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SPORTS

MEDICINE
MEDIA GUIDE
AN ILLUSTRATED RESOURCE ON THE MOST COMMON
INJURIES AND TREATMENTS IN SPORTS FALL 2011

Material developed in partnership by:


SPORTS MEDICINE MEDIA GUIDE

Created by the American Orthopaedic Society for Sports Medicine (AOSSM), in


partnership with the American Academy of Orthopaedic Surgeons (AAOS), this media
guide serves to help reporters and members of the media with sports-related stories.
As you write or produce stories about a professional athletes ACL tear, or shed light
on concussions, this guide will be your one-stop shop. In this guide you will find:
Definitions for common orthopaedic sports injuries
Injury statistics
Expert perspective on recovery issues and returning to the game and
Tips on how to prevent injury

If at any time, you need additional information, a quote for a story, or to speak with one of our
sports medicine experts, please dont hesitate to contact media relations staff at AOSSM or AAOS.
AOSSM: lisa@aossm.org or 847-292-4900
AAOS: media@aaos.org or 847-823-7186

About AOSSM
Formed primarily as a forum for education and research, AOSSM has increased its membership
from its modest start of less than 100 to nearly 3,000 today. AOSSM members are physicians
and allied health professionals who demonstrate scientific leadership, involvement and dedication
in the daily practice of sports medicine.

The unifying interest of the membership is their concern with the effects of exercise and the
monitoring of its impact on active individuals of all ages, abilities and levels of fitness. While many
members treat high profile athletes who play on professional teams, many devote their practices
to helping out their community and treating players on the local high school or junior college team.

About AAOS
The American Academy of Orthopaedic Surgeons serves orthopaedic surgeons who are medical
doctors with training in the diagnosis and non-surgical as well as surgical treatment of the
musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.

With more than 36,000 members, AAOS (www.aaos.org) is the premier not-for-profit organization
that provides education programs for orthopaedic surgeons and allied health professionals, champions
the interests of patients and advances the highest quality musculoskeletal health. Orthopaedic
surgeons and the Academy are the authoritative sources of information for patients and the general
public on musculoskeletal conditions, treatments and related issues. An advocate for improved
patient care, AAOS is participating in the Bone and Joint Initiative (www.usbjd.org) the global
initiative established in 2002 to raise awareness of musculoskeletal health, stimulate research
and improve peoples quality of life.

This information is brought to you by the American Orthopaedic Society for Sports Medicine and the American Academy of Orthopaedic
Surgeons. They provide general information only and are not a substitute for your own good judgement or consultation with a physician.
For more information on sports injuries, please visit www.sportsmed.org and www.orthoinfo.org.

SPORTS MEDICINE 2
SPORTS MEDICINE
MEDIA GUIDE

AC Joint Injuries 4
Ankle Sprains 6
Anterior Cruciate Ligament Injuries 7
Articular Cartilage Injuries 9
Concussion 11
Heat Illness 13
The Mature Athlete 15
Meniscal Tears 16
MRSA Infections 17
Overuse Injuries 19
Rotator Cuff Tears 21
Shoulder Impingement 23
Shoulder Instability/Dislocations 24
SLAP Tears 26
Steroids 27
Stress Fractures 28
Sudden Cardiac Death in Athletes 30
Throwing Injuries in Children 31
Treatment of Tendon/Ligament
Disorders with Platelet-Rich Plasma 32
Sources 33

Copyright 2011. American Orthopaedic Society for Sports Medicine. All rights reserved. SPORTS MEDICINE 3
AC JOINT
INJURIES
EXPERT CONSULTA NT | Edward McFarland, MD

What is the AC joint? extent) military press. AC joint arthritis


may also be present when there are Statistics
The AC (acromioclavicular) joint
rotator cuff problems. In 2008, nearly 95,000 people
is a joint in the shoulder where the visited a physician with
collarbone (clavicle) meets the shoulder an AC joint related injury.
blade (scapula). The specific part of the What is an AC separation?
More males than females
scapula adjacent to the clavicle is called When the AC joint is separated, it suffer AC joint injuries.
the acromion, hence the name AC joint. means that the ligaments connecting
the acromion and clavicle have been Athletes who have had
AC joint injuries
What kinds of problems damaged, and the two structures no
Sam Bradford, St. Louis Rams
occur at the AC joint? longer line up correctly. AC separations
Quarterback
The most common problems that can be anywhere from mild to severe,
Matthew Stafford, Detroit Lions
occur at the AC joint are arthritis, and AC separations are graded
fractures and separations. Arthritis depending upon which ligaments
is a condition characterized by loss of are torn and how badly they are torn.
effect is unpredictable and may not be
cartilage in the joint. AC joint arthritis Grade I Injury the least damage permanent. Surgery may be indicated if
is common in weight lifters, especially is done, and the AC joint still lines up. nonsurgical measures fail. Since the pain
with the bench press, and (to a lesser is due to the ends of the bones making
Grade II Injury damage to the
contact with each other, the treatment
ligaments which reinforce the AC joint.
is removal of a portion of the end of the
In a grade II injury these ligaments
clavicle. This outpatient surgery can be
are only stretched but not entirely torn.
performed through a small incision about
When stressed, the AC joint becomes
one inch long or arthroscopically using
painful and unstable.
several small incisions. Regardless of
Grade III Injury AC and secondary the technique utilized, the recovery and
ligaments are completely torn and results are about the same. Most patients
the collarbone is no longer tethered have full motion by six weeks and
to the shoulder blade, resulting return to sports by 12 weeks.
in a visible deformity.
What is the treatment
How is AC joint arthritis for AC separation?
treated? These can be very painful injuries, so the
If rest, ice, medication, and modifying initial treatment is to decrease pain. This
activity does not work, then the next step is best accomplished by immobilizing
is a cortisone shot. One shot into the the arm in a sling, and placing an ice
joint sometimes takes care of the pain pack to the shoulder for 2030 minutes
and swelling permanently, although the every two hours as needed.

SPORTS MEDICINE | AC Joint Injuries 4


AC JOINT INJURIES

Acetaminophen and non-steroidal anti-inflammatory


drugs can also help the pain. As the pain starts to
subside, it is important to begin moving the fingers,
wrist, and elbow, and eventually the shoulder in order
to prevent a stiff or frozen shoulder. The length of
time needed to regain full motion and function depends
on the severity or grade of the injury. Recovery from
a Grade I AC separation usually takes 10 to 14 days,
whereas a Grade III may take six to eight weeks.

When is surgery indicated?


Grade I and II separations very rarely require surgery.
Even Grade III injuries usually allow return to full
activity with few restrictions. In some cases a painful
lump may persist, necessitating partial clavicle
excision in selected individuals such as high caliber
throwing athletes. Surgery can be very successful
in these cases, but as always, the benefits must
be weighed against the potential risks.

Additional Information
www.sportsmed.org
www.orthoinfo.org
www.STOPSportsInjuries.org

SPORTS MEDICINE | AC Joint Injuries 5


ANKLE SPRAINS
EXPERT CONSULTANT | Michael S. George, MD

What is an ankle sprain? in the lower leg. This most commonly


occurs with an eversion injury when Statistics
A sprain is a stretch injury of the
the ankle is twisted outward. About 25,000 ankle sprains occur
ligaments that support the ankle. The in the United States every day.
ligaments on the outside of the ankle The ankle is tender and swollen on Ankle sprains are common
are the most commonly injured when the outside, below, and just in front in all sports that involve cutting
the foot is turned inward (inverted). of the ankle bone. Typically, the bone and pivoting.
A lateral ankle sprain is a stretch is not as tender at the area above and
injury to the ligaments in the outer/lower Athletes with similar injuries
in front of it. A sprain may be mild,
In 2011, Maurkice Pouncey,
part of the ankle. This most commonly causing only modest pain, or severe Pittsburgh Steelers center, suffered
occurs with an inversion injury when enough to prevent weightbearing. a high ankle sprain in the AFC
the ankle is twisted inward. Championship game against the
How is an ankle sprain New York Jets and was forced to
A high ankle sprain (or syndesmosis miss the Super Bowl two weeks later.
injury) is a stretch injury to the ligament
treated?
In 2011, Tim Duncan, San Antonio
that holds the tibia and fibula together The initial treatment is RICE (rest, ice, Spurs center, suffered a lateral
compression, and elevation). Severe ankle sprain. He required crutches
injuries may benefit from a walking for several days, then returned
8 days later to score 20 points in 33
boot to help support the ankle. The goal
minutes against the Boston Celtics.
of rehabilitation is to reduce pain and
swelling and to restore strength, range
of motion, and balance.

