Sports Medicine

Sprains and strains are injuries affecting the muscles and ligaments. A sprain is an injury or tear of one or more ligaments that commonly occurs at the wrists, knees, ankles and thumbs. A strain is an injury or tear to the muscle. Strains occur commonly in the back and legs. Sprains and strains occur due to overstretching of the joints during sports activities and accidents such as falls or collisions.

Symptoms of sprains include pain, swelling, tenderness, bruising and joint stiffness. Symptoms of strains include muscle spasm and weakness, pain in the affected area, swelling, redness and bruising.

Immediately following an injury and before being evaluated by a medical doctor, you should initiate the P.R.I.C.E. method of treatment.

• Protection: Protect the injured area with the help of a support.
• Rest:Give rest to the affected area as more damage could result from putting pressure on the injury.
• Ice:Ice should be applied over a towel to the affected area for 15-20 minutes every two to three hours during the day. Never place ice directly over the skin.
• Compression: Wrapping the knee with an elastic bandage or an elasticated tubular bandage can help to minimize the swelling and support to the injured area.
• Elevation: Elevating the injured area above heart level will also help with swelling and pain.

Diagnosis involves a thorough physical examination. Your doctor will inspect the area of injury and joint mobility. X-rays or other tests may be ordered to rule out fractures or other pathology.

Your doctor may prescribe nonsteroidal anti-inflammatory drugs to reduce pain and inflammation. Physical therapy may be recommended for severe injuries. Surgery is rarely needed.

The hip joint is a ball and socket joint. The "ball" is the head of the femur, or thigh bone, and the "socket" is the cup shaped acetabulum. The joint is surrounded by muscles, ligaments, and tendons that support and hold the bones of the joint in place. Hip dislocation occurs when the head of the femur moves out of the socket. The femoral head can dislocate either backward (posterior dislocation) or forward (anterior dislocation).

Hip dislocation can be caused by injuries from motor vehicle accidents or severe falls. The common symptoms of hip dislocation include pain, inability to move your legs and numbness along the foot or ankle. A dislocation may also be associated with a fracture in the hip, back or knee bones. When you present to the clinic with these symptoms, your doctor performs a thorough physical examination and may order imaging studies such as X-rays to confirm the diagnosis.

Treatment involves reduction, in which your doctor repositions the bones to their normal position under anesthesia. Surgery may be performed to remove fragments of bone or torn tissues that block and prevent reduction. During your recovery, you are advised to limit movement and placing weight on the injured hip with the use of crutches. Physical therapy is vital in regaining the strength and mobility in your hip joint after treatment.

Acromioclavicular joint (AC joint) dislocation or shoulder separation is one of the most common injuries of the upper arm. It commonly occurs in athletic young patients and results from a fall directly onto the point of the shoulder. It involves separation of the AC joint and injury to the ligaments that support the joint. The AC joint forms where the clavicle (collarbone) meets the shoulder blade (acromion).

A mild shoulder separation is said to have occurred when there is AC ligament sprain that does not displace the collarbone. In more serious injury, the AC ligament tears and the coracoclavicular (CC) ligament sprains or tears slightly causing misalignment in the collarbone. In the most severe shoulder separation injury, both the AC and CC ligaments get torn and the AC joint is completely out of its position.

Anatomic reconstruction

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

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

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

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

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

Causes

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

Symptoms

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

Types of fractures

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

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

Diagnosis

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

Treatments

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

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

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

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

Post-operative care

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

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

Risks and complications

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

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

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

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

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

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

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

The foot has 26 bones, and can be divided into 3 parts:

• The hind foot is comprised of two bones, the talus bone which connects to the bones of the lower leg, and the calcaneus bone which forms the heel.
• The midfoot is comprised of the navicular, cuboid, and three cuneiform bones.
• The forefoot is made up of five metatarsal bones and 14 toe bones called phalanges.

The hind foot is separated from the midfoot by the medio tarsal joint and the midfoot is separated from the forefoot by the lisfranc joint. Muscles, tendons and ligaments support the bones and joints of the feet enabling them to withstand the entire body's weight while walking, running and jumping. Despite this, trauma and stress can cause fractures in the foot. Extreme force is required to fracture the bones in the hind foot. The most common type of foot fracture is a stress fracture, which occurs when repeated activities produce small cracks in the bones.

Types of foot fractures

Foot fractures can involve different bones and joints and are classified into several types:

• Calcaneal fractures: This type affects the heel bone and occurs mostly because of high-energy collisions. It can cause disabling injuries and if the subtalar joint is involved it is considered a severe fracture.
• Talar fractures: The talus bone helps to transfer weight and forces across the joint. Talus fractures usually occur at the neck or mid portion of the talus.
• Navicular fractures: Navicular fractures are rare and include mostly stress fractures that occur with sports activities, such as running and gymnastics, because of repeated loading on the foot.
• Lisfranc fractures: This type of fracture occurs due to excessive loading on the foot, which leads to stretching or tearing of the midfoot ligaments.

Causes

Foot fractures commonly occur because of a fall, motor vehicle accident, dropping a heavy object on your foot, or from overuse such as with sports.

Symptoms

The common symptoms of a foot fracture include pain, bruising, tenderness, swelling, deformity and inability to bear weight.

