Dr. Slattery Brochures by Kyle

AC JOINT INJURIES

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WHAT IS THE AC JOINT? The AC (acromioclavicular) joint is a joint in the shoulder where the collarbone (clavicle) meets the shoulder blade (scapula). The specific part of the scapula adjacent to the clavicle is called the acromion, hence the name AC joint. This is in contrast to the glenohumeral joint, the main “ball and socket” shoulder joint.

WHAT KINDS OF PROBLEMS OCCUR AT THE AC JOINT? The most common problems that occur at the AC joint are arthritis, fractures and “separations.” Arthritis is a condition characterized by loss of cartilage in the joint. Like arthritis at other joints in the body, it is characterized by pain and swelling, especially with activity. Over time, the joint can wear out, leading to swelling and formation of spurs around the joint. These spurs are a

symptom of the arthritis and not the primary cause of the pain. Motions which aggravate arthritis at the AC joint include reaching across the body toward the other arm. AC joint arthritis is common in weight lifters, especially with the bench press, and (to a lesser extent) military press. AC joint arthritis may also be present when there are rotator cuff problems.

HOW DO YOU TREAT ARTHRITIS OF THE AC JOINT? There is currently no way to replace the cartilage that is damaged by arthritis. As a result, the primary way to control the symptoms of arthritis is to modify your activities so as not to aggravate the condition. Application of ice to the joint helps decrease pain and inflammation. Medication including aspirin, acetaminophen, and nonsteroidal drugs anti-inflammatory drugs (NSAIDs) are also used commonly.

WHAT CAN BE DONE IF THOSE TREATMENTS DO NOT WORK? If rest, ice, medication and modifying your activity does not work, then the next step is a cortisone shot. One shot into the joint sometimes takes care of the pain and swelling permanently, although the effect is unpredictable and may be only transient. Surgery may be indicated if nonsurgical measures fail. Since the pain is due to the ends of the bones making contact with each other, the treatment is removal of a portion of the end of the clavicle. This outpatient surgery can be performed through a small incision about one inch

long or arthroscopically using several small incisions. Regardless of the technique utilized, the recovery and results are about the same. Most patients have full motion by six weeks and return to sports by 12 weeks.

WHAT IS AN AC SEPARATION? When the AC joint is “separated” it means that the ligaments connecting the acromion and clavicle have been damaged, and the two structures no longer line up correctly. AC separations can be anywhere from mild to severe, and AC separations are “graded” depending upon which ligaments are torn and how badly they are torn. Grade I Injury — the least damage is done, and the AC joint still lines up. Grade II Injury — damage to the ligaments which reinforce the AC joint. In a grade II injury these ligaments are only stretched but not entirely torn. When stressed, the AC joint becomes painful and unstable. Grade III Injury — AC and secondary ligaments are completely torn and the collarbone is no longer tethered to the shoulder blade, resulting in a visible deformity.

WHAT IS THE TREATMENT FOR AC SEPARATION? These can be very painful injuries, so the initial treatment is to decrease pain. This is best accomplished by immobilizing the arm in a sling, and placing an ice pack to the shoulder for 20 to 30 minutes every two hours as needed.

AC JOINT INJURIES

Acetaminophen and non-steroidal antiinflammatory drugs can also help the pain. As the pain starts to subside, it is important to begin moving the fingers, wrist, and elbow, and eventually the shoulder in order to prevent a stiff or “frozen” shoulder. Instruction on when and how much to move the shoulder should be provided by your physician, physical therapist, or certified athletic trainer. The length of time needed to regain full motion and function depends on the severity or grade of the injury. Recovery from a Grade I AC separation usually takes 10 to 14 days, whereas a Grade III may take six to eight weeks.

WHEN IS SURGERY INDICATED? Grade I and II separations very rarely require surgery. Even Grade III injuries usually allow return to full activity with few restrictions. In some cases a painful lump may persist, necessitating partial clavicle excision in selected individuals such as high caliber throwing athletes. Surgery can be very successful in these cases, but as always, the benefits must be weighed against the potential risks. Expert Consultant: Edward McFarland, MD

Sports Tips are brought to you by the American Orthopaedic Society for Sports Medicine. They provide general information only and are not a substitute for your own good judgement or consultation with a physician. To order multiple copies of this fact sheet or learn more about other orthopaedic sports medicine topics, please visit www.sportsmed.org.

ANTERIOR CRUCIATE LIGAMENT (ACL) INJURY PREVENTION AOSSM SPORTS TIPS

ACL INJURY RATES The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee. Approximately 150,000 ACL injuries occur in the United States each year. Female athletes participating in basketball and soccer are two to eight times more likely to suffer an ACL injury compared to their male counterparts. Recent data from the Women’s National Basketball Association indicates white European-American players may be at increased risk for ACL injury compared with AfricanAmerican, Hispanic or Asian players. Athletes who have suffered an ACL injury are at increased risk of developing arthritis later on in life, even if they have surgery for the injury. ACL injuries account for a large health care cost estimated to be over half-billion dollars each year.

WHY DO ACL INJURIES OCCUR? Researchers believe there are external and internal factors associated with ACL injury. External factors include any play where the injured athlete’s coordination is disrupted just prior to landing or slowing down (deceleration). Examples of a disruption include being bumped by another player, landing in a pothole, or a ball deflection. Other external factors which have been studied include the effect(s) of wearing a brace, shoe-surface interface (how certain types of athletic footwear perform on different surfaces), and the playing surface itself.

Internal factors include differences in the anatomy of men and women, increased hamstring flexibility, increased foot pronation (flat-footed), hormonal effects, and variations in the nerves and muscles which control the position of the knee. Anatomical differences between men and women, such as a wider pelvis and a tendency towards “knock knee” in women, may predispose women to ACL injury. Differences in ACL injury rates between men and women seem to begin shortly after puberty because the nerve/muscle system (coordination) adapts at a slower pace than the anatomical and hormonal changes. It is possible that the incidence of injuries in women increases at this age because the nerve/muscle system (coordination) adapts to these changes at a slower rate than in men. Women also tend to have knees that are less stiff than men, placing more forces on the ligaments. In addition, the female hormone estrogen may relax or allow stretching of the ACL, thereby predisposing female athletes to ACL injury. Nerve/muscle factors pertain to the interaction and control of the knee by the quadriceps and hamstrings muscles in the legs. Researchers are very interested in studying this particular factor since it may be the easiest to modify.

HOW DO ACL INJURIES OCCUR? Careful study of videos of athletes tearing an ACL show that approximately 70 percent of these injuries are noncontact and 30 percent occur during contact. The noncontact injuries usually

Figure 1

Figure 2

occur during landing or sharp deceleration. In these cases, the knee at the time of injury is almost straight and may be associated with valgus (inward) collapse (see Figure 1). The athlete often lands with a flat-foot position and the leg is placed in front or to the side of the trunk.

ACL INJURY PREVENTION

PREVENTION OF ACL INJURY Several prevention programs have been developed in an attempt to decrease the incidence of noncontact ACL injuries. The focus of current prevention programs is on proper nerve/muscle control of the knee. These programs focus on plyometrics, balance, and strengthening/stability exercises. Plyometrics is a rapid, powerful movement which first lengthens a muscle (eccentric phase) then shortens it (concentric phase). The length-shortening cycle increases muscular power. An example would be an athlete jumping off a small box and immediately jumping back into the air after contact with the floor. Balance training commonly involves use of wobble or balance boards. On-field balance exercises may include throwing a ball with a partner while balancing on one leg. To improve single-leg core strength and stability, athletes perform exercises such as jumping and landing on one leg with the knee flexed and then momentarily holding that position.

PLYOMETRIC EXERCISES High-intensity plyometrics may be key in reducing the number of ACL injuries. To be most successful, plyometric training should be performed more than once per week for a minimum

of six weeks. Athletes are taught proper landing techniques which emphasize landing on the balls of the foot with the knees flexed and the chest over the knees (see Figure 2). The athlete should receive feedback on proper knee position to prevent inward buckling. Many of the newer programs are being adapted by coaches as an integral part of warm-up during practice, such as jumping over a soccer ball and landing in the correct position.

REFERENCES Boden BP, Dean GS Feagin JA et al. Mechanisms of anterior cruciate ligament injury. Orthopedics. 200;23:573-578. Hewett TE, Lindenfeld TN, Riccobene JV et al. The effect of neuromuscular training on the incidence of knee injury in female athletes: A prospective study. American Journal of Sports Medicine. 1999;27:699-706. Mandelbaum BR, Silvers HJ, Watanabe D et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: Two year follow up. American Journal of Sports Medicine. 2005;33:1003-1010. Expert Consultant: Barry P. Boden, MD

THE INJURED ACL

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WHAT IS THE ACL? ACL stands for anterior cruciate ligament of the knee. The knee is the largest and most complex joint in your body. It depends on four primary ligaments as well as multiple muscles, tendons and secondary ligaments to function properly. There are two ligaments on the sides of the knee: the medical collateral ligament (MCL) and

the lateral collateral ligament (LCL), and two crossed ligaments in the center of the knee, the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). The ACL connects the front top part of the shin bone to the back bottom part of the thigh bone and keeps the shin bone from sliding forward.

HOW IS THE ACL INJURED? One of the common ways for the ACL to be injured is by a direct blow to the knee, which commonly happens in football. In this case, the knee is forced into an abnormal position that results in the tearing of one or more knee ligaments. However, most ACL tears actually happen without contact between the knee and another object. Such noncontact injuries happen when the running athlete changes direction or hyperextends their knee when landing from a jump. These movements are common to all agility sports.

WHAT ARE THE SIGNS OF AN ACL TEAR? In many cases, when the ACL is torn, you will feel the knee give way with an audible â&#x20AC;&#x153;pop.â&#x20AC;? The injury is usually associated with a moderate amount of pain and continued activity is usually not possible. Over the next several hours, the knee becomes very swollen and walking becomes difficult. The swelling and pain usually increase over the first two days and then begin to gradually subside.

HOW IS AN ACL TEAR DIAGNOSED? Discomfort after an ACL tear is usually severe enough that the injured person will seek medical attention. The physician will examine the knee, and, in most cases, be able to identify which ligaments are injured. However, there may also be injuries to the joint surface that are more difficult to diagnose. At

THE INJURED ACL

times, swelling may make it difficult to diagnose a tear. This will necessitate the use of an MRI scan or arthroscope to ensure that an accurate diagnosis is made.

WILL I NEED SURGERY? The most frequent question after an ACL injury is “Will I need surgery?” The answer varies from person to person. Many factors must be considered by the patient and the physician when determining the appropriate treatment. These factors include the activity level and expectations of the patient, the presence of associated injuries (cartilage tears, etc.) and the amount of abnormal knee laxity. A young patient with an ACL tear and knee laxity who wants to return to competitive sports is more likely to require surgery for a satisfactory outcome. The older patient who can return to limited activity is less likely to require surgical stabilization. In either scenario, rehabilitation of the knee begins with exercises to help restore full range of motion. This is followed by strengthening exercises for the muscles around the knee. Return to sports with or without a brace is allowed only after leg strength, balance, and coordination have returned to near normal.

HOW ARE ACL TEARS TREATED SURGICALLY? Many different surgical approaches have been developed for the ACL injured knee. Years of experience have shown

that simply stitching the ligament together is rarely successful. Therefore, current techniques involve reconstructing the ACL by building a new ligament out of tissue harvested from one of the other tendons around the knee or from an organ donor. This tissue is passed through drill holes in the thigh bone and shin bone and then anchored in place to create a new ACL. Over time this graft matures and becomes a new, living ligament in your knee.

WHAT HAPPENS AFTER SURGERY? Rehabilitation of the knee after ACL reconstruction requires time and hard work. Time off from work varies depending on job type. Desk job employees can return in one or two weeks, whereas construction workers usually are not able to return for approximately three to six months. The same is true for athletes. The rate of rehabilitation may take even longer, depending on the specific requirements of the individual’s sport/activity and rate of recovery. The overall success rate for ACL surgery is very good. Many studies have shown that over 90 percent of patients are able to return to sports and workplace activities without symptoms of knee instability. Although some patients do complain of stiffness and pain after surgery, these problems have been minimized by current surgical techniques and aggressive rehabilitation. Expert Consultant: Wayne J. Sebastianelli, MD

ALPINE SKIING AND SNOWBOARDING INJURIES

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The popularity of skiing has increased dramatically in the past century. Since its inception in the 1960s, snowboarding has become increasingly popular as well. In fact, almost 40 percent of all “sliding snow” sports participants today are snowboarders. Skiing and snowboarding are both wonderful sports. As with most any physical activity, however, there is an element of risk. By following some basic guidelines and learning more about the risks, it is possible to decrease those risks. Remembering the following information can minimize your risks and allow more fun on the slopes.

from conditioning. One study looking at female ski racers found that their anterior cruciate ligament (ACL) injury rate was six times that of their male counterparts. Physical conditioning may have a significant impact on injury rates — that is, the better shape a skier is in, the less frequent the injuries. Most studies focus on destination ski resorts, where most skiers are vacationers. Injuries are most likely to occur on: 䡲

the first day of ski week;

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in the early morning when the skier is not warmed up;

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in the late morning and late in the day when fatigue sets in; and

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at the end of the week when the cumulative effects of the vacation make the skier tired.

HOW DO SKIERS GET HURT? Many variables affect injury rates in skiers, most commonly ability, age, gender, physical conditioning and snow conditions. Beginners have three times the injury rate of experts, but their injuries are less severe. Experts have less frequent but more severe injuries (head injuries, fractures and high grade ligament sprains). This is probably due to their higher speed on the ski slope. Intermediate skiers fall somewhere in-between. Another key factor is age. The highest injury rate is among 11 to 13 year olds. Their ability is intermediate, but their judgment is not as good as adults’. Injures in teenagers (13 to 20 year olds) are slightly less frequent, but more severe. Many have the skill levels of adults with immature judgment. Finally, children younger than 12 years old have twice the injury rate of adults, but fewer than that of adolescents. Females have twice the injury rate of males, which is thought to stem

Snow conditions affect injury patterns, as well. Hard pack snow generally yields high-speed and impact injuries. Powder and heavy snow is associated with more torsional or twisting injuries. Quick changes in snow conditions, such as hitting the line between groomed and ungroomed snow, may cause a fall that leads to an injury.