Recovery time for lateral ankle sprains How can an ankle sprain
is typically one to three weeks. Recovery be prevented?
time for high ankle sprains is typically Taping the ankle or using a brace
three to six weeks. for support can help prevent re-injury.
There are many different types of braces:
Rehabilitation can begin a few days
some made of neoprene, some made
after the injury, when the swelling starts
of elastic material, and some that have
to go down. There are three goals to
extra straps or ties for support. Braces
aim for in rehabilitation:
with straps or ties generally provide
1. Restore motion greater support.
and flexibility.
2. Restore Additional Information
strength. www.sportsmed.org
3. Restore www.orthoinfo.org
balance. www.STOPSportsInjuries.org

SPORTS MEDICINE | Ankle Sprains 6


ANTERIOR
CRUCIATE
LIGAMENT
INJURIES
EXPERT CONSULTA NT | Wayne J. Sebastianelli, MD

What is the ACL? How is an ACL tear


ACL stands for anterior cruciate ligament diagnosed? Statistics
One of the most commonly
of the knee. The knee is the largest The physician will examine the knee,
injured ligaments in the knee
and most complex joint in the body. and, in most cases, be able to identify
Approximately 150,000 ACL
It depends on four primary ligaments which ligaments are injured. However, injuries each year in U.S.
as well as multiple muscles, tendons, there may also be injuries to the Female athletes participating in
and secondary ligaments to function joint surface that are more difficult to basketball and soccer are 28 times
properly. There are two ligaments on the diagnose. At times, swelling may make more likely to suffer ACL injury.
sides of the knee: the medial collateral it difficult to diagnose a tear. This will Athletes who suffer ACL injury
ligament (MCL) and the lateral collateral necessitate the use of an MRI scan or at increased risk of arthritis
development later in life.
ligament (LCL), and two crossed arthroscope to ensure that an accurate
ACL injuries account for an
ligaments in the center of the knee, diagnosis is made.
estimated half-billion dollars
the anterior cruciate ligament (ACL) and each year in health care costs.
the posterior cruciate ligament (PCL).
Athletes who had ACL injuries
The ACL connects the front top part Tiger Woods, PGA Golfer
of the shin bone to the back bottom
Tom Brady, New England Patriots
part of the thigh bone and keeps Quarterback
the shin bone from sliding forward.

How is the ACL injured?


One of the common ways for the ACL to
be injured is by a direct blow to the knee,
which commonly happens in football.
In this case, the knee is forced into
an abnormal position that results in the
tearing of one or more knee ligaments.

However, most ACL tears actually


happen without contact between
the knee and another object. Such
noncontact injuries happen when the
running athlete changes direction or
hyperextends their knee when landing
from a jump. These movements are
common to all agility sports.

SPORTS MEDICINE | ACL Injuries 7


ACL INJURIES

How can ACL injuries be prevented? or from an organ donor. This tissue is passed through
Several prevention programs have been developed in drill holes in the thigh bone and shin bone and then
an attempt to decrease the incidence of noncontact anchored in place to create a new ACL. Over time
ACL injuries. The focus of current prevention programs this graft matures and becomes a new, living
is on proper nerve/muscle control of the knee. ligament in your knee.
These programs focus on plyometrics, balance,
and strengthening/stability exercises. What does ACL injury recovery entail?
Rehabilitation of the knee after ACL reconstruction
Plyometrics is a rapid, powerful movement which first
requires time and hard work. Return to full function
lengthens a muscle (eccentric phase) then shortens
can vary from 6 weeks to 6 months depending on
it (concentric phase). The length-shortening cycle
severity and activity levels. The rate of rehabilitation
increases muscular power. An example would be
may take longer, depending on the specific
an athlete jumping off a small box and immediately
requirements of the individuals sport/activity.
jumping back into the air after contact with the floor.
The overall success rate for ACL surgery is very good.
Balance training commonly involves use of wobble
Many studies have shown that more than 90 percent
or balance boards. On-field balance exercises
of patients are able to return to sports without
may include throwing a ball with a partner while
symptoms of knee instability. Although some patients
balancing on one leg.
do complain of stiffness and pain after surgery, these
To improve single-leg core strength and stability, problems have been minimized by current surgical
athletes perform exercises such as jumping and techniques and aggressive rehabilitation.
landing on one leg with the knee flexed and then
momentarily holding that position. Additional Information
www.sportsmed.org
How are ACL tears treated surgically? www.orthoinfo.org
Many different surgical approaches have been www.STOPSportsInjuries.org
developed for the ACL injured knee. Years of
experience have shown that simply stitching the
ligament together is rarely successful. Therefore,
current techniques involve reconstructing the ACL
by building a new ligament out of tissue harvested
from one of the other tendons around the knee

SPORTS MEDICINE | ACL Injuries 8


ARTICULAR
CARTILAGE
INJURIES
EXPERT CONSULTA NTS | Daniel Romanelli, MD, John Uribe, MD, Diane S. Watanabe, ATC, Bert R. Mandelbaum, MD

What is articular cartilage? absorber. It is organized into five distinct


layers, with each layer having structural Statistics
Articular cartilage can sometimes
and biochemical differences. On the basis of published studies
be confusing, because there are three to date, the overall prevalence
different types of cartilage found in of articular cartilage defects in the
the body: articular or hyaline cartilage What causes an articular knee is 36% among all athletes and
(covers joint surfaces), fibrocartilage
cartilage injury? up to 59% among asymptomatic
Articular cartilage injuries can occur as basketball players and runners.
(knee meniscus, vertebral disk), and
elastic cartilage (outer ear). These a result of either traumatic or progressive
Athletes who have had articular
different cartilages are distinguished degeneration (wear and tear). With cartilage injuries
by their structure, elasticity, and strength. mechanical destruction, a direct blow Greg Oden, Penny Hardaway,
or other trauma can injure the articular Chris Webber (NBA)
Articular cartilage is a complex, living
cartilage. Depending on the extent Tracy Porter, Marques Colston,
tissue that lines the bony surface New Orleans Saints
of the damage and the location of the
of joints. Its function is to provide Brandon Graham,
injury, it is sometimes possible for the
a low friction surface enabling the joint Philadelphia Eagles
articular cartilage cells to heal. Articular
to withstand weight bearing through
cartilage has no direct blood supply,
the range of motion needed to perform
thus it has little or no capacity to repair
activities of daily living as well as
itself. If the injury penetrates the bone
athletic endeavors. In other words, point continued activity may not be
beneath the cartilage, the underlying
articular cartilage is a very thin shock possible. If a loose body is present,
bone provides some blood to the area,
words such as locking or catching
improving the chance of healing.
might be used to describe the problem.
Mechanical degeneration (wear and tear) With wear and tear, the patient often
of articular cartilage occurs with the experiences stiffness, decreased range
progressive loss of the normal cartilage of motion, joint pain, and/or swelling.
structure and function. This initial loss
begins with cartilage softening then How is an articular cartilage
progresses to fragmentation. As the loss defect (injury) diagnosed?
of the articular cartilage lining continues, The physician examines the knee,
the underlying bone has no protection looking for decreased range of motion,
from the normal wear and tear of daily pain along the joint line, swelling,
living and begins to break down, fluid on the knee, abnormal alignment
leading to osteoarthritis. of the bones making up the joint, and
ligament or meniscal injury. Injuries
How often does an articular to the articular cartilage are difficult
cartilage injury occur? to diagnose, and evaluation with
In many cases, a patient will experience MRI (magnetic resonance imaging)
knee swelling and vague pain. At this or arthroscopy may be necessary.