Diagnosis

Your doctor diagnoses a foot fracture by reviewing your medical history and performing a thorough physical examination of your foot. Imaging tests such as X-rays, MRI or CT scan may be ordered to confirm the diagnosis. Navicular fractures can be especially difficult to diagnose without imaging tests.

Treatment

Treatment depends on the type of fracture sustained. For mild fractures, nonsurgical treatment is advised and includes rest, ice, compression, and elevation of the foot. Your doctor may suggest a splint or cast to immobilize the foot. For more severe fractures, surgery will be required to align, reconstruct or fuse the joints. Bone fragments may be held together with plates and screws.

Physical therapy may be recommended to improve range of motion and strengthen the foot muscles. Weight bearing however should be a gradual process with the help of a cane or walking boot.

The wrist is comprised of two bones in the forearm, the radius and ulna, and eight tiny carpal bones in the palm. The bones meet to form multiple large and small joints. A wrist fracture refers to a break in one or more of these bones.

Types of wrist fracture include:

• Simple wrist fractures in which the fractured pieces of bone are well aligned and stable.
• Unstable fractures are those in which fragments of the broken bone are misaligned and displaced.
• Open (compound) wrist fractures are severe fractures in which the broken bones cut through the skin. This type of fracture is more prone to infection and requires immediate medical attention.

Causes

Wrist fractures may be caused due to fall on an outstretched arm, vehicular accidents or workplace injuries. Certain sports such as football, snowboarding, or soccer may also be a cause of wrist fractures. Wrist fractures are more common in people with osteoporosis, a condition marked by brittleness of the bones.

Signs and Symptoms

Common symptoms of a wrist fracture include severe pain, swelling, and limited movement of the hand and wrist. Other symptoms include:

• Deformed or crooked wrist
• Bruising
• Numbness
• Stiffness

Diagnosis

Your doctor performs a preliminary physical examination followed by imaging tests such as an X-ray of the wrist to diagnose a fracture and check alignment of the bones. Sometimes a CT scan may be ordered to gather more detail of the fracture, such as soft tissue, nerves or blood vessel injury. MRI may be performed to identify tiny fractures and ligament injuries.

Your doctor will order a bone scan to identify stress fractures due to repeated trauma. The radioactive substance injected into the blood gets collected in areas where the bone is healing and is detected with a scanner.

Treatment

Your doctor may prescribe analgesics and anti-inflammatory medications to relieve pain and inflammation.

Fractures that are not displaced are treated with either a splint or a cast to hold the wrist in place.

If the wrist bones are displaced, your surgeon may perform fracture reduction to align the bones. This is performed under local anesthesia. A splint or a cast is then placed to support the wrist and allow healing.

Surgery

Surgery is recommended to treat severely displaced wrist fractures and is carried out under the effect of general anesthesia.

External fixation, such as pins may be used to treat the fracture from the outside. These pins are fixed above and below the fracture site and are held in place by an external frame outside the wrist.

Internal fixation may be recommended to maintain the bones in proper position while they heal. Devices such as rods, plates and screws may be implanted at the fracture site.

Crushed or missing bone may be treated by using bone grafts taken from another part of your body, bone bank or using a bone graft substitute.

During the healing period, you may be asked to perform some motion exercises to keep your wrist flexible. Your doctor may recommend hand rehabilitation therapy or physical therapy to improve function, strength and reduce stiffness.

Risks and Complications

As with any procedure, wrist fracture surgery involves certain risks and complications. They include:

• Infection
• Residual joint stiffness
• Arthritis

A hip labral tear is an injury to the labrum, the cartilage that surrounds the outside rim of your hip joint socket. The hip joint is a ball and socket joint in which the head of the femur is the ball and the pelvic acetabulum forms the socket. The labrum helps to deepen the socket and provide stability to the joint. It also acts as a cushion and enables smooth movements of the joint.

Causes

A tear in the labrum of the hip can result from traumatic injury, such as a motor vehicle accident or from participating in sports such as football, soccer, basketball, and snow skiing. These sports are associated with sudden changes of direction and twisting movements that can cause pain in the hip. Repetitive movements and weight bearing activities over time can lead to joint wear and tear that can ultimately result in a hip labral tear. Degenerative changes to the hip joint in older patients can also lead to a labral tear.

Symptoms

Many patients with a hip labral tear do not have symptoms. However, some patients may experience pain in the hip or groin area, a catching or locking sensation in the hip joint, or significant restriction in hip movement.

Diagnosis

Your doctor will order certain tests to determine the cause of your hip pain.

X-rays of the hip allow your physician to rule out other possible conditions such as fractures or structural abnormalities.

Magnetic resonance imaging (MRI) may also be used to evaluate the labrum. An injection of contrast material into the hip joint space at the time of the MRI can help show the labral tears much clearer.

Injection of local anesthetic into the joint space is sometimes performed to confirm the location of the pain. If the injection completely relieves your pain, it is likely that the cause of the problem is located inside the hip joint.

Treatment Options

Treatment for a hip labral tear will vary depending on the severity of the condition. People with a minor labral tear recover within a few weeks with the help of non-surgical treatments.

Conservative treatments include:

• Medications: Anti-inflammatory medications can be helpful in relieving pain and reducing inflammation associated with labral tears. Your doctor may also recommend cortisone injections to alleviate the pain associated with a hip labral tear.
• Physical therapy: Physical therapy that helps to improve hip range of motion, strength, and stability are also recommended.

