Sport PDF Preparticipation Physical Evaluation

SPORT Preparticipation Physical Evaluation The PPE is a tool for screening athletes before the start of training & competition. The purpose of the PPE is to facilitate and encourage safe participation, not to exclude athletes from participatio...

SPORT Preparticipation Physical Evaluation The PPE is a tool for screening athletes before the start of training & competition. The purpose of the PPE is to facilitate and encourage safe participation, not to exclude athletes from participation. The 1ry goals of the PPE are : Determine general physical & psychological health Evaluate for disabling or life-threatening conditions Evaluate for conditions that may predispose to injury or illness Provide an opportunity for discussion of health and lifestyle issues Serve as an entry point into the health care system for adolescents without a medical home. Timing Ideally, the PPE is integrated into an athlete’s annual health supervision examination. The PPE can be incorporated into well-child care visits starting at 6 years of age. PPE should be completed at least 6 weeks before the start of preseason practice Musculoskeletal History The musculoskeletal history alone will identify 67% to 92% of the musculoskeletal problems a ecting athletes. The most e cient way to obtain a complete and accurate history is to have the athlete and parent complete a comprehensive, validated questionnaire The goal is to identify any chronic conditions or incompletely rehabilitated injuries. Ask if there is pain, instability, or limitations caused by previous injuries or surgeries. Any condition that has previously disqualified an athlete from competition should be reexamined in depth.  Previous surgery should be documented in detail (eg, “anterior cruciate ligament reconstruction” rather than “knee surgery”). Inquire whether the surgeon has prescribed specific activity restrictions, a brace or support, protective equipment, or modifications for sports, and whether postoperative rehabilitation has been completed. Use of a supportive brace or device may be prescribed by a treating physician forreturn to play, or it may indicate a self-treated or unresolved injury. Further questioning and examination of the specific joint may be necessary to determine whether additional treatment is required and whether the brace is appropriate. Inspect braces for proper fit and integrity before each season. BONE AND JOINT QUESTIONS Yes No For any athletes with a history of stress fracture Dietary and menstrual history should be reviewed in detail ( relative energy deficiency in sport ). Training errors should be corrected and improper equipment (eg, shoes) replaced. Examination should focus on identifying risk factors such as muscle weakness, pes cavus, or overpronation that can be addressed through rehabilitation or supportive orthoses. Examination should focus on identifying risk factors such as muscle weakness, pes cavus, or overpronation that can be addressed through rehabilitation or supportive orthoses. Goals of the musculoskeletal examination are to: Evaluate for recovery from previous injuries. Identify any modifiable risk factors for reinjury (eg, muscle weakness,inflexibility) Identify any asymmetries in joint motion or muscle strength or size that may indicate an underlying musculoskeletal condition. The orthopaedic screening examination is su cient in the asymptomatic athlete with no history of prior injury. The orthopaedic screening examination should be supplemented with a comprehensive examination of the a ected area(s) for patients with History of previous injury’ Pain, instability, locking, limited range of motion, weakness, or atrophy noted in the history or on the screening examination Referral to a sports medicine physician is indicated when the required comprehensive examination is beyond the examiner’s expertise. Preparticipation physical evaluation history form. Criteria for Clearance to Play After a Sprain, Strain, Dislocation, or Overuse Injury The general musculoskeletal screening examination consists of the following: (1) inspection, athlete standing, facing toward examiner (symmetry of trunk, upper extremities); (2) forward flexion, extension, rotation, lateral flexion of neck (range of motion, cervical spine); (3) resisted shoulder shrug (strength, trapezius); (4) resisted shoulder abduction (strength, deltoid); (5) internal and external rotation of shoulder (range of motion, glenohumeral joint); (6) extension and flexion of elbow (range of motion, elbow); (7) pronation and supination of forearm or wrist (range of motion, elbow and wrist); (8) clench fist, then spread fingers (range of motion, hand and fingers); (9) inspection, athlete facing away from examiner (symmetry of trunk, upper extremities); (10) back extension,knees straight (spondylolysis /spondylolisthesis); (11) back flexion with knees straight, facing toward and away from examiner (range of motion, thoracic and lumbosacral spine; spine curvature; hamstring flexibility); (12) inspection of lower extremities, contraction of quadriceps muscles (alignment, symmetry); (13) “duck walk” 4 steps (motion of hip, knee, and ankle; strength; balance); (14) toe stand and heel walk (symmetry, calf; strength; balance). From Miller SM, Peterson AR. The sports preparticipation evaluation. Clearance For fractures, clearance should be determined by the treating physician. In some cases, return to play may be allowed in a padded cast or splint,depending on the child’s comfort, the risk of further injury, and the rules of the sports organization. For developmental conditions and deformities, activity modifications may be necessary based on symptoms or physical abilities. Clearance falls into one of 5 categories and should be individualized based on the following questions: Does participation place the athlete at risk for serious injury or illness? Does participation place other participants at risk for injury or illness? Can the athlete safely participate while being treated (eg, rehabilitation program, brace)? In some cases, a protective brace, padding, or taping may provide the stability or protection needed for clearance. Whether a specific brace or padding technique is allowed is determined by the rules of the specific sports organization, and the final decision is usually made by the sporting event’s officials. Can limited participation be allowed while treatment is being completed? For example, a baseball pitcher with an elbow injury may be able to safely bat and play first base. Determine which strength and conditioning activities are safe so that the athlete can maintain fitness during recovery. Determine which strength and conditioning activities are safe so that the athlete can maintain