Showing papers in "American Journal of Sports Medicine in 1990"

Accelerated rehabilitation after anterior cruciate ligament reconstruction

Abstract: To overcome many of the complications after ACL reconstruction (prolonged knee stiffness, limitation of complete extension, delay in strength recovery, anterior knee pain), yet still maintain knee stability, we developed a rehabilitation protocol that emphasizes full knee extension on the first postoperative day and immediate weightbearing according to the patient's tolerance. Of 800 patients who underwent intraarticular ACL patellar tendon-bone graft reconstruction, performed by the same surgeon, the last 450 patients have followed the accelerated rehabilitation schedule as outlined in the protocol. A longer than 2 year followup is recorded for 73 of the patients in the accelerated rehabilitation group. On the 1st postoperative day, we encouraged these patients to walk with full weightbearing and full knee extension. By the 2nd postoperative week, the patients with a 100 degree range of motion participated in a guided exercise and strengthening program. By the 4th week, patients were permitted unlimited activities of daily living and were allowed to return to light sports activities as early as the 8th week if the Cybex strength scores of the involved extremity exceeded 70% of the scores of the noninvolved extremity and the patient had completed a sport-specific functional/agility program. The patient database was compiled from frequent clinical examinations, periodic knee questionnaires, and objective information, such as range of motion measurements, KT-1000 values, and Cybex strength scores. A series of graft biopsies obtained at various times have revealed no adverse histologic reaction.(ABSTRACT TRUNCATED AT 250 WORDS)

Viscoelastic properties of muscle-tendon units. The biomechanical effects of stretching.

Abstract: Most muscle stretching studies have focused on defining the biomechanical properties of isolated elements of the muscle-tendon unit or on comparing different stretching techniques. We developed an experimental model that was designed to evaluate clinically relevant biomechanical stretching properties in an entire muscle-tendon unit. Our objectives were to characterize the viscoelastic behavior of the muscle-tendon unit and to consider the clinical applications of these viscoelastic properties. Rabbit extensor digitorum longus and tibialis anterior muscle-tendon units were evaluated using methods designed to simulate widely used stretching techniques. Additionally, the effects of varying stretch rates and of reflex influences were evaluated. We found that muscle-tendon units respond viscoelastically to tensile loads. Reflex activity did not influence the biomechanical characteristics of the muscle-tendon unit in this model. Experimental techniques simulating cyclic stretching and static stretching resulted in sustained muscle-tendon unit elongations, suggesting that greater flexibility can result if these techniques are used in the clinical setting. With repetitive stretching, we found that after four stretches there was little alteration of the muscle-tendon unit, implying that a minimum number of stretches will lead to most of the elongation in repetitive stretching. Also, greater peak tensions and greater energy absorptions occurred at faster stretch rates, suggesting that the risk of injury in a stretching regimen may be related to the stretch rate, and not to the actual technique. All of these clinically important considerations can be related to the viscoelastic characteristics of the muscle-tendon unit.

The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder

Abstract: The gross and histologic anatomy of the inferior glenohumeral ligament was studied in 11 fresh frozen cadaver shoulders. Arthroscopic observations of the joint capsule through the normal range of motion revealed that the inferior glenohumeral ligament is actually a complex of structures consisting of an anterior band, a posterior band, and an interposed axillary pouch. While these components of the inferior glenohumeral ligament complex were present in all 11 specimens, they were best demonstrated in some shoulders by placing the humeral head in internal or external rotation in varying degrees of abduction. Histologic examination of the joint capsule revealed that the anterior and posterior bands of the inferior glenohumeral ligament complex were readily identifiable as distinct structures comprised of thickened bands of well-organized collagen bundles. Although slight variations were noted in the attachment sites of the anterior and posterior bands to the glenoid, the inferior glenohumeral ligament complex was observed to attach to the humeral neck in one of two distinct configurations. A collar-like attachment, in which the entire inferior glenohumeral ligament complex attaches just inferior to the articular edge of the humeral head, was observed in six specimens. In the remaining five specimens, the attachment was in the shape of a "V," with the anterior and posterior bands attaching adjacent to the articular edge of the humeral head and the axillary pouch attaching at the apex of the "V" distal to the articular edge. The orientation and design of the inferior glenohumeral ligament complex supports the functional concept of this single structure as an important anterior and posterior stabilizer of the shoulder joint.