EQUIPMENT-RELATED INJURIES Skis have a rigid coupling with the foot that increases the forces to the leg and knee. These forces are often greater than our bodies can absorb. This bootbinding interface is the most common cause of equipment-related injury. The modern bindings, which release in a multidirectional pattern, have decreased the incidence of fractures by more than 80 percent. Unfortunately, knee liga-

ment sprains have not decreased and have actually increased over the last 20 to 30 years. Bindings are continuing to improve every year. If you have only one piece of equipment that is new, it should be your ski binding. To improve the safety of your skiing, your bindings should be no more than 3 to 4 years old. The release properties should be tested each year in a certified shop. You can also perform a self-release test each day of skiing by kicking out of your bindings. It is also very important to make sure that you have no dirt or grit in your binding or in the boot/binding interface. Boots are less important in the prevention of injuries, though you should be mindful of their proper fit and the amount of external wear on your boots. When buying boots, be sure to get a proper fit from a knowledgeable salesperson. Check that the toe and heel of your boots have little external wear and are clean. This will allow proper release from the binding. Proper ski length may also affect injury rate. Shorter skis are easier to turn and control but may be less stable at high speeds. Newer skis have more sidecut (the curve on the sides of your ski). This helps skiers of all ability levels carve turns more easily. Some research suggests that this feature may cause more twisting injuries to the knee. Regardless, it is important to keep your ski edges in good condition to allow for proper carving of a turn and to control your speed, especially on hard pack or icy conditions. Ski poles can influence thumb and hand injuries. When a skier falls on an outstretched hand that is holding a ski pole, the pole can cause a tear of the ALPINE SKIING

ulnar collateral ligament of the thumb. This is one of the most common injuries in skiing. The best way to prevent this injury is to drop your pole when you fall. It is important to not wear your ski pole straps. This allows the pole to fall away when you drop it. In deep powder snow this may not be as important. Ski clothing, goggles, and headgear are important as well. It is important to dress in layers to allow for adjustment to changing weather conditions. Goggles and sunglasses will protect your eyes from UV radiation, wind, snow and other hazards you may find on the slope. One important trend is the use of helmets on the ski mountain, which is analogous to biking helmets. After all, most of us would not go biking without a helmet, particularly at speeds in excess of 30 miles per hour. Head injuries are the most common cause of death from skiing collisions. Many of these may be prevented by wearing a helmet.

SNOWBOARDING INJURY TRENDS Snowboarding has a slightly higher potential for upper extremity injuries, but it may be safer on the knees. There is an increased rate of foot and ankle injuries associated with snowboarding. The lead foot has twice the number of injuries than the back foot. One study showed that the hybrid or “mid-stiffness” boots were the safest style of boots. There may be more high-energy injuries such as femur fractures, highspeed injuries and injuries caused by getting “big air.”

GENERAL INJURY PREVENTION 䡲

Prepare for the season and get in shape.

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Get your equipment checked at a certified shop.

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Self-release your bindings each day you ski.

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Warm up and stretch before skiing.

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Don’t ski while intoxicated.

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Wear a helmet.

ACL INJURIES One of the most common injuries in skiing is the ACL tear. Some experts say that incidence of this injury has tripled over the last 20 years. Vermont Safety Research has instituted a program to prevent ACL injuries in ski professionals. Their techniques, which have been shown to significantly reduce the ACL injury rate, are available from http://www.vermontskisafety.com/.

Expert Consultant: John D. Campbell, MD

ANKLE SPRAINS: HOW TO SPEED YOUR RECOVERY

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WHAT IS AN ANKLE SPRAIN? A sprain is a stretch injury of the ligaments that support the ankle. About 25,000 ankle sprains occur in the United States every day. The ligaments on the outside of the ankle are the most commonly injured when the foot is turned inward (inverted).

WHAT SHOULD I DO IF I SPRAIN MY ANKLE? Initial care is the same as for all other acute injuries: RICE (Rest, Ice, Compression, and Elevation). Use ice for 20 to 30 minutes each hour. Do not put the ice directly on the skin because it can cause frostbite. Wrap the ice in a wet towel or cloth to protect the skin. See a physician if you are unable to bear weight or if the ankle fails to improve within several days.

HOW SHOULD I REHABILITATE MY ANKLE? Rehabilitation can begin a few days after the injury, when the swelling starts to go down. There are three goals to aim for in rehabilitation.

lean forward with your hands on the wall, bend the front leg while keeping the back leg straight and both heels on the floor. Lean forward until you feel a gentle stretch, and hold for 10 seconds. Switch legs and repeat. 2. Restore strength. After 60 to 70 percent of the ankleâ&#x20AC;&#x2122;s normal motion has returned, you can begin strengthening exercises using a rubber tube for resistance. Fix one end of the tube to an immovable object like a table leg, and loop the other end around the forefoot. Sit with your knees bent and heels on the floor. Pull your foot inward against the tubing, moving your knee as little as possible. Return slowly to the starting position. Repeat with the other foot. You can also sit on the floor with your knees bent and the tube looped around both feet. Slowly pull outward against the tube, moving your knee as little as possible. Return slowly to the starting position. Repeat with the other foot. 3. Restore balance. As the ankle recovers and strength returns, balance is restored by standing on the injured leg, with the other foot in the air and your hands out to the side.

WHAT ARE THE SYMPTOMS OF AN ANKLE SPRAIN? The ankle is tender and swollen on the outside, below, and just in front of the ankle bone. Typically, the bone is not as tender at the area above and in front of it. A sprain may be mild, causing only modest pain, or severe enough to prevent weightbearing.

1. Restore motion and flexibility. Gently move the ankle up and down. After 5 to 7 days, start restoring motion to the hindfoot by turning the heel in and out. You should also begin to restore flexibility to the calf muscles. One way to do this is to face a wall with one foot in front of the other and

After the first week you may want to warm the ankle before doing these exercises by soaking it in warm water. Warmed tissue is more flexible and less prone to injury. Use ice when finished with the exercises to minimize any irritation to the tissue caused by the exercise.

ANKLE SPRAINS

WHEN CAN I RETURN TO SPORTS? Return to sports only after you have met these goals: 1. You have full range of motion in all directions (up and down, side to side, and in and out).

2. You have near-normal strength in all muscles around the ankle. 3. You have good balance. 4. You have no pain or swelling with exercise or activity.

SHOULD I USE A BRACE WHEN I PLAY SPORTS? Taping the ankle or using a brace for support can help prevent re-injury. There are many different types of braces: some made of neoprene, some made of elastic material, and some that have extra straps or ties for support. Select a brace that feels like it gives you the best support for the activity you want to do. Braces with straps or ties generally provide greater support. Never use a brace that is too tight. Remember, a brace helps support strong muscles but should never be used as a substitute for a strengthening program. Continue to do strengthening exercises as you return to sports. Expert Consultant: Andrew J. Cosgarea, MD

ARTHROSCOPY

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WHAT IS ARTHROSCOPY? Surgeons use arthroscopy as a means of seeing inside joints. Initially used as a diagnostic tool, Japanese surgeon, Watanabe, developed the technique of knee arthroscopy in the 1960s. More extensive procedures were popularized in the 1980s. Each year orthopaedic surgeons perform more than five million arthroscopies. During an arthroscopic procedure a small device called an arthroscope is inserted into a joint through a small cut. The tiny lens and fiber optic light of the arthroscope is connected to a camera and monitor that allows the orthopaedic surgeon to see inside the joint and perform a variety of different procedures.

WHEN DO YOU NEED ARTHROSCOPY? While many different conditions in many kinds of joints can be treated with an arthroscopic procedure, it is not right for every problem or every patient. A surgeon can tell if the problem can be treated with arthroscopy or if a more invasive approach may be better. Surgeons sometimes still use arthroscopy as a diagnostic tool, occasionally performing both arthroscopy and an open procedure afterward. Knee arthroscopy for a torn meniscus remains one of the most common orthopaedic procedures. The knee and the shoulder are the most common arthroscopy areas with more than four million knee arthroscopies and 1.4 million shoulder arthroscopies performed annually, worldwide. Most large or medium sized joints, such as knees and shoulders, can be repaired using arthroscopic approaches.

WHAT ARE THE ADVANTAGES OF ARTHROSCOPY

WHAT CAN BE EXPECTED FOLLOWING SURGERY

With the small incisions needed for arthroscopic procedures, these surgeries are typically less painful than similar open procedures. Arthroscopy also affords the surgeon an outstanding view of the inside of the joint with many different specialized techniques, procedures, and instruments. In most cases, surgery that years ago was done through an open approach now can be done via an arthroscopic approach, with similar long-term outcomes, decreased post-operative pain, and shorter hospital stays. Additionally, most arthroscopies are outpatient procedures.

Healing is different from patient to patient and from procedure to procedure. Even though the incisions are small, a surgeon may have done a large amount of work inside the joint. This can include tendon repair and reconstruction or joint articular cartilage surgery. The procedure performed will dictate a rehabilitation schedule much more than the size of the incisions. Every person is different, so be sure to ask the surgeon what to expect and when various activities are allowed post-operatively. Expert Consultant: Dan Solomon, MD

WHAT KIND OF ANESTHESIA IS AVAILABLE? Many arthroscopic surgeries are done using regional anesthesia during which only the area or extremity that is being operated on is anesthetized. General anesthetic may be preferred in some cases. A surgeon and anesthesiologist will work with you prior to surgery to determine the best solution.

WHAT ARE THE POTENTIAL COMPLICATIONS OF ARTHROSCOPY? Complications during or after most arthroscopic surgeries are rare, however, every surgery has risks. The complications which can occur during or following an arthroscopic procedure include: 䡲䡲䡲䡲

Blood clots Infection Joint stiffness Damage to nerves or blood vessels

ARTHROSCOPY

ARTICULAR CARTILAGE INJURIES

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WHAT IS ARTICULAR CARTILAGE? Articular cartilage can sometimes be confusing, because there are three different types of cartilage found in the body: articular or hyaline cartilage (covers joint surfaces), fibrocartilage (knee meniscus, vertebral disk), and elastic cartilage (outer ear). These different cartilages are distinguished by their structure, elasticity, and strength. In some joints, such as the knee, both articular cartilage and fibrocartilage are found functioning side-by-side as distinctly different structures with different functions. When the meniscus is injured, it is sometimes referred to as “torn cartilage” or “torn meniscus.” This is different than joint surface articular cartilage problems discussed here. Articular cartilage is a complex, living tissue that lines the bony surface of joints. Its function is to provide a low friction surface enabling the joint to withstand weight bearing through the range of motion needed to perform activities of daily living as well as athletic endeavors. Those daily activities include walking, stair climbing and work-related activities. In other words,

articular cartilage is a very thin shock absorber. It is organized into five distinct layers, with each layer having structural and biochemical differences.

HOW IS ARTICULAR CARTILAGE INJURED? Articular cartilage injuries can occur as a result of either traumatic mechanical destruction, or progressive mechanical degeneration (wear and tear). With mechanical destruction, a direct blow or other trauma can injure the articular cartilage. Depending on the extent of the damage and the location of the injury, it is sometimes possible for the articular cartilage cells to heal. Articular cartilage has no direct blood supply, thus it has little or no capacity to repair itself. If the injury penetrates the bone beneath the cartilage, the underlying bone provides some blood to the area, improving the chance of healing. Occasionally an articular cartilage fragment completely breaks loose from the underlying bone. This chip, called a loose body, may float in the joint interfering with normal joint motion. Mechanical degeneration (wear and tear) of articular cartilage occurs with the progressive loss of the normal cartilage structure and function. This initial loss begins with cartilage softening then progresses to fragmentation. As the loss of the articular cartilage lining continues, the underlying bone has no protection from the normal wear and tear of daily living and begins to break down, leading to osteoarthritis. Also known as degenerative joint disease, osteoarthritis is characterized by three processes:

1. a progressive loss of cartilage 2. the body’s attempt to repair the cartilage 3. destruction of the bone underneath the articular cartilage The cause of osteoarthritis is poorly understood, but lifelong moderate use of normal joints does not increase the risk. Factors such as high impact twisting injuries, abnormal joint anatomy, joint instability, inadequate muscle strength or endurance and medical or genetic factors can contribute to osteoarthritis.

WHAT ARE THE SIGNS OF AN ARTICULAR CARTILAGE DEFECT (INJURY)? In many cases, a patient will experience knee swelling and vague pain. At this point continued activity may not be possible. If a loose body is present, words such as “locking” or “catching” might be used to describe the problem. With mechanical degeneration (wear and tear), the patient often experiences stiffness, decreased range of motion, joint pain and/or swelling.

HOW IS AN ARTICULAR CARTILAGE DEFECT (INJURY) DIAGNOSED? The physician examines the knee, looking for decreased range of motion, pain along the joint line, swelling, fluid on the knee, abnormal alignment of the bones making up the joint and ligament or meniscal injury. Injuries to the articular cartilage are difficult to diagnose, and evaluation with MRI (magnetic resonance imaging) or arthroscopy

ARTICULAR CARTILAGE

may be necessary. Plane X-rays are not usually good in diagnosing articular cartilage problems but are usually taken to rule out other abnormalities.