fitness during recovery. If clearance is denied only for certain sports, in what activities can the athlete safely participate? For example, an athlete with an upper extremity injury may be able to safely participate in soccer or cross-country running. The athlete may be referred to a sports medicine physician if there are any questions or uncertainties regarding clearance. Medical decisions to permanently restrict sports participation are best made by consensus with subspecialty consultation and discussion with the athlete and family. Legal Issues By the high school level, all states require some type of PPE. Legislative requirements vary by state for the timing and content of the evaluation and qualifications of the examiner. In several states, nurses, physician assistants, and chiropractors are allowed to complete the PPE. Health Insurance Portability and Accountability Act guidelines allow a physician to communicate to the school only that the athlete is cleared or not cleared. Discussion with nonmedical school personnel of the details of the PPE or the reason an athlete is not cleared is not permitted without the athlete’s and parent’s consent. The use of the PPE Medical Eligibility Form allows physicians (with athlete’s and parent’s consent) to communicate medical information (eg, allergies, medicines) and relevant medical conditions (eg, seizure disorder, asthma, diabetes).  It is in the athlete’s best interest to have relevant medical information available to the team’s athletic trainer. Athletic trainers are frequently the first responders at sporting events. Athletic trainers can supervise rehabilitation protocols and communicate with physicians about the athlete’s progress or ability to perform sports-specific exercises. Medical eligibility form. Athletes With Special Needs: The Rehabilitation Act of 1973 and the Americans With Disabilities Act of 1990 mandate equal opportunity to anyone wishing to participate in athletics. For athletes with special needs, the PPE should be more comprehensive. An evaluation of braces, prosthetic devices, or specialized equipment such as wheelchairs should be included in the PPE. Input from physical or occupational therapists about functional abilities is helpful. Supplemental history form for athletes with disabilities. Strains, Sprains, & Dislocations Muscle Strains INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY A strain is a tear of some or all of the fibers in a muscle. A strain is caused by a sudden, forceful change in the length of the muscle-tendon unit, most commonly an eccentric contraction against a significant load. Less frequently, strains result from a rapid or forceful stretch to a muscle or from repetitive overuse. Athletes who sprint, jump, leap, or kick are most susceptible to strain. Strains usually occur at the musculotendinous junction. Strains most commonly affect muscles in the lower extremity & those that cross 2 joints (ie, hamstrings, rectus femoris, gastrocnemius). The hamstrings are the most frequently strained muscle in the lower extremity; this can lead to significant disability. SIGNS AND SYMPTOMS Acute-onset muscle pain during activity Some patients report a pop or tearing sensation. Weight bearing is usually painful. Physical examination reveals some or all of the following: Muscle tenderness Edema or ecchymosis Pain and weakness with contraction of the injured muscle Pain with passive stretch of the injured muscle Palpable defect in the muscle DIFFERENTIAL DIAGNOSIS Apophyseal avulsion fracture Frequently mistaken for a muscle strain in the skeletally immature athlete If there is any bony tenderness or if pain is at the proximal or distal aspect of the muscle, rather than the midsubstance,radiographs should be obtained to rule out an avulsion fracture. Stress fracture A stress fracture may produce reactive edema in the adjacent muscle, mimicking a muscle strain. DIAGNOSTIC CONSIDERATIONS The diagnosis is established clinically. Strains are graded into 3 categories. Magnetic resonance imaging (MRI) may be performed to confirm location and degree of injury. Ultrasonography is an emerging imaging modality in the diagnosis of muscle injuries. Common Grading of Strains and Sprains TREATMENT Initial treatment includes rest, ice, compression, and elevation (RICE). Ice can be applied for 10 to 15 minutes every few hours. Heat and vigorous stretching or massage should be avoided during the initial injury period. Crutches may be necessary until weight bearing is comfortable. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is controversial. Studies demonstrate that NSAIDs can reduce inflammation and pain in the short term but may impair the muscle repair process in the long term, resultingin decreased muscle tensile strength and force production. A rehabilitation program of progressive stretching and strengthening exercises should be initiated as soon as pain begins to subside because early mobilization can help facilitate recovery. A compression sleeve for the injured muscle may help reduce pain and improve function during the healing process. EXPECTED OUTCOMES/PROGNOSIS Return to play ranges from 2 to 3 days for mild strains to 3 to 12 weeks for severe strains. Hamstring strains have a high rate of recurrence (12%–31%) and can lead to prolonged disability if rehabilitation is inadequate or return to play is rushed. Hip adductor strains (groin pulls) take longer to heal and are also prone to reinjury. WHEN TO REFER Rarely, muscle strains require management by a sports medicine physician or orthopaedic surgeon. Severe strains with significant loss of motion, strength, or function Large, tense, painful hematomas, which may be aspirated to reduce pain PREVENTION Warming up (5-10 minutes of light jogging or calisthenics) before physical activity may reduce the risk of muscle strains by increasing blood flow to muscles, making them more pliable. Avoiding exercise while already fatigued may help reduce the risk of a muscle strain. Joint Sprains INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY A sprain is a tear of some or all of the fibers in a ligament.  A sprain is caused by a sudden, unnatural movement of a joint (eg,inversion or twisting of an ankle). Sprains are the most common injuries in sports for all age groups. Radiographs are frequently necessary to rule out fracture. Severity is graded into 3 categories. PRINCIPLES OF TREATMENT PRICEM: protection, rest, ice, compression, elevation, and mobilization 1. Protection Crucial for early ligament healing Provides needed stability for moderate and severe sprains Continued until Weight bearing is pain-free for lower extremity injuries. ™™Functional motion is pain-free for upper extremity injuries Reduce activities to a pain-free level. 