Patterns of flexibility, laxity, and strength in normal shoulders and shoulders with instability and impingement

Abstract: Imbalance of the internal and external rotator musculature of the shoulder, excess capsular laxity, and loss of capsular flexibility, have all been implicated as etiologic factors in glenohumeral instability and impingement syndrome; however, these assertions are based largely on qualitative clinical observations. In order to quantitatively define the requirements of adequate protective synergy of the internal and external rotator musculature, as well as the primary capsulolabral restraints, we prospectively evaluated 53 subjects: 15 asymptomatic volunteers, 28 patients with glenohumeral instability, and 10 patients with impingement syndrome. Range of motion was evaluated by goniometric technique in all patients with glenohumeral instability and impingement. Laxity assessment was performed and anterior, posterior, and inferior humeral head translation was graded on a scale of 0 to 3+. Isokinetic strength assessment was performed in a modified abducted position using the Biodex Clinical Data Station with test speeds of 90 and 180 deg/sec. Internal and external rotator ratios and internal and external rotator strength deficits were calculated for both peak torque and total work. Patients with impingement demonstrated marked limitation of shoulder motion and minimal laxity on drawer testing. Both anterior and multidirectional instability patients had excessive external rotation as well as increased capsular laxity in all directions. Sixty-eight percent of the patients with instability had significant impingement signs in addition to apprehension and capsular laxity. Isokinetic testing of asymptomatic subjects demonstrated a 30% greater internal rotator strength in the dominant shoulder. Comparison of all three experimental groups demonstrated a significant difference between internal and external rotator ratios for both peak torque and total work. Conclusions are that there appears to be a dominance tendency with regard to internal rotator strength in asymptomatic individuals. Impingement syndrome and anterior instability have significant differences in both strength patterns of the rotator muscles and flexibility and laxity of the shoulder. Isokinetic testing potentially may be helpful in diagnostically differentiating between these two groups in cases where there is clinical overlap of signs and symptoms.

Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg

Abstract: One hundred fifty-nine patients were referred to the authors for evaluation of chronic exertional leg pain from 1978 to 1987. The records of 131 patients were complete and available for retrospective review. Forty-five patients were diagnosed as having a chronic compartment syndrome (CCS) and seventy-five patients had the syndrome ruled out by intramuscular pressure recordings. The only significant difference found between the two groups on history and physical examination was a 45.9% incidence of muscle herniae in the patients with CCS, compared to a 12.9% incidence in those without the syndrome. One-third of the patients with the syndrome and over one-half of those without it reported persistent, moderate to severe pain at 6 month to 9 year followup. Modified, objective criteria were developed for the diagnosis of CCS. The criteria were based upon the intramuscular pressures recorded with the slit catheter before and after exercise in 210 muscle compartments without CCS. In the presence of appropriate clinical findings, we consider one or more of the following intramuscular pressure criteria to be diagnostic of chronic compartment syndrome of the leg: 1) a preexercise pressure greater than or equal to 15 mm Hg, 2) a 1 minute postexercise pressure of greater than or equal to 30 mm Hg, or 3) a 5 minute postexercise pressure greater than or equal to 20 mm Hg.

Intraarticular reaction associated with the use of freeze-dried, ethylene oxide-sterilized bone-patella tendon-bone allografts in the reconstruction of the anterior cruciate ligament

Abstract: One hundred nine patients over a 3 year period underwent reconstruction for chronic ACL ruptures using a freeze-dried, ethylene oxide-sterilized bone-patella tendon-bone allograft. Seven patients (6.4%) developed a characteristic persistent intraarticular reaction. This reaction was characterized by persistent synovial effusion with collagenous particulates and cellular inflammatory response. Synovial biopsies in all cases showed a similar chronic inflammatory process, characterized by fibrin, collagen, and phagocytic cells. The intraarticular white cells were predominantly lymphocytes. Removal of the allograft resulted in resolution of the reaction in all of the patients. Three of the seven patients showed HLA conversion. Gas chromatography demonstrated detectable levels of ethylene chlorohydrin, a toxic reaction product of ethylene oxide, within the allograft and synovium 14 months following implantation of one graft. These seven cases presented strongly suggest a nonspecific or immune mediated response that must be further delineated. The use of freeze-dried, ethylene oxide-sterilized allografts using standard techniques cannot be recommended for reconstruction of the ACL.