WHEN IS SURGERY NECESSARY? When a joint is injured, the body releases enzymes that may further break down the already damaged articular cartilage. Injuries to the cartilage that do not extend to the bone will generally not heal on their own. Injuries that penetrate to the bone may heal, but the type of cartilage that is laid down is structurally unorganized and does not function as well as the original articular cartilage. Defects smaller than 2 cm have the best prognosis and treatment options. Those options include arthroscopic surgery using techniques to remove damaged cartilage and increase blood flow from the underlying bone (e.g. drilling, pick procedure). For smaller articular cartilage defects which are asymptomatic, surgery may not be required. For larger defects, it may be necessary to transplant cartilage from

other areas of the knee (joint). Consult your specialist for further information on the decision to have surgery. For patients with osteoarthritis, nonsurgical treatment consists of physical therapy, lifestyle modification (e.g. reducing activity), bracing, supportive devices, oral and injection drugs (i.e. non-steroidal anti-inflammatory drugs, cartilage protective drugs) and medical management. Surgical options are very specific to osteoarthritis severity and can provide a reduction in symptoms that are generally only short lived. Tibial or femoral osteotomies (cutting the bone to rebalance joint wear) may reduce symptoms, help to maintain an active lifestyle and delay the need for total joint replacement. Total joint replacement can provide relief for the symptom of advanced osteoarthritis, but generally requires a change in a patient's lifestyle and/or activity level. Expert Consultants: Daniel Romanelli, MD Diane S. Watanabe, ATC Bert R. Mandelbaum, MD

CORTISONE INJECTIONS

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WHAT IS CORTISONE? Injectable corticosteroid medications, commonly called “cortisone,” have been used by orthopaedic professionals since the early 1950s for a variety of conditions, including tendonitis, arthritis, tennis elbow, and carpal tunnel syndrome. Cortisone is naturally produced in the body through the adrenal gland and released when the body is under stress. Injectable cortisone is synthetically produced and is similar to the body’s own product. By minimizing inflammation, injectable cortisone can provide significant pain relief and allow for an earlier return to activity, whether to complete a weekend home repair effort or to win a football game. Cortisone injections are completely legal and different from the illegal anabolic steroids used to increase athletic strength and speed.

HOW DOES CORTISONE WORK? Cortisone is not a pain-relieving medication, but rather works by minimizing the body’s reaction to inflammation. When the inflammation is lessened, the pain is also. By injecting the medicine directly into the inflamed area, such as a wrist or shoulder joint, high concentrations of cortisone can be administered with minimal side effects. Discomfort usually improves within a few days and lasts for several weeks or permanently. If cortisone injections are used, they must be combined with the appropriate rest period and rehabilitation to gain the best results. Medical professionals are often hesitant to use these injections routinely for injury treatment as they may turn off the body’s “alarm system,” ultimately leading to a more significant injury later on.

WHO SHOULDN’T HAVE A CORTISONE INJECTION? There are very few contraindications in the use of cortisone injections. However, following conditions should be fully discussed with an orthopaedic professional before seeking a cortisone injection: 䡲

Infection of a joint (septic arthritis)

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Skin infection at the site of the injection

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Allergic reaction to previous cortisone injections

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Usage of blood thinners, such as Coumadin®

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Acute injury (head trauma, broken bones)

Finally, athletes should not receive cortisone injections into a joint or bursa sac immediately before competition, as the athletic activity may cause the injury to resurface, resulting in pain, swelling, and stiffness. In addition, an injection immediately before an athletic activity may increase the risk of infection due to sweat getting into the site.

WHAT ARE THE SIDE EFFECTS OF CORTISONE INJECTIONS? As with nearly any procedure where medications are injected into the body, adverse reactions may occur. The socalled “cortisone flare” reaction has been reported to occur in approximately two percent of patients. This occurs when the injected cortisone crystallizes and causes pain worse than before the shot. Fortunately, these “flares” usually do not last long and resolve with icing after 12 to 48 hours.

Whitening of the skin around the injection site is also a common side effect in dark-skinned individuals. This discoloration is not harmful, and usually reversible. Additional side effects include softening of cartilage and weakening of tendons at the injection site. This usually occurs in patients who receive shots on a weeklyto-monthly basis, during a period of months to years. Most surgeons currently recommend having injections at least three months apart and avoiding repeat injections within a short-time period. Diabetic patients may experience a temporary, but significant, elevation in blood sugar due to absorption of the cortisone into the bloodstream. Diabetic patients should therefore carefully monitor blood sugar levels for 24 to 48 hours following an injection. Although rare, infection at the injection site is another side effect. This can be avoided with proper skin sterilization using iodine and/or alcohol. Expert Consultant: Matthew J. Matava, MD

CORTISONE INJECTIONS

FLEXIBILITY AND STRETCHING

AOSSM SPORTS TIPS

OVERVIEW Flexibility is recognized as an important component of physical fitness. Like other components of fitness, flexibility is more important for some sports than others. For example, long distance runners tend to be relatively inflexible because the activity of running does not require large deviations in motion. However, sprinters, and especially hurdlers, require excessive hip motion for sprinting and hurdle clearance. Not only are flexibility requirements sports-specific, but they can also be joint- specific. In general, athletes must have sufficient musculoskeletal flexibility to meet the demands of the sport, otherwise top performance will not be achieved and injury risk will increase.

HOW CAN FLEXIBILITY BE DEVELOPED? An individual’s flexibility is a genetic attribute with potential for improvement with training and exercise. There are many approaches to stretching, but typically it involves some type of active and non-active (static) motion. Static stretches are thought to be safer because they involve a slow passive stretch to the targeted muscle, such as a straight leg raise for the hamstrings. The muscle is held in a stretched position for 10–60 seconds and is repeated two-to-six times. Active stretches are movements intended to be repeated and release the targeted muscle group without a hold period, such as standing with the knees straight, feet spread apart, and alternately touching the right foot with the left hand and the left foot with the right hand. Five to ten repetitions for

up to 60 seconds are typical. Injury risk may increase with active stretching if the movements are too fast. Active stretches are also an integral component of yoga. Many athletes may improve their flexibility by incorporating yoga movements into their training program. Regardless of the type of stretch to make improvements, it is essential that it sufficiently stresses the target muscle or joints. However, it is also important to avoid causing an injury by overstressing the target area. The general recommendation is to stretch to the point of mild discomfort, but not to the point of pain. One of the first noticeable improvements to a flexibility program is an increased tolerance of a stretch, where the perceived discomfort decreases. Improving flexibility will allow for an increase in joint range of motion. For long-term improvements in flexibility, stretching should be performed at least every other day, for a minimum of six-weeks. If the stretching regime is not maintained, the gains in flexibility will soon start to reverse.

WHAT IS THE INJURY RISK TO STRETCHING? The flexibility concerns of the athlete should be two-fold: 䡲

Is there sufficient specific flexibility to adequately perform the activities required

䡲

Is the overall flexibility sufficient so as not to place an increased risk for injury

Too often, the emphasis is on overall flexibility rather than addressing the specific flexibility requirements of a

given sport. The association between flexibility and injury risk is often overstated and interpreted simplistically. The inflexible or “tight” athlete may not be at an increased risk for injury. It is probably those athletes at either extreme of the flexibility realm that may increase their injury risk. The key is to determine the flexibility patterns typical for individuals in a given sport, and encourage the athletes with inadequate flexibility to work on specific stretching activities. Warm-up and stretching prior to a sports activity can also help prevent injury. It is important to differentiate between warm-up and stretching prior to an activity from flexibility. Flexibility is largely an inherent or intrinsic attribute while pre-activity warm-up and stretching are practices that an athlete chooses to perform. Warm-up and stretching are as important to the flexible athlete as the inflexible athlete. Warming-up by lightly exercising the major muscle groups for given activity has the same effect as stretching. Both activities decrease tension in the muscles and increase available joint motion.

HOW DOES AGING AFFECT FLEXIBILITY? Flexibility is known to decrease with age and the older athlete often complains of increased stiffness when performing habitual sporting activities. Loss of flexibility is common as one ages. The muscles simply get shorter throughout the aging process and subsequently lose their ability to operate effectively at the extremes of motion. Although flexibility exercises are useful in improving FLEXIBILITY AND STRETCHING

mobility, maintaining muscle strength by performing exercises such as the seated hip stretch is probably more important for the elderly.

SUMMARY Athletes must have sufficient flexibility to meet the demands of their sport, otherwise performance will be impaired and injury risks may increase. Flexibility patterns are specific to given sports and are typically quantified using non-active tests of maximum range of motion. Stretching techniques involving constant stretches or cyclic stretches are used to improve flexibility in the long-term and are also used as part of pre-activity warm-up. Expert Consultant: Stephen J. Nicholas, MD

FROZEN SHOULDER

AOSSM SPORTS TIPS

WHAT IS FROZEN SHOULDER? Frozen shoulder is also referred to as adhesive capsulitis and is characterized by pain and loss of motion of the shoulder joint. The exact cause of frozen shoulder is unknown, even though it has been found to affect somewhere between two and five percent of people during their lifetime. Diabetes, thyroid disorder, a history of shoulder trauma and periods of shoulder immobilization have been found to be risk factors that may lead to frozen shoulder. Females are also at higher risk. Occasionally, patients develop frozen shoulder after shoulder surgery or traumatic injury to the shoulder. Research suggests that the process is started with an inflammation of the lining of the joint within the shoulder. Gradually this area thickens and results in the shoulder becoming stiffer and more painful.

WHAT ARE THE SYMPTOMS OF FROZEN SHOULDER? Patients with frozen shoulder often have a significant amount of shoulder pain, both when they use their arm and at rest. It is often very painful and often cannot be traced to any particular injury or event. This painful period often lasts several months. During that time the shoulder joint becomes stiffer and patients lose their range of motion. This often affects sleep and common daily activities such as dressing, reaching behind the back and any overhead activity. Gradually, after several weeks or months, the shoulder pain will diminish when the patient is not using their arm and only be present with shoulder usage and with stretching. Patients with frozen shoulder usually

experience a dramatic difference in their range of motion between shoulders when motion is measured.

HOW IS FROZEN SHOULDER DIAGNOSED? The physician examines the shoulder for range of motion and compares it to the patient’s opposite side and to normal values. The diagnosis of frozen shoulder is usually evident after this examination and in combination with their physical history. Frozen shoulder does not appear on X-rays. Occasionally an MRI can confirm findings of frozen shoulder, but is often not needed.

HOW DOES FROZEN SHOULDER PROGRESS? A frozen shoulder typically progresses through three stages. Initially there is a “painful stage” where the shoulder is very painful at rest and with use. The shoulder gradually gets stiffer during this phase. This stage typically lasts about four months, but may last up to nine months. The next stage is the “frozen stage” when the shoulder is painful with movement, but the pain at rest is resolved. During this stage the shoulder is very stiff and is painful with attempts at movement. This stage can last four to 12 months. The last stage is the “thawing stage,” during which slow and steady return of motion occurs. This stage can last several months, as well. The entire course of a frozen shoulder can take 12 to 24 months to resolve.

HOW IS FROZEN SHOULDER TREATED? The treatment for frozen shoulder requires tremendous patience on the part of the patient and the treating physician. Frozen shoulder often takes a long time to improve and there are relatively few shortcuts. Treatment during the painful stage involves medication possibly, including cortisone injections. These injections may shorten the painful stage. The cortisone injection is placed inside the shoulder joint where the inflammation is located and where the pain is generated. Patients with frozen shoulder should do physical therapy and/or a home stretching program to help limit the loss of shoulder motion that occurs in the early stages. Stretches for frozen shoulder that are helpful include walking the fingers up the wall, pulling the arm/shoulder across the chest with the opposite arm, rotating the arm with a cane or broomstick, and pulling the arm behind the back. Once the shoulder becomes less painful at rest, physical therapy and stretching are helpful in restoring lost shoulder motion.

FROZEN SHOULDER

WHEN IS SURGERY NECESSARY? Fortunately, surgery is rarely necessary for frozen shoulder. In fact, surgery during the early stages of frozen shoulder should be avoided because the frozen shoulder will often return. Surgery can be performed after the majority of shoulder pain has resolved and is done to improve range of motion, if the “thawing” of the shoulder is not progressing appropriately. Treatment can also include arthroscopy which releases the thickened lining of the shoulder joint. This is followed by manipulation of the shoulder to break tissue free that is restricting the shoulder’s motion. Surgery is always followed by more therapy and stretching, to maintain any gains in range of motion. Consult your specialist for further information on the decision to have surgery. Expert Consultant: Brian R. Wolf, MD, MS

GOLF INJURIES

AOSSM SPORTS TIPS

Golf is a wonderful sport which has experienced an increase in popularity over the last 10 to 15 years. The National Golf Foundation’s records show an estimated 12.98 million core adult golfers, with over 27.8 million golfers in the United States alone as of 2004. There are over 16,000 golf facilities in the United States. In 2002, golfers spent over $24.3 billion on equipment and fees. The average golfer typically plays approximately 37 rounds per year and spends many more days practicing, so it is not surprising that the rate of injuries is on the rise. Golf, however, is perceived as a low-risk sport. Other sports such as football, basketball or skiing have higher injury rates, but several studies show that golf has its share of injuries, too. One recent study showed that during a two year period, 60 percent of golf professionals and 40 of amateurs suffered either a traumatic or overuse injury while golfing. Over 80 percent of the reported injuries were related to overuse.

TYPES OF GOLF INJURIES There are some unusual injuries associated with golfing. Errant backswings frequently deal blows to golfing partners. Golf clubs thrown in anger or disgust often injure their owners or others in proximity. Golfers also suffer bone-jarring sensations when their clubs strike the ground during a misplaced swing. Low back pain is the most common injury or complaint among both professional and amateur golfers, followed by injuries to the upper extremities (elbow and shoulder). Professional golfers experience a higher number of wrist

injuries, and amateur golfers experience more elbow problems. Both groups have a relatively high rate of shoulder injuries. Low back problems can occur as a result of the powerful rotation and extension motion in the golf swing. In elite golfers the golf swing can generate club head speeds of over 120 mph. In a study of PGA golfers, 33 percent had experienced low back problems of greater than two weeks’ duration in the past year. A 2004 study suggests that increasing the range of motion of lumbar spine extension and rotation of the lead hip (left hip in right-handed golfers) may decrease the incidence of low back pain. Golfers who carry their own bag have twice the incidence of back, shoulder and ankle injuries as those who do not carry their bag. The elbow is the second most commonly injured area in golfers. The two most common problems are medial epicondylitis (also known as golfer’s or thrower’s elbow) and lateral epicondylitis (more commonly known as tennis elbow). Both are thought to occur as a result of poor swing mechanics. Medial epicondylitis is thought to be caused by hitting shots “fat” (that is, hitting the ground first), and lateral epicondylitis may be caused by over-swinging with the right hand in right-handed golfers. Both of these problems increase with age and frequency of play. Good preround stretching of the upper extremity and a good strengthening program have been shown to decrease these problems. In professional golfers, injuries to the low back are followed in incidence by injuries to the wrist. The lead wrist (left wrist in right-handed golfers) is most commonly injured. The majority

of golf injuries are overuse injuries of the wrist flexor and extensor tendons. Such overuse injuries are treated with rest, splinting and either oral antiinflammatory medicines or steroid injections. Therapy exercises, altering swing mechanics and strengthening the forearm and hand muscles have also been shown to be beneficial. (See exercises for strengthening these areas.) Another commonly injured area in golfers is the shoulder. There are specific muscles in the shoulder that are most active in the swing. These are the subscapularis (one of the rotator cuff muscles), pectoralis (“Pecs”) and latissimus (“Lats”) muscles. Impingement syndrome (a bursitis and tendonitis in the shoulder), rotator cuff problems, and arthritis are the most common shoulder problems. These occur most frequently in the lead arm. A good warm-up routine and specific exercises that target the shoulder (see illustrations) can help decrease the incidence of these injuries.

