Sports Medicine

Sports injuries occur when playing indoor or outdoor sports or while exercising. They can result from accidents, inadequate training, improper use of protective devices, or insufficient stretching or warm-up exercises. The most common sports injuries are sprains and strains, fractures and dislocations.

The most common treatment recommended for injury is rest, ice, compression and elevation (RICE).

  • Rest: Avoid activities that may cause injury.
  • Ice: Ice packs can be applied to the injured area, which will help reduce swelling and pain. Ice should be applied over a towel on the affected area for 15-20 minutes, four times a day, for several days. Never place ice directly over the skin.
  • Compression: Compression of the injured area also helps reduce swelling. Elastic wraps, air casts and splints can accomplish this.
  • Elevation: Elevate the injured part above your heart level to reduce swelling and pain.

Some of the measures that are followed to prevent sports-related injuries include:

  • Follow an exercise program to strengthen the muscles.
  • Gradually increase your exercise level and avoid overdoing the exercise.
  • Ensure that you wear properly-fitted protective gear such as elbow guards, eye gear, facemasks, mouth guards and pads, comfortable clothes, and athletic shoes before playing any sports activity, which will help reduce the chances of injury.
  • Make sure that you follow warm-up and cool-down exercises before and after the sports activity. Exercises will help stretch muscles, increase flexibility and reduce soft tissue injuries.
  • Avoid exercising immediately after eating a large meal.
  • Maintain a healthy diet, which will nourish the muscles.
  • Avoid playing when you are injured or tired. Take a break for some time after playing.
  • Learn all the rules of the game you are participating in.
  • Ensure that you are physically fit to play the sport.

Conditions

Sprains/Strains

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.

Shoulder Dislocation

Patellar Dislocation

Acromioclavicular joint (AC joint) dislocation

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.

Ankle Fracture

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.

Ankle Sprain

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.

Golfer's Elbow

Golfer's elbow, also called Medial Epicondylitis, is a painful condition occurring from repeated muscle contractions in the forearm that leads to inflammation and microtears in the tendons that attach to the medial epicondyle. The medial epicondyle is the bony prominence that is felt on the inside of the elbow.

Golfer's elbow and Tennis Elbow are similar except that Golfer's elbow occurs on the inside of the elbow and Tennis Elbow occurs on the outside of the elbow. Both conditions are a type of Tendonitis which literally means "inflammation of the tendons".

Signs and symptoms

Signs and symptoms of Golfer's Elbow can include the following:

  • Elbow pain that appears suddenly or gradually
  • Achy pain to the inner side of the elbow during activity
  • Elbow stiffness with decreased range of motion
  • Pain may radiate to the inner forearm, hand or wrist
  • Weakened grip
  • Pain worsens with gripping objects
  • Pain is exacerbated in the elbow when the wrist is flexed or bent forward toward the forearm

Causes

Golfer's Elbow is usually caused by overuse of the forearm muscles and tendons that control wrist and finger movement but may also be caused by direct trauma such as with a fall, car accident, or work injury.

Golfer's elbow is commonly seen in golfer's, hence the name, especially when poor technique or unsuitable equipment is used when hitting the ball. Other common causes include any activity that requires repetitive motion of the forearm such as: painting, hammering, typing, raking, pitching sports, gardening, shoveling, fencing, and playing golf.

Diagnosis

Golfer's Elbow should be evaluated by an orthopedic specialist for proper diagnosis and treatment.

  • Medical History
  • Physical Examination
  • Your physician may order an x-ray to rule out a fracture or arthritis as the cause of your pain.
  • Occasionally, if the diagnosis is unclear, your physician may order further tests to confirm golfer's elbow such as MRI, ultrasonography, and injection test

Conservative Treatment Options

Your physician will recommend conservative treatment options to treat the symptoms associated with Golfer's Elbow. These may include the following:

  • Activity Restrictions: Limit use and rest the arm from activities that worsen symptoms
  • Orthotics: Splints or braces may be ordered to decrease stress on the injured tissues
  • Ice: Ice packs applied to the injury will help diminish swelling and pain. Ice should be applied over a towel to the affected area for 20 minutes four times a day for a couple days. Never place ice directly over the skin
  • Medications: Anti-inflammatory medications and/or steroid injections may be ordered to treat the pain and swelling
  • Occupational Therapy: OT may be ordered for strengthening and stretching exercises to the forearm once your symptoms have decreased
  • Pulsed Ultrasound: A non-invasive treatment used by therapists to break up scar tissue and increase blood flow to the injured tendons to promote healing
  • Professional instruction: Consulting with a sports professional to assess and instruct in proper swing technique and appropriate equipment may be recommended to prevent recurrence

Surgery

If conservative treatment options fail to resolve the condition and symptoms persist for 6 -12 months, your surgeon may recommend surgery to treat Golfers Elbow. The goal of surgery to treat Golfers Elbow is to remove the diseased tissue around the inner elbow, improve blood supply to the area to promote healing, and alleviate the patient's symptoms.

Tennis Elbow

Tennis elbow is the common name used for the elbow condition called lateral epicondylitis. It is an overuse injury that causes inflammation of the tendons that attach to the bony prominence on the outside of the elbow (lateral epicondyle). It is a painful condition occurring from repeated muscle contractions at the forearm that leads to inflammation and micro tears in the tendons that attach to the lateral epicondyle. The condition is more common in sports activities such as tennis, painting, hammering, typing, gardening and playing musical instruments. Patients with tennis elbow experience elbow pain or burning that gradually worsens and a weakened grip

Your doctor will evaluate tennis elbow by reviewing your medical history, performing a thorough physical examination and ordering X-rays, MRI or electromyogram (EMG) to detect any nerve compression.

Your doctor will first recommend conservative treatment options to treat the tennis elbow symptoms. These may include:

  • Limit use and rest the arm from activities that worsen symptoms.
  • Splints or braces may be ordered to decrease stress on the injured tissues.
  • Apply ice packs on the elbow to reduce swelling.
  • Avoid activities that bring on the symptoms and increase stress on the tendons.
  • Anti-inflammatory medications and/or steroid injections may be ordered to treat pain and swelling.
  • Physical therapy may be ordered for strengthening and stretching exercises to the forearm once your symptoms have decreased.
  • Pulsed ultrasound may be utilized to increase blood flow and promote healing to the injured tendons.

If conservative treatment options fail to resolve the condition and symptoms persist for 6 -12 months, your surgeon may recommend a surgical procedure to treat tennis elbow called lateral epicondyle release surgery. Your surgeon will decide whether to perform your surgery in the traditional open manner (single large incision) or endoscopically (2 to 3 tiny incisions and the use of an endoscope –narrow lighted tube with a camera). Your surgeon will decide which options are best for you depending on your specific circumstances.

Your surgeon moves aside soft tissue to view the extensor tendon and its attachment on the lateral epicondyle. The surgeon then trims the tendon or releases the tendon and then reattaches it to the bone.  Any scar tissue present will be removed as well as any bone spurs. After the surgery is completed, the incision(s) are closed by suturing or by tape.

Following surgery, you are referred to physical therapy to improve the range of motion and strength of your joint.

Meniscal Tears

Patellofemoral Instability

Patellofemoral Pain Syndrome

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

Biceps Tendon Rupture

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

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

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

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

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

Causes

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

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

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

Symptoms

The most common symptoms of a biceps tendon rupture include:

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

Diagnosis

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

Treatment

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

Nonsurgical treatment includes:

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

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

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

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

Surgical Treatment

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

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

Risks and Complications

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

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

Rotator Cuff Tear

Clavicle fracture

Procedures

Achilles Tendon Tear Repair

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.

ACL Reconstruction Hamstring Method

ACL Reconstruction Patellar Tendon

Medial Collateral Ligament Reconstruction

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

Posterior Cruciate Ligament Reconstruction

Open reduction and Internal Fixation of Proximal Humerus Fracture

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)

SLAP Repair

Shoulder Labrum Reconstruction