Anteromedial tibial tubercle transfer without bone graft

Abstract: We followed 30 patients for more than 2 years after anteromedial tibial tubercle transfer for persistent patellofemoral pain associated with patellar articular degeneration Twelve of these patients were followed more than 5 years We report 93% good and excellent results subjectively and 89% good and excellent results objectively The quality of improvement was sustained in all 12 of the patients who were evaluated again after more than 5 years from surgery When examined separately, 75% of those patients with advanced patellar arthrosis achieved a good result; none of these patients achieved an excellent result Postoperative continuous passive motion has markedly reduced the incidence of stiffness Serious complications such as compartment syndrome, infection, and skin slough were avoided completely in 51 consecutive cases Patellofemoral contact pressure studies in five cadaver knees have shown that anteromedial tibial tubercle transfer can provide substantial reduction of patellofemoral contact stress while helping to balance medial and lateral facet pressures This surgical procedure is mechanically and clinically successful for alleviating intractable pain related to patellar malalignment and articular degeneration This procedure enables the majority of appropriately selected patients with malalignment and patellar articular degeneration to resume increased levels of activity with substantially diminished pain

Lateral release of the patella: Indications and contraindications:

Abstract: Charts were reviewed on patients at the Salt Lake Knee and Sports Medicine Clinic who had had a lateral release of the patella. Patients were divided into two groups. Group I contained patients who were entirely satisfied with the procedure, and Group II included patients who were complete failures (defined as a need for further surgical procedures). In Group I, 74 patients were included in the subjective followup. Forty of the 74 patients also had an objective followup, including roentgenograms and a physical examination. Group II contained 43 patients. Results indicated that the most predictable criterion for success was a negative passive patellar tilt. Secondary criteria included a medial and lateral patellar glide of two quadrants or less and a normal tubercle-sulcus angle at 90 degrees of flexion. Patients had less predictable results after an isolated lateral release with a positive (greater than 5 degrees) passive patellar tilt and a three quadrant or greater medial and lateral patellar glide or an abnormal tubercle-sulcus angle at 90 degrees of flexion.

Arthroscopic evaluation of acute initial anterior shoulder dislocations

Abstract: Arthroscopic evaluation of patients with an acute anterior shoulder dislocation was done to identify and classify the intraarticular lesions that might predict recurrent dislocations. Forty-five shoulders fit the following criteria for inclusion in our study: initial dislocation with no prior history of shoulder problems; confirmation of the dislocation radiographically or reduction by a physician; and arthroscopy within 10 days. The 42 men and 3 women had an average age of 21.2 years (range, 14 to 28 years). Mechanism of injury was a twisting of the arm into forced abduction and external rotation, a fall on the outstretched arm, or a direct blow to the shoulder. Based on this preliminary study of 45 shoulders, we present a classification of the lesions found in the acute shoulder dislocation. Group 1 (six shoulders) had capsular tears with no labral lesions: these shoulders were stable under anesthesia and had no or minimal hemarthrosis. Group 2 (11 shoulders) had capsular tears and partial labral detachments: these shoulders were mildly unstable and had mild to moderate hemarthrosis. Group 3 (28 shoulders) had capsular tears with labral detachments: these shoulders were grossly unstable and had large hemarthrosis. They had complete capsular/labral detachments. In the past, redislocation rates have been primarily related to age at the time of initial dislocation and, to a lesser degree, the period of immobilization. We have identified the intraarticular lesions in 45 patients with an initial anterior glenohumeral dislocation and classified these shoulders into three groups based on the lesions found. By doing so, we can develop a more accurate method of determining which shoulders are prone to recurrent dislocation.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study.

Abstract: A comparative study between percutaneous repair and open surgical repair of acute spontaneous Achilles ten don ruptures in young athletic patients is presented. Twenty-seven patients with acute Achilles ruptures were evaluated objectively and with subjective ques tionnaires. Fifteen of the patients were treated by re construction with a gastrocsoleus fascial graft (fol lowup, 4.6 years) and 12 treated by percutaneous repair (followup, 1.8 years).Subjectively, both groups were very satisfied with the results of their treatment. Cybex II dynamometer measuring strength, power, and endurance revealed no statistical significant differences between groups, even in light of the shorter followup of the percutaneous group. The percutaneous repairs demonstrated signifi cantly more symmetry in injured/uninjured tendon size than did the open surgical repairs. Two reruptures occurred in the percutaneous group. No other compli cations were noted. After evaluation of both subjective and objective data we recommend percu...