SPORTS MEDICINE | Articular Cartilage Injuries 9


ARTICULAR CARTILAGE INJURIES

Plain X-rays are not usually good in diagnosing For patients with osteoarthritis, non-surgical treatment
articular cartilage problems but are usually taken consists of physical therapy, lifestyle modification
to rule out other abnormalities. (e.g., reducing activity), bracing, supportive devices,
oral and injection drugs (i.e., non-steroidal anti-
How is an injury treated? inflammatory drugs, cartilage protective drugs),
Injuries to the cartilage that do not extend to the and medical management. Surgical options are
bone will generally not heal on their own. Injuries very specific to osteoarthritis severity and can provide
that penetrate to the bone may heal, but the type of a reduction in symptoms that are generally only short
cartilage that is laid down is structurally unorganized lived. Total joint replacement can provide relief for
and does not function as well as the original articular the symptom of advanced osteoarthritis, but generally
cartilage. Defects smaller than 2 cm have the best requires a change in a patients lifestyle and/or
prognosis and treatment options. Those options activity level.
include arthroscopic surgery using techniques to
remove damaged cartilage and increase blood flow
from the underlying bone (e.g. drilling, pick procedure,
or microfracture). For smaller articular cartilage
defects which are asymptomatic, surgery may not
be required. For larger defects, it may be necessary Additional Information
to transplant cartilage from other areas of the knee www.sportsmed.org
(joint). Consult your specialist for further information www.orthoinfo.org
on the decision to have surgery. www.STOPSportsInjuries.org

SPORTS MEDICINE | Articular Cartilage Injuries 10


CONCUSSION
EXPERT CONSULTA NTS | Jeffrey S. Kutcher, MD, Wayne Sebastianelli, MD, Kenneth Fine, MD

What is a concussion? Sleeping more than usual


or difficulty falling asleep Statistics
A concussion is a traumatic injury to the
Visual problems According to the Centers
brain that alters mental status or causes for Disease Control:
other symptoms. Many people assume blurry or double vision
Each year, U.S. emergency
they do not have a concussion if they Vomiting departments treat an estimated
have not lost consciousness. However, 135,000 sports- and recreation-
significant injury can occur without How is a concussion related traumatic brain injuries,
diagnosed? including concussions, among
losing consciousness at all. Football
children ages 5 to 18.
players often say, I just got my bell When concussion is suspected,
Athletes who have ever had
rung, when a blow to the head causes a trained coach, certified athletic a concussion are at increased
ringing in the ears, but those symptoms trainer, or the team physician should risk for another concussion.
are often consistent with concussion. immediately perform an initial Children and teens are more
sideline evaluation, including: likely to get a concussion and
What are the signs/symptoms take longer to recover than adults.
Symptoms list review
of a concussion?
Focused neurological exam Athletes who had concussions
Balance problems Ted Johnson, New England Patriots
Difficulty communicating, Focused orientation exam that tests Linebacker
concentrating short-term memory recall such Tim Tebow, University of Florida
as the event, play, opponent, score, Quarterback, Denver Broncos
Dizziness
or last meal
Drowsiness
Focused orientation exam that tests
Fatigue
long-term recall such as name,
Feeling emotional birth date, place of birth
What is second impact
Feeling mentally foggy Assessment of athletes ability to stay
syndrome?
Headache attentive to a complex task such
Second impact syndrome is a potentially
Irritability as reciting months backwards
FATAL injury that occurs when an
Memory difficulties If left undiagnosed, a concussion may athlete sustains a second head injury
Nausea place an athlete at risk of developing before a previous head injury has
second impact syndrome (SIS) completely healed. Unfortunately it
Nervousness
a potentially fatal injury that occurs is difficult to determine if the brain has
Numbness or tingling
when an athlete sustains a second healed from the first injury. Even after
Sadness head injury before a previous head all symptoms have resolved, healing may
Sensitivity to light or noise injury has completely healed. not be complete and the brain may still

You DO NOT have to lose consciousness to have sustained a concussion!

SPORTS MEDICINE | Concussion 11


CONCUSSION

be at increased risk of second impact syndrome. Baseline testing is important for assessing concussion
Neurocognitive testing may help doctors determine symptoms after an incident. The baseline testing
when it is safe to return to competition. often includes neurocognitive tests, symptom
checklists, sideline assessment tools such as
What is neurocognitive testing? the Sideline Concussion Assessment Tool (SCAT),
Neurocognitive testing is a questionnaire the athlete and balance testing.
takes (usually by computer) that tests multiple areas
of brain function including memory, problem solving, Additional Information
reaction times, brain processing speeds, and post www.sportsmed.org
concussion symptoms. It is most valid if the athlete www.orthoinfo.org
has a pre-injury baseline test on file to compare the www.STOPSportsInjuries.org
post concussion test. This information can be very
helpful to the physician in determining return to play.
It is not a substitution for an evaluation by a physician.

When should a concussed athlete


return to play?
All athletes who sustain a concussionno matter
how minorshould undergo an evaluation by a
qualified health care provider before returning to play.
Athletes can return to play after they are completely
free of all symptoms of a concussion and remain
symptom free during and after physical testing.

It is recommended that all athletes who sustain a concussive


episode, no matter how minor, undergo an evaluation by a
medical physician before return to play.

SPORTS MEDICINE | Concussion 12


HEAT ILLNESS
EXPERT CONSULTA NT | Douglas Casa, PhD, ATC, FACSM, FNATA, Marjorie J. Albohm, MS, ATC

Every summer hundreds of people fall How can heat-related


prey to the sun and the heat. Being illnesses be prevented? Statistics
prepared and hydrated can largely Heat stroke, a severe form of heat-
The most effective treatment for heat-
related illness, is one of the three
prevent a large variety of heat illnesses related illnesses is prevention, including: leading causes of death in athletes
from happening. and likely the leading cause of death
Proper training for the heat
among athletes in July and August.
Why does heat illness occur? Fluid replacement before, The body produces a half of gallon
When an athlete exercises, the bodys during, and after exertion of perspiration to cool it every
hour. If theres not enough fluid
temperature is elevated and the body Appropriate clothing or the heat overwhelms the body,
sweats to cool itself down. During this light colored, loose fitting, the person develops a heat
process, body fluid as well as critical and limited to one layer related illness.
electrolytes are lost. If the body isnt Early recognition via direct While many cases of heat stroke,
replenished with fluids and electrolytes, heat-related disorders arent lethal;
monitoring of athletes by other about 175 to 200 people die
dehydration may occur and increase the players, coaches, and medical staff from heat stroke each year
risk of a heat illness such as heat stroke. in the United States.
Monitoring the intensity of physical
activity appropriate for fitness
What are the symptoms Athlete who had heat illness
and how an athlete has acclimated
of heat illness? Korey Stringer, Minnesota Vikings
to conditions (died from heat illness)
Some symptoms include:
If possible, having an athletic trainer
Chills on site during events and practices
to properly prevent and treat heat When should an athlete
Dark colored urine
illnesses hydrate?
Dizziness Hydration should begin before the
At the beginning of a strenuous exercise
Dry mouth exercise period. Drinking 16 ounces of
program or after traveling to a warmer
Headaches water or a sports drink is recommended
climate, an athlete should initially limit
one hour before exertion. Hydration
Thirst the intensity and duration of exercise
should continue with 48 ounces
and then gradually increase it during
Weakness of fluid every 1520 minutes as long
a period of 714 days to allow time for
as exertion continues.
If heat illness progresses, more serious the body to adjust to the new climate
symptoms such as difficulty breathing, and environmental conditions. Athletes The type of fluid replacement depends
body temperature increasing to with respiratory, gastrointestinal, on the duration of the event. Plain
dangerous levels, muscle cramps, or other illness should be evaluated water is adequate for events lasting
nausea, tingling of the limbs, before exercise, as these conditions less than one hour. However, for events
and even death may occur. increase the risk of heat illness. that last more than one hour or multiple

SPORTS MEDICINE | Heat Illness 13


HEAT ILLNESS

bouts of exercise in the same day, the replacement Treatment tips include:
fluid should contain carbohydrates, sodium,
Getting the athlete to a shaded area.
and potassium, which are standard components
of commercial sports drinks. If it is heat stroke, cool the athlete rapidly
using cold water immersion. If immersion
Weighing oneself before and after activity provides is not available you may use spray from
good feedback on the level of hydration. If the athlete a hose, cold water sponging, or placing
is lighter after an activity, then it is likely a fluid cold towels over the entire body.
deficit has occurred and it is necessary to replace
Monitoring body temperature.
the weight loss by drinking more during the next
practice to approximate sweat losses. An athlete Providing cool beverages if possible (i.e., if the
who loses more than two percent to three percent athlete does not have altered consciousness).
of body weight during exercise may be at a point Getting medical assistance as soon as possible.
of compromising performance and physiological
Heat exhaustion is a form of heat illness that can
function. If the athlete gains weight after an activity,
develop after several days of exposure to high
then the quantity of rehydration fluid during activity
temperatures and inadequate or unbalanced
should be reduced.
replacement of fluids.

How can heat illnesses be treated?