However, severe cases may require arthroscopic surgery to remove or repair the torn portion of the labrum.

Surgery

Hip arthroscopy, also referred to as keyhole surgery or minimally invasive surgery, is a surgical procedure in which an arthroscope, a narrow tube with a tiny camera on the end, is used to assess and repair damage to the hip.

The surgery is performed with the patient under general, spinal or local anesthesia.

Your surgeon will make 2 or 3 small incisions around the hip joint area. The arthroscope is inserted into the hip joint through one of the incisions to view the labral tear. The camera attached to the arthroscope displays the image of the joint on the monitor. A sterile solution will be pumped into the joint to have a clear view and room to work. Through the other incisions specially designed instruments are inserted. Your surgeon repairs the torn tissue by sewing it back together or removes the torn piece all together, depending upon the cause and extent of the tear. After the completion of the procedure, the arthroscope and instruments are removed and the incisions are closed.

Post- Operative Care

Following the surgery, you will be given instructions on caring for your incisions, activities to avoid and exercises to perform for a fast recovery and a successful outcome. Physical therapy will be recommended by your doctor to restore your strength and mobility. Your doctor will also prescribe pain medications to keep you comfortable.

Risks and complications

Possible risks and complications specific to arthroscopic hip surgery include:

• Infection
• Deep vein thrombosis(DVT)
• Blood vessel or nerve damage
• Hemarthrosis (bleeding inside the joint)
• Failure to relieve pain

A gluteus medius tear is a condition characterized by severe strain on the gluteus medius muscle that results in partial or complete rupture of the muscle.

The gluteus medius is one of the major muscles of the hip and is essential for movement of the lower body and keeping the pelvis level during ambulation. The gluteus medius muscle arises from the top of the pelvic bone and attaches to the outer side of the thigh bone or femur at the greater trochanter by the gluteus medius tendon. The muscle functions as a hip abductor, controlling side to side movement of the hip and providing stabilization to the joint. Gluteus medius tears often occur at the tendinous attachment to the greater trochanter of the femur bone.

Causes

The tear or rupture of the gluteus medius muscle is commonly seen in runners and athletes involved in high-impact sports such as soccer or basketball. It can occur from sudden bursts of activity and poor flexibility of the gluteus muscle. Any traumatic or overuse injury, or degenerative changes can also lead to partial or complete tear of the gluteus muscle.

Symptoms

The symptoms of a gluteus medius tear involve pain and tenderness over the lateral aspect of the hip which may be aggravated with activities such as running, climbing stairs, prolonged sitting or walking, and lying on the affected side of the hip. One of the main symptoms of a gluteus medius tear is the presence of trendelenburg sign, evidenced by dropping of the pelvis towards the unaffected side during ambulation from being unable to properly bear weight on the affected limb.

Diagnosis

The diagnosis of a torn gluteus medius muscle starts with a physical examination of the patient including palpation of the affected muscle, testing muscle strength and assessing the walking pattern or gait of the patient. Special tests such as single-leg squat test or positive trendelenburg sign confirms the diagnosis of a gluteus medius tear. MRI or ultrasound may be helpful to view the pathological changes of the muscle.

Treatment

The aim of treatment is to restore the normal function of the gluteus medius muscle. Immediately following the rupture, RICE therapy is initiated and involves:

• Rest
• Ice
• Compression
• and
• Elevation

Medications such as non-steroidal anti-inflammatory drugs or NSAIDs and steroid injections may be given to reduce the pain and inflammation. You should use a pillow between your legs when sleeping and avoid positions that overstretch the muscle. Assistive devices such as a cane or crutches may be used temporarily to facilitate pain free ambulation.

Surgical treatment may be recommended to repair a complete, full-thickness gluteus medius tear. The surgery can be performed endoscopically through tiny incisions to reattach the torn tendon back onto the greater trochanter with stitches. This helps to restore strength and function to the gluteus medius muscle.

Conclusion

The gluteus medius is one of the main muscles of the hip that works to stabilize and control various hip movements. The tear or rupture of the muscle can result in pain, improper gait, and disability. Treatment includes surgical and non-surgical methods and the selection depends on the extent of the injury and the lifestyle of the patient.

Femoroacetabular impingement (FAI) is a condition where there is too much friction in the hip joint from bony irregularities causing pain and decreased range of hip motion. The femoral head and acetabulum rub against each other creating damage and pain to the hip joint. The damage can occur to the articular cartilage (the smooth white surface of the ball or socket) or the labral tissue (the lining of the edge of the socket) during normal movement of the hip. The articular cartilage or labral tissue can fray or tear after repeated friction. Over time, more cartilage and labrum is lost until eventually the femur bone and acetabulum bone impact on one other. Bone on bone friction is commonly referred to as Osteoarthritis.

FAI impingement generally occurs as two forms: Cam and Pincer.

CAM Impingement: The Cam form of impingement is when the femoral head and neck are not perfectly round, most commonly due to excess bone that has formed. This lack of roundness and excess bone causes abnormal contact between the surfaces.