2. Ice 15 to 20 minutes at a time Can be done as frequently as once an hour Do not apply ice directly to skin. Heat should be avoided during the first few days because it will worsen swelling 3. Compression An elastic bandage should be wrapped distal to proximal. Remove for sleeping 4. Elevation Above the heart as much as possible 5. Mobilization Early mobilization, which is appropriate for most mild and moderate sprains, can help facilitate recovery. For all but the mildest of sprains, a rehabilitation program to restore range of motion, flexibility, strength, and proprioception will speed recovery and should be initiated as early as tolerated by the athlete. NSAIDs Reduce pain and inflammation, which may shorten recovery time by allowing rehabilitation to progress more quickly May increase early ligament strength Ibuprofen 10 mg/kg 3 times a day or naproxen 5 to 7 mg/kg twice a day for 7 to 10 days Criteria for return to sports : Little to no pain Full range of motion —Near-normal strength Able to perform sport-specific drills with no pain or instability A functional brace or taping technique may be used to achieve this. Ankle Sprains Ankle sprains account for up to 28% of all sports-related injuries. Athletes between 15 and 19 years of age are most frequently affected. Basketball, soccer, American football, and volleyball are the most commonly involved sports. 85% are lateral. 1. The anterior talofibular and calcaneofibular ligaments are the most frequently injured. 2. Usual mechanism is excessive inversion of a plantar flexed ankle  10% are syndesmotic (high ankle sprains) : 1. Injury to the syndesmosis complex (interosseous membrane and inferior tibiofibular ligaments) 2. Usual mechanism is excessive external rotation on a dorsiflexed ankle 5% are medial. 1. Injury to deltoid ligament 2. Mechanism is excessive eversion, usually from a high impact injury. 3. More commonly associated with fibula fractures A, Lateral ankle ligaments (posterior talofibular ligament, anterior talofibular ligament, and calcaneofibular ligament) and inferior tibiofibular ligaments. B, Location of lateral ankle ligaments drawn on patient’s ankle. SIGNS AND SYMPTOMS Pain after a twisting injury to the ankle Some report a pop at the time of injury. Weight bearing is usually painful. Swelling and bruising may be mild, moderate, or severe. Range of motion is often limited because of pain. The injured ligament is tender to palpation. Anterior drawer test and talar tilt test. Can confirm the diagnosis of lateral ankle sprain and grade injury severity  Sensitivity (96%) and specificity (84%) for detecting a ligament tear is best at 5 days after the injury. Less reliable during the acute phase because patient guarding can cause falsenegative result Reverse talar tilt test Grades severity of medial ankle sprains External rotation test ——Forced external rotation of the ankle ——Painful with syndesmotic sprains, but also with fractures Squeeze test Compression of tibia and fibula at mid-calf Causes pain at the ankle with syndesmosis sprains, but also with fractures Clear space between tibia and fibula. DIFFERENTIAL DIAGNOSIS Ankle fracture Skeletally immature patients with tenderness over the physis but norml radiographic findings should be treated for a Salter-Harris type 1 injury. Avulsion fracture of the fifth metatarsal 1. Caused by same mechanism as a lateral ankle sprain 2. There will be tenderness at the base of the fifth metatarsal. 3. Foot radiographs (anteroposterior [AP], lateral, oblique) are required for diagnosis. Peroneal tendon subluxation Subluxation can be reproduced with active ankle eversion. The diagnosis of a lateral ankle sprain can be established clinically. Radiographs (AP, lateral, mortise) should be obtained to rule out fracture if there is bony tenderness or inability to bear weight immediately after the injury and for 4 steps in the clinic/emergency department. Radiographs should be obtained for all medial and syndesmosis sprains. 1. Medial sprains are more commonly associated with fractures. 2. Syndesmosis sprains require radiographs to grade severity. The clear space between the tibia and fibula 1 cm above the joint line should be less than 5 to 6 mm on AP and mortise views.  ™™Grade 1: no widening of clear space ™™Grade 2: clear space widened but less than 10 mm ™™Grade 3: clear space 10 mm or wider TREATMENT Initial treatment includes RICE and weight bearing as tolerated. Ice should be applied for 15 to 20 minutes every 2 to 4 hours. Heat should be avoided. An air stirrup or lace-up ankle brace is preferred over a compression wrap because it also provides protection and support,which is helpful in promoting earlier weight bearing. Athletes with more severe sprains may require use of crutches or a walking boot until weight bearing is more comfortable. NSAIDs can facilitate treatment during the first 7 to 10 days after injury. 1. They reduce pain and inflammation, which may shorten recovery time by allowing rehabilitation to progress more quickly. 2. Studies also show they may increase early ligament strength. Prolonged immobilization weakens the ligaments, whereas early mobilization decreases adhesions and increases ligament strength. Rehabilitation to restore range of motion, flexibility, strength, andproprioception speeds recovery and should be initiated as early as tolerated by the athlete. EXPECTED OUTCOMES/PROGNOSIS 1. Lateral ankle sprains Average time to return to sports Grade 1: 8 days Grade 2: 15 days Grade 3: 28 days 1. After an initial sprain, the risk for reinjury is up to 5 times higher. 2. An estimated 20% to 40% of athletes experience chronic instability. 3. Very few require surgical stabilization. 4. The most common reason for persistent pain is inadequate rehabilitation. 5. Severe and repetitive ankle sprains increase the risk for osteoarthritis. 2. Medial ankle sprains Recovery takes twice as long as it does for lateral ankle sprains. 