When you see any signs of heat illness or heat
stroke, you may be dealing with a life-threatening Additional Information
emergency. Have someone call for immediate www.sportsmed.org
medical assistance while you begin cooling www.orthoinfo.org
the individual at risk. www.STOPSportsInjuries.org

SPORTS MEDICINE | Heat Illness 14


THE MATURE
ATHLETE
EXPERT CONSULTA NT | Paul R. Reiman, MD

Exercise is not only for the young, but for minutes, three to four days per week. significant deformity, such as flat feet
the mature population as well. Exercise If there are physical conditions that (fallen arches), the use of foot orthotics
can be a good way for older adults need correction, a cardiac, pulmonary, can decrease stress on the entire lower
to maintain independence and remain or physical therapy rehabilitative program extremity. Symptoms from arthritic
healthy in body and mind. Major health may be helpful before beginning an changes in the knee may be decreased
problems the mature population often exercise program. These rehabilitation through the use of specialized braces.
faces can include arthritis, high blood programs should instruct the mature
pressure, heart disease, lung disease, athlete to a fitness level where they How can the mature athlete
depression, and hearing and sight loss. may then pursue their own program. prevent injury or discomfort
during exercise?
With the exception of hearing and sight
loss, all of these problems can potentially What type of exercises should Any discomfort during or after
a program include? exercise should be investigated to
improve in the mature athlete with
a controlled exercise program. The types of exercises an individual prevent reoccurrence or worsening.
takes on should be based on the Over-the-counter pain relievers and
All mature athletes should have athletes desires, pre-existing conditions, anti-inflammatory medications can
a comprehensive medical and and the ability to exercise pain-free. be used short-term if there are no
musculoskeletal evaluation prior to For individuals with lower extremity joint adverse interactions with other medical
beginning any exercise program. These issues, such as arthritis or instability, it is conditions. Additionally, the use of ice,
examinations and subsequent medical best to avoid repetitive impact activities heat, massage, and flexibility programs
and exercise counseling may prevent like running. Athletes with shoulder can relieve many exercise-induced
catastrophic health events and injuries. disabilities should avoid repetitive symptoms. More aggressive treatments
The evaluation should satisfy the overhead activities, such as military with narcotic analgesics and/or
mature athletes needs for disease presses and pull-ups. Using multiple cortisone injections should be reserved
prevention, endurance, strength, types of activities to enhance strength to treat a specific injury and not simply
body image, and competitiveness. can allow for even better muscle and to allow for short-term competition.
tendon tissue recovery. If the mature
How can exercise benefit adult desires to play a sport which may Summary
the mature athlete? aggravate pre-existing muscle, tendon, By working together with a medical
Creating a specialized program with or bone problems, they should be in and/or exercise professional to create
a qualified personal trainer can improve good condition prior to performing the a tailored program, the mature athlete
flexibility, balance, endurance, and sport. A decrease in the frequency of the can maintain independence, increase
strength. If the exercise program sport may decrease painful symptoms. physical capabilities, prevent injury and
includes sports, such as golf or tennis, add significantly to ones quality of life.
technique education by qualified What types of equipment will
instructors may also be useful for the mature athlete need? Additional Information
performance and injury prevention. Wearing shoes that match the specific www.sportsmed.org
To achieve results, any program must exercise and/or sport program can be www.orthoinfo.org
be done consistently for at least 3045 beneficial. If the individuals foot has www.STOPSportsInjuries.org

SPORTS MEDICINE | The Mature Athlete 15


MENISCAL TEARS
EXPERT CONSULTA NT | Sabrina Strickland, MD

What is a meniscus tear? The orthopaedic surgeon may also


require further diagnostic studies like Statistics
Meniscal injuries are one of the most
an MRI (magnetic resonance imaging) Acute meniscal tears are common
common knee injuries in athletes and affecting 61 out of 100,000 persons
can occur acutely after a traumatic twist which provides a three-dimensional
per year.
or after a contact injury. The meniscus image of the interior of the knee joint.
Females suffer meniscal injuries
is a wedge of cartilage that provides In some cases, surgeons may also more often than men and at an
a cushion in both the medial and recommend arthroscopic inspection earlier age and these tears are
of the knee joint, a minimally invasive often associated with ACL injury.
lateral part of the knee joint. Acting as
a shock absorber, the meniscus actually surgical procedure. Only some variants of meniscal
tear can be repaired and despite
increases the contact area of the joint repair they do not always heal.
to minimize the load on the articular How is a meniscal However, arthritis can be avoided
cartilage and helps stabilize the knee
tear treated? in most cases if repair is successful.
as well. In addition, the meniscus helps Meniscal tears, if small, can be treated In one study, 60% of patients
undergoing meniscectomy (partial
provide nutrition to the knee by aiding with rest, ice and anti-inflammatory
removal) demonstrated some
in diffusion of joint fluid. Athletes can medication. However, if there is degree of progressive arthritis.
feel acute pain with this injury as well significant loss of motion or catching
as swelling and often a catching or then the appropriate treatment is often Athletes who had meniscal tears
locking sensation. surgical. Depending on the location and Adam Moore, Seattle Mariner,
type of tear, treatment can be a simple had a torn meniscus
arthroscopy to remove the torn fragment. Kendrik Perkins, Boston Celtics,
underwent an ACL reconstruction
Athletes can return to full activity in
with a meniscal repair.
as little as a week to as long as a few
T. J. Schiller, extreme skier, suffered
months depending on how quickly an ACL and a meniscal tear.
the inflammation goes away. In athletes Marc-Andre Tarte, a professional
with a repairable tear, sutures are used snowboarder, required an ACL
to sew the meniscus back together and reconstruction and meniscal repair.
then the knee is braced for 6 weeks, Gilbert Arenas, Washington Wizards
these athletes take at least 3 to 6 months point guard, underwent a lateral
meniscal repair and microfracture.
to return to full activity but maintain
Fernando Torres, a professional
the full cushion in their knee.
soccer player from Spain,
underwent a partial meniscectomy.
How is a meniscal tear Can meniscal tears
diagnosed? be prevented?
An injury to the meniscus can There is no real way to prevent a Additional Information
be diagnosed based upon the meniscal tear aside from a conditioning www.sportsmed.org
history that the patient provides and program to try to prevent an ACL tear www.orthoinfo.org
a physical examination of the knee. and knee instability. www.STOPSportsInjuries.org

SPORTS MEDICINE | Meniscal Tears 16


MRSA INFECTIONS
EXPERT CONSULTA NT | Matthew Matava, MD

What causes MRSA or cuts. MRSA also has the capability


infections? of spreading to any organ in the body, Statistics
and when this occurs, more severe Today, MRSA accounts for about
Methicillin-resistant Staphylococcus
5070% of the S. aureus infections
aureus (S. aureus) bacteria, or MRSA, symptoms may result. These symptoms
that are present in healthcare
is an organism known for causing skin include fever, chills, low blood pressure, facilities across the world.
infections as well as many other types of joint pain, severe headaches, shortness Statistics from the Kaiser
infections. MRSA was first seen in U.S. of breath, and an extensive rash over foundation in 2007 indicated
hospitals during the 1970s as a bacteria the body. These more advanced, that approximately 1.2 million
systemic symptoms require immediate hospitalized patients contract
that caused healthcare-associated MRSA infections, and that
infections among the elderly and sick. medical attention. as many as 19,000 people per
Since that time, MRSA has spread to year die from MRSA in the U.S.
healthcare facilities throughout the world, How is MRSA treated? Serious MRSA infection is still
and has become the most common The first choice for treatment for a MRSA predominantly related to exposure
in the healthcare setting, where
pathogen to cause healthcare-associated skin infection is the use of an antibiotic
approximately 85 percent of all
infections. Recently, a new strain of that has been determined to reliably kill serious MRSA infections occur.
MRSA know as Community Acquired the bacteria with minimal side effects. Fortunately, in children under
Methicillin-Resistant Staphylococcus Most early infections without widespread 18 years of age, mortality rates
aureus, or CA-MRSA, has left hospitals symptoms can be treated with oral are much lower (1%), even
though the number of hospitalized
and began to spread in the community. antibiotics. Because of the nature of this
children with MRSA has almost
This is the strain that is prevalent disease and antibiotic options, some tripled since 2002.
among athletes. The difference between patients think they are cured after just
CA-MRSA and Healthcare-Associated a few doses, and decide to stop taking Athlete who had MRSA infections
MRSA (HA-MRSA) lies in their effects, their prescribed medication. However, Tom Brady, New England Patriots
as CA-MRSA typically causes skin MRSA is capable of re-infecting the
infection while HA-MRSA causes patient and becoming resistant to the
bloodstream, urinary tract, and surgical previously used antibiotics. Moderate-
site infections. As a result, CA-MRSA to-severe infections may require
is less dangerous than HA-MRSA. treatment with intravenous antibiotics. Early identification and treatment of
Another major difference between Those infections associated with deep MRSA infections will reduce the amount
the two strains is that CA-MRSA abscesses or boils require open surgical of playing time lost and decrease the
is more vulnerable to antimicrobials. drainage in addition to antibiotic therapy. chance that the infection will become
Most infections resolve with appropriate severe. Skin can be protected by wearing
What are the symptoms treatment within seven to 10 days, protective clothing or gear designed
of MRSA? though a deep abscess may take up to prevent skin abrasions or cuts.
Signs of infection include redness, to four weeks in order to eradicate
warmth, swelling, pus, and pain at sites the infection with resolution of the
where there are skin sores, abrasions, abscess cavity.