PINCER Impingement: The Pincer form of impingement is when the socket or acetabulum rim has overgrown and is too deep. It covers too much of the femoral head resulting in the labral cartilage being pinched. The Pincer form of impingement may also be caused when the hip socket is abnormally angled backwards causing abnormal impact between the femoral head and the rim of the acetabulum.

Most diagnoses of FAI include a combination of the Cam and Pincer forms.

Symptoms of FAI

Symptoms of femoroacetabular impingement can include the following:

• Groin pain associated with hip activity
• Complaints of pain in the front, side or back of the hip
• Pain may be described as a dull ache or sharp pain
• Patients may complain of a locking, clicking, or catching sensation in the hip
• Pain often occurs to the inner hip or groin area after prolonged sitting or walking
• Difficulty walking uphill
• Restricted hip movement
• Low back pain
• Pain in the buttocks or outer thigh area

Risk Factors

A risk factor is something that is likely to increase a person's chance of developing a disease or condition. Risk factors for developing femoroacetabular impingement may include the following:

• Athletes such as football players, weight lifters, and hockey players
• Heavy laborers
• Repetitive hip flexion
• Congenital hip dislocation
• Anatomical abnormalities of the femoral head or angle of the hip
• Legg-Calves-Perthes disease: a form of arthritis in children where blood supply to bone is impaired causing bone breakdown.
• Trauma to the hip
• Inflammatory arthritis

Diagnosis

Hip conditions should be evaluated by an orthopedic hip surgeon for proper diagnosis and treatment.

• Medical History
• Physical Examination
• Diagnostic studies including X-rays, MRI scans and CT Scan

Treatment Options

Conservative treatment options refer to management of the problem without surgery. Nonsurgical management of FAI will probably not change the underlying abnormal biomechanics of the hip causing the FAI but may offer pain relief and improved mobility.

Conservative treatment measures

• Rest
• Activity Modification and Limitations
• Anti-inflammatory Medications
• Physical Therapy
• Injection of steroid and analgesic into the hip joint

Surgical treatment

• Hip arthroscopy to repair femoroacetabular impingement is indicated when conservative treatment measures fail to provide relief to the patient.

A hip fracture is a break that occurs near the hip in the upper part of the femur or thigh bone. The thigh bone has two bony processes on the upper part - the greater and lesser trochanters. The lesser trochanter projects from the base of the femoral neck on the back of the thigh bone. Hip fractures can occur either due to a break in the femoral neck, in the area between the greater and lesser trochanter or below the lesser trochanter.

Subtrochanteric hip fracture is a break between the lesser trochanter and the area approximately 5 centimeters below the lesser trochanter. The fracture can be classified based on its location:

Type I occurs at the level of the lesser trochanter,

Type II occurs within 2.5 cm below the lesser trochanter and, Type III occurs between 2.5 and 5 cm below the lesser trochanter.

Causes

A subtrochanteric hip fracture is most frequently caused from minor trauma in elderly patients with weak bones, and by high-energy trauma in young people. Long term use of certain medicines, such as bisphosphonates to treat osteoporosis (a disease causing weak bones) and other bone diseases, increases the risk of subtrochanteric hip fractures.

Signs and Symptoms

Signs and symptoms of subtrochanteric hip fracture include

• Pain in the groin or outer upper thigh
• Swelling and tenderness
• Discomfort while rotating the hip
• Shortening of the injured leg
• Outward or inward turning of the foot and knee of the injured leg

Diagnosis

Your doctor may order an X-ray to diagnose subtrochanteric hip fracture. Other imaging tests, such as magnetic resonance imaging (MRI) may also be performed to detect the fracture.

Treatment

A subtrochanteric fracture can be corrected and aligned with non-operative and operative methods. Traction may be an option to treat your condition if you are not fit for surgery. Skeletal traction may be applied under local anesthesia, where screws, pins and wires are inserted into the femur, and a pulley system is set up at the end of the bed to bear heavy weights. The heavy weights help in correcting the misaligned bones until the injury heals.

Surgery

Surgery is usually the main treatment for subtrochanteric fractures. Surgical options include external fixation, intramedullary fixation or by using plates and screws.

External fixation is a temporary fixation and used for severe open fractures. Pins are inserted into each of the fractured fragment and supported with tubes close to the bone. The tubes are interconnected together with short tubes to provide more stiffness for the frame.

Intramedullary fixation involves managing the fracture with a long intramedullary nail which is fixed with a large screw. Additional screws known as interlocking screws are inserted at the lower end of the nail to prevent rotation of bones around the nail.

You surgeon may use a plate with screws attached instead of a nail in certain cases. Screws will be fixed into the bone from the outer side of the femur. A large screw will be inserted through the femoral neck and head, and other screws will be inserted across the length of the plate to hold the fracture together.

Risks and complications

As with any surgical procedure, surgery for a sub trochanteric fracture involves certain risks and complications including:

• Nonunion of fracture with pain
• Limp or limited hip rotation due to malunion
• Nail or screw fixation failure
• Wound infection

The Femoral neck is a part of the thigh bone (femur) which connects the head of the femur to the shaft of the femur. An injury or crack caused in the femoral neck due to repetitive force, overuse of the bone or insufficiency in bone development is termed a femoral neck stress fracture. These fractures are usually caused in athletes and gymnasts because of their excessive training and changes in practice surfaces.