The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint.

Abstract: The purpose of this study was to investigate the ligamentous stabilizing mechanisms preventing anterior instability in the glenohumeral joint. Six freshly thawed, unembalmed cadaveric shoulders were dissected, preserving the joint capsule and glenohumeral ligaments, the coracohumeral ligament, and the subscapularis tendon. Hall-effect strain transducers were placed on the superior, middle, and inferior glenohumeral ligaments. The humerus and scapula were fixed in a specifically designed mounting apparatus that allowed the glenohumeral joint to be placed in 0 degree, 45 degrees, or 90 degrees of abduction. The mounting apparatus was placed in a model TTC Instron Universal Testing Instrument, which applied an external rotation torque to the humerus. Strain produced in the three glenohumeral ligaments was recorded on a three-channel X-Y chart recorder. At 0 degree of abduction, the superior and middle glenohumeral ligaments developed the most strain. At 45 degrees of abduction, the inferior and middle glenohumeral ligaments developed the most strain, with considerable strain also being developed in the superior glenohumeral ligament. At 90 degrees of abduction, the inferior glenohumeral ligament developed the most strain, with strain also seen in the middle glenohumeral ligament.

Primary surgical treatment of anterior cruciate ligament ruptures A long-term follow-up study

Abstract: We reviewed 52 patients who underwent primary sur gical repair of their acutely injured ACL using a multiple loop, varying depth suture technique. The average fol lowup was 6 years and 10 months. Nine patients (17%) were considered as having failed repairs, with failure based on the presence of clinical instability (giving way) with sports participation and a positive Lachman test and/or pivot shift maneuver. In addition, of 26 patients in whom KT-1000 (MEDmetric Corp., San Diego, CA) measurements were performed, 42% were found to have abnormal laxity. Although using multiple sutures in primary repair of the anterior cruciate may work in some patients, it is an unpredictable operative proce dure and resulted in a 17% failure rate in our study.

Repeatability of the KT-1000 arthrometer in a normal population.

Abstract: Despite its popularity, the MEDmetric KT-1000 arthro meter's reliability remains inadequately documented. We conducted this study to determine the magnitude of trial-to-trial (within installation), installation-to-instal lation (within day), and day-to-day (between day) vari ability of anterior/posterior translation measurements in normal knees.We selected six normal subjects, three males and three females, and tested each on 6 consecutive days with three separate installations per day. We recorded the total anterior/posterior translation at ±89 and ±134 N force at 25° of flexion during three consecutive trials in a single installation.Analysis of variance showed that no significant differ ence existed between trials (within installation) or be tween installations (within day) for all parameters. How ever, we did find a significant difference between days for individual right and left knee translation measure ments at 89 and 134 N force. More importantly, no significant difference existed between days for...

Prevention of common overuse injuries by the use of shock absorbing insoles. A prospective study.

Abstract: Sedentary individuals, particularly new military recruits, who start a physical training program have a substantial risk of developing an overuse injury of the lower limb. In this study we investigated the effect of neoprene insoles on the incidence of overuse injuries during 9 weeks of basic military training. The experimental group consisted of 237 randomly selected new recruits, while 1151 recruits were the control group. Insoles were given to the experimental group and compliance was monitored. A panel of doctors documented and classified all injuries occurring during the 9 week period. A total of 54 (22.8%) and 237 (31.9%) injuries were reported in the experimental and control groups, respectively. In both groups, the majority of injuries were overuse (experimental group, 90.7%; control group, 86.4%). The mean weekly incidence of total overuse injuries and tibial stress syndrome was significantly lower (P less than 0.05) in the experimental group. The mean incidence of stress fractures was lower in the experimental group but not significantly so (0.05 less than P less than 0.1). This study shows that the incidence of total overuse injuries and tibial stress syndrome during 9 weeks of basic military training can be reduced by wearing insoles.

