occurring from an accident or activities such as jumping or falling causing sudden stress to the joint.

Symptoms

With an ankle fracture, there is immediate swelling and pain around the ankle as well as impaired mobility. In some cases, blood may accumulate around the joint, a condition called hemarthrosis. In cases of severe fracture, deformity around the ankle joint is clearly visible where bone may protrude through the skin.

Types of fractures

Ankle fractures are classified according to the location and type of ankle bone involved. The different types of ankle fractures are:

• Lateral Malleolus fracture in which the lateral malleolus, the outer part of the ankle is fractured.
• Medial Malleolus fracture in which the medial malleolus, the inner part of the ankle, is fractured.
• Posterior Malleolus fracture in which the posterior malleolus, the bony hump of the tibia, is fractured.
• Bimalleolar fractures in which both lateral and medial malleolus bones are fractured
• Trimalleolar fractures in which all three lateral, medial, and posterior bones are fractured.
• Syndesmotic injury, also called a high ankle sprain, is usually not a fracture, but can be treated as a fracture.

Diagnosis

The diagnosis of the ankle injury starts with a physical examination, followed by X-rays and CT scan of the injured area for a detailed view. Usually it is very difficult to differentiate a broken ankle from other conditions such as a sprain, dislocation, or tendon injury without having an X-ray of the injured ankle. In some cases, pressure is applied on the ankle and then special X-rays are taken. This procedure is called a stress test. This test is employed to check the stability of the fracture to decide if surgery is necessary or not. In complex cases, where detail evaluation of the ligaments is required an MRI scan is recommended.

Treatments

Immediately following an ankle injury and prior to seeing a doctor, you should apply ice packs and keep the foot elevated to minimize pain and swelling.

The treatment of ankle fracture depends upon the type and the stability of the fractured bone. Treatment starts with non-surgical methods, and in cases where the fracture is unstable and cannot be realigned, surgical methods are employed.

In non-surgical treatment, the ankle bone is realigned and special splints or a plaster cast is placed around the joint, for at least 2-3 weeks.

With surgical treatment, the fractured bone is accessed by making an incision over the ankle area and then specially designed plates are screwed onto the bone, to realign and stabilize the fractured parts. The incision is then sutured closed and the operated ankle is immobilized with a splint or cast.

Post-operative care

After ankle surgery, you will be instructed to avoid putting weight on the ankle by using crutches while walking for at least six weeks.

Physical therapy of the ankle joint will be recommended by the doctor. After 2-3 months of therapy, the patient may be able to perform their normal daily activities.

Risks and complications

Risks and complications that can occur with ankle fractures include improper casting or improper alignment of the bones which can cause deformities and eventually arthritis. In some cases, pressure exerted on the nerves can cause nerve damage, resulting in severe pain.

Rarely, surgery may result in incomplete healing of the fracture, which requires another surgery to repair.

A sprain is the stretching or tearing of ligaments, which connect adjacent bones and provide stability to a joint. An ankle sprain is a common injury that occurs when you suddenly fall or twist the joint or when you land your foot in an awkward position after a jump. Most commonly it occurs when you participate in sports or when you jump or run on a surface that is irregular. Ankle sprains can cause pain, swelling, tenderness, bruising, stiffness, and inability to walk or bear weight on the ankle.

The diagnosis of an ankle sprain is usually made by evaluating the history of injury and physical examination of the ankle. X-ray of your ankle may be needed to confirm if a fracture is present. The most common treatment recommended for ankle sprains is rest, ice, compression and elevation (RICE).

• Rest: You should not move or use the injured part to help to reduce pain and prevent further damage. Crutches may be ordered that help while walking.
• Ice: An ice-pack should be applied over the injured area up to 3 days after the injury. You can use a cold pack or crushed ice wrapped in a towel. Never place ice directly over the skin. Ice packs help reduce swelling and relieve pain.
• Compression: Compression of the injured area helps to reduce swelling and bruising. This is usually accomplished by using an elastic wrap for a few days or weeks after the injury.
• Elevation: Place the injured ankle above your heart level to reduce swelling. Elevation of an injured leg can be done for about 2 to 3 hours a day.

The doctor may also use a brace or splint to reduce motion of the ankle. Anti-inflammatory pain medications may be prescribed to help reduce the pain and control inflammation.