SPORTS MEDICINE | MRSA Infections 17


MRSA INFECTIONS

How can MRSA be prevented? Athletes Who Have Had MRSA


In addition to practicing good personal hygiene, Several high school, college, and professional athletes
athletes and visitors to athletic facilities should also have contracted MRSA infections. In some situations
keep their hands clean by washing frequently with there have been large outbreaks among multiple
soap and water or using an alcohol-based hand rub. athletes of the same team. A study published in
At a minimum, hands should be cleaned before and The New England Journal of Medicine observed
after playing sports and activities such as using shared MRSA infection among members of the St. Louis
weight-training equipment, when caring for wounds Rams professional football franchise. During that
(including changing bandages), and after using the
single season, 8 MRSA infections were found among
toilet. Both plain and antimicrobial soap are effective
5 of the 58 Rams players (9 percent) that were
for hand washing, but liquid soap is preferred over bar
tested. All infections developed on areas of the body
soap in these settings to limit sharing. Alcohol-based
that are common locations for turf injury.
hand antiseptics with at least 60 percent alcohol
content are preferred. Athletes should shower
immediately after exercise and not share bar soap
or towels. It is important to wash all uniforms and
clothing after each use. Athletes should avoid sharing
items that come into contact with the skin and avoid
Additional Information
sharing personal items such as towels and razors www.sportsmed.org
that contact bare skin. Fortunately, most surfaces www.orthoinfo.org
do not pose a risk of spreading staph and MRSA. www.STOPSportsInjuries.org

SPORTS MEDICINE | MRSA Infections 18


OVERUSE INJURIES
EXPERT CONSULTANT | Matthew J. Matava, MD

There are basically two types of injuries: What factors cause


acute injuries and overuse injuries. overuse injuries? Statistics
Acute injuries are usually the result Nearly 50% of all injuries sustained
Training errors are the most common
by middle school and high school
of a single, traumatic event. Common cause of overuse injuries. These athletes are overuse.
examples include wrist fractures, ankle errors involve rapid acceleration 3.5 million kids are treated
sprains, and shoulder dislocations. of the intensity, duration, or frequency for overuse injuries each year.
While overuse injuries are more of activity. Overuse injuries also happen
common in sports than acute injuries, in people who are returning to a sport
they are subtle and usually occur or activity after injury and trying to How are overuse injuries
over time, making them challenging usually diagnosed?
make up for lost time by pushing
to diagnose and treat. They are themselves to achieve the level of The diagnosis can usually be made
the result of repetitive micro-trauma participation they were at before injury. after a thorough history and physical
to the tendons, bones, and joints. Proper technique is critical in avoiding examination. This is best done by a
Common examples include tennis overuse injuries, as slight changes in sports medicine specialist with specific
elbow, swimmers shoulder, Pitchers form may be the culprit. For this reason, interest and knowledge of your sport or
elbow, runners knee, Achilles coaches, athletic trainers, and teachers activity. In some cases, X-rays are needed
tendinitis, and shin splints. can play a role in preventing recurrent and occasionally additional tests like a
overuse injuries. bone scan or MRI are required as well.
Why do overuse injuries occur?
Some people are more prone than What is the treatment
The human body has a tremendous
others to overuse injuries. Imbalances for overuse injuries?
capacity to adapt to physical stress.
between strength and flexibility around
We tend to think of stress in the Some tips for treating an overuse
certain joints predispose individuals
context of its negative effect on our injury include:
to injury. Body alignment, such as
emotional wellbeing, but physical
knock-knees, bowlegs, unequal leg Cutting back the intensity, duration,
stress, which is simply exercise and and frequency of an activity
lengths, and flat or high arched feet,
activity, is beneficial for our bones,
also impact overuse injuries. Many Adopting a hard/easy workout
muscles, tendons, and ligaments,
people also have weak links due to schedule and crosstraining
making them stronger and more
old injuries, incompletely rehabilitated with other activities to maintain
functional. This happens because of
injuries, or other anatomic factors. fitness levels
an internal process called remodeling.
The remodeling process involves both Other factors include equipment, Learning about proper training
the breakdown and buildup of tissue. such as the type of running shoe and technique from a coach
There is a fine balance between the two, or ballet shoe, and terrainhard or athletic trainer
and if breakdown occurs more rapidly versus soft surface in aerobic dance Performing proper warm-up
than buildup, an overuse injury occurs. or running. activities before and after

SPORTS MEDICINE | Overuse Injuries 19


OVERUSE INJURIES

Using ice after an activity for minor aches and pain Always remember to warm up and cool down
properly before and after activity. Incorporating
Using anti-inflammatory medications as necessary
strength training, increasing flexibility, and improving
If symptoms persist, a sports medicine specialist will core stability will also help minimize overuse injuries.
be able to create a more detailed treatment plan for
Seek the advice of a sports medicine specialist or
your specific condition. This may include a thorough
athletic trainer when beginning an exercise program
review of your training program and an evaluation
or sport to prevent chronic or recurrent problems.
for any predisposing factors. Physical therapy and
Your program can also be modified to maintain overall
athletic training services may also be helpful.
fitness levels in a safe manner while you recover
from your injury. You should return to play only when
Can overuse injuries be prevented?
clearance is granted by a health care professional.
Most overuse injuries can be prevented with proper
training and common sense. Learn to listen to your
body. Remember that no pain, no gain does not
apply here. The 10 percent rule is very helpful in Additional Information
determining how to take things to the next level. www.sportsmed.org
In general, you should not increase your training www.orthoinfo.org
program or activity more than 10 percent per week. www.STOPSportsInjuries.org
This allows your body adequate time for recovery and
response. This rule also applies to increasing pace
or mileage for walkers and runners, as well as to the
amount of weight added in strength training programs.

SPORTS MEDICINE | Overuse Injuries 20


ROTATOR
CUFF TEARS
EXPERT CONSULTANT | Dan Solomon, MD

What is the rotator cuff What causes a rotator


and what does it do? cuff tear? Statistics
Rotator cuff tears occur in 540%
The rotator cuff is a group of four A rotator cuff tear may result from
of individuals with risk significantly
muscles and their tendons that combine an acute injury such as a fall or may be increasing with increased age.
to form a cuff around the head of caused by chronic wear and tear with Relative risk in the 3040 year old
the humerus (the upper end of the degeneration of the tendon. Pinching age group is small, but in some
studies tears are more common than
arm). The four musclessupraspinatus, of the tendon on the undersurface of
not in the over 70 year old group.
infraspinatus, subscapularis and teres the scapula may contribute to cuff tears
minororiginate from the scapula in individuals older than 40 years. Athletes who had a rotator cuff tear
(shoulder blade). The tendon for each Monica Seles, Professional
muscle inserts on the tuberosities How are rotator cuff tears Tennis Player
of the humerus. diagnosed? John Smolz, Atlanta Braves
Baseball Pitcher
The rotator cuff helps to lift and rotate Rotator cuff tears are diagnosed based
Janet Evans, Professional Swimmer
the arm and to stabilize the humerus on examination and/or a diagnostic
within the joint. study such as MRI (magnetic resonance
imaging) to confirm the diagnosis. Early
diagnosis and treatment of a rotator cuff shoulder that does not improve with
tear may help improve treatment results. nonsurgical treatment. Frequently,
patients who require surgery will report
What is the treatment pain at night and difficulty using the
for a rotator cuff tear? arm for lifting and reaching. Many
will report ongoing symptoms despite
The goals of treatment are to relieve
several months of medication and
pain and restore strength to the involved
limited use of the arm.
shoulder. Many rotator cuff tears can be
treated nonsurgically. Anti-inflammatory Surgery is also indicated in active
medication, steroid injections, and individuals who use the arm for
physical therapy may all be of benefit overhead work or sports.
in treating symptoms of a cuff tear.
Even though a full-thickness tear cannot What options are available
heal without surgery, satisfactory for surgical repair?
function can often be achieved The type of repair performed is based
with non-surgical treatments. on the findings at surgery. A partial
tear may require only a trimming
At what point does a rotator or smoothing procedure called a
cuff tear require surgery? dbridement. A full-thickness tear with
Surgery is recommended if there is the tendon torn from its insertion on the
Rotator cuff tear on an MRI persistent pain or weakness in the humerus is repaired directly to bone.