A prospective, randomized study of three surgical techniques for treatment of acute ruptures of the anterior cruciate ligament

Abstract: Treatment of ACL tears is controversial. Recent reports on nonoperative treatment have shown poor results. Results after primary repair have deteriorated with time, leading to augmentation procedures that seem to have improved the results. However, there have been few prospective, randomized studies in this field. Our goal was to compare primary repair with a bone-patellar tendon-bone augmentation method and with a new method using the Kennedy Ligament Augmentation Device. One hundred fifty patients aged 16 to 50, all of whom had acute ACL tears, were randomized with the closed envelope method to one of three groups treated with open surgical methods. Fifty patients were treated with primary repair, 50 patients with patellar tendon augmentation, and 50 patients were augmented with the Kennedy Ligament Augmentation Device. All patients were operated on within 10 days of injury. The rehabilitation protocol was identical, consisting of a long leg cast for 2 weeks, followed by a brace with no weight-bearing and limited motion for 6 weeks. The patients were followed prospectively by one surgeon (LE) using the Lysholm functional score, Tegner activity level score, clinical evaluation and KT-1000 arthrometer at 6 months, 1, and 2 years. Three patients were lost to followup. There was no age or activity level difference between the groups. Sport activities led to 85% of the injuries, with skiing, soccer, and European handball representing 80% of injuries. All three groups reduced their activity level the 1st year. The repair group remained at the same level after 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of joint velocity on the contribution of the antagonist musculature to knee stiffness and laxity

Abstract: The electromyographic (EMG) coactivation patterns of the knee flexors and extensors when acting as antag onists were studied as a function of limb velocity to assess their contribution to joint stiffness and laxity.Normalized antagonist coactivation patterns devel oped from surface EMG recordings from the hamstrings and quadriceps during maximal effort isokinetic exten sion and flexion, respectively, demonstrated character istic variations as the joint velocity increased from 15 deg/sec up to 240 deg/sec. The two-tailed t-test (P 100%) in their antagonist coactivation pattern during the final 40° of fast extension and flexion movements, respectively, as limb velocity increases. A minor de crease in antagonist activity of the hamstrings (24%) and quadriceps (8%) was evident during the initial phase of the extension and flexion movements, respec tiv...

The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion

Abstract: Lateral extraarticular reconstructions are used as isolated procedures in knees with moderate rotatory instability and as "backups" in knees requiring primary repair or intraarticular reconstruction for major rotatory instability We used an experimental knee testing system to analyze the immediate postoperative mechanical effect of an iliotibial band tenodesis on an intraarticular reconstruction of the ACL in fresh cadaver knees using a composite graft consisting of a bone-patellar tendonbone segment augmented with the Kennedy Ligament Augmentation Device (LAD, 3M Co, St Paul, MN) The intraarticular graft was standardized by using a forcesetting technique Ligament and graft forces were measured using buckle transducers, and joint motion was measured using an instrumented spatial linkage as 90 N anteriorly directed tibial loads were applied to seven fresh knee specimens at 0 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion The following knee states were tested in each specimen: intact ACL, excised ACL, intraarticular reconstruction, intraarticular reconstruction with the tenodesis added, and tenodesis with the intraarticular reconstruction added Adding the iliotibial band tenodesis to an existing standardized intraarticular reconstruction significantly decreased the force in the ACL composite graft by an average of 43% When the standardized intraarticular reconstruction was added to an existing tenodesis, the graft forces were an average of 15% below the level of when the reconstruction was performed alone The force in the tenodesis was significantly less than the composite graft force at extension; however, the differences between the tenodesis and total graft force were not significant from 30 degrees to 90 degrees of flexion(ABSTRACT TRUNCATED AT 250 WORDS)

Capsular ligaments of the shoulder. Anatomical and functional study of the anterior superior capsule.

Abstract: One hundred shoulders of 50 cadavers were dissected using the anterior approach. The normal appearance of the capsule, particularly the anterior superior, and the functions of the structures during passive motion were noted. There was a distinct capsular pattern with a Z formation which included the coracohumeral ligament and the superior, middle, and inferior glenohumeral ligaments. The middle and proximal capsular structures appeared to restrain external rotation. The coracohumeral ligament aided in restraint of external rotation at the lower range of abduction. The middle glenohumeral ligament was critical in restraining external rotation between 60 degrees and 90 degrees of abduction. It was readily identifiable except in a small percentage of individuals, who had a weak or absent ligament. The large capsular opening sometimes seen in shoulder repairs is due to an absent or attenuated middle glenohumeral ligament. Both the coracohumeral and middle glenohumeral ligaments were found to support the dependent arm.