During your recovery, rehabilitation exercises are recommended to strengthen and improve range of motion in your foot. You may need to use a brace or wrap to support and protect your ankle during sports activities. Avoid pivoting and twisting movements for 2 to 3 weeks. To prevent further sprains or re-injury you may need to wear a semi-rigid ankle brace during exercise, special wraps and high-top lace shoes.

Patellofemoral pain syndrome, also referred to as PFPS, is one of the most commonly reported knee problems, accounting for one in four knee complaints seen by orthopedists. To learn more about patellofemoral pain syndrome, let us first learn about normal knee anatomy and function.

Signs and symptoms of Patellofemoral Pain Syndrome can include the following:

• Pain in front of the knee, under and around the knee cap
• Increased pain when walking up stairs and especially with walking down stairs.
• Increased pain with kneeling and squatting
• Pain can worsen with activity and also occur with long bouts of inactivity
• Pain can occur in one or both knees
• Pain is usually described as “aching” but can also be “sharp” or “burning” pain
• A sensation that the knee may “give out” is often reported
• A grinding sensation can be felt or heard when the knee is extended
• Swelling around the knee can occur but is rare

Causes

Patellofemoral Pain Syndrome is caused by a multitude of factors that affect the way the patella moves along the groove of the femur (trochlear groove) when the leg is bent or straightened. The patella normally moves up and down with a slight tilt without touching the other knee bones. In PFPS patients, the patella rubs against the femur causing pain.

A combination of factors can cause this abnormal tracking and include the following:

• Overuse/overload injury: Repeated weight bearing impact sports such as soccer and running can cause PFPS.
• Anatomical defect: Flat feet and high arches can cause misalignment of the knee joint.
• Weak quadriceps muscles: Quadriceps, the anterior thigh muscles, function to help hold the kneecap in place during movement. Weak thigh muscles can lead to abnormal tracking of the patella, causing it to rub against the femur, producing pain in the kneecap.

Risk Factors

Anyone can develop patellofemoral pain at any point in their lives; however, there are certain risk factors that may predispose you to developing patellofemoral pain. These include the following:

• Starting a new physical activity
• Increasing the intensity of a physical activity too quickly
• Injury or trauma to the kneecap can lead to recurring episodes of instability
• Unusual alignment of the kneecap
• Arthritis
• Obesity
• Weak or tight thigh muscles
• Flat feet, knock knees, or high arches
• Females are affected more than men as wider hips increase stress on the kneecap
• Commonly seen in young athletes

Prevention

Although it may not always be possible to prevent Patellofemoral Pain Syndrome, there are some measures you can take to decrease your risk.

These include:

• Appropriate warm-up prior to beginning an activity
• Alternate high impact activities with low impact activities
• Run on softer surfaces
• Gradually increase distance or intensity level
• Proper footwear for your activity is essential
• Strengthening your quadriceps to prevent abnormal tracking of the patella
• Stop the activity if symptoms of PFPS occur with a gradual return once symptoms improve.

Diagnosis

Evaluating the source of patellofemoral pain is critical in determining your treatment options for relief of the pain. Knee pain should be evaluated by an orthopedic specialist for proper diagnosis and treatment.

Your physician will perform the following:

• Medical History
• Physical Examination

Depending on what the history and exam reveal, your doctor may order medical tests to determine the cause of your knee pain and to rule out other conditions.

Diagnostic Studies may include:

• X-rays
  • A form of electromagnetic radiation that is used to take pictures of bones
• CT Scan
  • This test creates 3D images from multiple x-rays and shows your physician structures not seen on regular x-ray.
•  MRI
  • Magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments.

Treatment Options: Acute

Treatment for patellofemoral pain will depend on the exact cause of the pain and whether the pain is acute or chronic.

Treatment guidelines for acute PFPS include:

Pain Medications: Over the counter NSAID’s (non-steroidal anti-inflammatory drugs) such as ibuprofen can help with the pain and any swelling.

Rest: Stay off the injured knee as much as possible and avoid activities that cause the pain as more damage could result from putting pressure on the injury. You can perform non-weight bearing activities such as swimming. Slow, gradual resumption of activities

Ice: Ice packs applied to the injury will help diminish swelling and pain. Ice should be applied over a towel to the affected area for 20 minutes every hour. Never place ice directly over the skin.