SPORTS MEDICINE | Rotator Cuff Tears 21


ROTATOR CUFF TEARS

Three techniques are used for rotator cuff repair: Additional Information
open repair (through a traditional incision) www.sportsmed.org
www.orthoinfo.org
mini-open repair (partially assisted by a camera
www.STOPSportsInjuries.org
view, with a smaller incision)
arthroscopic (performed with only a small camera
inserted through multiple small puncture wounds)

What does the recovery and


rehabilitation process entail?
Rehabilitation plays a critical role in both the
nonsurgical and surgical treatment of a rotator
cuff tear. Typical recovery can be six months
or more depending on the extent of the tear.

When a tear occurs, there is frequently loss


of motion of the shoulder. An exercise or physical
therapy program is necessary to regain strength
and improve function in the shoulder.

Even though surgery repairs the defect in the tendon,


the muscles around the arm remain weak, and
a strong effort in rehabilitation is necessary for
the procedure to succeed. Complete rehabilitation
after surgery may take several months.

SPORTS MEDICINE | Rotator Cuff Tears 22


SHOULDER
IMPINGEMENT
EXPERT CONSULTA NT | Ben Shaffer, MD

What is shoulder How does shoulder This may mean temporarily avoiding
impingement? impingement occur? activities like tennis, pitching or
Impingement refers to mechanical Any process which compromises this swimming. A nonsteroidal anti-
compression and/or wear of the rotator normal gliding function may lead to inflammatory medication may also
cuff tendons. The rotator cuff is actually impingement. Common causes include be recommended by your doctor.
a series of four muscles connecting the weakening and degeneration within the The mainstay of treatment involves
scapula (shoulder blade) to the humeral tendon due to aging, the formation of exercises to restore normal flexibility
head (upper part of the shoulder joint). bone spurs and/or inflammatory tissue and strength to the shoulder girdle,
The rotator cuff is important in within the space above the rotator cuff including strengthening both the
maintaining the humeral head within and overuse injuries. Overuse activities rotator cuff muscles and the muscles
the glenoid (socket) during normal that can lead to impingement are most responsible for normal movement
shoulder function and also contributes commonly seen in tennis players, of the shoulder blade. This program of
to shoulder strength during activity. pitchers and swimmers. instruction and exercise demonstration
Normally, the rotator cuff glides smoothly may be initiated and carried out either
between the undersurface of the How is shoulder impingement by the doctor, certified athletic trainer or
acromion, the bone at the point of diagnosed? a skilled physical therapist. Occasionally,
the shoulder and the humeral head. an injection of cortisone may be helpful
The diagnosis of shoulder impingement
in treating this condition.
can usually be made with a careful
history and physical exam. Patients with
impingement most commonly complain
Is surgery necessary?
of pain in the shoulder, which is worse Surgery is not necessary in most
with overhead activity and sometimes cases of shoulder impingement. But
severe enough to cause awakening in if symptoms persist despite adequate
the night. Manipulation of the shoulder nonsurgical treatment, surgical
in a specific way by your doctor will intervention may be beneficial.
usually reproduce the symptoms and Surgery involves debriding, or surgically
confirm the diagnosis. X-rays are also removing, tissue that is irritating the
helpful in evaluating the presence rotator cuff. This may be done with
of bone spurs and/or the narrowing either open or arthroscopic techniques.
of the subacromial space. Outcome is favorable in about
90 percent of the cases.
How is shoulder
impingement treated? Additional Information
The first step in treating shoulder www.sportsmed.org
impingement is eliminating any www.orthoinfo.org
identifiable cause or contributing factor. www.STOPSportsInjuries.org

SPORTS MEDICINE | Shoulder Impingement 23


SHOULDER
INSTABILITY/
DISLOCATIONS
EXPERT CONSULTANT | Daniel J. Solomon, MD

The shoulder is the most mobile joint The shoulder is made up of three
in the body. It allows one to lift the arm, bones: humerus (upper arm bone), Statistics
rotate it, and reach up over head. It is scapula (shoulder blade), and 70,000 shoulder dislocations
occur each year.
able to turn in many directions. This clavicle (collarbone).
greater range of motion, however, Athletes who have suffered
Shoulder dislocations can be partial,
results in less stability. a shoulder dislocation:
with the ball of the upper arm coming
just partially out of the socket. This Lance Armstrong,
How do shoulder dislocations Professional Cyclist
is called a subluxation. A complete
happen? Drew Brees, New Orleans Saints
dislocation means the ball comes Quarterback
Shoulder instability occurs when the all the way out of the socket.
head of humerus (the upper arm bone)
is forced out of the shoulder socket. What are the symptoms
This usually occurs as a result of of shoulder instability?
a sudden traumatic injury.
Common symptoms of chronic shoulder A persistent sensation of the shoulder
Once a shoulder has dislocated, it is instability include: feeling loose, slipping in and out
vulnerable to repeat episodes. When of the joint, or just hanging there
Pain caused by shoulder injury
the shoulder is loose and slips out of
place repeatedly, it is called chronic Repeated shoulder dislocations How is shoulder instability
shoulder instability. Repeated instances of the shoulder
diagnosed?
giving out There are specific tests that help assess
instability in the shoulder, including
general looseness in ligaments. A doctor
may order imaging tests, including
Clavicle
(Collarbone) X-rays, CT Scan or MRI to help
Rotator
confirm a diagnosis and identify
Cuff Tendon
any other problems.

How is shoulder instability


treated and how long is
Humerus
(Upper Arm)
recovery?
Chronic shoulder instability is often
first treated with nonsurgical options.
If these options do not relieve the pain
Biceps Tendon and instability, surgery may be needed.
Scapula
Glenoid (Shoulder Blade)

SPORTS MEDICINE | Shoulder Instability/Dislocations 24


SHOULDER INSTABILITY/DISLOCATIONS

Nonsurgical Treatment Rehabilitation


It often takes several months of nonsurgical treatment After surgery, the shoulder may be immobilized
before an assessment of success can be made. temporarily with a sling.
Nonsurgical treatment typically includes:
When the sling is removed, exercises to rehabilitate
Activity modification the ligaments will be started. These will improve
Non-steroidal anti-inflammatory medication. the range of motion in the shoulder and prevent
scarring as the ligaments heal. Exercises to
Physical therapy
strengthen a shoulder will gradually be added
Surgical Treatment to a rehabilitation plan.
Surgery is often necessary to repair torn or stretched
ligaments so that they are better able to hold the Additional Information
shoulder joint in place. www.sportsmed.org
www.orthoinfo.org
Bankhart lesions (tearing of the front labrum from
www.STOPSportsInjuries.org
the socket) can be surgically repaired by using suture
anchors to reattach the ligament to the bone.

Arthroscopy Soft tissues in the shoulder can be


repaired using tiny instruments and small incisions.
This is a same-day or outpatient procedure.
Arthroscopy is minimally invasive surgery. A surgeon
will look inside the shoulder with a tiny camera
and perform the surgery with special instruments.

Open Surgery Some patients may need an open


surgical procedure. This involves making a larger
incision over the shoulder and performing the repair
under direct visualization.

Dislocated shoulder and shoulder realigned

SPORTS MEDICINE | Shoulder Instability/Dislocations 25


SLAP TEARS
EXPERT CONSULTA NT | Robert A. Gallo, MD

What is a SLAP tear? How are SLAP tears treated?


Statistics
SLAP is an acronym that stands for A trial of non-operative treatment is the
SLAP repair procedure only has
superior labrum anterior to posterior. preferred initial step for a SLAP tear.
a 3366% success rate in putting
The labrum is a rim of tissue that While the SLAP tear likely will not heal, athletes back on the field.
adds depth to the bony socket of a recent study confirmed that many have SLAP tears have been reported in
the shoulder. The superior or top improvement of symptoms and function. up to one of four people undergoing
portion of the labrum is important If non-operative treatments, such as a shoulder arthroscopy.
and frequently injured because physical therapy, are not successful, Among active populations, SLAP
then surgery may be considered. tears may be even more common:
the biceps attaches to this region.
according to one study, nearly 40%
Surgery is usually performed of military personnel had a SLAP
How do SLAP tears happen? arthroscopically and involves tear at the time of arthroscopy.
SLAP tears occur as a result of trauma reattaching the torn labrum back Athlete who had a SLAP tear
or chronic overhead activity. A fall to the top of the socket. Usually Jameer Nelson, Orlando Magic,
on an outstretched hand with the arm bone anchors loaded with sutures basketball player
overhead and a fall directly onto the are inserted into the top of the socket.
shoulder are thought to be the most The sutures are passed through the
common mechanism of injury. Chronic torn area of the labrum. The sutures are
tears are often seen in overhead tied with knots, which reapproximates
athletes, such as baseball pitchers the torn labrum back to the bone.
and tennis players. Experts believe
that SLAP tears can be the end result How can SLAP tears Additional Information
of imbalances in the shoulder. be prevented? www.sportsmed.org
While acute SLAP tears are difficult www.orthoinfo.org
How are SLAP tears to prevent, chronic tears, especially www.STOPSportsInjuries.org
diagnosed? among overhead athletes, can be
Because of overlap among different prevented by maintaining balance
shoulder problems, SLAP tears are within the shoulder. Exercises that
rarely diagnosed on physical examination strengthen the muscles around the
alone. MRIs with or without contrast are shoulder blade and stretches that
the diagnosis tool of choice. However, focus on preventing a tight posterior
differentiating a SLAP tear from normal shoulder are thought to be important
variations of the labrums attachment in minimizing the chance of a chronic
to the socket can be difficult. SLAP tear.