Strain measurement in lateral ankle ligaments

Abstract: We measured strain in the lateral ligaments of 10 human cadaver ankles while moving the ankle joint and apply ing stress in a variety of ways. We studied the anterior talofibular, calcaneofibular, posterior talofibular, ante rior tibiofibular, and posterior tibiofibular ligaments. Strain measurements in the ligaments were recorded continuously while the ankle was moved from dorsiflex ion into plantar flexion. We then repeated measure ments while applying inversion, eversion, internal rota tion, and external rotation forces.Strain in the anterior talofibular ligament increased when the ankle was moved into greater degrees of plantar flexion, internal rotation, and inversion. Strain in the calcaneofibular ligament increased as the talus was dorsiflexed and inverted. These findings support the concept that the anterior talofibular and calcaneofibular ligaments function together at all positions of ankle flexion to provide lateral ankle stability. We measured maximum strain in the posterior talofibular ligame...

The epidemiologic, pathologic, biomechanical, and cinematographic analysis of football-induced cervical spine trauma

Abstract: Epidemiologic, pathologic, biomechanical, and cinematographic data on head and neck injuries occurring in tackle football have been compiled since 1971 by the National Football Head and Neck Injury Registry. Preliminary analysis performed in 1975 indicated that the majority of serious cervical spine football injuries were caused by axial loading. Based on this observation, the National Collegiate Athletic Association (NCAA) and National Federation of High School Athletic Associations (NFHSAA) implemented rule changes banning "spearing" and the use of the top of the helmet as the initial point of contact in striking an opponent during a tackle or block. Between 1976 and 1987, as a result of these rule changes, the Registry has documented a dramatic decrease in both the total number of cervical spine injuries and those resulting in quadriplegia at both the high school and college level. It is suggested that development and implementation of similar preventative measures based on clearly defined injury mechanisms would decrease injury rates in diving, rugby, ice hockey, trampolining, wrestling, and other high-risk sports as well.

Flexibility comparisons of junior elite tennis players to other athletes

Abstract: Flexibility measurements were obtained in 86 junior elite tennis players and compared to the flexibility measurements of 139 athletes involved in other sports. The measurements obtained included sit and reach flexibility, quadricep flexibility, hamstring flexibility, gastrocnemius flexibility, shoulder internal rotation, and shoulder external rotation. All measurements except sit and reach flexibility were obtained goniometrically. Tennis players were significantly tighter in sit and reach flexibility, dominant shoulder internal rotation, and nondominant shoulder internal rotation. They were significantly more flexible in dominant shoulder external rotation and nondominant shoulder external rotation. The flexibility differences found in tennis players suggest adaptations to the musculoskeletal demands of their sport. These results suggest that a sport-specific flexibility program may be necessary for junior elite tennis players in order to promote maximum performance and help prevent flexibility-related injuries.

Stress fractures of the femoral neck in athletes The consequence of a delay in diagnosis

Abstract: Twenty-three patients with stress fractures of the femoral neck were followed up at an average of 6.5 years after the injury. There were 16 recreational athletes and seven elite athletes. Most injuries (N = 15) occurred during running. The diagnosis was confirmed within 3 to 104 weeks (mean, 14 weeks) after the initial onset of symptoms. Sixteen of the patients were treated with internal fixation, the remaining seven were treated conservatively. Seven patients (30%) developed complications requiring major surgery. Five of these patients had Type 3 fractures (displaced) and four had been treated with internal fixation initially. The remaining two patients had Type 1 fractures (endosteal or periosteal callus without an overt fracture line); one was treated operatively and the other conservatively. Three patients developed avascular necrosis and two were treated by hip replacement. The third patient was treated with arthrodesis. Three refractures and one pseudarthrosis were treated by osteotomy. At followup, all elite athletes stated that they had to end their career as a result of the injury. Results were rated by the ability of the athlete to return to sports. There were 9 bad or fair results, 13 good, and 1 excellent result. No difference in activity level or subjective rating was observed between the surgically and conservatively treated group either preinjury or postinjury. The most important factor influencing the complication rate seems to be the type of fracture. The high incidence of displaced fractures (Type 3) could speculatively be caused by undiagnosed tension side stress fractures. If so, the delay in correct diagnosis may be disastrous. However, we could only objectively observe this in one of our cases.