INJURY PREVENTION Warming up before golfing has been shown to decrease the incidence of golf injuries. One survey showed that over 80 percent of golfers spent less than 10 minutes warming up before a round. Those who did warm up had less than half the incidence of injuries of those who did not warm up before playing. Lower handicap and professional golfers were more than twice as likely to warm up for more than 10 minutes as compared to other golfers. Many of these problems can be improved by using good swing mechanics. Instruction by a golf pro to improve

GOLF INJURIES

technique is one of the best ways to decrease your chances of being injured. A regular exercise program that includes core strengthening, stretching and strengthening all the major muscle groups can also help decrease your injury rate and increase your playing time.

LIGHTNING: A WORD OF CAUTION Lightning is a risk on any golf course. Every year there are injuries from lightning strikes. Golfers should seek safe shelter such as the clubhouse or a closed metal vehicle. Avoid standing in the middle of the fairway, near a metal pole or near isolated trees. It is also advisable to lie down in a sand trap and wait for the storm to be well past. Golfers should also consider separating from each other as opposed to staying together as a group. Know and follow the course’s guidelines for lightning safety.

REFERENCES 1. Cherington, M. Lighting injuries in sports: Situations to avoid. Sports Med 2001;31:301-8. 2. Pink, MM. Preventative exercises in golf: Arm, leg and back. Clin Sports Med 1996;15:147-62. 3. Kim DH et al. Shoulder injuries in golf. AJSM 2004;32:1324-1330. 4. Kohn, HS. Prevention and treatment of elbow injuries in golf. Clin Sports Med 1996;15:65-83. 5. McCarroll, JR. The frequency of golf injuries. Clin Sports Med 1996;15:1-7. 6. Murray, PM. Golf-induced injuries of the wrist. Clin Sports Med 1996;15:85-109. 7. Vad, VB et al. Low back pain in professional golfers: The role of associated hip and low back range-of-motion deficits. AJSM 2004;32:494-497. 8. Ludwig, K et al. Injuries and overuse syndromes in golf. AJSM 2003;31:438-443.

Exercise for building wrist extensor muscles.

Exercise for building wrist flexor muscles.

Exercise for forearm pronator muscles.

Expert Consultant: John D. Campbell, MD

Exercise for forearm supinator muscles.

Exercise to build up deltoid and external rotator cuff muscles.

Copyright © 2008. American Orthopaedic Society for Sports Medicine. All rights reserved. Multiple copy reproduction prohibited. Exercise to build internal and external rotator cuff muscles. Use dumbbells to add difficulty. You should be able to do 8–12 repetitions.

HAND AND WRIST INJURIES

AOSSM SPORTS TIPS

With so many bones, ligaments, tendons, and joints keeping hands and wrists working, there is ample opportunity for injury. In fact, injuries to the hand and wrists are some of the most common ailments facing athletes. If managed properly, however, most athletes can expect their injury to heal without any significant long-term disability.

WHAT ARE THE MOST COMMON SPORTS-RELATED HAND AND WRIST INJURIES? There are a number of injuries that may occur in an athlete’s hands or wrists. They can be classified into two main categories: traumatic (acute) and overuse (chronic). Traumatic injuries are more likely to occur in athletes who participate in sports that require higher levels of contact (i.e., football, hockey, or wrestling), whereas overuse injuries result in athletes who participate in sports that require them to “overdo” a particular movement (i.e., baseball, tennis, or golf). Some common traumatic injuries in athletes include joint dislocations, sprains, muscle strains, broken bones, tendon inflammation, and ligament tears. The most common fracture injury in the athletic population occurs in the fingers. Overuse injuries are stress-induced and include tendon inflammation and dislocation, nerve injury, and over use stress fractures. Long-term disability is less likely to occur from overuse injuries than from traumatic injuries. However, if left untreated, an athlete’s sports performance may be significantly diminished. Surgical treatment may be required if an injury persists.

WHAT SHOULD I DO IF I INJURE MY HAND OR WRIST? Should you sustain a hand or wrist injury while participating in a game where an attending team physician is not present, seek immediate medical care if any of the following symptoms are present: Severe pain 䡲 Severe swelling 䡲 Numbness 䡲 Coldness or grayness in the finger, hand, or wrist 䡲 Abnormal twisting or bending of the finger or hand 䡲 A clicking, grating, or shifting noise while moving your finger, hand, or wrist 䡲 Bleeding that does not slow and persists for more than 15 minutes. Contact your physician during regular practice hours if mild wrist pain, bruising, or swelling after an injury persists and does not improve after two weeks. 䡲

For minor hand injuries, home treatment, including rest, ice, compression, and elevation to the effected limb can help relieve pain, swelling, and stiffness. An anti-inflammatory medication such as ibuprofen or naproxen may also be taken to help with the pain and inflammation.

WHAT TREATMENT OPTIONS ARE AVAILABLE FOR HAND AND WRIST INJURIES? Treatment depends on the location, type, duration, and severity of the injury. While surgery is needed for some injuries, such as ligament tears, medication, “buddy-taping” (taping the injured finger to a neighboring

one for support), splints, braces, casts, or physical therapy may be used as a treatment option. Your doctor will determine the best option, taking into consideration short and long-term damage; deformities, and stiffness.

HOW CAN I PREVENT A HAND OR WRIST INJURY? Wearing wrist guards, gloves, and stretching are just a few ways to help prevent a traumatic hand or wrist injury. You can prevent overuse injuries by taking breaks to rest the hands or wrists, using proper posture and technique, and utilizing protective equipment. Expert Consultant Dan Matthews, MD

ADDITIONAL RESOURCES American Physical Therapy Association American Medical Society for Sports Medicine

HAND AND WRIST INJURIES

COMMON HAND AND WRIST INJURIES

INJURY

CAUSES/DESCRIPTION

SYMPTOMS

TREATMENT

RETURN TO PLAY

Jammed Finger

Striking the end of the finger while fully extended

Pain, swelling at the joint, difficult to bend, tenderness over the joint

Ice, rest, buddy tape to adjacent finger

As tolerated with buddy tape

Finger Fracture

Force of contact overwhelms strength of bone (ball, ground, helmet)

Pain, tenderness over the bone, deformity may be present

Ice, splint, doctor evaluation, X-rays

Only after proper evaluation, realignment from a physician, and wearing appropriate protection until healed

“Mallet” Finger

Impact on tip of finger leads to rupture of tendon that holds finger tip straight

Unable to hold small joint at finger tip out straight, tender just behind nail

Doctor evaluation, splinting finger in full extension 8 weeks

May return as tolerated in splint which must be worn at all times for 8 weeks

Nail Bed Injury

Impact or crushing injury on top of nail

Blood under nail, tender may represent tear in nailbed under nail

If blood covers >50% of nail, need doctor evaluation may need repair of nail bed

As tolerated

Finger Dislocation

Force on finger overwhelms ligaments and joint displaces

Most common at middle joint of finger, with visible displacement

Relocation of joint best performed by doctor, may require local anesthesia and X-ray evaluation. May require surgery.

After proper evaluation, use buddy tape or splint as determined by physician

Tendon Tear “Jersey Finger”

Force of grasp with object (jersey) pulling away, ruptures tendon

Most commonly seen in ring finger, unable to flex the joint at finger tip

Needs medical evaluation within 24–48 hours, requires surgery, possibly within 10 days

Only after surgical repair is fully healed. Early RTP places the athlete at risk of long-term problems with finger function and motion

Wrist Bone Fracture “Scaphoid”

Fall on outstretched hand

Pain with wrist motion, tenderness in wrist at the base of thumb

Needs doctor evaluation may require special X-ray (CT scan). May require surgery.

Not allowed until thorough evaluation by physician. If fracture present may be able to return with proper protection (cast) which is worn until healed.

Wrist Ligament Tear

Impaction or twisting injury of wrist

Pain in wrist with gripping rotation of wrist

Needs physician evaluation, X-rays, possible MRI

Not allowed until thorough evaluation by physician. Evaluation and early treatment can prevent long-term problems.

Ulnar Collateral Ligament Tear “Skiers Thumb”

Tear of ligament that stabilizes the thumb with grasping

Pain and instability of thumb with grasping objects

Needs physician evaluation, X-rays, may need surgery or casting

May return to play in cast protection.

Tendonitis

Repetitive activity of one specific movement

Tenderness over the tendon may feel “grading” over tendon with finger or wrist motion

Rest, ice, limitation of repetitive motion, NSAIDS

As tolerated

Stress Fractures

Repetitive activity overcomes strength of bones and leads to small fractures

Pain with activity, most commonly in lower extremities (running, jumping)

Physician evaluation, X-rays, bone scans, may need casting, surgery, must have rest, nutritional evaluation

Must rest and cease offending activity until fully healed. May need bone growth stimulator, casting, surgery

Growth Plate Stress

Over stressing bone of still growing children, most commonly seen in gymnastics (wrist bone), baseball pitchers(shoulder, elbow)

Persistent pain, tenderness swelling over growing bone, bone pain/tenderness

Physician evaluation rest, ice, must cease offending activity

Athlete cannot return to play until fully healed as growing problems can have long-term problems

MENISCAL TEARS IN ATHLETES

AOSSM SPORTS TIPS

WHAT IS THE MENISCUS? The human meniscus is a wedge shaped structure in the knee that consists of fibrocartilage, a very tough but pliable material. The medial meniscus is located on the inside of the knee (towards the middle of the body) and the lateral meniscus is located on the outside of the knee. Together, they act primarily as shock absorbers and stabilizers in the knee joint. They also help nourish the articular cartilage through their rich blood supply. This blood enhances the ability of the cartilage to repair itself.

HOW IS THE MENISCUS TORN OR INJURED? In young athletes, most injuries to the meniscus are the result of trauma. The menisci are especially vulnerable to injuries in which there is both compression and twisting applied across the knee. It is also common for the meniscus to be damaged in association with injuries to the anterior cruciate ligament.

View of Right Knee

In older athletes, many meniscal tears are the result of trivial trauma, like twisting the knee, squatting or through repetitive activities like running, which stress the knee joint. These tears happen because the meniscus has a tendency to degenerate as part of the aging process. This degeneration often takes place in conjunction with early arthritic changes in the knee joint.

HOW IS A MENISCAL TEAR DIAGNOSED? When a meniscus is torn, it will often produce pain, swelling and mechanical symptoms like catching, or locking, in the knee joint. An injury to the meniscus can be diagnosed based upon the history that the patient provides and a physical examination of the knee. The orthopaedic surgeon may also require further diagnostic studies like an MRI (magnetic resonance imaging) which provides a three-dimensional image of the interior of the knee joint. In some cases, surgeons may also recommend arthroscopic inspection of the knee joint, a minimally invasive surgical procedure.

HOW IS A MENISCAL TEAR TREATED? Certain patterns of injury, especially in younger patients, may call for repair of the meniscus. The decision to repair is based on many factors, including: location and pattern of the tear, age of the patient and predictability of whether the injury will be able to heal. Other patterns of tears, especially in older patients, are not suitable for repair. If the patient is symptomatic, and conservative treatment options

like physical therapy are not working, surgery to remove the torn section is recommended. This surgery is called arthroscopic partial meniscectomy and is usually performed on an outpatient basis, typically in one hour or less. Most patients ask, “What is the benefit of removing the meniscus? Isn’t it an important structure in my knee?” Clearly, the meniscus does play an important role in the human knee, but once torn and unable to be repaired, many of the beneficial effects of that structure are lost. If a tear is causing pain and impaired function, removal of that tear is the treatment of choice. Expert Consultant: Thomas L. Wickiewicz, MD

MENISCAL TEARS IN ATHLETES

OSTEOARTHRITIS AND EXERCISE

AOSSM SPORTS TIPS

WHAT IS OSTEOARTHRITIS? Osteoarthritis, or degenerative joint disease, is the most common type of arthritis, affecting nearly 20 million Americans. The disease gradually wears away the protective covering of the joint ends (articular cartilage). Once this cartilage wears away, it is not recreated and often progresses to painful bone–on-bone contact.

HOW IS OSTEOARTHRITIS TREATED? The best treatment is early intervention with a well-designed exercise program. For people who suffer with osteoarthritis, moderate intensity exercise has been shown to have a protective effect on the articular cartilage. Through proper exercise, nutrition and activity modification, most people are able to perform daily activities with minimal to no difficulty. The key is an active lifestyle.

HOW DO I DEVELOP AN APPROPRIATE EXERCISE PROGRAM? Every person has different goals for an exercise program. For people with osteoarthritis realistic goals include: 䡲

Reduced pain and inflammation

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Improved flexibility and range of motion

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Enhanced muscular strength

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Improved balance and coordination

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Enhanced muscular and cardiovascular endurance

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Loss of excess weight

If you have not exercised in some time, have cardiovascular problems, a family history of heart disease or are over 40 years old, consult your physician prior to beginning any exercise program. To determine the best exercises for your particular degree of osteoarthritis, consult an orthopaedic specialist for tests on bone quality, degree of arthritis, location of arthritis and the bony/joint alignment.

WHAT SHOULD AN EXERCISE PROGRAM ENTAIL? There are four components to an exercise program: 䡲

Warm-up

䡲

Stretching/flexibility

䡲

Aerobic

䡲

Anaerobic

Your exercise program should take 30 to 45 minutes to complete and should be performed three to five times a week.