3.Syndesmosis sprains Average time to return to sports is 6 weeks. Grade 3 injuries usually require surgical stabilization. Recurrent instability is less common than it is with lateral ankle sprains. Heterotopic ossification in the syndesmosis is a possible complication. WHEN TO REFER To a sports medicine physician Lateral or medial ankle sprains that remain symptomatic despite a comprehensive rehabilitation program To an orthopaedic surgeon who specializes in sports injuries Grade 2 and 3 syndesmosis sprains PREVENTION Strategies proven to reduce the risk of recurrent ankle sprains A rehabilitation program that includes proprioception training  A semirigid ankle brace during athletic activities Acromioclavicular Joint Sprain INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY Acromioclavicular (AC) joint sprain is also called a shoulder separation. This injury is rare before 13 years of age. Most are type I injuries involving only the AC ligament. Type II injuries involve the AC ligament and one of the coracoclavicular (CC) ligaments. Type III injuries involve the AC ligament and both CC ligaments. The usual mechanism is a blow to the side or top of the shoulder or a fall directly onto the shoulder. Shoulder separations usually occur in collision sports (eg, American tackle football, hockey) This injury is 5 to 10 times more common in boys than in girls. Classification of acromioclavicular separations. SIGNS AND SYMPTOMS Pain and tenderness at the injured ligaments There may be slight swelling. For grade 2 and 3 sprains, the distal clavicle may be visibly elevated. Bruising is uncommon and usually indicates a fracture. Crossover test is positive Arm adduction across body causes pain Piano key sign is positive in grade 2 and 3 injuries. Ability to depress the distal end of clavicle DIFFERENTIAL DIAGNOSIS Clavicle fracture Shoulder dislocation or subluxation DIAGNOSTIC CONSIDERATIONS 1. The diagnosis is based on clinical and radiographic findings. 2. Severity is graded by degree of displacement on radiographs. Ten-degree cephalad view of the AC joint (Zanca view) Comparison is made to the uninjured side. Radiographs with and without weights are not needed to diagnose theinjury.  Acromioclavicular (AC) separation (type II)—anteroposterior (AP) view. AP view of the left shoulder shows minimal displacement of the AC joint (black arrow). TREATMENT RICE NSAIDs A sling should be used for comfort. Rehabilitation is helpful if the arm has been immobilized for more than 5 to 7 days. EXPECTED OUTCOMES/PROGNOSIs Prognosis for return to play for high-level sports, even throwing, is excellent with nonoperative treatment. Average time to return to sports depends on injury severity. 1. Grade 1: 3 days to 2 weeks 2. Grade 2: 2 to 4 weeks 3. Grade 3: 6 to 12 weeks Surgical stabilization is very rarely needed and is more appropriate for more severe and rarer injuries, such as the grade 4 through 6 sprains. There may be some discomfort at the joint for up to 6 months after the injury. In grade 2 and 3 sprains, the distal clavicle will remain visibly elevated. There is an increased risk of AC joint osteoarthritis. WHEN TO REFER To an orthopaedic surgeon who specializes in sports injuries or shoulder surgery 1. Significant displacement on radiographs 2. Limited improvement with nonoperative treatment PREVENTION Several taping techniques and braces are available, but there is no evidence that they reduce the risk for AC joint injury. Shoulder stabilizing Brace Traumatic Muscle Injuries Muscle Contusions Contusions are the second most common type of muscle injury, after muscle strain.  Contusions are caused by direct, non-penetrating blows to a muscle belly, which leads to bleeding in the muscle and hematoma formation. Most common locations are the quadriceps (anterior or lateral thigh) and brachialis (upper arm). They occur most frequently in contact and/or collision sports such as American tackle football, rugby, soccer, and martial arts. Almost all resolve with rest, ice, compression, and elevation (RICE) in combination with rehabilitation exercises. Adductor Strain and Sprain An adductor strain is a common injury to the adductor muscle group that occurs as a result of forceful hip extension & external rotation of an abducted leg. Diagnosis is made clinically with groin pain with tenderness over the inferior pubic rami and decreased strength with resisted leg adduction compared to the other leg. How does it occur? Most commonly, strains occur during acute muscle contraction, such as when kicking, pivoting or skating. Factors that can predispose a patient to injury include failure to warm up, properly stretch, or fatigue from overuse. Risk increases with: Sports involving acceleration such as sprinting, soccer, football, hockey. Sports with repeated movements such as soccer, martial arts, and gymnastics. Failure to warm up, stretch or be properly conditioned. What are the symptoms? Sudden onset of pain, sometimes accompanied by the sensation of a pop in the inner thigh. Inability to continue activity after initial onset of pain How is it diagnosed? History and physical exam are usually sufficient to establish the diagnosis Physical findings include tenderness to palpation (touch), bruising over the inner thigh and sometimes, swelling and warmth over the site of injury. With severe tears there may be a palpable defect over the site of the injury, though this is uncommon. Range of motion testing of the hip is usually normal, but pain is usually reproduced when the patient is asked to contract the muscles. In this case, asking the patient to bring their leg towards midline (adducting their leg) reproduces pain and is usually accompanied by weakness. Are any special tests used to diagnose an adductor muscle strain? Special tests are typically unnecessary. X-rays are almost always negative, but are appropriate in cases in which there is tenderness at the site of bony insertion, or in skeletally immature athletes/patients. In children, attachment sites of muscle/tendon units are vulnerable to fracture and are weaker than the muscle/tendons. MRI is indicated in elite professional athletes, in which precise knowledge of injury location and extent may help in estimating return to activity, or in rare cases, help identify any cases which may require operative treatment. How is it treated? Most adductor muscle strains respond to conservative treatment. Initial treatment includes activity modification, which may temporarily include crutches. Ice and anti-inflammatory medication are appropriate for acute muscle strains. As symptoms improve, gentle stretching and strengthening exercises are appropriate. Your physician may recommend a physical therapy program to aid with these exercises.  