SPORTS MEDICINE | SLAP Tears 26


STEROIDS
EXPERT CONSULTA NT | Edward McDevitt, MD

The newspapers are full of articles are likelier to engage in risky behavior,
revealing the use of anabolic steroids, such as taking other illegal drugs, or Statistics
a performance enhancing drug, in the engaging in dangerous sexual practices. As many as four million American
children and teens are using
Olympics and professional sports, but
Signs of anabolic steroid use include: performance enhancing drugs
these dangerous drugs are also being such as anabolic steroids.
used by children in college, high school, Acne, often severe, and seen
and even middle school! on the back and face
Severe mood swings, extreme
What are anabolic steroids? aggression, and even suicidal behavior drugs on a daily basis. Get involved.
Anabolic steroids are synthetic derivatives Ask kids about what they know about
Premature balding, irreversible
of the male sex hormone testosterone. breast enlargement, and smaller these drugs. Ask them if they know if
The steroids help with the construction testicles in boys any of their classmates are using these
of new proteins and increase muscle drugs. Ask them if they know the
Deeper voice, shrinking breasts,
size and strength. This is something potential dangers of performance
and clitoral enlargement in girls
that already takes place in the body, enhancing drugs.
but the steroids simulate or increase this Dangerous enlargement of the heart,
If you think your child may be
normal biologic activity. Performance that may increase bad cholesterol
and blood pressure experimenting with these drugs,
enhancing drugs are easily available talk to your doctor.
in communities, weight rooms, or even Often irreversible liver damage
via the Internet. It is also important to talk with the
In children, premature closure
coaches and ask if yearly physicals
Steroids can either be taken orally or of the growth plates, stopping
are required by the league or school for
by an injection. Anabolic steroids in and normal growth of bones.
athletic participants. A pre-participation
of themselves are not effective. However, physical by a physician is an invaluable
when used in conjunction with strength Is there ever a reason to take
way to screen for potential performance
training they may cause gains in size anabolic steroids?
enhancing drug use in athletes. Ask
and strength, along with dangerous Anabolic steroids are invaluable to people the coaches if they know if any of their
side effects. who have lost testicular function, such athletes have experimented with
as men with testicular tumors. Anabolic performance enhancing drugs.
What are the side effects steroids are also used in some types of
of anabolic steroids? anemia to stimulate the bone marrow.
Performance enhancing drugs do have
the ability to make athletes bigger and How can we prevent children
stronger but users face potentially deadly from using anabolic steroids? Additional Information
health risks. Many of the side effects of Do not think that performance enhancing www.sportsmed.org
performance enhancing drugs continue drugs are only a problem of the elite www.orthoinfo.org
even after stopping the drugs. Users also athletes. Children are exposed to these www.STOPSportsInjuries.org

SPORTS MEDICINE | Anabolic Steroids 27


STRESS
FRACTURES
EXPERT CONSULTA NT | Barry P. Boden, MD, Michael Leddy, MD, Matthew J. Matava, MD

What is a stress fracture? on their own and the muscles act as


shock absorbers. As muscles become Statistics
A stress fracture is an overuse injury.
tired and stop absorbing, all forces are The annual incidence of stress
Each day, the body produces new bone fractures in athletes and military
to replace the bone that is broken down transferred to the bones. Although stress
recruits ranges from 5% to 30%,
by the stress of everyday living. Usually, fractures have been described in nearly depending on the sport and
this process is balanced, with the body every bone of the human body, they are other risk factors.
replacing the amount of bone lost. more common in the lower extremity Stress fractures occur less
weight-bearing bones. The most frequently in those of black African
However, this balance may become
common area for a stress fracture descent than in Caucasians, due
upset with excessive physical training. to a generally higher BMD (bone
The body, due to several factors, may is in the tibia. Stress fractures may mineral density) in the former.
not produce sufficient bone. As a result, be associated with a specific sport
Women and highly active
micro cracks, called stress fractures, such as the elbow in throwing sports, individuals are also at a higher
can occur in the bone. the ribs in golfing and rowing, the risk. The incidence probably
spine in gymnastics, the lower extremity also increases with age due
The most common cause of stress to age-related reductions in BMD.
in running activities and the foot
fractures is an abrupt increase in the Children may also be at risk
in gymnastics and basketball.
because their bones have yet to
duration, intensity or frequency of
reach full density and strength.
physical activity without adequate How are stress fractures The female athlete triad also can
periods of rest. In addition to mechanical diagnosed? put women at risk, as disordered
influences, systemic factors (such eating and osteoporosis can cause
Stress fractures produce pain in a
as hormonal imbalances), nutritional the bones to be severely weakened.
limited area directly over the point of the
deficiencies, sleep deprivation and
bone where the fracture has occurred. Athletes who had stress fractures
metabolic bone disorders may contribute
The pain is exacerbated by activity and Yao Ming, NBA basketball player
to the development of stress fractures.
is relieved with rest. Bone tenderness Deena Kastor, Olympic distance
Furthermore, some female athletes
is the most obvious finding on physical runner
who train competitively develop eating
examination. Jerry Hairston Jr., San Diego Padres
disorders and/or amenorrhea (infrequent
Julio Jones, Alabama WR
menstrual periods). Both conditions X-rays may not be helpful in diagnosing
Paul Stastny, Avalanche NHL player
may lead to a low estrogen state with an early stress fracture because the
resultant decreased bone mineral density bone often appears normal and the
and an increased risk of stress fractures. micro cracks are not visible. After
How is a stress fracture
several weeks of rest, the bone begins treated?
Stress fractures are frequently seen in
to repair itself and often demonstrates
military recruits and athletes, especially Stress fractures may be broadly
a healing reaction or callus on X-ray.
runners. For every mile a runner runs, classified as either low-risk injuries (less
more than 110 tons of force must be The diagnosis of an early stress fracture likely to become more serious fractures)
absorbed by the legs. Bones are not can usually be confirmed by a bone scan or high-risk injuries (more likely to
made to withstand so much energy or magnetic resonance imaging (MRI). become serious fractures). Low-risk

SPORTS MEDICINE | Stress Fractures 28


STRESS FRACTURES

stress fractures infrequently require expensive imaging Maintain a healthy diet. Make sure to incorporate
modalities such as bone scans or MRIs. A rest period calcium and vitamin D rich foods in your meals.
of one to six weeks of limited weight bearing activity Use the proper equipment. Do not wear old
progressing to full weight bearing may be necessary. or worn running shoes.
Return to activity should be a gradual process.
If pain or swelling occurs, immediately stop the
Low-impact activities, such as swimming or biking,
activity and rest for a few days. If continued pain
can be performed to maintain cardiovascular
persists, see an orthopaedic surgeon.
conditioning once the pain subsides. When the
patient can comfortably perform low-impact activities It is important to recognize the symptoms early
for prolonged periods without pain, high-impact and treat them appropriately to return to sports
exercises may be initiated. Typically, the athlete at a normal playing level.
gradually increases jogging mileage and eventually
returns to sport-specific activities. Additional Information
www.sportsmed.org
High-risk stress fractures, involving areas such as the
www.orthoinfo.org
hip, have a predilection for progressing to complete
www.STOPSportsInjuries.org
fracture; therefore, they require a more aggressive
approach. In athletes who have chronic pain and
normal findings on initial X-rays, a bone scan or MRI
is recommended. Because of the high complication
rate, high-risk stress fractures should be treated like
traumatic fractures often with a cast and
occasionally with surgery when necessary.

How are stress fractures prevented?


Here are some tips developed by AAOS to help
prevent stress fractures:
When participating in any new sports activity, set
incremental goals. For example, do not immediately
set out to run five miles a day; instead, gradually
build up your mileage on a weekly basis.
Cross-training alternating activities that
accomplish the same fitness goals can help
to prevent injuries like stress fractures. Instead
of running every day to meet cardiovascular goals,
run on even days and bike on odd days. Add
some strength training and flexibility exercises
to the mix for the most benefit.