Warm-up A warm-up helps the body get ready to exercise by elevating the heart rate slowly and increasing body temperature. Some warm-up activities include five minutes of mild intensity walking or riding a stationary bike.

Stretching/flexibility Flexibility is an essential element to joint health and relative to the individual. Everyone’s degree of flexibility varies greatly. Stretching should not be painful and should begin with easy stretches being held for 20 to 30 seconds each. Stretches to include in an exercise program are: 䡲

Standing, reach for toes

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Standing diagonal, reach for toes

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Arm across chest

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Hands over head

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Sitting on floor with knees straight, reach for toes

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Using railing or wall for balance, hold ankle behind buttocks

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Standing with one forefoot up on a small step, gently push heel to the floor

Aerobic Exercises A stationary bicycle may provide the best aerobic exercise for an arthritic patient. It is easy on the joints and maintains flexibility, motion and strength. Begin with five minutes on the bicycle and gradually increase by one minute or two per week. Other activities to incorporate that won’t injure the joints include: 䡲

Water aerobics

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Walking either outside or on a treadmill

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Elliptical trainers

OSTEOARTHRITIS AND EXERCISE

Anaerobic Exercises

SUMMARY

Strength training is beneficial for the prevention and treatment of osteoarthritis. Light to moderate resistance exercise is best, such as:

With all exercise programs, start slowly and gradually increase duration and activity intensity. Begin with light exercises and do not over do it in the first couple of weeks. Create a program that you enjoy and want to continue. Integrating your exercise program into your daily routine will help you progress and improve.

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Laying down straight leg raises

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Sidelying hip abduction/adduction

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One-half squat

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Knee flexion

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Calf raises

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Step lunges

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Arm circles

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Abdominal crunches

Do not use heavy weights as they may cause more wear and tear of the joint.

WHAT COULD PREVENT ME FROM DOING MY EXERCISE PROGRAM? If any of the following occur reduce or stop the exercise and consult your physician: 䡲

Increased joint pain

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Swelling

䡲

Increased stiffness

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Dizziness

䡲

Light headedness

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Shortness of breath

Expert Consultant: Dan Solomon, MD

OVERUSE INJURIES

AOSSM SPORTS TIPS

WHAT IS AN OVERUSE INJURY? There are basically two types of injuries: acute injuries and overuse injuries. Acute injuries are usually the result of a single, traumatic event (macro-trauma). Common examples include wrist fractures, ankle sprains, shoulder dislocations, and hamstring muscle strain. Overuse injuries are more subtle and usually occur over time. They are the result of repetitive micro-trauma to the tendons, bones and joints. Common examples include tennis elbow (lateral epicondylitis), swimmer’s shoulder (rotator cuff tendinitis and impingement), Little League elbow, runner’s knee, jumper’s knee (infrapatellar tendinitis), Achilles tendinitis and shin splints. In most sports and activities, overuse injuries are the most common and the most challenging to diagnose and treat.

WHY DO OVERUSE INJURIES OCCUR? The human body has a tremendous capacity to adapt to physical stress. In fact, many positive changes occur as a result of this. With exercise and activity, bones, muscles, tendons, and ligaments get stronger and more functional. This happens because of an internal process called remodeling. The remodeling process involves both the break down and build up of tissue. There is a fine balance between the two and if break down occurs more rapidly than build up, injury occurs. This can happen when you first begin a sport or activity and try to do too much too soon. If you begin playing tennis and

play for several hours in an attempt to improve rapidly, you are setting yourself up for an overuse injury. This is because you are trying to do too much and do not allow your body adequate time to recover. As a beginner, you may also have poor technique which may predispose you to tennis elbow. With overuse injuries, it often takes detective-like work to understand why the injury occurred.

WHAT FACTORS ARE USUALLY RESPONSIBLE FOR OVERUSE INJURIES? Training errors are the most common cause of overuse injuries. These errors involve a too rapid acceleration of the intensity, duration or frequency of your activity. A typical example is a runner who has run several miles three times a week without any problem. That runner then begins advanced training for running in a marathon, running a longer distance every day at a faster pace. Injury or break down is inevitable. Overuse injuries also happen in people who are returning to a sport or activity after injury and try to make up for lost time. There are also technical, biomechanical and individual factors. Proper technique is critical in avoiding overuse injuries. Slight changes in form may be the culprit. For this reason, coaches, athletic trainers and teachers can play a role in preventing recurrent overuse injuries. Some people are more prone to overuse injuries and this is usually related to anatomic or biomechanical factors. Imbalances between strength and flexibility around certain joints predispose to injury. Body alignment, like knock-knees, bow legs, unequal leg lengths and flat

or high arched feet, is also important. Many people also have weak links due to old injuries, incompletely rehabilitated injuries or other anatomic factors. Other factors include equipment, like the type of running shoe or ballet shoe, and terrain, hard versus soft surface in aerobic dance or running.

HOW ARE OVERUSE INJURIES USUALLY DIAGNOSED? The diagnosis can usually be made after a thorough history and physical examination. This is best done by a sports medicine specialist with specific interest and knowledge of your sport or activity. In some instances, X-rays are needed and occasionally additional tests like a bone scan or MRI are needed.

WHAT IS THE TREATMENT? Treatment depends on the specific diagnosis. In general, for minor symptoms, cutting back the intensity, duration or frequency of the offending activity brings relief. Adopt a hard/easy workout schedule and cross train with other activities that allow you to maintain overall fitness levels while your injured part recovers. This is very important for treating the early symptoms of overuse injuries. Working with a coach or teacher or taking lessons can assure proper training and technique. Paying particular attention to proper warm up before activity and using ice after activity may also help. Aspirin or other over the counter anti-inflammatory medications can also be taken to relieve symptoms.

OVERUSE INJURIES

If symptoms persist, a sports medicine specialist will be able to create a more detailed treatment plan for your specific condition. This may include a thorough review of your training program and an evaluation for any predisposing anatomic or biomechanical factors. Physical therapy and athletic training services may also be helpful.

The 10 percent rule is very helpful. In general, you should not increase your training program or activity more than 10 percent per week. This allows your body adequate time for recovery and response. The 10 percent rule also applies to increasing pace or mileage for walkers and runners, as well as to the amount of weight added in strength training programs.

CAN OVERUSE INJURIES BE PREVENTED?

Seek the advice of a sports medicine specialist when beginning an exercise program or sport to prevent chronic or recurrent problems. Your program can also be modified to maintain overall fitness levels in a safe manner while you recover from your injury.

Most overuse injuries can be prevented with proper training and common sense. Learn to listen to your body. Remember that “no pain, no gain” does not apply here.

Expert Consultant: Matthew J. Matava, MD

PATELLOFEMORAL PAIN

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WHAT IS PATELLOFEMORAL PAIN? Pain around the front of the knee is often referred to as patellofemoral pain. This pain may be caused by soft cartilage under the kneecap (patella), referred pain from another area such as the back or hip, or soft tissues around the front of the knee. In athletes, soft tissue pain in the retinaculum (tendon tissue) of the anterior (front of the knee) is fairly common. This may come from strain of the tendon â&#x20AC;&#x201D; which connects the kneecap to the lower leg bone (patellar tendon), upper leg bone (quadriceps tendon), or the retinaculum (which supports the kneecap on both the left and right sides). Some patellofemoral pain is caused because the kneecap is abnormally aligned. If the patella is not correctly

aligned, it may come under excessive stress, particularly with vigorous activities. This can also cause excessive wear on the cartilage of the kneecap, which can result in chondromalacia (a condition in which the cartilage softens and may cause a painful sensation in the underlying bone or irritation of the synovium [joint lining]).

TREATMENT OF PATELLOFEMORAL PAIN Treatment depends on the specific problem causing the pain. If the soft tissues (retinaculum, tendon or muscle) are the source of the pain, stretching, particularly in the prone (face down) position, can be very helpful to make the support structures more resilient and flexible. One simple stretch is to lie prone, grab the ankle of the affected leg with one hand and gently stretch the front of the knee. Hamstring stretching (rear thigh) can also be very helpful. It helps to warm up before doing these, or any other stretches. Other treatments may involve exercises to build the quadriceps muscle, taping the patella, or using a specially designed brace which provides support specific to the problem. Using ice and non-steroidal anti-inflammatory medications can also be helpful. It is often necessary to temporarily modify physical activities until the pain decreases. In more extreme situations, a specific surgical procedure may be needed to help relieve the pain. If the cartilage under the kneecap is fragmented and causing mechanical symptoms and swelling, arthroscopic removal of the fragments may be helpful. If the patella is badly aligned, however, a surgical

procedure may be needed to place the kneecap back into proper alignment, thereby reducing abnormal pressures on the cartilage and supporting structures around the front of the knee. In some people, particularly those who have had previous knee surgery, there may be a specific painful area in the soft tissue around the patella which may require resection (removal).

CONTROLLING OR PREVENTING PATELLOFEMORAL PAIN Good general conditioning is important. Stretching, particularly in the prone position, will keep the supporting structures around the front of the knee, flexible and less likely to be irritated with exercise. Proper training, without sudden increases of stress to the front of the knee, will help avoid pain. Weight reduction and activity modification may be necessary in some people. Expert Consultant: John P. Fulkerson, MD

PATELLOFEMORAL PAIN

PLANTAR FASCIITIS

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WHAT IS PLANTAR FASCIITIS? Plantar fasciitis is pain felt at the bottom of the heel. It is usually felt on the first step out of bed in the morning or when walking again after resting from a walking or running activity. However, plantar fasciitis pain can, if it persists, soon be felt any time you are walking, running or jumping.

pull your toes and foot toward your head, you will feel this tissue tighten.

ANATOMY OF THE PLANTAR FASCIA The plantar fascia consists of dense bands of tissue deep below the skin that extend out in a fan-like fashion from the heel bone to the toes. If you

Massage the plantar fascia by rolling your foot over a round tubelike object with a diameter of 3 to 4 inches. A rolling pin works nicely for this.

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Strengthen the muscles of the foot and ankle that support the arch. One way to do this is to scrunch up a hand towel with your toes or use your toes to pull a towel weighted with a food can across the floor.

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Warm up well before stretching. Cold tissues cannot stretch as effectively. After stretching, ice your heel for 20 to 30 minutes at the point of maximum tenderness to decrease any inflammation that may result from too vigorous a workout.

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Consider the use of oral antiinflammatory medications such as aspirin or ibuprofen. These medications can decrease the inflammation of the plantar fascia and thus decrease your symptoms so that you can stretch and improve your flexibility. In some cases, your physician may recommend a prescription antiinflammatory for you.

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Try a night splint. These devices, prescribed by your physician, keep the foot flexed at 90 degrees instead of the typical relaxed foot position of toes pointed down that occurs during sleep. Wearing a splint may lessen the pain of the first step in the morning.

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Massage the heel with a sports cream, which may lessen symptoms. A variety of “hands on” therapeutic treatments can also be administered by a physical therapist.

WHAT CAUSES PLANTAR FASCIITIS? Plantar fasciitis is thought to be caused by repetitive stretching of the tight bands of the plantar fascia which result in micro tears in these bands as they extend from the heel. Because these tears usually do not occur from a single traumatic event, an immediate healing reaction is not triggered. A chronic irritation or inflammation process thereby begins which increases with activity. A sudden weight gain may also increase stress to an otherwise normal plantar fascia. Pulling of the tight plantar fascia on the heel bone during activity can result in the formation of a bone spur off the tip of the heel bone, at the origin of the plantar fascia tissue. This bone spur itself is not the cause of pain, but rather the mechanical result of the chronic inflammatory process on the bone caused by the stretching of the tight tissue.

Although the pain is mostly felt at the bottom of the heel, it can also radiate down the entire bottom of the foot toward the toes. Plantar fasciitis is not usually associated with numbness or tingling.

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TREATMENT TIPS Surgery is rarely necessary to treat plantar fasciitis. To decrease your pain and symptoms, you may want to: 䡲

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Tape the heel and arch. Custom shoe inserts may be needed to support the arch and the heel. Increase the flexibility of the plantar fascia and calf muscles by doing stretching exercises. Tight calf muscles increase he stress on the plantar fascia and predispose you to plantar fasciitis.

PLANTAR FASCIITIS

HOW TO PREVENT PLANTAR FASCIITIS Always warm up well and stretch before participating in sports. Wear good, supportive shoes for your athletic activities.

Keep the muscles of your feet and ankles strong to support your arch. Donâ&#x20AC;&#x2122;t try running to lose weight after a rapid weight gain. Walk first, and stretch the muscles of the foot and calf to help condition your body before running. Avoid activities that cause pain in your heel. See your physician if pain persists despite these measures. Expert Consultant: Wayne J. Sebastianelli, MD

PREVENTING WRESTLING INJURIES

AOSSM SPORTS TIPS

Wrestling, one of the world’s oldest sports is offered at various levels of competition, including the Olympics, the American Athletic Union, the U.S. Wrestling Federation, and high school and college-sponsored tournaments. It’s a sport for all sizes of people. Competition rules require that athletes be paired against each other according to their weight class. Some competitions require that contestants be matched by age, experience, and/or gender. This not only allows more people to participate, but also decreases the risk for injury. Nevertheless, injuries do occur, particularly in the knee, shoulder, skin and head.

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WHAT ARE SOME COMMON WRESTLING INJURIES? The face and head are the most common areas to be injured during wrestling, including concussions, scrapes and bruises. However, knee injuries occur with more severity than all other injuries and are responsible for the most lost time, surgeries and treatments. Specifically, prepatella bursitis, ligament sprains and skin infections are among the most common injuries. 䡲

Prepatella bursitis Prepatella bursitis is the inflammation of the sac (bursa) located in front of the knee (patella). For wrestlers, the constant stance of being on the kneecaps can irritate the area and keep the kneecap from moving smoothly under the skin. Once prepatella bursitis has developed, it’s treated by anti-inflammatory medication, such as ibuprofen or aspirin, ice, rest, and kneepads.