Surgery for these injuries is rarely necessary. Avulsion injuries, in which the tendon is pulled away with its bony attachment, may require operative reattachment. Some cases of complete muscle tendon tears may require surgery. Repair involves an open incision over the site of injury and reattachment of the tendon origin, or suture repair of torn soft tissue. Surgery is also necessary in patients with chronic pain whose symptoms do not respond to conservative treatment. When can you return to your sport/activity? Time out of activity varies greatly with the extent of the injury. Most strains start to improve within 10-14 days, and continue to improve over many months. A severe strain may require crutches for several weeks and take a longer recovery period. Some patients will continue to struggle with mild chronic symptoms of pain for more than 6 months. How can an Adductor Muscle Strain be prevented? Most (but not all) strains can be avoided through proper warm up and stretching before activity. Stretching should include the hip, thigh and knee If injury does occur, avoid premature return to activities. Quadriceps Contusion INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY Quadriceps are the most common location for muscle contusion. A blunt contact of a knee to the thigh is the most common mechanism of injury. SIGNS AND SYMPTOMS Pain and swelling in the anterior or lateral thigh is worse with movement; bruising may be visible. The patient may report knee stiffness and difficulty bearing weight. Physical examination findings include tenderness, edema, ecchymosis, weakness, and pain with passive stretch of the quadriceps muscle. A palpable mass may be present if the intramuscular hematoma is substantial. Active straight-leg raise will be painful and may be impossible for the patient toperform. One grading system for contusion severity is based on the degree of active knee flexion post- injury. Mild: active knee flexion greater than 90 degrees Moderate: active knee flexion between 45 and 90 degrees Severe: active knee flexion less than 45 degrees DIFFERENTIAL DIAGNOSIS Quadriceps strain Femur fracture Morel-Lavallee lesion Bony or soft tissue tumor Hip pointer DIAGNOSTIC CONSIDERATIONS The diagnosis can be determined clinically. If the history is unclear or atypical, imaging may be helpful. Radiographic findings are normal in the setting of an acute muscle contusion. Ultrasonography may be used to measure hematoma size to help determine if surgical evacuation should be considered in a high-level athlete. Magnetic resonance imaging (MRI) can provide detailed characterization of the lesion. 1. MRI is typically ordered when there is concern for higher level muscle tear, consideration of surgical treatment, or prolonged failure of conservative treatment.  2. MRI is especially helpful in identifying small hematomas deep within the muscle belly, when ultrasonography is inconclusive. TREATMENT RICE Immobilization of the knee in maximal tolerable flexion for the first 24 to 48 hours after diagnosis facilitates healing, reduces the risk of complications by limiting the size of hematoma formation, andresults in faster return to sports and activities. After 24 to 48 hours, active quadriceps stretching and isometric strengtheningshould begin in a pain-free range, while continuing the use of a compression wrap around the thigh only (without the knee included in flexion). Crutches should be used until there is at least 90 degrees of knee flexion and no limp. The athlete may return to play when knee flexion is full and pain-free andquadriceps size and strength are equal to the uninjured side. Athletes should wear a modified thigh pad to prevent reinjury. EXPECTED OUTCOMES/PROGNOSIS Prognosis is excellent if treatment is begun promptly. In general, disability ranges from less than 2 weeks for mild contusions to greater than 3 weeks for severe contusions. In one study, following the protocol of immediate immobilization in knee flexion, the average time to return to play was 3.5 days, compared with 18 days when immobilization was delayed and 47 days when the thigh was wrapped with the knee in extension. Complications are more likely when treatment is delayed. Myositis ossificans, a benign proliferation of bone and cartilage at the site of the hematoma, is the most common complication. „„It should be suspected if a patient is not improving after 4 to 5 days of treatment or if symptoms, especially knee flexion, worsen 2 to 3 weeks after initial injury. „„It can be detected on radiographs within 3 to 6 weeks after initial injury. „„Myositis ossificans may delay rehabilitation and return to play for up to 1 year. „„If symptomatic, the lesion may be excised once it shows decreased activity on a bone scan. Acute compartment syndrome of the quadriceps compartment caused by large hematoma occurs less frequently (see Chapter 48, CompartmentSyndrome). Nerve palsy can result when the hematoma compresses a nerve, or, rarely, if the nerve itself is damaged from the initial impact. PREVENTION Wearing thigh pads during contact sports will help protect from injury, but thigh pads are not currently commonplace in activities such as rugby and martial arts. Early immobilization in flexion may decrease the risk and/or severity of myositis ossificans. While selective COX-2 inhibitors and indomethacin have been shown to protect against heterotopic ossification following total hip arthroplasty, they have not been studied for preventing myositis ossificans after quadriceps contusions. WHEN TO REFER Severe swelling, progressive pain, or numbness and/or weakness warrantsimmediate referral to an emergency department for evaluation, which may include compartment pressure testing, and possible decompression surgery. Refer to a pediatric orthopaedic specialist 1. —In the case of a large hematoma, when surgical evacuation may be considered 2. —If functional improvement is not dramatic once treatment is initiated 3. —If complications such as myositis ossificans develop Myositis ossificans. Computed tomography scan showing well-circumscribed mass with a sharply marginalized ossified rim (white arrow) andma central lucent area (black arrow). Notethat there is no connection to the femur (arrowhead). Immobilization of the knee immediately after quadriceps contusion. Radiograph of the femur showing myositis ossificans in the quadriceps (arrow). Pelvic Avulsion Fractures INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY The pelvis has several apophyses (ossification centers) that are vulnerable to injury during adolescence. Pelvic avulsion fractures occur when a forceful muscle contraction or elongation causes separation of the apophysis from the pelvic bone. The most common mechanisms of injury are sprinting, kicking, or performing leaps or splits in gymnastics or cheerleading.  Less often, there is gradual onset of pain when the fracture results from repetitive loading during these activities over time. The most common locations are the ischial tuberosity ), anterior superior iliac spine (ASIS) , and anterior inferior iliac spine (AIIS), but avulsions can also occur at the lesser trochanter, iliac crest, and pubic symphysis. Eighty percent are sports related, and 70% to 90% occur in boys. Peak incidence is between 14 and 18 years of age. 1. ——During adolescence, the pelvic apophyses are weaker than the attached musculotendinous units, so a forceful contraction is more likely to cause an avulsion fracture than a muscle strain in this age group. 