The most common symptom of a femoral neck fracture is deep thigh or groin pain which increases during your activity, spreads to other parts, and increases during the night or while sitting on the chair with your legs down.

Femoral neck stress fracture can be diagnosed with the help of a physical examination and tests such as the fulcrum test or one-legged hop test. Your doctor may also recommend imaging tests such as X-rays and MRI to confirm the diagnosis and find the specific location and cause of the fracture.

Femoral neck stress fracture is treated by taking complete rest from your sports activities. Your doctor may also recommend physical therapy to improve your mobilization and stretching abilities. For severe fractures, surgery would be necessary.

Runner's knee, also called patellofemoral pain syndrome refers to pain under and around your kneecap.  Runner's knee includes a number of medical conditions such as anterior knee pain syndrome, patellofemoral malalignment, and chondromalacia patella that cause pain around the front of the knee. As the name suggests, runner's knee is a common complaint among runners, jumpers, and other athletes such as skiers, cyclists, and soccer players.

Causes

Runner's knee can result from poor alignment of the kneecap, complete or partial dislocation, overuse, tight or weak thigh muscles, flat feet, direct trauma to the knee.  Patellofemoral pain often comes from strained tendons and irritation or softening of the cartilage that lines the underside of the kneecap. Pain in the knee may be referred from other parts of the body, such as the back or hip.

Symptoms

The most common symptom of runner's knee is a dull aching pain underneath the kneecap while walking up or down stairs, squatting, kneeling down, and sitting with your knees bent for long period of time.

Anatomy

Pain usually occurs under or around the front of the kneecap (patella) where it attaches with the lower end of the thighbone (femur). The patella, also called kneecap, is a small flat triangular bone located at the front of the knee joint. The kneecap or patella is a sesamoid bone that is embedded in a tendon that connects the muscles of the thigh to the shin bone (tibia). The function of the patella is to protect the front part of the knee.

Diagnosis

To diagnose runner's knee, your doctor will ask about your symptoms, medical history, any sports participation, and activities that aggravate your knee pain. Your doctor will perform a physical examination of your knee. Diagnostic imaging tests such as X-rays, MRIs, and CT scans, and blood tests may be ordered to check if your pain is due to damage to the structure of the knee or because of the tissues that attach to it.

Treatment

The first treatment step is to avoid activities such as running and jumping, that causes pain.  Treatment options include both non-surgical and surgical methods. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling.  Non-steroidal anti-inflammatory medications may be prescribed to reduce pain.

Exercises: Your doctor may recommend an exercise program to improve the flexibility and strength of thigh muscles. Cross-training exercises to stretch the lower extremities may also be recommended by your doctor.

Other non-surgical treatments include:

• Knee taping: An adhesive tape is applied over the patella, to alter the kneecap alignment and movement. Taping of the patella may reduce pain.
• Knee brace: A special brace for knee may be used during sports participation which may help reduce pain.
• Orthotics: Special shoe inserts may be prescribed for those with flat feet that may help relieve the pain.

In some cases, you may need surgery that includes arthroscopy and realignment. During arthroscopy, damaged fragments are removed from the kneecap, while realignment moves the kneecap back to its alignment, thus reducing the abnormal pressure on cartilage and supporting structures around the front of the knee.

Prevention

• If you are overweight, you may need to control your weight to avoid overstressing your knees
• Gradually increase the intensity of your workout
• If you have flat feet or other foot problems use shoe inserts
• Avoid running on hard surfaces
• Wear proper fitting good quality running shoes with good shock absorption
• Avoid running straight down hills; instead walk down it or run in a zigzag pattern
• Warm up for 5 minutes before starting any exercise. Also stretch after exercising

Introduction

The shoulder is made up of the clavicle (collar bone), humerus (upper arm) and scapula (shoulder blade). The shoulder is a ball and socket joint where the ball of the upper arm bone articulates with the socket of the shoulder blade called the glenoid cavity. The shoulder blade is a flat triangular bone present on either side of the upper back. It articulates with the other two bones at the glenohumeral joint and acromioclavicular joint to provide stability and mobility to the arm. Scapula fracture refers to a fracture of the shoulder blade.

Causes

Scapula fractures can result from severe trauma such as a motor vehicle accident, a fall from a height, contact sports, a fall on an outstretched arm and direct blow on the shoulder during a fight.

Signs and symptoms

The signs and symptoms of scapula fracture are:

• Severe pain with movement
• Swelling on the back of the shoulder
• Numbness, tingling or weakness of the shoulder and arm

Scapula fractures are rare but can occur with rib or skull fractures and lung or spinal cord injuries.

Diagnosis

To diagnose a scapula fracture your doctor reviews your medical history and performs a physical examination. Imaging studies including X-rays and a CT scan may be ordered.

Treatment

Scapular fractures can be treated with nonsurgical or surgical intervention depending upon the type of fracture.

Nonsurgical treatment involves immobilizing the shoulder with a sling for 3 to 4 weeks, allowing the bones to heal on their own. Your doctor will prescribe medication to manage your pain. Physical therapy and stretching exercises should be started a week after the injury to reduce stiffness.

Scapular fractures that involve displacement at the glenoid articular surface, or fracture of the scapula neck or acromion process may require surgery to repair.