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Ligament injuries Ligament injuries can also occur during wrestling, most commonly to the inside or outside of the knee. These injuries are often the result of the leg twisting outward from the midline of the body. First-degree strains can be treated with RICE (Rest, Ice, Compression and Elevation) and the athlete can return when the pain subsides. Second and third degree strains need to be treated by a physician, but they rarely need surgical intervention. Anterior cruciate ligament (ACL) strains are injuries that cause instability of the knee, and in most cases, require surgery for the athlete to compete at the same level. The wrestler can expect to return to competition sixto-nine months after surgery, following a rehabilitation program. Skin Infections With deadly infections such as MRSA developing in schools across the country, infection prevention is key. Epidemics of skin infections have been known to spread quickly from team member to team member with the three most common infections in wrestlers being herpes simplex, ringworm, and impetigo. With so much skin-to-skin contact, it is especially important to minimize risk by: 䡲

Taking routine and thorough showers both before and after practice and matches

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Wearing clean clothing at each practice session

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Sanitizing mats with antiseptic solution after each practice

If an infection does develop, a doctor should treat it promptly with antibiotics or antibiotic creams. Wrestlers may continue to drill or participate in conditioning workouts, but should avoid bodily contact with other team members until the infection is completely resolved.

HOW DOES WEIGHT CONTROL AFFECT WRESTLERS? Proper control of diet, preferably with the advice of the coach and a dietician, is the preferred method of “making weight.” If a wrestler maintains his weight near his weight class limits, it is then a simple matter to lose two-to-four pounds to “make weight.” Nutritional advice should emphasize daily caloric requirements associated with a balanced diet based on age, body size, growth, and physical activity level. Weight reduction in wrestling, unfortunately is practiced most commonly to “make a weight class.” This desire to make weight is often influenced by uninformed friends and other wrestlers. Such extreme tactics as utilizing rubber suits and a sauna to sweat off weight pose a health hazard and definitely weaken the wrestler before a match. Severe dehydration and food deprivation also diminish muscle strength and endurance, leading to a weakened physical condition. Additionally, entering a bout under these conditions will make the wrestler more susceptible to injury and illness. Recently, most wrestling associations have adopted regulations to ensure control of body weight by establishing

PREVENTING WRESTLING INJURIES

minimum weight certification programs. In these programs, each wrestler must weigh in during the first two weeks of the season. The athlete’s minimum weight is not established as the athlete’s best weight, but rather as no less than seven percent of his/her initial weigh-in.

Sports Tips are brought to you by the American Orthopaedic Society for Sports Medicine. They provide general information only and are not a substitute for your own good judgement or consultation with a physician. To order multiple copies of this fact sheet or learn more about other Orthopaedic sports medicine topics, please visit www.sportsmed.org.

SUMMARY An injury, no matter how trivial, should be treated as soon as possible. A small cut or scrape may not be of much consequence in hockey, football, or track athletes, but for a wrestler, even a minor infection can keep him out of a match. Any injury should be reported to the coach, trainer, or personal physician as soon as possible, so that proper care can be started. Rehabilitation after an injury is an important part of preventing further injury, since a large number of all injuries result from aggravation of an old injury. Injury prevention should be a primary goal of all participants, coaches, and trainers. This requires using good-quality equipment, including mats, uniforms, headgear and pads. The wrestler should be coached and supervised at all times, stressing proper technique and discipline to avoid injury. Proper officiating can also do much to prevent injuries. Finally, a well-structured strengthening program conducted under proper supervision can help prevent injury and enhance the athlete’s performance. Expert Consultant: Stephen J. Nicholas, MD

RETURN TO PLAY

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WHAT DOES RETURN TO PLAY MEAN? Return to play refers to the point in recovery after an injury or surgery when an athlete is able to participate in their sport or activity at a level similar to that before the injury or the surgery took place. No one likes to be sidelined with an injury. One of the goals of sports medicine is to enable an athlete to participate in his or her sport as soon as possible. When an individual returns before adequate healing and recovery, he or she can risk a re-injury and possibly a longer rehabilitation. When dealing with sports injuries, employing the right game plan — from early diagnosis and treatment to full functional rehabilitation — can often safely accelerate an athlete’s return to play.

WHAT WE CAN LEARN FROM THE PROS

hard with a physical therapist and/or a certified athletic trainer during their recovery. Additionally, they bring to their recovery what they bring to their sport: a positive attitude and a strong desire to get better as soon as possible. While you may not have access to many things professional athletes have, you can harness the power of a positive attitude for your own benefit during recovery.

TIPS FROM THE PROS TO SPEED YOUR RECOVERY 䡲

Maintain year-round balanced physical conditioning

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Make sure that injuries are recognized early and treated promptly

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Participate in a full functional rehabilitation program

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Stay fit while injured

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Keep a positive, upbeat attitude

HOW TO IMPROVE YOUR ROAD TO RECOVERY

Why does it seem that professional athletes return to play so much faster than recreational athletes? Professional athletes are usually in tremendous physical condition at the time of their injury. This fitness level helps them in many ways. Studies have shown that good conditioning can not only prevent injuries, but can also lessen the severity of an injury and help speed recovery.

Recovery from an injury proceeds with a series of logical steps beginning with the initial injury and ending with the athlete returning to his or her sport at a functional level similar to that before the injury. Each step should be outlined and monitored by your physician and your physical therapist.

Professional athletes usually get prompt treatment after an injury. This lessens the acute phase of the injury. Early treatment often means less swelling, stiffness and loss of muscle tone. In addition, the pros work extremely

During the acute phase, the emphasis should be to minimize swelling and decrease inflammation. This involves the RICE formula (Rest, Ice, Compression and Elevation) along with restricting activities. Depending on your injury,

treatment may also involve surgery, bracing or casting. During this initial period, it is very important to maintain overall conditioning while the injury heals. Creative techniques can be used to safely work around the injury. For example, a runner with a leg injury can often run in water or use a stationary bicycle to maintain conditioning. Even if one leg is in a cast, the rest of the body can be exercised by performing strength training exercises. Do not wait until your injury is healed to get back into shape. In the second phase of recovery, the athlete should work on regaining full motion and strength of the injured limb or joint. A specific plan should be outlined by a physician, physical therapist or certified athletic trainer. For most injuries, gentle protective range of motion exercises can be started immediately. Muscle tone can be maintained with the use of electrical stimulation or simple strengthening exercises. When strength returns to normal, functional drills may be initiated. This may include brisk walking, jumping rope, hopping or light jogging for lower extremity injuries and light throwing or easy ground strokes for upper extremity injuries. Specific balance and agility exercises can bring back coordination that may have been lost as a result of the injury. In addition, many therapists are now using “core stabilization” techniques to improve athletic function during rehabilitation. Core stabilization or strengthening involves performing specific exercises on a large rubber ball. Since many normal rehabilitation exercises

RETURN TO PLAY

are more difficult when performed on a ball, this enables the athlete’s central muscles – upper and lower back and abdominals, or “core” of the body — to become stronger. Once the athlete has progressed with improving motion, strength, endurance and agility, and is able to tolerate functional drills, he or she can try higher levels of functional tests and drills. These often incorporate sport-specific movement patterns on the field or court. These drills should be monitored by your physical therapist or athletic trainer. You may find that tape, braces or other supports help during this transition time. Only when the athlete is practicing at a high level without difficulty and the healing has progressed where the likelihood of re-injury is low is he or she ready to return to play. During these final phases of recovery, the athlete should be closely monitored and special attention given to adequate warm-up before, and icing after, the activity.

A WORD OF CAUTION Following a systematic progression of recovery not only lessens the chance of re-injury but enables the athlete to perform at his or her best when he or she returns to play. Frequently, athletes convince themselves that they are ready to return after the limp or the swelling subsides. They may feel ready to return, yet they are often only 70 to 75 percent recovered. This situation invites re-injury. Sports medicine experts are using medical technology to help athletes return safely from injuries with 100 percent recovery as quickly as possible. There is often tremendous pressure to get the athlete back as soon as possible, but the athlete’s health and safety must be placed above all other concerns. A systematic recovery plan is used successfully every day, at all levels of play, from the recreational athlete to the elite professional or Olympic athlete. Expert Consultant: Albert W. Pearsall IV, MD

RUNNING AND JOGGING INJURIES

AOSSM SPORTS TIPS

WHAT CAUSES RUNNING INJURIES? There are four periods of time when runners are most vulnerable to injury: 䡲

During the initial 4 to 6 months of running

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Upon returning to running after an injury

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When the quantity of running is increased (distance)

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When the quality of running is increased (speed)

Most running injuries are caused by recurring factors that runners can often prevent or avoid themselves: Training errors are the most common source of injury, particularly lack of adequate stretching; rapid changes in mileage; an increase in hill training; interval training (going from slow speeds over long distances to faster over less ground); and insufficient rest between training sessions. When selecting a running shoe, the athlete should look for a style that will fit comfortable and that will accommodate his or her particular foot anatomy. When a shoe’s mileage exceeds 500– 600 miles, it should be replaced. Runners should keep also in mind potential anatomic abnormalities: Hip disorders typically manifest themselves as groin pain. Back discomfort that radiates down the leg is cause for referral to a sports medicine specialist. The patella (kneecap) is a common site of overuse injuries that can benefit from a 20 minute ice massage, a program of stretching and strengthening of the

hamstring and quadriceps muscles and a short course of an over-the-counter anti-inflammatory medication. Surgery is rarely indicated. Ankle laxity can lead to frequent ankle sprains and pain. Beneficial treatment includes muscle strengthening to increase stability, shoe modification to alter gait, and change of a running surface. Foot problems in runners are related to foot types. Nonoperative treatment such as orthotics and shoe modifications should be used if necessary. The ideal surface on which to run is flat, smooth, resilient, and reasonably soft. Avoid concrete or rough road surfaces. If possible, use community trails that have been developed specifically for jogging and running. Hills should be avoided at first because of the increased stress placed on the knee and ankle.

per week) can be allowed after flexibility, strength and endurance has returned. When severe pain, swelling, loss of motion and/or other alterations in running form are present, immediate medical treatment is advised. (See reverse side for specific injuries.) The goal of rehabilitation is to safely return the runner to the desired level of running. Remember, training errors constitute the most common cause of injuries. A well-planned program prevents injury while benefiting the athlete. Expert Consultant: Matthew J. Matava, MD

During warmer, humid weather, increase fluid intake; in cool weather, dress appropriately. It is often helpful to weigh yourself before and after running on a hot, humid day. One pint of water should be consumed for every pound of weight lost. Avoid running during extremely hot and cold temperatures or when the air pollution levels are high. When running at higher altitudes, the runner should gradually acclimate to the lower oxygen levels by slow, steady increases in speed and distance.

HOW ARE RUNNING INJURIES TREATED?

The basic approach to treating running injuries includes rest or modification of activity to allow healing and reduction of inflammation. A gradual return to running (10 percent increase in mileage

RUNNING INJURIES

COMMON RUNNING AND JOGGING INJURIES

Injury

Cause/Description

Symptoms

Treatment

Plantar Fasciitis

Inflammation of fibrous connective tissue in sole of foot

Low-grade, insidious heel pain

Activity modification, nonsteroidal anti-inflammatory medication, heel/foot stretching, ice massage, soft heel pad

Metatarsalgia

Excessive pressure on ball of foot, abnormality, stress fractures

Pain in five long bones of the foot

Use of orthotics, activity modification, change to softer running surface

Stress Fractures

Fatigue or stress from frequent, repeated physical activity (overuse)

Localized pain over affected bone

Rest/immobilization; resume running gradually after 4â&#x20AC;&#x201C;6 weeks

Stress Fractures

Complete or hairline break in fibula or tibia

Localized pain over affected bone

Rest/immobilization; resume running gradually after 4â&#x20AC;&#x201C;6 weeks

Exertional Compartment Syndromes

Decrease of blood supply to leg muscles; caused by overuse

Leg pain, numbness, tightness and weakness in leg muscles

Surgery or cessation of running

Achilles Tendonitis

Repetitive overuse of Achilles tendon (hill running or increasing mileage too rapidly); may become chronic

Pain and tightness in calf, especially with uphill running

Rest, Achilles stretching, ice massage, anti-inflammatory medication, shoe appliances such as heel lifts

Medial Tibial Stress Syndrome (Shin Splints)

Inflammation of muscles, tendons, or bone coverings caused by imbalance in calf muscles and shin muscles

Pain along inner side of lower leg

Discontinuing exercise until pain subsides, icing of affected area, stretching, occasionally taping of the leg

Patellofemoral Joint Pain

Increased mileage, change in terrain, change in running shoe

Pain centering on kneecap

Anti-inflammatory medication, change running terrain (avoid hills), strengthen quadriceps

Meniscal Tear

Tearing of internal structures such as the meniscus

Pain, swelling, joint locking, buckling

Surgery to repair or remove torn cartilage

Tendonitis

Inflammation; can become chronic if not treated

Pain and tenderness in one of tendons surrounding knee

Rest until acute symptoms subside, icing, stretching, antiinflammatory medication

Bursitis

Bursa (fluid-filed sac between a tendon or muscle and bony prominence) becomes inflamed from chronic, repetitive use

Pain, superficial swelling

Rest until acute symptoms subside, icing, stretching, antiinflammatory medication

Hamstring Strains and Tendonitis

Overstretching involved muscle/tendons

Pain, tenderness, swelling in hamstring muscles in back of thigh

Rest, ice massage, stretching, nonsteroidal anti-inflammatory medication

Sciatica

Irritation of nerve(s) in lower back caused by lumbar disc herniation

Sharp, burning pain radiating down sciatic nerve into buttock and down back of leg

May indicate ruptured disk and should be evaluated and treated promptly by a physician

Lumboscral Strain

Abnormal strain of lower back muscles

Pain, spasms, and tenderness in lower back

Rest, stretching, and ice massage

Spinal Stenosis

Gradual narrowing of spinal canal

Back and hip pain, particularly in the older runner

Lying down usually relieves symptoms in minutes; can be treated by activity modification, stretching, and (occasionally) cortisone injections or surgery

FOOT

LEG

KNEE

THIGH/PELVIS

BACK

SHOULDER IMPINGEMENT

AOSSM SPORTS TIPS

WHAT IS SHOULDER IMPINGEMENT? Impingement refers to mechanical compression and/or wear of the rotator cuff tendons. The rotator cuff is actually a series of four muscles connecting the scapula (shoulder blade) to the humeral head (upper part of the shoulder joint). The rotator cuff is important in maintaining the humeral head within the glenoid (socket) during normal shoulder function and also contributes to shoulder strength during activity. Normally, the rotator cuff glides smoothly between the undersurface of the acromion, the bone at the point of the shoulder and the humeral head.