2. ——Ischial tuberosity avulsions occur at an average age of 19 years because of the later age of formation of this apophysis. SIGNS AND SYMPTOMS Patients typically report a sudden, painful pop in the anterior or lateral hip or buttocks. Weight-bearing is painful. Local swelling and ecchymosis may be noted. The injured apophysis will be tender, but the attached muscle is usually non-tender. There will be pain with active contraction or passive stretch of the attached muscle and often decreased flexibility and strength. DIFFERENTIAL DIAGNOSIS Muscle strain Pelvic apophysitis (overuse injury to the apophysis, similar to Osgood-Schlatter disease and Sever disease; Bony or soft tissue tumor Hip pointer DIAGNOSTIC CONSIDERATIONS Radiographs are required for diagnosis and will reveal a displaced bony fragment at the involved site. 1. —Anteroposterior view of the pelvis will show most avulsions 2. —Oblique (Judet) view of the pelvis allows better visualization of the AIIS and ASIS, may be helpful for diagnosing these avulsions, and may allow comparison with the appearance of the non-injured side. TREATMENT Most patients with pelvic avulsion fractures recover fully with nonoperative treatment and are able to return to previous level of sports activity, even when bony nonunion persists on radiographs. During the initial post-injury period, the young athlete should use ice and should remain non- weight bearing on crutches until ambulation is no longer painful, which usually takes 2 to 4 weeks. Heat, massage, and vigorous stretching should be avoided during this period. Once weight bearing is no longer painful, rehabilitation may begin, concentrating on gentle flexibility exercises initially and strengthening later. Once there is full, pain-free range of motion and near-normal strength, the athlete may start a gradual, stepwise return to sporting activities, starting with jogging, then running, then sport- specific drills, before full return to play. Repeat radiographs are not usually necessary unless symptoms persist beyond the expected healing time. EXPECTED OUTCOMES/PROGNOSIS Time to return to sports varies depending on the site and severity of injury. 1. —ASIS, AIIS, and iliac crest: 6 to 8 weeks. 2. —Ischial tuberosity and pubic symphysis: 2 to 4 months. Premature return to activities can result in reinjury and prolonged recovery. Chronic pain and nonunion are possible complications, especially in cases of delayed or inadequate treatment. Acute-onset meralgia paresthetica has been reported with ASIS avulsions. AIIS avulsions can also result in hip impingement and chronic hip pain. Ischial tuberosity fractures can cause pain with sitting that persists for months to years as well as limitations with sports activity (eg, patient can tolerate a fast run without pain but not necessarily sprinting). PREVENTION Adolescent athletes should be counseled to seek medical care for any lingering muscle strain of the hip or thigh, so an evaluation for apophysitis or previously unrecognized or occult avulsion fracture can be performed. WHEN TO REFER Refer to a pediatric orthopedic surgeon or pediatric sports medicine physician for diagnosis and management, especially if the following situations are present: ——For avulsions with more than 2 cm of separation ——If assistance is needed for supervision of rehabilitation or clearance to return to play ——For persistent pain beyond expected time for recovery and inability to resume prior level of sports participation  ——For chronic, symptomatic nonunion. Overuse Injuries Overuse injuries occur when an anatomic structure is subjected to repetitive stress, force, or trauma without adequate rest to allow for the structure to heal. Young athletes may sustain overuse injuries to bones, growth centers, tendons, muscles, and fascia. Common contributing factors: Training errors are the most common contributing factor causing these injuries.These include rapid increases in training loads, insufficient rest time in between training sessions, and long- term, high-level repetitive training, often associated with early sport specialization. Other contributing factors include preexisting deconditioning, suboptimalequipment, poor training surfaces or sudden change in training surface, improper technique, imbalances in muscle strength or flexibility, and variants of normal anatomic alignment such as pes planus or pes cavus. Overuse injuries involving the growth plates (physes and apophyses) are unique to children and adolescents. 1. ——Unlike bone and tendon, which are composed of a strong extracellular matrix designed to withstand compressive and tensile loads, growth plates are composed mainly of cartilage cells and have less resistance to stress. 2. ——Injuries to the apophyses are most common. These areas of secondary ossification, where muscle-tendon units attach to bone, are the weakest point in the immature biomechanical chain. Rotator Cuff Tendinitis/Impingement INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY Inflammation and thickening of rotator cuff tendons or subacromial bursa cause impingement under the coracoacromial arch when the arm is elevated. This injury commonly occurs in overhead sports such as tennis, baseball, softball, volleyball, and swimming. In younger athletes, rotator cuff tendinitis or impingement is usually caused by shoulder ligamentous laxity or muscle imbalance, rather than narrowing of the subacromial space seen in adults. Additional etiologic factors include improper throwing technique and excessive pitching, oversized tennis rackets, and use of hand paddles and drag suits by swimmers. Tears of the rotator cuff due to overuse are rare in pediatric and adolescent athletes. SIGNS AND SYMPTOMS Pain with overhead activity that does not improve with warm-up May progress to pain with activities of daily living, pain at rest, or nighttime pain Patients may report diminished strength with overhead activities. Tenderness with palpation of the rotator cuff tendons in the subacromial space Shoulder range of motion, especially elevation, may be limited and strength may be diminished. Resisted strength testing of individual rotator cuff muscles may Reproduce symptoms. Neer or Hawkins impingement tests may be positive. DIFFERENTIAL DIAGNOSIS  Biceps tendinitis Glenohumeral instability Acromioclavicular sprain Proximal humeral fracture Labral tear, including SLAP lesion Thoracic outlet syndrome DIAGNOSTIC CONSIDERATIONS Diagnosis may be determined clinically. Imaging is usually not necessary. When the diagnosis is uncertain, radiographs may be helpful to rule out bony injury such as Little League shoulder, and they may be helpful in identifying predisposing anatomy such as type II or III acromion that narrows the subacromial space. MRI or in-office ultrasonography may be useful in cases