Surgery is performed to align and hold the displaced bones in their proper anatomical position until they heal. This is achieved with the help of screws and plates. The surgery can be performed traditionally by an open method or by a minimally invasive open reduction internal fixation surgery (ORIF). ORIF surgery as compared to open surgery is done by smaller incisions and thus recovery is much faster.

The upper arm is made up of the humerus bone. The head of the humerus fits into a shallow socket in your scapula (shoulder blade) to form the shoulder joint. The humerus narrows down into a cylindrical shaft and joins at its base with the bones of the lower arm to form the elbow joint.

Fractures can occur at any site of the humeral bone. Mid humeral fractures are fractures that occur in between the shoulder joint and elbow. They are classified into Type A, B or C fractures. Type A fractures are simple fractures where the bone is not shattered. Type B fractures are fractures when the broken bone forms a wedge, and type C fractures are where the bone is shattered into many pieces.

Causes

Mid humeral fractures can be caused by:

• A direct blow or bending force applied to the middle of the humerus
• falling onto an outstretched arm
• violent muscle contraction in sports such as weight lifting

Signs and symptoms

Patients usually present with considerable pain and swelling following a mid humeral fracture. Shortening of the arm is apparent with significant displacement of the bones.

Diagnosis

Mid humeral fractures can be diagnosed through X-ray imaging and ultrasound.

Treatment

Most mid humeral fractures can be successfully treated through conservative treatment without the need for surgery. Your doctor may place the limb in a hanging arm cast or a co-amputation splint for 1-3 weeks followed by a functional brace. Patients will be instructed on range of motion exercises of the fingers, wrist, elbow and shoulder as soon as can be tolerated.

Surgical treatment

Surgical treatment is recommended for

• Fractures that cannot be managed conservatively
• Segmental fractures
• Pathologic fractures (bone tumor)
• When blood vessels get injured
• Patients who need to have upper extremity weight-bearing capability
• Open fractures when the skin is opened up by the fractured bone
• Obese patients in whom alignment is difficult

Surgical treatment is called open reduction and internal fixation (ORIF). This procedure is usually performed under general anesthesia. First your broken bones are put back into their normal anatomic position. Internal fixation devices such as plates, screws, or intramedullary (IM) implants are then used to hold your broken bones together. You will be placed in a dressing and/or cast following your procedure.

Risks and complications

As with any surgery, complications can occur. Complications related to surgical repair of mid humeral fracture are rare but may include:

• Nerve injury
• Bleeding
• Infection
• Blood clots
• Recurrent instability
• Malunion or nonunion
• Hardware failure

Tendons are the soft tissues connecting muscles to the bones. The achilles tendon is the longest tendon in the body and is present behind the ankle, joining the calf muscles with the heel bone. Contraction of the calf muscles tightens the achilles tendon and pulls the heel, enabling foot and toe movements necessary for walking, running and jumping.

The achilles tendon is often injured during sports resulting in an inflammatory condition called tendonitis which is characterized by swelling and pain. In some cases, severe injury results in a tear or rupture of the Achilles tendon requiring immediate medical attention.

Causes

The tear or rupture of the Achilles tendon is commonly seen in middle aged male who involve in sports activities occasionally or in weekend athletes. The tendon ruptures because of weakened tendons due to advanced age or from sudden bursts of activity during sports such as tennis, badminton, and basketball.

People with a history of tendonitis, those suffering from certain diseases such as arthritis and diabetes, or taking certain antibiotics are more susceptible for ruptures.

Symptoms

The classic symptom of an Achilles tendon rupture is the inability to rise up on your toes. Patients often describe a "popping" or "snapping" sound with severe pain, swelling and stiffness in the ankle region followed by bruising of the area. If the tendon is partially torn and not ruptured, pain and swelling may be mild.

Diagnosis

The diagnosis of a torn or ruptured Achilles tendon starts with a physical examination of the affected area, followed by a Thompson test in which the calf muscle is pressed with the patient lying on their stomach to check whether the tendon is still connected to the heel or not.

In certain cases, an ultrasound or MRI scan may be needed for a clear diagnosis.

Treatment

The main objective of treatment is to restore the normal physiology of the Achilles tendon so the patient can perform activities as before the injury.

Immediately following a torn or ruptured Achilles tendon you should employ the RICE method as follows:

• Rest of the injured part
• Ice packs application at the site of injury to prevent swelling
• Compress the injured area to prevent swelling
• Elevate the injured part to reduce swelling

Treatment of a torn or ruptured Achilles tendon includes non-surgical or surgical methods. Non-surgical methods involve casting the injured area for six weeks for the ruptured tendon to reattach itself and heal. After removal of the cast, physical therapy is recommended to prevent stiffness and restore lost muscle tone.

Surgery may be recommended especially for competitive athletes, those who perform physical work, or in instances where the tendon re-ruptures. Your surgeon will stitch the torn tendon back together with strong sutures and tie the sutures together. Your surgeon may reinforce the Achilles tendon with other tendons depending on the extent of the tear. If the tendon has avulsed or pulled off the heel bone, your surgeon will reattach the tendon to the heel bone.

Risks and complications

Every medical treatment including surgeries is associated with certain risks and complications. Some of them include infection, bleeding, nerve injury, and blood clots.

Ankle instability surgery is performed to treat an unstable ankle and involves the repair or replacement of a torn or stretched ligament.