HOW DOES SHOULDER IMPINGEMENT OCCUR? Any process which compromises this normal gliding function may lead to mechanical impingement. Common causes include weakening and degeneration within the tendon due to aging,

the formation of bone spurs and/or inflammatory tissue within the space above the rotator cuff (subacromial space) and overuse injuries. Overuse activities that can lead to impingement are most commonly seen in tennis players, pitchers and swimmers.

HOW IS SHOULDER IMPINGEMENT DIAGNOSED?

rotator cuff muscles and the muscles responsible for normal movement of the shoulder blade. This program of instruction and exercise demonstration may be initiated and carried out either by the doctor, certified athletic trainer or a skilled physical therapist. Occasionally, an injection of cortisone may be helpful in treating this condition.

IS SURGERY NECESSARY? The diagnosis of shoulder impingement can usually be made with a careful history and physical exam. Patients with impingement most commonly complain of pain in the shoulder, which is worse with overhead activity and sometimes severe enough to cause awakening in the night. Manipulation of the shoulder in a specific way by your doctor will usually reproduce the symptoms and confirm the diagnosis. X-rays are also helpful in evaluating the presence of bone spurs and/or the narrowing of the subacromial space. MRI (magnetic resonance imaging), a test that allows visualization of the rotator cuff, is usually not necessary in cases of shoulder impingement, but may be used to rule out more serious diagnoses.

HOW IS SHOULDER IMPINGEMENT TREATED? The first step in treating shoulder impingement is eliminating any identifiable cause or contributing factor. This may mean temporarily avoiding activities like tennis, pitching or swimming. A nonsteroidal anti-inflammatory medication may also be recommended by your doctor. The mainstay of treatment involves exercises to restore normal flexibility and strength to the shoulder girdle, including strengthening both the

Surgery is not necessary in most cases of shoulder impingement. But if symptoms persist despite adequate nonsurgical treatment, surgical intervention may be beneficial. Surgery involves debriding, or surgically removing, tissue that is irritating the rotator cuff. This may be done with either open or arthroscopic techniques. Outcome is favorable in about 90 percent of the cases. Expert Consultant: Ben Shaffer, MD

SHOULDER IMPINGEMENT

CHEERLEADING INJURIES

AOSSM SPORTS TIPS

Legend has it that cheerleading started with a University of Minnesota student standing up in the stands and leading his fellow students in “cheering” for their team during a football game. Cheerleading has morphed drastically since that first instance. Today, it’s considered an athletic activity that incorporates elements of dance and gymnastics along with stunts and pyramid formations. In 2002, there were an estimated 3.5 million people in the U.S. participating as cheerleaders, from as young as six-years-old to those who cheerlead for professional athletic teams. While cheerleading is meant to support an athletic team, its intense competitions at the high school and collegiate levels have created a whole new dynamic, including increased risk for injury.

WHAT TYPES OF INJURIES ARE MOST COMMON IN CHEERLEADING? The Consumer Product Safety Council (CPSC) estimated that 16,000 emergency room visits occurred from cheerleading in 2002 (the latest year for data). While not as frequent as injuries in other sports, cheerleading injuries tend to be more severe. Cheerleading injuries make up more than half of the catastrophic injuries in female athletes. All areas of the body can be affected by cheerleading injuries, but the most commonly affected areas include the wrists, shoulders, ankles, head, and neck.

Ranging from height restrictions in human pyramids, to the thrower-flyer ratio, to the number of spotters that must be present for each person lifted above shoulder level. For example: the limit for pyramids is two body lengths at the high school level and 2.5 body lengths for the college level, with the base cheerleader in direct contact with the performing surface. Base supporters must remain stationary and the suspended person is not allowed to be inverted or rotate on dismount. Basket toss stunts in which a cheerleader is thrown into the air (sometimes as high as 20 feet) are only allowed to have four throwers. The person being tossed (flyer) is not allowed to drop the head below a horizontal plane with the torso. One of the throwers must remain behind the flyer at all times during the toss. Mats should be used during practice sessions and as much as possible during competitions. Cheerleaders should not attempt a stunt if tired, injured, or ill, as this may disrupt their focus causing the stunt to be performed in an unsafe manner. The importance of a qualified coach is also critical. Coaching certification is encouraged.

HOW CAN INJURIES BE PREVENTED?

Precautions should always be taken during inclement weather for all stunts. Also, a stunt should not be attempted without proper training, and not until the cheerleader is confident and comfortable with performing the stunt. Supervision should be provided at all times during stunt routines.

In an attempt to curb the amount of catastrophic injuries in cheerleading, restrictions have been placed on stunts.

As with any sport, proper conditioning and training are important to minimize injury, including:

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Targeting the lower back, stomach, and shoulders to gain strength through resistive exercises.

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Improving flexibility through regular stretching, yoga or pilates instruction

HOW ARE INJURIES TREATED? One of the more common injuries cheerleaders suffer is an ankle or wrist sprain or strain. For treatment of a sprain or strain, remember RICE: R Rest the injured site for at least 24 hours. I Ice the injury at least every hour for 10–20 minutes during the initial 4 hours after injury. Icing then can be done 10–20 minutes 4 times a day for two days. C Compress the injured site with a snug, elastic bandage for 48 hours. E Elevate the injured limb for at least 24 hours. Immediate medical attention is required for any cheerleader with a suspected head or neck injury. Basket toss

Reprinted with permission Boden et al.

CHEERLEADING INJURIES

References Campbell, John D, and Barry P. Boden. Cheerleading Injuries. Sports Medicine Update. September/October 2008. Boden BP, Tacchetti R, Mueller FO. Catastrophic cheerleading injuries. Am Journal of Sports Med. 2003;31 :881-888. Shields BJ, Smith GA. Cheerleading related injuries to children 5 to 18 years of age: United States, 1990-2002. Pediatrics. 2006; 117:122-129.

CONCUSSION IN ATHLETICS

AOSSM SPORTS TIPS

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Feeling more emotional

Traumatic induced alteration in mental status that may or may not be accompanied by loss of consciousness (LOC)

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Numbness or tingling

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Feeling mentally foggy

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Difficulty communicating

Disturbance of brain function without measurable change in brain anatomy

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Difficulty concentrating

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Difficulty remembering

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Visual problems (blurry or double vision)

WHAT IS A CONCUSSION? 䡲

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Also called Mild Traumatic Brain Injury (MTBI)

YOU DO NOT HAVE TO LOSE CONSCIOUSNESS TO HAVE SUSTAINED A CONCUSSION!

WHAT ARE THE SIGNS/SYMPTOMS AN ATHLETE HAS SUSTAINED A CONCUSSION?

HOW DO TRAINERS AND DOCTORS EVALUATE ATHLETES WHO MAY HAVE SUSTAINED A CONCUSSION? An initial evaluation should be performed by a trained coach, certified athletic trainer, or the team physician. This “sideline” evaluation should include the following: 䡲

Focused neurological exam

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Focused orientation exam

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Headache

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Nausea

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Immediate recall of event

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Vomiting

•

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Balance problems

Recall of play, opponent, game score, last meal etc.

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Dizziness

Recall name, birth date, place of birth etc.

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Fatigue

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Trouble falling asleep

Immediate short-term memory recall

Sleeping more than usual

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Symptoms list review

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Drowsiness

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Sensitivity to light

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Sensitivity to noise

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Irritability

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Sadness

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Nervousness

COMMON MISCONCEPTIONS ABOUT CONCUSSIONS “I didn’t get ‘knocked out’ so I didn’t have a concussion.” FALSE: Significant injury can occur without loss of consciousness “I just got my ‘Bell Rung,’ I didn’t have a concussion.” FALSE: The most common findings associated with getting your “Bell Rung” are consistent with concussion and may place the athlete at risk of developing Second Impact Syndrome (SIS). “Once the player ‘feels better,’ he can go back in the game.” FALSE: Experts recommend that no athlete should go back to competition during the same game if the athlete has findings consistent with a concussion.

WHAT IS SECOND IMPACT SYNDROME? Second Impact Syndrome is a potentially FATAL injury that occurs when an athlete sustains a second head injury before a previous head injury has completely healed. Unfortunately it is difficult to determine if the brain has healed from the first injury. Even after all symptoms have resolved, healing may not be complete and the brain may still be at increased risk of second impact syndrome. Neurocognitive testing may help doctors determine when it is safe to return to competition.

CONCUSSION IN ATHLETICS

WHAT IS NEUROCOGNITIVE TESTING? Neurocognitive testing is a questionnaire the athlete takes (usually by computer) that tests multiple areas of brain function including memory, problem solving, reaction times, brain processing speeds and post concussion symptoms. It is most valid if the athlete has a pre-injury baseline test on file to compare the post concussion test. This information can be very helpful to the physician in determining return to play. It is not a substitution for an evaluation by a physician.

IT IS RECOMMENDED THAT ALL ATHLETES WHO SUSTAIN A CONCUSSIVE EPISODE, NO MATTER HOW MINOR , UNDERGO AN EVALUATION BY A MEDICAL PHYSICIAN BEFORE RETURN TO PLAY

WHEN SHOULD A CONCUSSED ATHLETE RETURN TO PLAY?

WHAT ABOUT MRI AND CT SCANS?

Athletes can return to play after they are completely free of all symptoms of a concussion AND when athletes remain completely free of symptoms during and after physical testing.

CT scans and MRI are not helpful in the evaluation of Concussion or Mild Traumatic Brain Injury (MTBI). A physician may recommend these tests if there are other findings discovered during the evaluation of the athlete.

It is also recommended that athletes be given another neurocognitive test.

SOURCES

Neurocognitive testing can be a very helpful tool in determining brain function even after all symptoms of concussion have resolved. With a comparison baseline test this evaluation, in conjunction with a physicianâ&#x20AC;&#x2122;s examination, may reduce risk of Second Impact Syndrome. Research has shown that youth athletes may take longer than adults athletes for their testing to return to normal.

American Orthopaedic Society of Sports Medicine Concussion Workshop Chicago 1997 Collins, Gioia, Langlios 2007 Concussion Management Guidelines CDC Physician ToolKit International Conference on Concussion in Sport Vienna 2001, Prague, 2004, Zurich 2008.

Expert Consultant Dan Matthews, MD Sports Tips are brought to you by the American Orthopaedic Society for Sports Medicine. They provide general information only and are not a substitute for your own good judgement or consultation with a physician. To order multiple copies of this fact sheet or learn more about other orthopaedic sports medicine topics, please visit www.sportsmed.org.

FOOTBALL INJURIES

AOSSM SPORTS TIPS

Football is one of the most popular sports played by young athletes, and it leads all other sports in the number of injuries sustained. In 2007, more than 920,000 athletes under the age of 18 were treated in emergency rooms, doctor’s offices, and clinics for football-related injuries, according to the U.S. Product Safety Commission.

WHAT TYPES OF INJURIES DO FOOTBALL PLAYERS ENDURE? Injuries during football games and practice are some of the most common due to the combination of high speeds and full contact. While overuse injuries can occur, traumatic injuries such as concussions are most common. The force applied to either bringing an opponent to the ground or to resisting being brought to the ground makes football players prone to injury anywhere on their bodies, regardless of protective equipment. Traumatic Knee injuries in football are the most common, especially those to the anterior or posterior cruciate ligament (ACL/PCL) and to the menisci (cartilage of the knee). These knee injuries can adversely affect a player’s long-term involvement in the sport. Football players also have a higher chance of ankle sprains due to the surfaces played on and cutting motions. Shoulder injuries are also quite common and the labrum (cartilage bumper surrounding the socket part of the shoulder) is particularly susceptible to injury, especially in offensive and defensive linemen. Injuries to the acromioclavicular joint (ACJ) are also seen in football players and commonly referred to as “shoulder separations”.

Concussions Football players are also very susceptible to concussions. A concussion is a change in mental state due to a traumatic impact. Not all those who suffer a concussion will lose consciousness; however, some signs that a concussion has been sustained are headache, dizziness, nausea, loss of balance, drowsiness, numbness/tingling, difficulty concentrating, and blurry vision.

HOW CAN FOOTBALL INJURIES BE PREVENTED? 䡲

Have a pre-season health and wellness evaluation

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Perform proper warm-up and cool-down routines

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Consistently incorporate strength training and stretching

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Hydrate adequately to maintain health and minimize cramps

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Stay active during summer break to prepare for return to sports in the fall

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Wear properly-fitted protective equipment, such as a helmet, pads, and mouthguard

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Tackle with the head up and do not lead with the helmet

Overuse Low back pain, or back pain in general, is a fairly common complaint in football players due to overuse. Overuse can also lead to overtraining syndrome, where a player trains beyond the ability for their body to recover. Patellar tendinitis (knee pain) is a common problem that football players develop and can usually be treated by a quadriceps strengthening program. Heat Injuries Heat injuries are a major concern for youth football players, especially at the start of training camp. This usually occurs in August when some of the highest temperatures and humidity of the year occur. Intense physical activity can result in the body becoming depleted of salt and water due to excessive sweating. The earliest symptoms are painful cramping of major muscle groups. However, if not treated with body cooling and fluid replacement, this can progress to heat exhaustion and heat stroke — which can even result in death. It is important for football players to be aware of the need for fluid replacement and to inform medical staff of symptoms of heat injury.

Expert Consultant William N. Levine, MD Brett D. Owens, MD Sports Tips are brought to you by the American Orthopaedic Society for Sports Medicine. They provide general information only and are not a substitute for your own good judgement or consultation with a physician. To order multiple copies of this fact sheet or learn more about other orthopaedic sports medicine topics, please visit www.sportsmed.org.

FOOTBALL INJURIES

RUNNING TIPS FOR CHILDREN AND ADOLESCENTS AOSSM SPORTS TIPS

Running is a great form of exercise, recreation, and sport participation for adults, children, and adolescents. Whether running alone or in a team environment, running, when done properly, can enhance physical fitness, coordination, a sense of accomplishment, as well as physical and emotional development.