refractory to conservative management or if there is concern for other injuries. ——In most cases of rotator cuff tendinitis or impingement, MRI & ultrasonography demonstrate fluid, inflammation, or thickening of the rotator cuff tendons or subacromial bursa. If there is concern for a labral tear, MRI with arthrography is the diagnostic study of choice. TREATMENT Athletes should temporarily rest from overhead activities until they can perform them without pain. NSAIDs can reduce inflammation and may be used for pain with activities of daily living or at rest. The most important aspect of treatment is a physical therapy program to correct muscle imbalance. A comprehensive program focusing on range of motion, rotator cuff and core strengthening, and periscapular stabilization should be initiated as soon as possible. Sport-specific technique and equipment should be evaluated. Surgical intervention is rarely needed in the pediatric and adolescent athlete. In cases unresponsive to nonoperative management, shoulder arthroscopy may be helpful for identification of additional pathology or débridement of chronically inflamed and injured rotator cuff tendons. A cortisone injection may relieve painful symptoms EXPECTED OUTCOMES/PROGNOSIS  Response to nonoperative management is usually excellent, resulting In return to full participation in previous activities. Return to sports depends on the severity of symptoms, ranging from 2 to 4 weeks to 4 to 6 months. Symptoms can progress if the underlying muscle imbalance and joint instability are not addressed. This may ultimately lead to inability to participate in the inciting activity. If biomechanical or equipment issues are not addressed, or if proper muscular balance is not maintained, symptoms may recur. WHEN TO REFER Refer to a pediatric sports medicine specialist when there has been no improvement after 6 to 8 weeks of rest and physical therapy. PREVENTION Pitchers should follow published guidelines for pitch count maximums andnumber of rest days between pitching appearances. Children and adolescents should not throw competitively for more than 9 months out of the year. All overhead athletes should be encouraged to pay close attention to correct technique. Throwing mechanics should be reviewed by a knowledgeable coach. Cardiovascular fitness and core strength should be maintained year-round. Specific strengthening programs exist for pitchers that focus on scapularstabilization. Initiating a preventive rotator cuff strengthening program may be useful in at-risk athletes. Continuing a rotator cuff maintenance program after recovery can help prevent recurrent episodes. Children in sports involving repetitive overhead activity should be encouraged to report any discomfort in the upper extremity immediately. Such reports should be promptly evaluated. Medial epicondylitis (Golfer Elbow) INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY. Inflammation of the medial side of the elbow is less common than inflammation of the lateral side. Overuse at work or throwing sports can initiate the process. It caused by repetitive valgus force at the elbow that occurs with the pitching motion. The valgus force causes tension forces on the medial side of the elbow and compression forces on the lateral side. The term is sometimes used more broadly to describe a constellation of overuse pitching injuries in the immature elbow, including medial epicondyle apophysitis, flexor-pronator muscle strain, and olecranon apophysitis. Annual incidence of elbow pain in baseball pitchers between 8 and 12 years of age has been reported to be 20% to 30%. Young athletes other than pitchers can be at risk for medial epicondyle apophysitis, including American tackle football quarterbacks, non-pitchingbaseball players, gymnasts, and tennis players. SIGNS AND SYMPTOMS Medial elbow pain during or after pitching or other throwing or overhead activity May have stiffness, swelling, limited elbow extension, and, occasionally,mechanical symptoms such as locking and popping Impaired performance, including loss of pitching accuracy and reduced velocity, may be reported. Patients have localized tenderness over the medial epicondyle. Medial elbow swelling or effusion may be present. DIFFERENTIAL DIAGNOSIS Medial epicondyle avulsion fracture Flexor-pronator tendinitis Ulnar collateral ligament sprain or tear Ulnar nerve injury or entrapment, ulnar neuritis Neoplasm Referred pain from the neck or shoulder DIAGNOSTIC CONSIDERATIONS Diagnosis may be determined clinically. Radiographs are often negative in the early stages of injury. ——AP, lateral, and oblique views of both elbows should be obtained forcomparison. MRI or ultrasonography may be helpful to evaluate for other conditions, such as osteochondritis dissecans of the capitellum (typically visible on radiographs, but MRI helpful to evaluate severity), ulnar collateral ligament injury, and flexor pronator tendinitis. TREATMENT Initial treatment includes complete rest from throwing until pain and tenderness resolve (usually 4–6 weeks). Ice and NSAIDs are rarely needed because pain typically occurs only withthrowing or overhead activity, but they may be helpful if swelling is present. As symptoms improve, a physical therapy rehabilitation program is initiated, beginning with stretching and range of motion exercises followed by progressive strengthening of upper body and core muscles. Once the athlete has no tenderness and full, pain-free range of motion and strength, return to throwing begins with light tosses over a short distance and progresses gradually over 4 to 6 weeks to maximum effort pitching from regulation distance. The athlete should work with an experienced coach to evaluate and correct any underlying errors in throwing or pitching technique. EXPECTED OUTCOMES/PROGNOSIS If treated properly early in the course, most athletes can return to pitching. The average time from initial diagnosis to return to competitive activity is 8 to 12 weeks. Some may not be able to return to their previous level of play, even with timely,proper treatment. Athletes who continue to throw with pain and disregard recommendations for treatment are at risk for long-term, possibly permanent, sequelae. ——Complications may include growth disturbance around the elbow; jointstiffness, including flexion contracture; chronic, progressive medial elbow pain; bony deformity, including premature elbow arthrosis; and acute displacement of apophysis that may lead to nonunion requiring surgery. WHEN TO REFER Refer to a pediatric sports medicine specialist if ——There is no improvement in symptoms after 6 to 8 weeks of rest ——Guidance is needed for supervision of physical therapy or clearance for return to throwing Refer to a pediatric orthopedic