Treatment Options: Chronic

If your knee pain persists despite the above treatments, your doctor may suggest more intensive treatments. These may include the following:

Physical Therapy: PT can teach you the proper stretching and strengthening exercises appropriate for your condition. Weak or tight quadriceps (thigh muscles) is a common cause of PFPS, so focusing on this muscle group is a primary focus for treatment of PFPS. If the cause of your knee pain is a different muscle group, such as hamstrings, your therapist will individualize your exercises accordingly.

Bracing: Soft braces with cut outs over the patella may be suggested for support and alignment.

Taping: Your therapist may show you how to tape the knee to bring it into proper alignment.

Orthotics: Shoe inserts may be ordered when PFPS is caused by foot abnormalities, such as flat feet.

Treatment Options: Surgery

Although uncommon, surgical treatment is sometimes necessary to help relieve the pain if your PFPS persists and does not respond to conservative treatment. Your surgeon may recommend arthroscopy to evaluate your condition and repair or remove any fragmented cartilage.

The biceps muscle is present on the front side of your upper arm and functions to help you bend and rotate your arm.

The biceps tendon is a tough band of connective fibrous tissue that attaches your biceps muscle to the bones in your shoulder on one side and the elbow on the other side.

Overuse and injury leads to fraying of the biceps tendon and eventual rupture.

A Biceps tendon rupture can either be partial, where it does not completely tear the tendon, or complete, where the biceps tendon completely splits in two and is torn away from the bone.

The Biceps tendon can tear at the shoulder joint or elbow joint. Most biceps tendon ruptures occur at the shoulder and is referred to as proximal biceps tendon rupture. When it occurs at the elbow it is referred to as a distal biceps tendon rupture, however this is much less common.

Causes

Biceps tendon ruptures occur most commonly from an injury, such as a fall on an outstretched arm, or from overuse of the muscle, either due to age or from repetitive overhead movements such as with tennis and swimming.

Biceps tendon ruptures are common in people over 60 who have developed chronic micro tears from degenerative changes and overuse. These micro tears weaken the tendon making it more susceptible to rupturing.

Other causes can include frequent lifting of heavy objects while at work, weightlifting, long term use of corticosteroid medications and smoking.

Symptoms

The most common symptoms of a biceps tendon rupture include:

• Sudden, sharp pain in the upper arm
• Audible popping sound at the time of injury
• Pain, tenderness and weakness at the shoulder or elbow
• Trouble turning the arm palm up or down
• Bulge above the elbow (Popeye sign)
• Bruising to the upper arm

Diagnosis

Your doctor diagnoses a biceps tendon rupture after observing your symptoms and taking a medical history. A physical exam is performed where your arm may be moved in different positions to see which movements elicit pain or weakness. Imaging studies such as X-rays may be ordered to assess for bone deformities such as bone spurs, which may have caused the tear or an MRI scan to determine if the tear is partial or complete.

Treatment

Nonsurgical Treatment: Nonsurgical treatment is an option for patients whose injury is limited to the top of the biceps tendon.

Nonsurgical treatment includes:

Rest: A sling is used to rest the shoulder and you are advised to avoid overhead activities and heavy lifting until healed.

Ice: Applying ice packs for 20 minutes at a time, 3 to 4 times a day, helps reduce swelling.

Medications: Non-steroidal anti-inflammatory medicines help reduce pain and swelling.

Physical therapy: Strengthening and flexibility exercises help restore strength and mobility to the shoulder joint.

Surgical Treatment

Surgery may be necessary for patients whose symptoms are not relieved by conservative measures and for patients who require full restoration of strength, such as athletes.

Your surgeon makes an incision either near your elbow or shoulder, depending on which end of the tendon is torn. The torn end of the tendon is cleaned and the bone is prepared by creating drill holes. Sutures are woven through the holes and the tendon to secure it back to the bone and hold it in place. The incision is then closed and a dressing applied.

Risks and Complications

As with any surgery, complications can occur related to the anesthesia or the procedure. Most patients suffer no complications following biceps tendon repair, however, complications can occur and may include:

• Infection
• Nerve damage
• Re-rupture of the tendon