WHAT ARE SOME COMMON RUNNING INJURIES?

HOW CAN I PREVENT RUNNING INJURIES?

Running injuries in kids are relatively common and may include:

Prior to beginning your running program:

WHAT ARE THE SIGNS THAT I MIGHT HAVE A RUNNING INJURY? Signs that you may be injured or need to alter or stop your running:

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Knee injuries — kneecap pain, tendonitis

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Talk about running with a coach or a knowledgeable adult runner

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Lower leg pain — shin splints, stress fractures, calf problems

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Read information in a specialized running magazine or Web site

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Foot and ankle injuries — ankle sprain, heel pain, plantar fasciitis (bottom of foot pain), toe injuries

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Become acquainted with a local running club or talk with a high school running coach

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Pelvic and hip injuries — muscle pulls, growth plate stress injuries, tendonitis, groin pain, buttock pain

Plan running goals together:

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Pain or discomfort while running

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Pain or discomfort after running

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Pain at rest

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Trouble sitting

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Can’t sleep

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Trouble climbing stairs

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Limping

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Can’t feel fingers or toes

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Short of breath easily (exercise asthma)

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Weakness

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Irritated skin

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Stiffness

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Blisters

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Headaches during or after running

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Foot or leg pain

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Dizziness or light headed feeling any time

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Heat injuries — sunburn, dehydration, heat exhaustion and possibly stroke

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Children and parents should consistently discuss what the goals of the running program are

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Determine the reason (goal) you are running (fitness, recreation, training, competition, etc.)

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Develop a running plan and strategy which is compatible with your goal and your current level of fitness

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Set safe achieveable goals and advance slowly and cautiously

Prepare a training plan: 䡲

Hydrate (water) well in advance of running — run on a full tank to avoid dehydration

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Stretch for 5 minutes before beginning

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Start off walking

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Speed up slowly

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When ending, slow down for a few minutes

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Finish off by walking until your heart rate slows to a normal rate

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Stretch for 3 minutes when finished

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Drink more water — fill the tank back up

WHY IS IT IMPORTANT TO STOP RUNNING IF I’M HURT? Pushing through pain just makes the problem worse, which will keep you out of running for a long time. Stopping when there is a problem and correcting it, gets you back running again in the shortest, safest amount of time. Whenever there is a problem, contact your doctor immediately for proper diagnosis and treatment. Most of the time, problems are easily fixed, if attended to quickly.

YOUTH RUNNING

Use proper running attire: The local running store is a good place to start and ask questions. It’s important to remember the following: 䡲

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Light weight, breathable clothing prevents perspiration build up and allows for better body heat regulation Running hats, head covers, and ear covers shield the sun but allow temperature regulation. They are also excellent for cold weather to avoid frostbite Proper fitting and proper thickness socks help avoid blisters and irritations Proper shoes with good support arches should fit well and be comfortable Inspect your shoes before running; If they have worn thin or are angled, purchase new shoes Orthotic shoe inserts (commercial off the shelf or custom made) are especially valuable for people with flat feet, high arched feet, unstable ankles, or foot problems If running in rainy climates, wear waterproof, breathable gear Wear gloves in cold weather

Select safe locations and times to run: 䡲

Flat ground is more gentle on the body than hills

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Avoid steep hills

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Avoid banked streets (running on uneven surfaces)

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All purpose track surfaces (high school track) are ideal — especially for beginners

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Avoid busy streets

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Avoid streets without sidewalks

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Running in daylight is preferable to running in the dark

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Stay in well-lit areas (schools, public streets)

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Always run with a partner (preferably a teen or parent)

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Avoid night running

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A parent should always know: •

where you are running

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when you are running

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how far you are running

•

with whom you are running

•

when you expect to be back

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when you are done

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Use a bag to carry a cell phone with you

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Avoid using head phones, especially if you are running on the street (so you can hear traffic and warning sounds)

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Do not pet stray or strange animals

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Do not stop to talk to strangers

Run in safe weather conditions: Children and adolescents cannot tolerate the heat extremes that adults can, making them more susceptible to heat and cold injuries. Prevent heat illnesses (sunburn, dehydration, exhaustion, stroke) or cold injuries (frostbite) by monitoring the weather conditions. Avoid running if: 䡲

Temperatures are over 90 degrees

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High humidity conditions are present

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Cold or freezing temperatures are present

Expert Consultant: Robert Burger, MD

TENNIS ELBOW TENNIS ELBOW AOSSM SPORTS TIPS

AOSSM SPORTS TIPS

WHAT IS TENNIS ELBOW? Tennis elbow is a form of tendonitis that causes pain over the bony prominence called the lateral epicondyle on the outside of the elbow. It is often referred to as lateral epicondylitis.

and are responsible for extending or bending back the wrist and fingers. The tendons are fibrous bands that connect the muscles to the bone, in this case the lateral epicondyle. If too much stress is placed on these muscles and tendons, micro tears can occur at the site where the tendons attach to the lateral epicondyle(see drawing). These micro tears cause pain that is usually localized at the lateral epicondyle but the pain can occasionally radiate down the forearm. Aging appears to make these tendons more prone to breakdown. Therefore, lateral epicondylitis is more common once we get in our fourth decade of life and beyond. The pain increases with activities that require contraction of the affected muscles and tendons: shaking hands, turning doorknobs, picking up objects with the palm down or hitting a backhand in tennis.

symptoms consistent with tennis elbow and has pain when pressure is applied to the outside of the elbow. The patient frequently cannot remember an injury, but will have noticed the pain either at the beginning or end of an activity that requires wrist and elbow movement. X-rays are not always required when evaluating a patient with tennis elbow symptoms, but a doctor may wish to order them just to make certain that the bone structures of the elbow are normal.

HOW IS TENNIS ELBOW TREATED? Like many overuse injuries of sport, there is no sure-fire treatment. Rest itself does not necessarily cure the problem, but it may decrease the pain and allows healing to progress. Decreased activity with the elbow and wrist is generally preferred over absolute rest and complete inactivity. The healing of tennis elbow can take weeks to months. Some physicians believe that the key to healing this overuse injury lies in increasing the circulation to the area while decreasing the tightness of the muscles. Therefore, stretching and strengthening exercises are frequently helpful.

WHAT CAUSES IT? Tennis elbow is caused by repetitive stress on the muscles and tendons that are connected to the lateral epicondyle. These muscles extend along the top, or dorsal, side of the forearm to the wrist

HOW DO I KNOW IF I HAVE TENNIS ELBOW? No special tests are needed to make the diagnosis. This diagnosis is made by history and physician examination of the patient. The patient may present

The following exercise may help: Support the forearm on a flat surface with the wrist and hand free. Hold a 1 to 2 pound weight in the hand. Keeping the palm down, slowly extend the wrist. Bring it backward, or up, and then bend it forward, or down. The muscles on the top of the forearm should contract when the wrist is moved upward and stretch when the hand is moved downward.

TENNIS ELBOW

To balance the forearm muscles, these exercises should be repeated with the palm facing up. Each exercise should be repeated 10 times slowly. A loop of rubber tubing, with one end attached to a table leg or held on the floor with a foot, can be used to provide resistance instead of the weight. This will also increase circulation to the area. A snug, but not tight, strap worn around the top of the forearm often decreases the pull of the muscles on the lateral epicondyle and lessens pain. When symptoms are present during everyday activities, the band should be worn during all waking hours. Occasionally, an elbow sleeve with a pad specially designed to put gentle pressure over the forearm muscles can be used. This sleeve has the advantage of not only changing the pull of the muscles, but keeping them warm as well, which increases their flexibility and circulation. A physician may also prescribe ultrasound or electrical stimulation to increase circulation to the area. Nonsteroidal anti-inflammatory medications like aspirin, ibuprofen, and ketoprofen, or various prescription drugs can treat the symptoms and may decrease the pain and irritation in and around the tendon. However, it appears unlikely that these medications can actually evoke more rapid healing of the condition. Icing the joint after activity may also decrease the irritation and relieve the pain.

If treatment with decreased activity, exercises and medication is not effective, your physician may recommend a corticosteriod injection in the affected area. This can further decrease the pain and irritation. In some cases this is not effective and surgery can be considered for these resistant and chronic cases.

TIPS FOR PREVENTING INJURY 䡲

Warm up well before play. Muscles and tendons are like Silly Putty and stretch more when they are warm. Make sure to keep the muscles and tendons warm as you play.

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Choose appropriate equipment and maintain it properly. A racquet handle that is too big or too small, strung too tightly or loosely, or has a too big or too small head, may increase stress to the elbow and wrist during play.

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Condition for the activity by stretching and strengthening all the muscles used in the sport. Also evaluate play techniques to make sure that they are not irritating the condition.

Expert Consultants: Louis A. Almekinders, MD Matthew J. Matava, MD

TRAUMATIC SHOULDER DISLOCATION

AOSSM SPORTS TIPS

The shoulder has the greatest range of motion of any of the joints in the human body. It is also the most commonly dislocated joint in the body. The shoulder is comprised of the humeral head (ball) and the glenoid (socket). The shoulder, as opposed to the hip, has a very shallow socket similar to a plate or saucer. The joint capsule of the shoulder encases the entire ball and socket articulation, and is attached to the socket at the labrum (bumper of tissue surrounding the rim of the socket).

WHAT HAPPENS WHEN THE SHOULDER DISLOCATES? When the shoulder dislocates, the ball comes off the plate or socket. In many cases the person cannot get the ball back in by themselves, and medical attention is required. The shoulder typically dislocates when the elbow is away from the body and the arm is rotated in a way that the humeral head rolls over the front edge of the socket. Less commonly, the humeral head can be driven off the back of the socket with the arm in front of the body. In either case, the capsule and/or labrum typically tear away from the socket side of the joint when the ball dislocates. In some cases, the capsule and labrum may pull off a piece of bone from the edge of the socket as the ball dislocates. In some cases the shoulder does not dislocate completely, and the ball spontaneously returns to its normal location after being perched on the rim of the socket. This is called shoulder subluxation. Although the ball does not completely come out of the socket in these cases, capsule and/or labral tears may still occur. Other tissues

around the shoulder may be injured at the time of dislocation, including the rotator cuff tendons, the biceps tendon, the deltoid muscle and its accompanying nerve, and the cartilage surfaces of the ball and socket joint.

WHAT IS THE TREATMENT FOR ACUTE SHOULDER DISLOCATION? Typically, shoulder dislocations are not subtle and can be diagnosed clinically. In some cases the direction of dislocation is not obvious. If the dislocation is recognized immediately, it is possible for the person to “pull the shoulder back in” using their own muscles. After several seconds, however, the pain and muscle spasm from the dislocation typically prevents a person from getting their own ball back in their socket. In the majority of cases, the person seeks medical attention, X-rays are taken to identify the nature of the dislocation, and the shoulder is “reduced” (put back in) by a medical professional. Many different methods of reducing dislocated shoulders have been proposed and proven effective. Regardless of method, the goal is to obtain an adequate reduction of the joint without causing further damage. Pain medicine and sedation may be necessary to get the shoulder back into place. In some cases where the shoulder cannot be put back in, the patient may be taken to the operating room for surgical relocation of the joint. Immediately following successful reduction of the joint, X-rays are obtained to confirm the reduction and the patient is placed in an immobilizing device to prevent re-dislocation.

WHAT IS THE TREATMENT AFTER REDUCTION OF THE DISLOCATION? Patients suffering shoulder dislocation are typically placed in an immobilizing device for a short period of days to weeks, and early range of motion exercises are initiated to prevent stiffness. In many cases a physical therapist will be consulted to assist with return of motion. Pain medicine and/or anti-inflammatory medicines can be used to decrease pain and swelling. Later, gradual strengthening exercises are added to return the shoulder to more normal function. Restoring strength to the shoulder also helps prevent re-dislocation. Avoidance of contact sports and other activities where the arm may undergo significant rotation is necessary in the early post-dislocation period to prevent reinjury. Typically it takes several weeks to return to the routine activities of everyday life and several months to return to heavy lifting and contact sports. If the shoulder has dislocated more than once, a longer period of immobilization may be required. In some cases, a shoulder may dislocate multiple times despite adequate management. In these cases, surgery is the best choice.

WHAT IS THE EXPECTED OUTCOME FROM SHOULDER DISLOCATION? If the shoulder continues to be unstable despite adequate management, it is reasonable to pursue surgical solutions. In these cases, the capsule and/or labrum are repaired back to the bone

SHOULDER DISLOCATION

from which they tore using sutures and anchors into the bone. In many cases, these repairs can be carried out arthroscopically (minimally invasive), but in some cases “open repair” through a small incision remains the best option. Sometimes a combination of arthroscopic and open repair may be best. The younger a person is when they dislocate for the first time the more likely they are to re-dislocate over the course of their life. For example, a 20 year-old who dislocates for the first time has an 80 percent chance of re-dislocation later on. In many cases, shoulder instability can be treated non-operatively with good success. Full return to activity at all levels should be expected. In those cases in which instability occurs repeatedly, surgical solutions have been shown to be nearly 95 percent successful in returning patients to full activity with no limitations.

HOW CAN I PREVENT MY SHOULDER FROM DISLOCATING AGAIN? By increasing the strength of the rotator cuff muscles and avoiding activities which place the shoulder at risk, the likelihood of re-dislocation diminishes. The rotator cuff muscles help squeeze the humeral head into the glenoid socket, thereby increasing the stability. Rehabilitation commonly focuses on the strengthening of these muscles using resistance weights, rubber bands and cables. If surgical management is undertaken, post-operative rehabilitation begins in the first few days or weeks after surgery. The goal of this therapy

is to restore the range of motion and subsequent muscle strength to the shoulder without jeopardizing the stability of the recently repaired tissue. Generally, early exercises are limited to range of motion only, followed several weeks later by strengthening of the rotator cuff after the repaired tissue has had a chance to complete the early healing process. Generally, several months are required for the shoulder to return to normal range of motion and strength, and a subsequent return to full activity. Expert Consultant: Jeffrey R. Dugas MD