surgeon for ——Widening or displacement of the medial epicondyle apophysis of more than 5 mm, which may require surgical fixation. PREVENTION Pitchers should be advised to follow published guidelines for pitch count maximums and number of rest days between pitching appearances Children and adolescents should not throw competitively for more than 9 months a year. All overhead athletes should be encouraged to pay close attention to correct technique. Throwing mechanics should be reviewed by a knowledgeable coach. Cardiovascular fitness and core strength should be maintained year-round. Children in sports involving repetitive overhead activity should be encouraged to report any discomfort in the upper extremity immediately. Such reports should be promptly evaluated. Lateral epicondylitis (Tennis elbow) Definition It is a condition in which the outer part of the elbow becomes sore and tender at the lateral epicondyle where the wrist & finger extensors originate. Causes: - Due to repetitive strain injury as in playing tennis. - Due to improper racquet size or backhand technique. - Due to overuse of the extensor Ms., which is common in carpenters and laborers who swing a hammer or other tool with the forearm and the wrist are flexed. - Direct trauma on the epicondyle. - Sudden forceful wrist extension. Treatment: 1)The first line of treatment is rest, a short course of anti-inflammatory medicine, and a wrist splint 2)The second line of treatment is local steroid injection in the area of greatest pain and symptom 3)If these measures fail, excision of the degenerative fascia with or without reattachment of the tendon origin Treatment of lateral epicondylitis is the same as that for the medial side, but success is more predictable.  Osgood-Schlatter Disease INTRODUCTION/ETIOLOGY/EPIDEMIOLOGY Osgood-Schlatter disease (OSD) is an apophysitis, or osteochondrosis, of the tibial tuberosity caused by repetitive, forceful contraction of the quadriceps muscle. Onset is usually associated with a period of rapid growth combined with activity. The disease usually affects boys between 10 and 15 years of age and girls between 8 and 13 years of age. Although the incidence has been higher among boys, incidence in girls has increased with increased participation in organized, year-round sports. It occurs bilaterally in 25% to 50% of patients. It is most commonly seen in running and jumping sports, such as basketball, soccer, and gymnastics. Intrinsic risk factors include tight quadriceps, tight hamstrings , patella alta, and external tibial rotation , which increase the traction forces on the tibial tubercle from the patellar tendon. SIGNS AND SYMPTOMS Pain at the tibial tubercle that is worse with activity and improves with rest. Onset of symptoms is usually gradual but can sometimes be triggeredor worsened by an acute event, such as a sprint, jump, or direct impact to the tubercle. Localized tenderness over the tibial tuberosity. Bony prominence and soft tissue swelling may be present. Resisted knee extension is typically painful. Tight quadriceps and hamstrings, external tibial rotation, or patella alta may be noted. The patient may have pain with active straight-leg raise test. Inability to perform active straight-leg raise, or inability to maintain a straight leg during this test, suggests a disruption of the extensor mechanism, such as a tibial tubercle avulsion fracture or patellar tendon rupture. DIFFERENTIAL DIAGNOSIS Tenderness over the tibial tuberosity with an otherwise normal knee examination will usually rule out other causes of knee pain. 1. ——Patellofemoral pain syndrome 2. ——Sinding-Larsen–Johansson syndrome 3. ——Patellar tendinitis  4. ——Prepatellar or infrapatellar bursitis 5. ——Stress fracture of the proximal tibia 6. ——Osteochondritis dissecans 7. ——Referred pain from the hip 8. ——Bony neoplasm or infection DIAGNOSTIC CONSIDERATIONS Diagnosis can be determined clinically; imaging is not usually necessary. Radiography ——Indicated to rule out other pathology in patients with atypical signs and symptoms or those who do not respond to usual treatment ——Most patients with OSD will have normal radiographic findings. ——Elevation, irregularity, and fragmentation of the tibial tubercle apophysis are normal variants of ossification and do not indicate abnormal pathology or OSD. ——Soft tissue swelling anterior to the tibial tubercle is suggestive of OSD. MRI is not necessary unless another diagnosis is suspected. Palpation of tibial tuberosity Lateral view of the knee showing Osgood-Schlatter disease with soft tissue swelling overlying the tibial apophysis (arrow) and widening of the apophysis. TREATMENT While some level of activity modification may be helpful initially (resting from painful activities), complete cessation of activity is not usually required. Activity that causes significant pain or altered gait should be avoided. Discomfort occurring after activity should not preclude participation. A patellar strap may reduce pain with activity. Anti-inflammatory medications should not be used before activity because they may mask pain and contribute to worsening injury. A protective pad over the tibial tuberosity can protect against direct trauma. Ice can help reduce pain (apply for 15–20 minutes, 2 or 3 times a day, not immediately before activity).  Quadriceps and hamstring stretching can reduce tension at the tibial tubercle. Patellar strap. Placed over patellar tendon, in between patella and tibial tubercle EXPECTED OUTCOMES/PROGNOSIS Symptoms generally resolve over time, before or concurrent with closure of the tibial tubercle apophysis. Many will have residual prominence of the tubercle into adulthood. Occasionally, pain persists following closure of the apophysis. Persistent discomfort with kneeling into adulthood may indicate the presence of a residual ossicle(s), which occasionally may need surgical removal. Rarely, chronic OSD can weaken the apophysis, making it more vulnerable to an acute avulsion fracture with forceful quadriceps contraction. Genu recurvatum (tibial forward curvature resulting in hyperextension of the knee) has been noted as a rare but serious complication of OSD, resulting from premature closure of the anterior portion of the proximal tibial epiphyseal plate. WHEN TO REFER Refer to a pediatric sports medicine specialist ——If there is no improvement after several weeks of rest and Non operative treatment Refer to a pediatric orthopedic specialist ——If there is concern for tibial tubercle avulsion (unable to perform a straightleg raise or significant widening or displacement of tubercle on lateral radiographs). PREVENTION Maintain quadriceps strength and flexibility, particularly during periods of rapid growth. Do not push through pain with activity.