Comparison of support provided by a semirigid orthosis and adhesive ankle taping before, during, and after exercise

Abstract: The purpose of this study was to compare the relative effectiveness of athletic taping and a semirigid orthosis in providing inversion-eversion range restriction before, during, and after a 3 hour volleyball practice. The effect of each support method on the subjects' vertical jump ing ability was also assessed. Fourteen ankles were treated with both methods of support. Passive inver sion-eversion range of motion was measured on an ankle stability test instrument during five testing ses sions : 1) before support, 2) before exercise, 3) 20 minutes during exercise, 4) 60 minutes during exercise, and 5) after exercise. The two-way analysis of variance and posthoc comparisons revealed maximal losses in taping restriction for both inversion and eversion at 20 minutes into exercise. The orthosis demonstrated no mechanical restrictive failure until before and after ex ercise comparisons were made, and then only eversion range of motion was compromised. Neither support system affected subjects' vertical jumping a...

Isokinetic evaluation of shoulder rotational strength between the plane of scapula and the frontal plane

Abstract: The purpose of this study was to determine whether shoulder rotational strength was greater in the plane of the scapula or the frontal plane.Isokinetic shoulder rotational strength was evaluated in 20 subjects. Using the Merac (Universal Gym Equip ment, Inc., Cedar Rapids, IA), test data was gathered in the right shoulders, in 45° abduction, at a speed of 60 deg/sec, in the plane of the scapula and the frontal plane. Each subject returned within 1 week for retests to establish reliability. The average correlational coeffi cient across tests was 0.87. The Merac computer system was used to analyze data. Mean and standard deviations for peak torque to body weight were calcu lated. A paired t-test was used to examine the differ ence in the means for internal and external rotation between the two positions. The results indicated no significant difference between the two positions for shoulder internal rotational strength values. However, shoulder external rotational strength values in the plane of the scapula ...

Anterior cruciate ligament injury: evaluation of intraarticular reconstruction of acute tears without repair. Two to seven year followup of 155 athletes.

Abstract: To evaluate the effectiveness of our treatment regimen, we retrospectively studied the surgically treated knees of 155 athletes, aged 15 to 42 years, who had sustained acute ACL tears. All were treated with ligament excision and intraarticular bone-patellar tendon-bone reconstruction followed by early motion with emphasis on full extension. The follow-up period ranged from 2 to 7 years. Of the 155 patients, 140 were available for final followup at a minimum of 2 years after reconstruction. The patients were evaluated by objective measures (KT-1000, Cybex, Lachman test, range of motion, and postoperative competition level) and subjective assessment scores (pain, swelling, stability, activity level, walking, stair climbing, running, jumping, or twisting). The subjective scores were tabulated for stability level, total score, and activity level. After the patients achieved full range of motion, the KT-1000 measurements at a 20 pound force revealed an average difference of 1.3 mm between the injured and noninjured knees. All but 3 of the 140 patients had a firm endpoint on the Lachman test, and the Cybex tests showed a mean hamstring strength of 98% and mean quadriceps strength of 90%. Sixty of the 69 varsity athletes who were eligible to play returned to preinjury competition level the following season. One had reconstruction failure and eight chose not to continue competition for academic reasons. The questionnaire score average was 92.7 (maximum, 100 points, normal athletic knee score 93.5). We concluded that the surgical procedure, with emphasis on early full extension postoperatively, achieved excellent results and provided a stable knee.

Does a major knee injury definitely sideline an elite soccer player

Abstract: Injuries occurring in three Swedish elite soccer teams were analyzed during 1 year. A total of 49 of 64 players (75%) sustained 85 injuries. The incidence of injury during games was 13 injuries per 1000 hours, while the incidence during training was 3 injuries per 1000 hours. Twenty percent of the injuries required hospital facilities. The majority of the traumatic injuries (93%) were to the lower extremities, with one third of the total injuries occurring in the knee. Overuse injuries accounted for 35% of all injuries and occurred mainly during preseason training and at the end of each season. Conversely, the majority of traumatic injuries occurred during games, equally distributed between the first and second halves with a predominance toward the end of each half. The position of the player within the team did not influence injury rate. The referee considered 28% of the traumatic injuries to be caused by violation of existing rules. Thirty-four percent of the injuries were major, causing more than 1 month of absence from training and/or games. Eleven knee injuries required surgical intervention revealing seven ruptured ACLs, of which three were chronic. At followup, 9 to 18.5 months after injury, 4 of 12 players with major knee injuries had returned to play at the elite level. The others had either been transferred to lower divisions or were still in rehabilitation.

