JAAOS

JAAOS, Volume 14, No. 13


Back pain in athletes.

The athlete with back pain presents a clinical challenge. Self-limited symptoms must be distinguished from persistent or recurrent symptoms associated with identifiable pathology. Athletes involved in impact sports appear to have risk factors for specific spinal pathologies that correlate with the loading and repetition demands of specific activities. For example, elite athletes who participate in longer and more intense training have higher incidence rates of degenerative disk disease and spondylolysis than athletes who do not. However, data suggest that the recreational athlete may be protected from lumbar injury with physical conditioning. Treatment of athletes with acute or chronic back pain usually is nonsurgical, and symptoms generally are self-limited. However, a systematic approach to the athlete with back pain, involving a thorough history and physical examination, pertinent imaging, and treatment algorithms designed for specific diagnoses, can facilitate symptomatic improvement and return to play. There are no reliable studies examining the long-term consequences of athletic activity on the lumbar spine.

    • Keywords:
    • Athletic Injuries|Back Pain|Biomechanics|Humans|Intervertebral Disk Displacement|Magnetic Resonance Imaging|Physical Examination|Risk Factors|Spinal Diseases|Spinal Fusion|Spondylolysis|Sports|Sprains and Strains|Tomography

    • Emission-Computed

    • Single-Photon

    • Subspecialty:
    • Sports Medicine

    • Spine

Partial-thickness rotator cuff tears.

Partial-thickness rotator cuff tears are not a single entity; rather, they represent a spectrum of disease states. Although often asymptomatic, they can be significantly disabling. Overhead throwing athletes with partial-thickness rotator cuff tears differ with respect to etiology, goals, and treatment from older, nonathlete patients with degenerative tears. Pathogenesis of degenerative partial-thickness tears is multifactorial, with evidence of intrinsic and extrinsic factors playing key roles. Diagnosis of partial-thickness rotator cuff tears should be based on the patient's symptoms together with magnetic resonance imaging studies. Conservative treatment is successful in most patients. Surgery generally is considered for patients with symptoms of sufficient duration and intensity. The role of acromioplasty has not been clearly delineated, but it should be considered when there is evidence of extrinsic causation for the partial-thickness rotator cuff tear.

    • Keywords:
    • Acromion|Algorithms|Arthroscopy|Athletic Injuries|Biomechanics|Humans|Magnetic Resonance Imaging|Rotator Cuff|Rupture|Tendon Injuries

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

Surgical exposures of the humerus.

The neurovascular and muscular anatomy about the humerus precludes the use of a truly "safe" fully extensile approach. Working around a spiraling radial nerve at the posterior midshaft requires either a transmuscular dissection or a triceps-avoiding paramuscular technique. To gain maximal exposure, the radial nerve must be mobilized at the spiral groove. For exposure of only the proximal humeral shaft, many surgeons prefer the anterolateral approach because it uses the internervous plane between the axillary and deltoid nerves proximally and the radial and musculocutaneous nerves distally. Proximally, the deltopectoral approach to the shoulder continues to be the most widely used. However, the lateral deltoid-splitting approach is a viable, less invasive approach for both rotator cuff repair and fixation of valgus-impacted proximal humeral fractures. Distally, intra-articular exposure is dependent on triceps mobilization, either by olecranon osteotomy or triceps release; this exposure can be coupled with either a triceps-splitting or a paratricipital approach for proximal extension.

    • Keywords:
    • Arthroplasty|Brachial Artery|Fracture Fixation

    • Internal|Humans|Humeral Fractures|Humerus|Osteotomy|Radial Nerve|Rotator Cuff|Rupture|Ulnar Nerve

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

Surgical management of anterior cruciate ligament injuries in patients with open physes.

Because of the increasing number of skeletally immature athletes who compete in highly demanding sports, more children than previously are sustaining anterior cruciate ligament injuries. Treatment and patient compliance with treatment recommendations are problematic. Pediatric issues include those specific to evaluation, projected growth, and surgery. Strict activity modification can protect the knee from further injury and delay surgery, sometimes until maturity. Surgical options include physeal-sparing, partial transphyseal, and complete transphyseal procedures. Surgical procedures are demanding because typical drilling and fixation techniques can affect the physis and possibly lead to growth disturbances. A wide range of growth disturbances has been reported; these must be understood to perfect surgical technique and avoid potential growth concerns. Surgical challenges, options regarding delayed surgery, and possible outcomes all need to be clearly communicated to the patient and parents.

    • Keywords:
    • Anterior Cruciate Ligament|Child|Female|Femur|Humans|Knee Injuries|Magnetic Resonance Imaging|Male|Orthopedic Procedures|Physical Examination|Reconstructive Surgical Procedures|Rupture|Tibia

    • Subspecialty:
    • Sports Medicine

The hallucal sesamoid complex.

The hallucal sesamoids are vitally important to normal weight bearing and foot mechanics. The sesamoid complex of the hallux normally transmits up to 50% of body weight and during push-off can transmit loads >300%. These high stresses may lead to both acute and chronic pathologies of the hallucal sesamoids. Sesamoidal problems may occur in the weekend warrior or the elite-level athlete. Thus, patients with sesamoid pathology may present to a general orthopaedic surgeon, sports medicine physician, foot and ankle specialist, or podiatrist. Physical examination, radiographs, and other specialized studies assist with the classification of sesamoid pathology. Initial treatment almost always involves an accommodative orthosis, but surgical intervention may be necessary in recalcitrant cases. Surgical options for managing problems of the hallucal sesamoid complex include curettage, bone grafting, shaving, internal fixation, and partial or complete excision.

    • Keywords:
    • Cumulative Trauma Disorders|Fractures

    • Bone|Hallux|Humans|Inflammation|Orthopedic Procedures|Osteoarthritis|Sesamoid Bones

    • Subspecialty:
    • Foot and Ankle

Total disk arthroplasty.

Spinal fusion remains the gold standard for surgical management of instability and mechanical low back or neck pain. However, even in carefully selected patients, successful clinical results can be difficult to achieve. Reasons for failure include pseudarthrosis and adjacent spine segment disease. The theoretic advantages of removing the painful disk while preserving motion have led to increasing interest in total disk arthroplasty. Although disk replacements have been implanted in Europe for decades, the procedure is relatively new in the United States. Recently, two artificial disks for symptomatic lumbar degenerative disk disease have been approved by the US Food and Drug Administration; several others are undergoing clinical trials. Short-term studies demonstrate similar clinical improvements for both disk replacements and fusion procedures at up to 2-year follow-up. Issues requiring further research include optimal design specifications, potential complications, and appropriate patient selection. Consequently, the long-term benefit of total disk arthroplasty over fusion for the treatment of axial low back or neck pain remains to be determined.

    • Keywords:
    • Arthroplasty

    • Replacement|Cervical Vertebrae|Humans|Intervertebral Disk|Lumbar Vertebrae|Prostheses and Implants|Spinal Diseases|Spinal Fusion|Spine

    • Subspecialty:
    • Spine

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