SPORTS MEDICINE | Stress Fractures 29


SUDDEN CARDIAC
DEATH IN ATHLETES
EXPERT CONSULTA NT | Kenneth Fine, MD

Sudden cardiac death (SCD) in athletes, (EKGs), although this screening is


although extremely rare, is a potentially controversial due to the high costs and Statistics
catastrophic complication of sports. relative rarity of the condition. However, Fortunately, SCD is extremely rare
in sports. For most, the cardiac
The most common cause of cardiac any athlete with cardiac symptoms,
benefits of activity and sports
death related to sports is hypertrophic such as dizziness, fatigue, shortness of participation far outweigh the risks.
cardiomyopathy, an abnormal breath out of proportion to the physical According to recent estimates,
enlargement of cardiac muscle. This activity, palpitations, seizures, and the incidence of sports related SCD
is a rare genetic condition of the heart especially syncope (passing out) should may be as high as 1:75,000 per year
that predisposes an individual to SCD be taken out of competition and in high school and college athletes.
with physical exertion. Another rare thoroughly tested. Further, a family Studies have shown the incidence
of SCD in U.S. military recruits
cause of sudden cardiac death is history of cardiac abnormalities,
to be 1:9,000 per year.
commotio cordis, where direct trauma especially a known relative with
The most common cause
to the chest at a specific moment in hypertrophic cardiomyopathy or in young athletes, hypertrophic
the cardiac cycle initiates a dangerous a history of unexplained sudden cardiomyopathy, accounts for
arrhythmia (abnormal rhythm) in the death in a family member, warrants 2530% of these cases and
commotio cordis accounts for 20%.
hearts electrical system. Commotio a complete cardiac evaluation.
cordis usually occurs in sports where Coronary artery abnormalities are
Various forms of chest protection and the cause of 14% of SCD in athletes.
a blunt projectile, such as a baseball
pads have been tried in order to prevent
or hockey puck, hits the athletes chest. Athletes who had a sudden cardiac
commotio cordis, but unfortunately
event
no method has been shown to prevent
How are sudden cardiac Hank Gathers, a basketball player
this tragic event. Rule changes in
events treated? at Loyola Marymount University
some sports may be of some benefit to
Life-threatening cardiac arrhythmias Reggie Lewis, Boston Celtics
prevent commotio cordis. For example,
that occur in young athletes are very Marc-Vivian Fo, a Cameroonian
limiting the use of aluminum bats in soccer star, died during a match
difficult to treat. Immediate use of an baseball and softball may protect the in 2003
AED (automated external defibrillator) pitcher by decreasing the speed that
may provide some benefit. the ball comes off the bat. Softer balls
and teaching players to turn their chests
How can SCD be prevented? away from a batted ball may also
Unfortunately, the only way to prevent reduce the risk of commotio cordis.
death from hypertrophic cardiomyopathy
is recognition of the condition and
counseling the athlete to avoid strenuous
activity. This condition can be diagnosed Additional Information
by cardiac ultrasound. Some experts www.sportsmed.org
have advocated screening athletes www.orthoinfo.org
with ultrasound or electrocardiograms www.STOPSportsInjuries.org

SPORTS MEDICINE | Sudden Cardiac Death in Athletes 30


THROWING
INJURIES
IN CHILDREN
EXPERT CONSULTA NT | Robert Gallo, MD

What causes throwing injuries? How is the condition treated?


With the start of the baseball season Statistics
Left untreated, throwing injuries in
The percentage of ulnar collateral
each spring, doctors frequently see the elbow can become complicated reconstructions on high school
an increase in elbow problems in young conditions. pitchers compared to college level
baseball players. A common elbow or above pitchers has increased
problem in these children is medial Nonsurgical Treatment from 8% between 1995 and 1998,
Younger children tend to respond better to 24% between 2003 and 2006.
apophysitis, commonly referred to as
(Andrews et al, AJSM, 2008)
Little Leaguer or Youth Pitching elbow. to nonsurgical treatments.
The overall risk of a youth pitcher
The elbow joint is made up of three Rest. Continuing to throw may lead sustaining a serious throwing injury
to major complications and jeopardize within 10 years was 5%. Those
bones: upper arm bone (humerus) and
a childs ability to remain active athletes who pitched more than
the two bones in the forearm (radius 100 innings in a year were 3.5 times
in a sport that requires throwing.
and ulna). Muscles, ligaments, and more likely to be injured than those
tendons hold the elbow joint together. Apply ice packs to bring down who pitched less than 100 innings.
any swelling. (Lyman et al, AJSM, 2002)
Little Leaguer Elbow
If pain persists after a few days of
This injury occurs when repetitive complete rest of the affected area, Depending upon a childs injury,
throwing creates an excessively strong or if pain recurs when throwing surgery may involve removing loose
pull on the tendons and ligaments of the is resumed, stop the activity again bone fragments, bone grafting, or
elbow. The young player feels pain at the until the child gets treatment. reattaching a ligament back to the bone.
prominence on the inside of the elbow.
Refine throwing technique.
Pitchers elbow can be serious if it How can the injury be
becomes aggravated. Repeated pulling What is the recovery time? prevented?
can tear ligaments and tendons away Recovery depends on the athletes age The general guideline for how many
from the bone. The tearing may pull and severity of injury. If identified early pitches a child can safely throw each
tiny bone fragments with it in the same and activity modification is started, week is 75 for 810 year olds, 100 for
way a plant takes soil with it when it could be only a short duration until 1112 year olds, and 125 for 1314
it is uprooted. This can disrupt normal the athlete is back to sport. On the year olds. This includes both practice and
bone growth, resulting in deformity. other hand, if the athlete continues to competitive play. To prevent throwing
play despite pain and other symptoms, injuries, young pitchers should only
What are the symptoms? the damage could take months play three to four innings each game.
Pitchers elbow may cause pain on to resolve or could be permanent.
the inside of the elbow. A child should
stop throwing if any of the following Surgical Treatment
symptoms appear: Surgery is occasionally necessary Additional Information
Elbow pain for severe problems, especially in girls www.sportsmed.org
Restricted range of motion older than 12 years and boys older www.orthoinfo.org
Locking or catching in the elbow joint than 14 years. www.STOPSportsInjuries.org

SPORTS MEDICINE | Throwing Injuries in Children 31


TREATMENT OF
TENDON/LIGAMENT
DISORDERS WITH
PLATELET-RICH PLASMA
EXPERT CONSULTA NT | Grant Jones, MD

What is platelet-rich plasma? Is it legal to use PRP in Additional Information


Multiple treatments have been developed athletes to aid recovery? www.sportsmed.org
to try to speed up the healing rate of In 2009, the World Anti-Doping agency www.orthoinfo.org
tendon injuries with mixed successes. determined that PRP is prohibited when www.STOPSportsInjuries.org
One recent development is the use given as an injection into muscle and
of platelet-rich plasma or PRP to that injections into tendons to aid in the
stimulate healing. PRP is made by healing from injury require a declaration
separating out the platelets from the of its use that is in compliance with the
rest of athletes blood and putting them International Standard for Therapeutic
into a concentrated form. The PRP is Use Exemptions (TUEs). Similarly,
then injected around the repair site in the U.S. Anti-doping Agency issued
acutely, torn surgically repaired tendons an athletes advisory in 2009 that
or ligaments or injected with a needle a PRP injection is equivalent to an
into the degenerative tendon in the injection of growth factors and that
non-surgically treated overuse conditions. an athlete needs a TUE if a medical
Platelets contain growth factors that professional determines that a PRP
stimulate healing, and laboratory injection is necessary. In U.S.
studies have shown that PRP may professional sports leagues, however,
improve tendon and ligament healing. PRP is not addressed in their lists
of banned substances.
What are the results of PRP
in athletes? Athletes who have had
Studies on the use of PRP in athletes PRP injections
have shown mixed results. A few The most publicized case of the use
studies on patients with tennis elbow of PRP in athletes involved Hines Ward
and jumpers knee have demonstrated of the Pittsburgh Steelers. He received
some potential benefit from PRP in a PRP injection into his medial collateral
terms of decreased pain and return ligament after sustaining an acute injury
to activity while other studies have not prior to the 2009 Super Bowl. His
shown any benefit for these conditions. recovery was reported to be quicker
Studies on patients undergoing Achilles than anticipated, and he was able
tendon repair, anterior cruciate ligament to play in the Super Bowl.
reconstruction, and rotator cuff repairs
have shown potential for decreased
pain levels in the early stages and
earlier tendon or ligament healing, but
no differences in the long-term outcome.

SPORTS MEDICINE | Treatment of Tendon/Ligament Disorders with Platelet-Rich Plasma 32


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SPORTS MEDICINE 33
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