Biomechanical and histological observations of the dog patellar tendon after removal of its central one-third

Abstract: The use of a central one-third patellar tendon as an autograft for surgical reconstruction of a damaged cru ciate ligament is common. Few complications of its use have been reported. However, recent clinical studies indicate that decreased quadriceps strength, de creased range of motion, decreased thigh circumfer ence, and patellofemoral problems can be associated with this procedure. Some of these complications may result from alterations in the biomechanical properties of the remaining patellar tendon. The objective of this study was to examine biomechanically and histologi cally the fate of the remaining patellar tendon after removal of its central one-third.Three groups of dogs were used for this study. On one knee the central third of the patellar tendon was removed, while the contralateral side was used as a control. One group was immediately euthanized, while the other two groups were euthanized at 3 and 6 months. Control and operated patella-patellar tendon- tibia preparations were harvested and s...

The use of magnetic resonance imaging in exertional compartment syndromes

Abstract: This prospective, double-blind study was carried out to assess the usefulness of magnetic resonance imaging (MRI) as a noninvasive method in the diagnosis of chronic compartment syndrome (CCS). As well, a new radiopharmaceutical known as methoxy isobutyl isonitrile that has been shown to be taken up by muscle in direct proportion to its blood flow was used to illustrate the possible pathophysiology of this syndrome. Twenty patients with a history of chronic leg pain and possible diagnosis of CCS and five normal volunteers had preexercise and postexercise MRI, nuclear medicine imaging, and static and dynamic slit catheter pressure studies. Nine patients had classic symptoms; only five of these nine had abnormal pressure studies. The other 11 patients had an element of pain at rest and had normal pressure studies. The nuclear blood flow studies were normal in all 25 legs tested in this study. Measurement of intrinsic MRI parameters T1 and T2 in the normal legs as well as in those with an atypical history showed a marked elevation with exercise and a gradual return to baseline postexercise that was similar to the pressure curves. In the five patients with a clinical history and elevated pressures, four had abnormal MRI studies with failure of T1 to return to baseline values. Although these results demonstrate the potential of MRI as a tool for noninvasively monitoring muscle status, clinical history and examination remain important in the diagnosis of CCS. This study indicates that the pathophysiology of exertional compartment syndrome does not appear to be related to ischemia.

Suprascapular neuropathy in pitchers

Abstract: The clinical features and preoperative and postopera tive electrodiagnostic studies were reviewed in two professional pitchers with a suprascapular neuropathy. These studies demonstrate that denervation of the infraspinatus and/or supraspinatus muscle is not al ways due to entrapment of the nerve at the suprascap ular or spinoglenoid notches, as is often proposed. Similar studies in healthy pitchers during spring training and again at midseason demonstrate that slowing of suprascapular nerve conduction is detectable in some cases as the season progresses.Sagittal sections of a cadaver with the arm fixed in the acceleration phase of the pitching motion demon strate five possible sites of trauma to the suprascapular nerve. Mechanisms proposed to explain these progres sive, but potentially reversible, changes include consid eration of biomechanical factors as well as anatomical features. An alternative hypothesis to nerve trauma that explains this symptom complex is intimal damage to the axillary or suprasca...

Long distance running and osteoarthrosis

Abstract: In order to evaluate the effect of long-term, long distance running on the incidence of degenerative joint disease in the lower extremities, we examined the hips, knees, and ankles of 30 long distance runners who had been serious competitive runners in the early 1950s (at the age of 20 to 30 years) Of three runners who were no longer active, one had stopped running in the late 1970s because of osteoarthrosis of both the lower and upper extremity joints The remaining 27 runners (90%) were still active, having run 20 to 40 km/week (12 to 24 miles/week) for a median of 40 years Subjective, objective, and roentgenographic data were compared with the data for 27 nonrunning controls matched as to age, weight, height, and occupation No differences in joint alignment, range of motion, or complaints of pain were found between runners and nonrunners Roentgenographic examinations for cartilage thickness, grade of degeneration, and osteophytosis were also without significant differences between the two groups Thus, our observations suggest that a lifetime of long distance running at mileage levels comparable to those of recreational runners today is not associated with premature osteoarthrosis in the joints of the lower extremities