There are two types of ankle instability surgery:

• Anatomic repair: This surgery involves shortening and tightening the stretched ligament; and
• Non-anatomic repair: This surgery uses a tendon as a graft to replace the damaged ligament.

Disease overview

Ankle instability is a chronic condition characterized by a recurrent slipping of the outer side of the ankle. Instability is generally noticed during movement of the ankle joint but can also occur during standing as well.

Symptoms include the following:

• The ankle feels unstable
• The ankle turns repeatedly while walking on uneven surfaces or during a sporting activity.
• Pain, tenderness and swelling is present in the ankle joint.

Ankle Instability usually results from repeated ankle sprains. Inadequate healing of a sprained ligament or incomplete rehabilitation of the affected ligament can result in instability. Recurrent injury to the ligaments further weakens them and aggravates the instability which predisposes to the development of additional ankle problems.

Indications

Surgery is recommended in patients with a high degree of ankle instability and in those who have failed to respond to non-surgical treatments.

• Anatomic repair is preferred in most cases of ankle instability.
• Non-anatomic repair is performed in obese patients requiring increased stability or when tightening of the stretched and scarred ligaments is not strong enough and needs to be reinforced with a tendon graft.

Surgical procedure

Ankle instability surgery involves the repair or reconstruction of the injured ankle ligaments.  Ankle-instability surgeries can be categorized into either anatomic repair or non-anatomic repair, also called reconstructive tenodesis.

Anatomic repair involves reconstruction of the stretched or torn ligaments. The surgery is performed under epidural anesthesia. Your surgeon makes an incision on the ankle to expose the damaged joint and ligaments. The joint capsule and ligaments are examined, and the edges of the torn ligament are shortened and repaired with sutures. The ends may be overlapped and then sutured to strengthen the ligament. Your surgeon then covers the repaired ligament with the extensor retinaculum, a dense band of connective tissue, to reinforce the ligament further. Range of motion is evaluated; the incision is closed, and a sterile bandage is applied.

Reconstructive tenodesis is a tendon transfer procedure that uses your own tendon or a cadaver tendon as a graft to replace the damaged tendon.  The surgery is performed under epidural anesthesia. Your surgeon makes an incision on your ankle. Drill holes are created where the damaged ligament normally attaches to the lower end of the fibula (calf bone) on one side and the talus (anklebone) on the other end. Your surgeon then harvests the peroneus brevis muscle tendon, found on the outer edge of the small toe, and weaves it through the drill holes to form a ligament complex. Range of motion is evaluated; the incision is closed and a sterile bandage is applied.

Post-Operative care

After surgery, your foot will be immobilized with a cast or splint. You will be provided crutches to avoid bearing weight on the operated ankle. Your doctor will remove the splint and provide a removable boot to be worn for 2 to 4 weeks. Physical therapy will be initiated to strengthen your joint and improve range of motion. Complete recovery may take 10 to 12 weeks.

Advantages & disadvantages

The advantages of the anatomic repair include:

• Simple surgical procedure that makes use of your own anatomy to repair the damage
• Preserves complete joint mobility
• Rapid recovery
• Smaller incision
• Fewer complications

The disadvantage of the anatomic repair includes:

• Loosening of the ligaments, requiring additional repairs

The advantages of the nonanatomic repair include:

• Provides increased strength
• Can be used when host tissues are severely damaged
• Provides additional stability in obese patients

The disadvantages of the nonanatomic repair procedures include:

• Decreased rear foot motion
• Does not preserve the peroneus brevis, an important structure for the ankle’s dynamic stability

Risks and complications

As with all surgical procedures, ankle instability surgery may be associated with certain complications including:

• Injury to the superficial nerves
• Chronic pain
• Stiffness
• Need for second surgery (rare)

Medial collateral ligament (MCL) is one of four major ligaments of the knee that connects the femur (thigh bone) to the tibia (shin bone) and is present on the inside of the knee joint. This ligament helps stabilize the knee. An injury to the MCL may occur as a result of direct impact to the knee. An MCL injury can result in a minor stretch (sprain) or a partial or complete tear of the ligament. The most common symptoms following an MCL injury include pain, swelling, and joint instability.

Diagnosis

An MCL injury can be diagnosed with a thorough physical examination of the knee and diagnostic imaging tests such as X-rays, arthroscopy, and MRI scans. X-rays may help rule out any fractures. In addition, your doctor will perform a valgus stress test to check for stability of the MCL. In this test, the knee is bent approximately 30° and pressure is applied on the outside surface of the knee. Excessive pain or laxity is indicative of medial collateral ligament injury.

Management

If the overall stability of the knee is intact, your doctor will recommend non-surgical methods including ice, physical therapy, and bracing.

Surgical reconstruction is rarely recommended for MCL tears but may be necessary in patients that fail to heal properly with residual knee instability. These cases are often associated with other ligament injuries. If surgery is required, a ligament repair may be performed, with or without reconstruction with a tendon graft; depending on the location and severity of the injury.

Indications and contraindications

Medial collateral ligament reconstruction is indicated in patients with chronic MCL instability despite appropriate nonsurgical treatment.

Medial collateral ligament reconstruction is contraindicated in patients with degenerative changes in the medial or lateral compartment, active infection, ligament instability, or presence of chronic diseases that can hamper surgical management or compliance to postoperative rehabilitation instructions.

Procedure

The procedure is performed under general anesthesia. Arthroscopic examination of the knee may be performed to rule out any associated injuries including anterior cruciate ligament (ACL) and posterior cruciate ligament PCL) tears.

The surgical procedure for medial collateral ligament reconstruction involves the following steps:

• Your surgeon will make an incision over the medial femoral condyle.
• Care is taken to move muscles, tendons and nerves out of the way.
• The donor tendon is usually harvested from the Achilles tendon.
• The soft tissue around the femur is debrided to assist the insertion of the Achilles bone plug.
• For placing the graft, a tunnel is created from a guide pin to the anatomic insertion of the MCL on the tibia, using the index finger and surgical scissors.
• The Achilles tendon allograft is inserted in the femoral tunnel and fixed using screws.
• The MCL graft is made taut, with the knee at 20° flexion under varus stress, and fixed to the tibia with a screw and a spiked washer.
• The incision is closed with sutures and covered with sterile dressings.

Postoperative care

In the first two weeks after the surgery, toe-touch and weight-bearing is allowed with the knee brace locked in full extension. After 2 weeks 0° to 30° of motion is allowed at the knee. At 4 weeks, knee flexion is allowed from 60° to 90° of motion and full weight bearing is permitted. At 6 weeks, the brace is removed, and you are allowed to perform full range of motion. Crutches are often required until you regain your normal strength.

Risks and complications

Knee stiffness and residual instability are the most common complications associated with MCL reconstruction. The other possible complications include:

• Numbness
• Infection
• Blood clots (Deep vein thrombosis)
• Nerve and blood vessel damage
• Failure of the graft
• Loosening of the graft
• Decreased range of motion

The humerus is the upper arm bone. A fracture of the proximal humerus, the region closest to the shoulder joint, can affect your work and activities of daily living.

Open reduction and internal fixation (ORIF) is a surgical technique employed in severe proximal humerus fractures to restore normal anatomy and improve range of motion and function.

Disease Overview

The shoulder is formed by 3 bones:

• Clavicle (collar bone)
• Scapula (shoulder blade)
• Humerus (upper arm bone)

The humerus and scapula articulate or join at the glenohumeral joint.

This joint is held together by a group of muscles and tendons called the rotator cuff.

The parts of the proximal humerus frequently involved in fractures include:

• The head of the humerus
• Greater tuberosity
• Lesser tuberosity
• Surgical neck

Proximal humerus fractures can cause pain and decreased mobility of the arm.

The elderly is more prone to proximal humerus fractures from accidents such as falling on an outstretched arm. They may also occur in young people involved in high-energy accidents.

Indications

Most proximal humerus fractures are not displaced and can be treated by a supportive sling and early rehabilitation. However, if fracture fragments are 5 mm apart or the angle between the fragments is more than 45 degrees, they are considered displaced and will require surgical intervention such as open reduction and internal fixation.

Other factors influencing the decision to perform surgery include age of the patient, bone quality, blood supply to the area and ability to tolerate the post-operative rehabilitation.

Surgical procedure

• The open reduction and internal fixation surgery involves the reduction of the fracture and securing the correctly aligned bones to allow healing. You are placed in the beach-chair position to allow shoulder movements and imaging from different angles.
• Sedation or general anesthesia are administered.
• An incision is made through the anterior and middle heads of the deltoid (shoulder) muscles.
• The axillary nerve is identified and protected, and the rotator cuff and proximal humerus are exposed.
• The fracture margins are trimmed and prepared, and the fracture bed is washed.
• Stay sutures are placed in the tendons of the rotator cuff muscles to gain control of the fracture fragments.
• Then your surgeon brings the fractured fragments into the correct anatomic alignment by manipulation and pulling on the stay sutures.
• K-wires are used to temporarily secure the fracture fragments.
• Once the bones are aligned, strong sutures, screws, or a system of plate and screws are used to hold the bone fragments together.
• Imaging tests are performed in different angles to verify the correct alignment of the fragments and position of the plate and screws, and to assess range of motion.

Post-Operative Care

Following surgery there is a minimum period of immobilization after which rehabilitation should begin. As early as the first post-operative day, you will be made to move your arm as much as you can without too much pain. Physical therapy starts with passive/assisted range of motion exercises. Activities of daily living can slowly be introduced but there must be no lifting or shoulder movements against resistance for at least 6 weeks. Strengthening and stretching should then begin gradually with resistance exercises. It is necessary to monitor progress in movement and strength as persistent weakness may indicate a rotator cuff tear or nerve damage.

Advantages & Disadvantages

Open reduction and internal fixation to treat proximal humerus fractures has the following advantages:

• Allows optimal reduction
• Allows visibility and direct access to reduce fracture fragments with advanced devices

Disadvantages include:

• Increased chance of secondary loss of reduction

Risks and complications

As with all operations there is a possibility of certain risks and complications and may include:

• Infection
• Bleeding
• Subacromial impingement (compression and inflammation of structures between acromion of the shoulder blade and humerus head)
• Frozen shoulder (shoulder pain and stiffness)
• Nerve damage
• Penetration of screws into the articular surface of the humeral head
• Avascular necrosis (bone death resulting from compromised blood supply to fracture fragments)